Page 147 - Registrar Orientation Manual 2016

Reference:
1257
Effective date:
7 July 2015
Expiry date:
6 July 2018
Page:
30 of 35
Title:
Imaging Guidelines
Type:
Clinical Guideline
Version:
02
Authorising initials:
Renal Artery Stenosis
Consider investigation only if:
• progressive CKD of uncertain aetiology in a high risk patient
• flash pulmonary oedema
• acute on chronic renal failure in a high risk patient after ACEI/ARB therapy is started
• a patient with features indicating possible fibromuscular hyperplasia (young women with bruits)
• resistant hypertension (poor BP control on 3+ agents in max doses, including a diuretic)
• accelerated hypertension
Duplex scanning is now our first line investigation, not MRA. MRA may still be required in selected cases. Requests for duplex scans are triaged by the Renal Service. Any request not meeting the above criteria will be returned to the requestor. The Renal Service will also triage MRA referrals.
The ‘Choosing Wisely’ recommendations include:
Don’t screen for renal artery stenosis in patients without resistant hypertension and with normal renal function, even if known atherosclerosis is present.
Clinical Urgency: Scans will be performed as outpatients.
Renal Disease
The new National Community Radiology Access Criteria have the following indications for referral for abdominal ultrasound in renal or kidney disease:
• eGFR is consistently reduced for age after repeat testing with the patient well hydrated: o <70yearseGFRisreducedto<45mls/min
o >70yearseGFRisreducedto<30mls/min
• Painless macroscopic haematuria or persistent microscopic haematuria on two or more
uncontaminated (epithelial cell count <15 x 106/L) mid-stream urinalyses (MSU) (not dipstix)
• Polycystic kidneys screening when >20 years age and a positive family history.
• Recurrent urinary tract infections (UTI). Only women with one or more of these risk factors for an identifiable underlying cause require imaging investigation:
o repeated (>2) pyelonephritis (fever, chills, vomiting, costo-vertebral angle tenderness) o persistence of infection on urinalysis after completion of a prolonged 3 week course of
appropriate antibiotics (i.e. laboratory confirmed sensitivity)
o gross haematuria or persistent microscopic haematuria (>15x106) on two separate
specimens) after resolution of infection
o recurrence of infection after 3 months of completed antibiotic prophylaxis o urea-splitting organisms e.g. proteus, klebsiella, pseudomonas
o history of abdomino-pelvic malignancy or immunocompromised
o history of urinary tract surgery or calculi
o obstructive symptoms with straining and weak stream
• Recurrent or persistent UTI in males.
• Suspected renal colic in pregnancy. For all other patients consider referral for CT KUB.
• Suspected urinary retention with palpable/suspected enlarged bladder.