When should you see a kidney specialist? A guide to nephrology referral in Ireland

Many of the patients I meet in clinic were not expecting to need a kidney specialist. They went to their GP for a routine check, a blood pressure review or a diabetes appointment, and a blood or urine result came back outside the normal range. This article sets out when a GP referral to a nephrologist makes sense, how the referral works, and what to expect when you come to see me.

What does a kidney specialist do?

A nephrologist is a doctor who specialises in the kidneys. The work covers:

• conditions that affect how well the kidneys filter the blood
• conditions that cause blood or protein to leak into the urine
• kidney stones
• the balance of salts in the blood
• blood pressure, which is closely linked to kidney health.

I am a consultant nephrologist and general physician in full-time private practice, and I have more than 20 years of clinical experience. I trained in nephrology and general internal medicine in Ireland through the Royal College of Physicians of Ireland, then completed a nephrology fellowship at the University of Toronto. You can read more about my background on the about page.

When should you see a kidney specialist?

These are the most common reasons GPs refer patients to me:

• a falling eGFR or rising creatinine on a blood test
• blood or protein in the urine
• acute kidney injury
• established chronic kidney disease that needs specialist input
• recurrent or high-risk kidney stones
• a persistent imbalance in salts such as sodium or potassium
• blood pressure that is hard to control
• signs of kidney involvement in someone with diabetes.

Each one is explained in more detail below.

Changes in kidney function (eGFR and creatinine)

The most common reason for referral is a change in kidney function on a blood test. Your GP measures kidney function with two related results:

• Creatinine is a waste product that builds up in the blood when the kidneys are not clearing it well.
• eGFR (estimated glomerular filtration rate) is calculated from creatinine and estimates how much filtering the kidneys are doing.

Referral is appropriate when eGFR is falling without a clear explanation, when it is falling steadily over time, when creatinine is rising, or when your GP suspects chronic kidney disease. The assessment aims to:

• look for any cause that can be reversed
• work out the stage of the disease
• put a plan in place to slow its progression and reduce the risk to your heart and circulation.

If you have been told your eGFR puts you in a particular stage, the guide to CKD stages explains what each stage means.

Blood or protein in the urine

Blood in the urine is called haematuria, and protein in the urine is called proteinuria. Either can be picked up on a routine urine test. When either finding is persistent or has no obvious explanation, a specialist assessment helps to find the underlying kidney cause and to guide treatment, or onward referral to another specialty if that is needed. The article on ACR and PCR urine tests explains how protein in the urine is measured.

Acute kidney injury

Acute kidney injury is a sudden drop in kidney function. Prompt assessment aims to identify what set it off, to get fluids and medications right, and to reduce the chance that it leads on to chronic kidney disease.

Established chronic kidney disease

Some patients are referred because they already have a diagnosis of chronic kidney disease and need specialist input. That can include:

• regular monitoring
• managing the complications of CKD
• reviewing medications
• planning long-term care.

Your kidney consultant works alongside your GP, who stays involved throughout.

Kidney stones

Kidney stones are another reason for referral, particularly for people who have had more than one stone or whose stones are considered high risk. The nephrology assessment is a metabolic evaluation: identifying the factors that contribute to stone formation, and then using diet, medication and lifestyle changes to reduce the chance of more stones. The guide to preventing kidney stones covers this in more detail.

Electrolyte disorders

The kidneys control the level of several salts in the blood. Your GP may refer you if a blood test shows a persistent or complex abnormality in sodium, potassium, calcium, phosphate or magnesium, particularly where the usual treatment has not worked. These are grouped together as electrolyte disorders.

High blood pressure that is hard to control

Blood pressure that is hard to control is a common reason for a kidney referral. When blood pressure stays high despite several medications, or when there is a suspicion that something specific is driving it (known as secondary hypertension), the assessment looks for an underlying kidney or hormonal cause and aims to get the medication right. The pages on hypertension and resistant hypertension go through this in more depth.

Diabetic kidney disease

People with diabetes can develop kidney involvement over time. If your GP sees signs of this, a referral for diabetic kidney disease aims to slow progression, improve control of blood sugar and related factors, and reduce the risk of kidney and cardiovascular complications.

Does a referral mean something is seriously wrong?

Being referred does not necessarily mean something serious is wrong. The purpose of a referral is to find out, and to have a clear plan either way. If you are worried about a result, the first step is always to talk to your GP.

If you feel acutely unwell at any point, contact your GP urgently or attend your nearest emergency department rather than waiting for an outpatient appointment.

How GP referral to a nephrologist works

All appointments with me are by GP referral. I do not accept self-referrals, so if you think you may need to see a kidney specialist, please speak to your GP first. Your GP holds your medical history and your recent results, and a referral letter that includes them means I can prepare properly and avoid repeating tests you have already had.

Your GP can refer you by phone, by Healthmail or by email. The two direct routes for GPs are:

• Phone: the direct referral line on 01 206 4209. The team will direct the referral to the most suitable clinic location and arrange the earliest available appointment.
• Healthmail: a secure referral to rory.mcquillan@healthmail.ie, including relevant clinical notes and investigations.

Full details for GPs, including the conditions I see, are on the For Referring GPs page.

What happens after your GP refers you

You do not need to chase the appointment yourself.

1. The clinic team at your chosen location receives the referral.
2. If more information is needed, the clinic may contact your GP first.
3. The clinic team contacts you to arrange an appointment and offers you the earliest suitable slot.

If you need to cancel or reschedule, please give at least 24 hours’ notice by calling the practice office so the appointment can be offered to another patient.

Health insurance and fees

• If you have private health insurance, check that your plan covers outpatient consultations with a consultant nephrologist or physician.
• Some policies need pre-authorisation.
• Patients without health insurance are welcome and are charged standard consultation fees. The practice can give you fee information.

What to bring to your appointment

A little preparation makes the first consultation much more useful. Please bring:

• a list of your current medications, including prescribed medicines, over-the-counter medicines and supplements, with doses if you have them
• copies of any recent blood test results or other investigations, which can help avoid unnecessary repeat testing
• your health insurance details, so the practice team can process your consultation correctly
• any relevant medical records, such as hospital letters, clinic correspondence or investigation reports related to your condition.

Photo identification is required for medical negligence and medico-legal appointments. The patient information page has the full checklist.

What happens at your first appointment

At the appointment I will:

• go through your referral and your medical history in detail
• ask about your symptoms and any concerns you have
• carry out a focused physical examination, where appropriate
• explain what I think is going on and what the options are
• arrange any further tests that are needed, such as blood tests or scans
• agree a management plan with you that suits your circumstances, which may be treatment, monitoring, or both.

After the appointment I send a written report to your GP setting out my findings and recommendations, so your GP remains fully involved in your care.

Where I see patients in Dublin

If you are looking for a private nephrologist in Dublin, I see private patients at five hospitals across the city, so you can choose the location most convenient for you:

• Blackrock Clinic, on Rock Road in south County Dublin
• The Beacon Hospital, in Sandyford, south Dublin
• Bon Secours Hospital Dublin, in Glasnevin, north Dublin
• Hermitage Medical Centre, in Lucan, west Dublin
• St Vincent’s Private Hospital, on the Elm Park campus alongside St Vincent’s University Hospital.

For acute medical patients who need in-patient care, I am also available for direct admission at St Vincent’s Private Hospital, subject to clinical appropriateness and bed availability. The locations page has details for each hospital.

Next steps

If you have had an abnormal kidney blood test, blood or protein in your urine, kidney stones, a salt imbalance or blood pressure that is hard to control, it is reasonable to ask your GP whether a referral to a nephrologist would help. Your GP can refer you by phone, Healthmail or email, and the clinic will then contact you directly to arrange your appointment at whichever of the five Dublin hospitals suits you best.