This Kidney Disease Referral Pathway is a modified version of that used by KidneyHealth.ca.
Its purpose is to assist in the decision for referral to nephrology when CKD is diagnosed based on chronic reduction in eGFR, sustained abnormal albuminuria or persistent hematuria.
It is built on the assumption that the primary care community has an appropriate management approach to diabetic nephropathy and/or CKD with a stable eGFR > nephrotic proteinuria.
Starting a CKD Referral
Use the CKD Referral Order when CKD is documented based on either:
- eGFR less than 60 mL/min/1.73m², and/or
- uACR greater than 30 mg/g, and/or
- Hematuria documented on two urine or serum samples
If these criteria are not met, select the "Other Clinical Question" referral option.
For a flowchart version of the information below, download the CKD Referral Guidance.
Pathway 1: eGFR Less Than 15 mL/min/1.73m²
Contact UVMMC Nephrology directly for an urgent referral.
If not completed within the past month, obtain:
- Basic metabolic panel (BMP)
- Phosphorus
- Serum albumin
- Urinalysis (UA)
- Urine albumin-to-creatinine ratio (uACR)
- Complete blood count (CBC) with differential
- Antineutrophil cytoplasmic antibody (ANCA) panel including:
- Anti-myeloperoxidase antibody
- Anti-proteinase 3 antibody
- Antinuclear antibody (ANA)
- Complement C3 and C4 levels
- Renal ultrasound
For patients older than 40 years:
- Serum protein electrophoresis (SPEP) with immunofixation
- Urine protein electrophoresis (UPEP)
- Serum free light chain ratio
Monitor BMP monthly until nephrology consultation is completed.
Pathway 2: eGFR 15 to 59.9 mL/min/1.73m²
Yes
Refer for a routine nephrology consultation.
If not completed within the past two months, order:
- BMP
- Phosphorus
- Serum albumin
- UA
- uACR
- CBC with differential
- ANCA panel
- ANA
- Complement C3 and C4 levels
- Renal ultrasound
For patients older than 40 years:
- SPEP with immunofixation
- UPEP
- Serum free light chain ratio
Monitor BMP monthly until consultation is completed.
If eGFR declines by more than 20% in one month, contact nephrology to expedite the consultation.
No
Proceed to Step 2.
Yes
Refer for a routine nephrology consultation.
If not completed within the past two months, order:
- BMP
- Phosphorus
- Albumin
- uACR
- UA
- CBC with differential
- Renal ultrasound
For patients older than 40 years:
- SPEP with immunofixation
- UPEP
- Serum free light chain ratio
Monitor BMP monthly until consultation is completed.
If eGFR declines by more than 20% in one month, contact nephrology to expedite the consultation.
No
Proceed to Step 3.
- eGFR less than 30 mL/min/1.73m²
- Kidney Failure Risk Equation (KFRE) risk greater than 3% over five years
Yes
Refer for a routine nephrology consultation.
Order:
- BMP
- Phosphorus
- Albumin
- uACR
- UA
- CBC with differential
- Renal ultrasound
For patients older than 40 years:
- SPEP with immunofixation
- UPEP
- Serum free light chain ratio
Monitor BMP monthly until consultation is completed.
If eGFR declines by more than 20% in one month, contact nephrology to expedite consultation.
No
Continue monitoring in primary care.
For patients with eGFR 30-59:
- Repeat blood and urine testing every 3-6 months.
Refer for routine nephrology consultation if:
- eGFR declines by more than 20% in one month, or
- eGFR declines by more than 10% over two years, or
- uACR rises above 700 mg/g on two consecutive measurements.
Pathway 3: eGFR 60 mL/min/1.73m² or Greater
Yes
Proceed to Step 2
No
Proceed to Step 5
Yes
Refer for a routine nephrology consultation.
If not completed within the past two months, order:
- BMP
- Phosphorus
- Serum albumin
- UA
- uACR
- CBC with differential
- ANCA panel
- ANA
- Complement C3 and C4 levels
- Renal ultrasound
For patients older than 40 years:
- SPEP with immunofixation
- UPEP
- Serum free light chain ratio
No
Proceed with additional evaluation.
Order:
- BMP
- Phosphorus
- Serum albumin
- UA
- uACR
- CBC with differential
- ANCA panel
- ANA
- Complement C3 and C4 levels within one month
Verify that a renal ultrasound has been completed.
Refer urgently to nephrology if any of the following occur:
- eGFR decreases by more than 20%
- uACR increases above 700 mg/g
- Any serologic test is positive
If none of the above occur:
Refer the patient to Urology.
Is uACR Greater Than 700 mg/g?
Yes
Refer for a routine nephrology consultation.
If not completed within the past two months, order:
- BMP
- Phosphorus
- Serum albumin
- UA
- uACR
- Renal ultrasound
For patients older than 40 years:
- SPEP with immunofixation
- UPEP
- Serum free light chain ratio.
No
Proceed to Step 6.
Yes
The patient does not meet criteria for CKD.
- Cancel the nephrology consultation.
- Continue annual screening for high-risk patients.
No
Proceed to Step 7.
- eGFR decline greater than 10% per year
- eGFR decline greater than 20% in one month
- eGFR less than 30 mL/min/1.73m²
Yes
Refer for a routine nephrology consultation.
Order, if not completed within the last two months:
- BMP
- Phosphorus
- Albumin
- uACR
- UA
- CBC with differential
- Renal ultrasound
Follow BMP monthly until consultation occurs.
If eGFR declines by more than 20% in one month, contact nephrology to expedite consultation.
No
Continue monitoring:
- Repeat eGFR and uACR in three months.
- Thereafter repeat every 6-12 months.
Refer if clinical status changes