Nephrology Resources for Physicians

If you feel your patient needs to be seen immediately, call 404-785-DOCS (3627). Some of these patients may warrant an Emergency Department evaluation or hospitalization.

Generally, conditions that may warrant an Emergency Department evaluation, hospitalization or an urgent initial outpatient visit include, but are not limited to:

• Nephrotic syndrome: Urgent clinic if normal renal function and absence of severe edema; else, Emergency Department
• Severe hypertension
  • Stage 2 hypertension: Urgent clinic
  • Symptomatic hypertension or BP > 30 mm Hg above the 95% (>160/100 in adolescent): Discuss with nephrologist
• Acute kidney injury with electrolyte abnormalities: Go to the nearest Emergency Department
• Acute glomerulonephritis: Discuss with nephrologist
• HSP with significant proteinuria: Urgent clinic visit if renal function is normal; else, discuss with nephrologist; obtain random or first AM (preferred) urine protein/creatinine ratio, renal function panel* and microscopic urinalysis
• Proteinuria with decreased kidney function: Discuss with nephrologist
• Gross hematuria: Discuss with nephrologist if findings of glomerulonephritis (elevated BP, elevated creatinine or hypoalbuminemia); consider these labs if suspect glomerulonephritis: renal function panel*, urine protein/creatinine ratio C3, C4 and ANA; consider urine culture if fever, dysuria, frequency; consider ultrasound if significant pain, may need urgent evaluation (urology or Emergency Department)
• Severe edema: Inability to open eyes or walk due to edema, difficulty breathing due to abdominal distension, GU swelling causing skin irritation

*Renal function panel includes electrolytes, BUN, creatinine, albumin and phosphorus. CMP is an alternative, but it does not include phosphorus.

Lab tests and ultrasounds do not need a referral.

• Elevated BUN/creatinine ratio: Normally elevated in young children due to low creatinine levels
• Elevated BUN and normal creatinine: Mildly elevated BUN is rarely a concern if creatinine is normal
• Elevated urine protein if urine protein/creatinine ratio is normal (< 0.2 mg/mg or <200 mg/g)
• Isolated urine crystals, unless cystine or 2,8-dihydroxyadenine crystals
• Kidney length asymmetry if both kidneys are normal in length
• Duplicated collecting system is a normal variant unless associated with hydronephrosis, urine leaking due to ectopic ureter or dysplasia

Patients with the following conditions should be referred to other specialists.

• Hydronephrosis → urology
• Symptomatic kidney stones (inability to tolerate PO intake, severe pain, rigor, inability to urinate) require an evaluation in the ED and a discussion with urology
• Terminal (end-of-stream) visible hematuria → urology

Most referrals for the following conditions can be avoided with basic testing in your office.

• Microscopic hematuria: Only refer if red blood cells are confirmed by microscopy on at least 2 to 3 occasions; consider kidney ultrasound prior to referral if hematuria is persistent.
• If blood is detected on UA, send urine for microscopy to confirm red blood cells
• Dipstick tests can turn positive with myoglobin or hemoglobin in the urine
• Microscopic hematuria: > 5 RBCs per high powered field (hpf) on microscopy
• Proteinuria: Only refer after screening for benign orthostatic proteinuria by performing a first AM urine protein/creatinine ratio and demonstrating an elevated value (> 0.2 mg/mg or >200 mg/g). If non-orthostatic proteinuria, consider renal function panel*, cholesterol, C3, C4 and ANA prior to referral.
  • For protein that is detected on a urine sample, obtain a first morning urine sample to repeat the UA and send for a urine protein to creatinine ratio
• Hypertension: Confirm by obtaining auscultatory values using an appropriately sized cuff. Many overweight or muscular teenagers need a large adult cuff. For stage 1 hypertension, confirm 1 to 2 weeks before referring. Please refer patients with hypertension without associated significant kidney disease to our Nephrology Hypertension Clinic that has ambulatory blood pressure monitoring (ABPM) and nutritional support for patients.