Proteinuria
Adult

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Emergency Referrals

Important

If you believe your patient requires immediate attention, please refer the patient to the emergency department (via ambulance if necessary) or seek emergent medical advice.

Kidney transplant patients with significant intercurrent illness (eg diarrhoea and vomiting)

Acute decline in kidney function

Any acute kidney injury or significant decline in kidney function where the treating doctor believes the patient requires urgent hospital care (especially if evidence of abrupt increase in serum creatinine by > 50% of baseline)
Oliguria/anuria
Severe acute electrolyte disturbance for example:
- hyperkalaemia with K+ > 6.5 mmol/L OR > 6.0 mmol/L with ECG changes
- hypokalaemia with K+ < 2.5 mmol/L OR < 3.0mmol/L with symptoms
- severe metabolic acidosis (HCO3 < 15mmol/L)
Kidney transplant recipients with an acute decline in kidney function (e.g. > 20% increase in serum creatinine)
Suspected glomerulonephritis (proteinuria and haematuria) associated with acute kidney injury

Chronic kidney disease

Severe acute electrolyte disturbance for example:
- hyperkalemia with K+ > 6.5 mmol/L OR > 6.0 mmol/L with ECG changes
- hypokalemia with K+ < 2.5 mmol/L OR < 3.0mmol/L with symptoms
- severe metabolic acidosis (HCO3 < 15mmol/L)
Severe hypertension especially when accompanied with declining kidney function
Patients with severe uraemic symptoms or signs
Evidence of acute fluid overload or heart failure in a patient with known CKD
Kidney transplant recipients with acute intercurrent illness
Peritoneal or haemodialysis patients with acute issues or problems with dialysis access (eg vascular access issues or peritoneal dialysis catheter issues)
Peritoneal dialysis patients with suspected peritonitis (abdominal pain, cloudy dialysis fluid)

Cystic kidney disease

Significant cyst haemorrhage, suspected septicaemia related to cyst infection, suspected rupture of berry aneurysm

Glomerular Disease

Suspected Glomerular Disease (proteinuria and haematuria) with acutely declining kidney function or patient systemically unwell

Haematuria

Severe macroscopic haematuria

Hypertension

Severe hypertension (systolic BP >220/140~~180~~or >180/110 if under 50 years of age) with no known ischaemic heart disease, cardiomyopathy, or chronic kidney disease AND any of the following concerning features:
- headache
- confusion
- blurred vision
- retinal haemorrhage
- reduced level of consciousness
- seizures
- proteinuria
- papilloedema
- signs of heart failure
- chest pain
- acute kidney injury
- suspicion of aortic dissection
- new neurological deficits
If suspected gestational hypertension or pre-eclampsia refer patient to the emergency department of a facility that offers obstetric services where possible
If hypertension service available refer to hypertension service

Kidney Stones

Suspected urolithiasis / nephrolithiasis with infection or severe pain
Suspected urinary retention/obstruction (eg anuria, oliguria)

Proteinuria

Nephrotic syndrome (proteinuria > 3.5 grams/24 hours OR urine ACR > 300mg/mmol* or PCR > 300g/mol*) with any of the following concerning features:
- significant peripheral oedema
- signs of pulmonary oedema
- severe hypertension
- signs of DVT / PE
- infection
- acute kidney injury

Useful Management Information

Refer to HealthPathways

Quantifying proteinuria (Source – Tasmanian Health 2018):

Urine ACR (random or first morning) is generally a sufficient screen for albuminuria/microalbuminuria in diabetic and non-diabetic populations and is a useful test in most kidney clinic referrals (first morning specimens increase specificity - but not necessary). Additional protein creatinine ratio testing can assist with diagnostic evaluation.
24-hour quantification: Where urine ACR is significantly elevated (>100mg/mmol) consideration can be given to 24-hour urine protein collections (not generally required in most low-level albuminuria but is more likely to be helpful in those with suspected nephrotic syndrome)
Low level albuminuria/proteinuria can occur transiently during fever, cardiac failure, after strenuous exercise (usually no more than trace on dipstick)
Haematuria and proteinuria present together is strongly suggestive of a glomerular source for haematuria

Note: As per KHA guidelines, persistent significant albuminuria (ACR > 30mg/mmol) should be referred. Referral is not necessary for a urine ACR < 30mg/mmol with no haematuria.

Clinician resources

Proteinuria Consensus Statement, 2012

Patient resources

Kidney Health Australia – Albuminuria fact sheet

Minimum Referral Criteria

Does your patient meet the minimum referral criteria?

Category 1 (appointment within 30 calendar days)	Nephrotic range proteinuria* (urine ACR > 220mg/mmol or PCR > 350g/mol) without concerning features (see below) Proteinuria (urine ACR 30-220 mg/mmol or PCR 60-350 g/mol) with a declining eGFR but without concerning features (see below) Concerning features Significant peripheral oedema Signs of pulmonary oedema Severe hypertension Signs of DVT / PE Infection Acute kidney injury At the level of nephrotic range proteinuria, albumin accounts for 60-70% of total urinary protein. Within the CPC, ACR > 220mg/mmol OR PCR > 300mg/mmol has been used for simplicity and ease of application. Note*: If there is any uncertainty regarding the urgency of an acute referral, please contact your local Kidney Medicine clinician, as direct ward admission may be considered.
Category 2 (appointment within 90 calendar days)	Sub-nephrotic macroalbuminuria (urine ACR 25-220mg/mmol for men or urine ACR 35-350mg/mmol for women or PCR 60- 350mg/mmol) with a stable eGFR
Category 3 (appointment within 365 calendar days)	Asymptomatic microalbuminuria (urine ACR < 25mg/mmol for men or < 35mg/mmol for women OR PCR < 50mg/mmol) with other evidence of kidney disease (e.g. haematuria)

Category 1 (appointment within 30 calendar days)

Nephrotic range proteinuria* (urine ACR > 220mg/mmol or PCR > 350g/mol) without concerning features (see below)
Proteinuria (urine ACR 30-220 mg/mmol or PCR 60-350 g/mol) with a declining eGFR but without concerning features (see below)

Concerning features

Significant peripheral oedema
Signs of pulmonary oedema
Severe hypertension
Signs of DVT / PE
Infection
Acute kidney injury

*At the level of nephrotic range proteinuria, albumin accounts for 60-70% of total urinary protein. Within the CPC, ACR > 220mg/mmol OR PCR > 300mg/mmol has been used for simplicity and ease of application.

Note: If there is any uncertainty regarding the urgency of an acute referral, please contact your local Kidney Medicine clinician, as direct ward admission may be considered.

Category 2 (appointment within 90 calendar days)

Sub-nephrotic macroalbuminuria (urine ACR 25-220mg/mmol for men or urine ACR 35-350mg/mmol for women or PCR 60- 350mg/mmol) with a stable eGFR

Category 3 (appointment within 365 calendar days)

Asymptomatic microalbuminuria (urine ACR < 25mg/mmol for men or < 35mg/mmol for women OR PCR < 50mg/mmol) with other evidence of kidney disease (e.g. haematuria)

Standard Referral Information

Reason for request

To establish a diagnosis
For treatment or intervention
For advice and management
For specialist to take over management
Reassurance for GP/second opinion
For a specified test/investigation the GP can't order, or the patient can't afford or access
Reassurance for the patient/family
For other reason (e.g. rapidly accelerating disease progression)
Clinical judgement indicates a referral for specialist review is necessary

Relevant clinical information about the condition

Presenting symptoms (evolution and duration)
Physical findings
Details of previous treatment (including systemic and topical medications prescribed) including the course and outcome of the treatment
All conservative options that have been pursued unsuccessfully prior to referral
Body mass index (BMI)
Details of any associated medical conditions which may affect the condition or its treatment (e.g. diabetes), noting these must be stable and controlled prior to referral
Any special care requirements where relevant (e.g tracheostomy in place, oxygen required)
Current medications and dosages
Drug allergies
Alcohol, tobacco and other drugs use

Patient's Demographic Details

Full name (including aliases)
Date and country of birth
Residential and postal address including whether patient resides at an aged care facility
Telephone contact number/s – home, mobile and alternative
Medicare number (where eligible)
Name of the parent or caregiver (if appropriate)
Name of delegate and contact details (Department of Corrective Services)
Preferred language and interpreter requirements
Identifies as Aboriginal and/or Torres Strait Islander
Any special needs, access requirements and/or disability relevant to the referral

Referring Practitioner Details

Full name
Full address
Contact details – telephone, fax, email
Provider number
Date of referral
Signature
Nominated general practitioner’s details (if known), if the nominated general practitioner is different from the referring practitioner

Other relevant information

Willingness to have surgery (where surgery is a likely intervention)
Choice to be treated as a public or private patient
Compensable status (e.g. DVA, Work Cover, Motor Vehicle Insurance, etc.)

Essential Referral Information

Presence of comorbid conditions such as hypertension, diabetes, vascular disease or known chronic kidney disease
Current medications, medication history and allergies
Timeline of symptoms
Examination findings including BP, peripheral oedema, signs of pulmonary oedema
FBC, ELFT, urea, creatinine and eGFR results (include serial historical results, if available)
Urine albumin creatinine ratio (ACR) or urine protein creatinine ratio (PCR) (ideally early morning sample but a random sample is acceptable)
Urine midstream M/C/S (including testing for red cell morphology and casts preferable)

Additional Referral Information

Ethnicity (Aboriginal and Torres Strait Islander population especially at risk)
Fasting lipid results
HbA1c results (for patients with diabetes)
Ultrasound (kidney, ureters and bladder) results

Send Referrals To

Smart Referrals

Preferred Method
About Smart Referrals

Secure Web Transfer

Medical Objects Account: GQ42150009Z

HealthLink EDI: Qldgchsd

Internal Referrals

Nephrology qhRefer

Fax

(07) 5687 4497

Post

Booking and Referral Centre
Gold Coast University Hospital
1 Hospital Boulevard
Southport QLD 4215

Enquiries

1300 559 083

Related HealthPathways

No directly related pathways found

HealthPathways home page

Service Availability

Dr Jagadeesh Kurtkoti

Medical Director Nephrology/Renal Medicine

Facilities

Gold Coast University Hospital

If you would like to send a named referral, please address it to the specialist listed above, who will allocate a suitably qualified specialist to see the patient. Alternatively, you can view a full list of our specialists.

ProteinuriaAdult