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ADULT NEPHROLOGY REFERRAL PROFORMA page 1 ADULT NEPHROLOGY REFERRAL Referring to Patient Details NHS No. Surname Previous surname Address ROUTINE/URGENT Date Gender Forename Date of Birth Title Age Home tel. No Mobile/daytime tel no: Practice/Hospital Details Practice address or Hospital address and Ward Referring GP/Consultant Tel. No Fax No. Please note eGFR information is mandatory Diagnosis/Reason for referral (Please tick the relevant boxes) REFERRAL INFORMATION: eGFR value (ml/min/1.73m2) CKD Stage Category Other Markers CKD Stage 5 (<15) Urgent Refer immediate if symptomatic or potassium >7 mmol/l CKD Stage 4 (nondiabetics with eGFR 15-26- & diabetics with eGFR 15-29) CKD Stage 3 (30-59) and Stage 4 nondiabetics with eGFR 26-29) Urgent New Routine Stable Routine Progressive ↓ in eGFR/↑serum creatinine Microscopic Haematuria Isolated proteinuria-Urine ACR>45mg/mmol Unexplained anaemia (Hb<11gm), abnormal potassium, calcium or phosphate Suspected systemic illness like SLE Uncontrolled BP (>150/90 on 3 agents) CKD Stage 2 & 1 (60-89 & >90) Renal problems irrespective of eGFR No need to refer-Unless as listed below Immediate Urgent Routine Any other reason Specific reason for referral- Malignant hypertension Hyperkalaemia (potassium >7.0 mmol/l) Nephrotic Syndrome Multi system involvement with proteinuria +/- haematuria e.g. vasculitis, SLE Dipstick proteinuria present and urine Albumin/creatinine ratio >45 mg/mmol Microscopic Haematuria and ACR >30mg/mmol Persistent macroscopic haematuria but urological tests negative Structural abnormality of kidneys on ultrasound scanning or other radiological tests e.g: Polycystic kidney disease, reflux nephropathy Urgent Routine For information about local guidelines and the units visit http://www.merseyrenalunits.nhs.uk For more information on nephrology referral and management of kidney patients visit http://www.renal.org/CKDguide/ckd.html For Immediate referral contact relevant Nephrology department January 06 ADULT NEPHROLOGY REFERRAL PROFORMA page 2 Investigations and Examination: Test Date Latest Results Date Earlier (if available) Results eGFR Serum creatinine Blood urea Serum potassium Serum sodium Serum Bicarbonate Hb Immunology screen Urinary Albumin Creatinine Ratio (ACR) Urine dipstick MSSU Ultrasound scan of kidneys BP Peripheral Oedema Palpable bladder Enlarged prostate Additional information Past Medical History: Diabetes Mellitus Cardiovascular disease Peripheral Vascular disease Chronic Obstructive Pulmonary Disease Other Type I, II / No Yes/No Yes/No Yes/No Yes/No Hypertension Cerebrovascular disease Liver disease Yes/No Malignancy Yes/No Yes/No Specify Yes/No Medications and Allergies: ACEI/ARB: Yes/No Others: Additional Information: January 06 NSAIDS: Yes/No Antibiotics: ADULT NEPHROLOGY REFERRAL PROFORMA page 3 January 06
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