Ungraded Suggestions for Clinical Care

a. We recommend referral to a specialist renal service or nephrologist in the following situations: i. Stage 4 and 5 chronic kidney disease of any cause (estimated glomerular filtration rate <30mL/min/1.73m 2 ) (1C) ii. Persistent significant albuminuria (albumin creatinine ratio ≥30 mg/mmol, approximately equivalent to protein creatinine ratio ≥50 mg/mmol, or urinary protein excretion ≥500 mg/24 hours) (1C) iii. A consistent decline in estimated glomerular filtration rate from a baseline of <60 ml/min/1.73 m 2 (a decline >5 ml/min/1.73 m 2 over a six month period which is confirmed on at least three separate readings) (1C)* b. We suggest referral to a specialist renal service or nephrologist in the following situations: i. Glomerular haematuria with macroalbuminuria (2C) ii. Chronic kidney disease and hypertension that is hard to get to target despite at least 3 anti-hypertensive agents (2C) c. We suggest discussing management issues with a specialist by letter, email or telephone in cases where it may not be necessary for the person with chronic kidney disease to be seen by the specialist (2D). d. Once a referral has been made and a plan jointly agreed, routine follow-up could take place at the patient’s General Practitioner surgery rather than in a specialist clinic. If this is the case, we recommend that criteria for future referral or re-referral should be specified (1D). e. We suggest that the individual’s wishes and comorbidities when considering referral, be taken into account (2D).