Pediatric Nephrology Consult and Referral Guidelines Introduction We see children and teens from birth to 21 years. The most common reasons patients are referred to pediatric nephrology services include: Dialysis, End Stage Renal Disease Electrolyte Imbalance or Abnormalities Enuresis Glomerular Disorders: Hematuria and Proteinuria Henoch Schonlein Purpura * Hydronephrosis * Hypertension * Kidney Stones/Nephrocalcinosis Nephritic Syndrome Nephrotic Syndrome Renal Transplantation * Urinary Tract Infections Please ensure the patient has been seen in your office for the complaint in question prior to referring to nephrology so that an accurate description of the concern is available. We want to make referrals to our office easy, fast and efficient for our primary care providers. We developed this tool as one way to maximize a productive office visit for you and your patient. We view this as a pilot document and welcome your feedback to further refine the guidelines. Suggested work-ups may not apply to all patients, but these are what we typically consider during the office visits. Appointment Priority Guide Below represents the recommended prioritization. Priority Immediate Call our office and/or send to the closest emergency department. Call HDVCH direct at (616)391.2345 and Urgent Likely to receive an appointment within 2 days. Call our office at (616)267.2400 and ask for the on call physician to be paged regarding an urgent referral. Routine Likely to receive an appointment within 10 days. Fax completed referral form and records to (616)267.2401 or send through Michigan Health Connect. *Co-Management Protocols are also available on www.helendevoschildrens.org Pediatric Nephrology Referral Guidelines January 2014 For the most updated version of the Referral Guidelines, please visit www.helendevoschildrens.org 1
Dialysis to the on call Electrolyte Imbalance or abnormalities Isolated or as a concomitant finding in renal or nonrenal conditions Set random urine for: creatinine, sodium, potassium, chloride, osmolality, phosphorus and urea nitrogen. At the same time draw serum osmolality CMP, phosphorus and magnesium. Any abnormalities. Will be glad to provide consultations for interpretation of test and management guidance. Enuresis Daytime or nighttime incontinence. Primary Patient who has not achieved a period of nighttime dryness. Nocturnal > 5 years of age. Detailed history, UA and behavioral modifications. After 6 months of failed behavioral modifications. Patients with non-psychogenic polydipsia and polyuria Secondary Enuresis in children with urinary tract symptoms (non-psychological stressors identified). Any secondary without a psychosocial trigger, immediately. Pediatric Nephrology Referral Guidelines January 2014 For the most updated version of the Referral Guidelines, please visit www.helendevoschildrens.org 2
Glomerular Disorders Microscopic Hematuria UA with 5RBC/HPF pressure measurements. UA with microscopic studies. Family history of Alport Syndrome. Any degree of hearing loss or visual changes associated with hematuria. Any patient > 8 years of age. If proteinuria is present. If hypertensive. Any isolated microscopic hematuria in more than two separate visits. Complete family history and complete record of urinalysis of parents/siblings if obtained. Any prior work up including renal Isolated Proteinuria Urine protein/creatinine ratio > 0.2 pressure measurements. First morning voids for random protein and random creatinine. (Calculate protein/creatinine ratio). Discourage use of 24 hour urine collection. If patient < 8 years of age and finding is confirmed in three separate visits, refer to nephrology. Any P/C > 0.2 in a first morning void. Henoch Schonlein Purpura Hydronephrosis Congenital by prenatal ultrasound or found in renal ultrasound UA, microscopic study, urine random protein and creatinine. See co management guidelines. See co management guidelines. Protienuria, hematuria, hypertension or edema. Pediatric Nephrology Referral Guidelines January 2014 For the most updated version of the Referral Guidelines, please visit www.helendevoschildrens.org 3
Hypertension Prehypertensive without preexisting conditions such as Chronic Kidney Disease or diabetes. Three consecutive blood pressure readings at an office visit between the 90 th and 95 th percentile. Hypertension Stage 1 Blood pressure reading above the 95 th percentile. Hypertension Stage 2 blood pressures above the 95 th percentile plus 5mmHg. Kidney Stones and Hypercalciuria As defines by renal ultrasound. Calcium to creatinine ratio of >0.2 in a patient 6 years of age or greater. Three blood pressure readings on three separate clinic visits. Lifestyle modifications. Close follow up within a period of 6 months if unchanged. Detailed history and physical exam. Evaluate for symptoms of hypertension emergency. Detailed history and physical exam. Evaluate for symptoms of hypertension emergency. Urine random calcium and urine random creatinine. (Calculate calcium/creatinine ratio): U/A. Discourage use of CT scan as initial work up. 6 Months if no improvement with lifestyle modifications in obese patient. Any patient < 10 years old. See co-management protocol for obese patients older than 10 years of age. Immediately, if symptomatic dial HDVCH direct (616) 391.2345 and Immediately, if symptomatic dial HDVCH direct (616) 391.2345 and Immediately if symptomatic. Immediately if less than 6 years of age, has had more than one stone or a single stone > 5mm. any prior work up. Pediatric Nephrology Referral Guidelines January 2014 For the most updated version of the Referral Guidelines, please visit www.helendevoschildrens.org 4
Nephritic Syndrome Edema, hypertension and hematuria (microscopic or gross) pressure measurements. UA with microscopic study, CBC, CMP, magnesium, phosphorus, C3, C4, ANA, urine protein/creatinine ratio, rapid strep and ASO. to the on call Nephrotic Syndrome Urine protein/creatinine ratio > 2, edema pressure measurements. to the on call UTI UA suggestive of infection. Ex, WBC 10, nitrates, leukocyte esterase a positive urine culture with 50,000ufc. Recurring UTI. Any urinary tract abnormality. Any patient less than 2 years of age. Renal Transplantation to the on call Pediatric Nephrology Referral Guidelines January 2014 For the most updated version of the Referral Guidelines, please visit www.helendevoschildrens.org 5