What specialist should an adult patient with elevated Urine Albumin-to-Creatinine Ratio (UACR) and a history of diabetes, hypertension, or previous kidney issues be referred to?

Nephrologist Referral for Elevated UACR

Refer adult patients with elevated UACR to a nephrologist when eGFR falls below 30 mL/min/1.73 m², when UACR continuously rises despite optimal management, or when there is uncertainty about kidney disease etiology or difficult management issues. 1

Primary Care Management Before Referral

For most patients with elevated UACR and preserved kidney function (eGFR ≥30 mL/min/1.73 m²), primary care physicians should initiate treatment before nephrology referral:

• Start ACE inhibitor or ARB therapy immediately for any UACR ≥30 mg/g, regardless of blood pressure, targeting BP <140/90 mmHg (or <130/80 mmHg for higher cardiovascular risk) 2, 1
• Optimize glycemic control to near-normoglycemia to delay progression 2
• Monitor UACR and eGFR twice annually for patients with UACR >30 mg/g or eGFR 30-60 mL/min/1.73 m² 1, 2

Mandatory Nephrology Referral Criteria

Refer immediately when:

• eGFR <30 mL/min/1.73 m² (stage 4 CKD) to discuss renal replacement therapy and optimize pre-dialysis care 1
• Continuously rising UACR levels despite good blood pressure management and ACE inhibitor/ARB therapy 1
• Continuously declining eGFR, particularly if declining >5 mL/min/1.73 m² per year 1
• UACR ≥300 mg/g persistently (severely increased albuminuria) with inadequate response to initial therapy 1

Consider Nephrology Referral For:

• Uncertainty about kidney disease etiology, particularly in type 2 diabetes without retinopathy or atypical presentations 1

• Difficult management issues including:

  • Anemia of CKD 1
  • Secondary hyperparathyroidism or metabolic bone disease 1
  • Resistant hypertension requiring ≥4 antihypertensive agents 1
  • Electrolyte disturbances (hyperkalemia, metabolic acidosis) 1
  • Significant albuminuria increases despite optimal management 1

• eGFR 30-45 mL/min/1.73 m² (stage 3b CKD) for coordinated care to slow progression, though this may be managed in primary care depending on provider experience 1

Important Clinical Caveats

Before referring, confirm persistent elevation: Obtain 2 of 3 abnormal UACR specimens over 3-6 months, as biological variability exceeds 20% 3, 2. Transient elevations occur with exercise within 24 hours, infection, fever, heart failure, marked hyperglycemia, hypertension, or menstruation 3, 2.

Do not refer solely based on a single elevated UACR value if eGFR is preserved and the patient has not yet received optimal medical therapy (ACE inhibitor/ARB, blood pressure optimization, glycemic control) 2.

The threshold for referral varies based on provider experience with diabetic kidney disease—those who frequently manage these patients may appropriately defer referral until more advanced disease 1.

Early nephrology consultation (at eGFR <45 mL/min/1.73 m²) has been shown to reduce costs, improve quality of care, and delay dialysis, though mandatory referral is typically recommended at eGFR <30 mL/min/1.73 m² 1.