Emergency Department Referral for Suspected Glomerulonephritis
Yes, send the patient to the emergency room immediately if you suspect rapidly progressive glomerulonephritis (RPGN), which presents with rapid decline in kidney function over days to weeks, or if the patient shows signs of acute nephritic syndrome with significant renal dysfunction. 1, 2
When to Send to the ER Immediately
High-Risk Presentations Requiring Emergency Evaluation
Rapidly progressive glomerulonephritis (RPGN) with rapid decline in kidney function over days to weeks constitutes a medical emergency and must not be missed, as it can lead to irreversible kidney damage within weeks if left untreated 2, 3
Acute nephritic syndrome with full-blown presentation including tea-colored urine, significant proteinuria (>2+ on dipstick), red blood cell casts, hypertension, edema, and acute renal dysfunction requires urgent evaluation 4, 5
Acute renal failure with elevated creatinine, oliguria, or signs of uremia necessitates immediate hospital-based assessment 6
Systemic vasculitis symptoms including hemoptysis, palpable purpura, severe arthralgia, fever with renal involvement, or constitutional symptoms with declining kidney function warrant emergency referral 3
Critical Laboratory Findings
Serum creatinine >3 mg/dL severely limits drug efficacy and enhances toxicity, requiring urgent intervention 7
Serum creatinine >5 mg/dL may require hemofiltration or dialysis 7
Urinalysis showing glomerular hematuria with red blood cell casts plus proteinuria suggests glomerular source requiring urgent workup 4, 2
When Outpatient Management May Be Appropriate
Lower-Risk Presentations
Isolated microscopic hematuria without proteinuria, normal blood pressure, and stable renal function can be evaluated in the outpatient setting with close follow-up 4
Mild proteinuria (<3 g/24h) with microscopic hematuria, normal renal function, and no systemic symptoms may be worked up as an outpatient with expedited nephrology referral 4
Post-infectious glomerulonephritis in children with clear antecedent streptococcal infection, mild symptoms, and stable renal function can often be managed outpatient with close monitoring 4
Key Diagnostic Considerations Before Transfer
Essential Initial Workup
Urinalysis with microscopy to confirm glomerular hematuria (dysmorphic red blood cells, red cell casts) and quantify proteinuria 2
Basic metabolic panel including BUN, creatinine, and electrolytes to assess renal function 4, 7
Blood pressure measurement as hypertension frequently accompanies glomerulonephritis 3
Complete blood count to assess for anemia or thrombocytopenia 4
Critical Pitfall to Avoid
Do not delay transfer to obtain autoimmune serologies (ANCA, anti-GBM, ANA, complement levels) if clinical presentation strongly suggests RPGN or ANCA-associated vasculitis—these can be drawn in the ER, and immunosuppressive therapy should not be delayed while awaiting kidney biopsy if ANCA-positive vasculitis is suspected. 1, 2
Clinical Decision Algorithm
Assess tempo of renal decline: If creatinine rising over days to weeks → ER immediately 2, 3
Evaluate for systemic involvement: Hemoptysis, purpura, severe constitutional symptoms → ER immediately 3
Check for acute complications: Oliguria, severe hypertension, pulmonary edema, uremic symptoms → ER immediately 6
If stable with isolated urinary findings: Expedited outpatient nephrology referral within 1-2 weeks with close monitoring 4
The distinction between acute glomerulonephritis requiring emergency intervention and chronic presentations suitable for outpatient workup hinges primarily on the rate of renal function decline and presence of life-threatening complications. RPGN represents the most critical scenario, as early diagnosis and prompt initiation of immunosuppressive therapy are critical for favorable outcomes. 2, 8