When to Refer

HIV-associated renal disease should be jointly managed with a nephrologist.1 Although all decisions, including timing of specialist referral, should be made on a case-by-case basis, indications for referral include abnormal kidney function, declining kidney function or proteinuria.2 



In the general population, patients with CKD who may be considered for referral to a nephrologist include those with:3

  • estimated glomerular filtration rate (eGFR) <30mL/min/1.73m2
  • unexplained decline in kidney function (>15% drop in eGFR over 3 months)
  • proteinuria >1g/24hrs (urine protein to creatinine ratio of 100mg/mmol, approximate daily protein excretion of 1g/24hrs)
  • glomerular hematuria (particularly if proteinuria is present)
  • CKD and hypertension that is hard to control
  • diabetes with eGFR <60mL/min/1.73m2
  • unexplained anemia (Hb<100g/L) with eGFR <60mL/min/1.73m2
     

For people with CKD, but not infected with HIV, appropriate referral is associated with:3  

  • reduced rates of progression to end stage renal disease (ESRD)
  • decreased need for, and duration of, hospitalization
  • increased likelihood of permanent dialysis access being created prior to beginning dialysis
  • reduced initial costs of care following commencement of dialysis
  • increased likelihood of kidney transplantation
  • decreased patient morbidity and mortality
     

Patients presenting with sudden or acute onset of renal impairment or kidney disease symptoms, as well as those with signs of acute nephritis, should be regarded as medical emergencies and be referred to a nephrologist without delay.3





 

References

  1. European AIDs Clinical Society (EACS). Guidelines. Version 6.0. Accessed 4 July 2012.
  2. Gupta SK, Eustace JA, Winston JA, et al. Guidelines for the Management of Chronic Kidney disease in HIV-infected patients: Recommendations of the HIV Medicine Association of the Infectious Diseases Society of America. Clin Infect Dis. 2005;40:1559–1585. 
  3. Kidney Health Australia. Chronic kidney disease management in General Practice. Accessed 1 March 2011.