Quality statement 5: Discussion with a nephrologist

Quality statement

People with acute kidney injury have the management of their condition discussed with a nephrologist as soon as possible, and within 24 hours of detection, if they are at risk of intrinsic renal disease or have stage 3 acute kidney injury or a renal transplant.

Rationale

Input from nephrologists to the management of acute kidney injury is needed as soon as possible for people who are at risk of their condition worsening or of adverse outcomes. This helps to ensure that people get the specialist care they need to help their condition improve and to prevent it from deteriorating further.

Quality measures

Structure

Evidence of local arrangements to ensure that people with acute kidney injury who are at risk of intrinsic renal disease or have stage 3 acute kidney injury or a renal transplant have the management of their condition discussed with a nephrologist as soon as possible and within 24 hours of detection.

Data source: Local data collection.

Process

Proportion of presentations of people with acute kidney injury who are at risk of intrinsic renal disease or have stage 3 acute kidney injury or a renal transplant where management is discussed with a nephrologist within 24 hours of detection.

Numerator – the number in the denominator where management is discussed with a nephrologist within 24 hours of detection of acute kidney injury.

Denominator – the number of presentations of people with acute kidney injury who are at risk of intrinsic renal disease or have stage 3 acute kidney injury or a renal transplant.

Data source: Local data collection. Acute kidney injury (NICE guideline CG169) clinical audit tool adults, standard 9 and clinical audit tool children, standard 5.

Outcomes

a) Mortality from acute kidney injury.

Data source: Mortality statistics from the Office for National Statistics.

b) Progression of acute kidney injury.

Data source: Local data collection.

What the quality statement means for service providers, healthcare professionals, and commissioners

Service providers (district general hospitals) ensure that the management of acute kidney injury for people who are at risk of intrinsic renal disease or have stage 3 acute kidney injury or a renal transplant is discussed with a nephrologist or paediatric nephrologist as soon as possible, and within 24 hours of detection.

Healthcare professionals discussthe management of acute kidney injury for people who are at risk of intrinsic renal disease or have stage 3 acute kidney injury or a renal transplant with a nephrologist or paediatric nephrologist as soon as possible, and within 24 hours of detection.

Commissioners (clinical commissioning groups) ensure that secondary care providers have protocols in place so that the management of acute kidney injury for people who are at risk of intrinsic renal disease or have stage 3 acute kidney injury or a renal transplant is discussed with a nephrologist or paediatric nephrologist as soon as possible, and within 24 hours of detection.

What the quality statement means for patients, service users and carers

People with acute kidney injury who are at risk of kidney disease or have stage 3 acute kidney injury or a kidney transplant have their condition discussed with a specialist as soon as possible (within 24 hours at most), so that they get the right treatment.

Source guidance

Definitions of terms used in this quality statement

People with acute kidney injury

Acute kidney injury is detected in line with the (p)RIFLE[4], AKIN[5] or KDIGO[6] definitions, by using any of the following criteria:

  • a rise in serum creatinine of 26 micromol/litre or greater within 48 hours

  • a 50% or greater rise in serum creatinine known or presumed to have occurred within the past 7 days

  • a fall in urine output to less than 0.5 ml/kg/hour for more than 6 hours in adults and more than 8 hours in children and young people

  • a 25% or greater fall in estimated glomerular filtration rate (eGFR) in children and young people within the past 7 days.

[NICE guideline CG169, recommendation 1.3.1]

A national algorithm that standardises the definition of acute kidney injury has been agreed and endorsed by NHS England.

People with acute kidney injury who are at risk of intrinsic renal disease

People with acute kidney injury are at risk of intrinsic renal disease when one or more of the following is present:

  • a possible diagnosis that may need specialist treatment (for example, vasculitis, glomerulonephritis, tubulointerstitial nephritis or myeloma)

  • acute kidney injury with no clear cause

  • inadequate response to treatment

  • complications associated with acute kidney injury

  • chronic kidney disease stage 4 or 5.

[NICE guideline CG169, recommendation 1.5.15]

People who have stage 3 acute kidney injury

Stage 3 acute kidney injury is defined in the (p)RIFLE[4], AKIN[5] or KDIGO[6] definitions as:

  • eGFR decrease by 75% or greater

  • or 200% or greater rise in creatinine from baseline within 7 days[7]

  • or rise in creatinine to 354 micromol/litre or greater with an acute rise of 44 micromol/litre or greater

  • or rise in creatinine to 354 micromol/litre or greater with an acute rise of 26 micromol/litre or greater within 48 hours or 50% or greater within 7 days

  • or (pRIFLE only) eGFR less than 35 ml/min/1.73 m2

  • or any requirement for renal replacement therapy.

[NICE guideline CG169, full guideline, table 36]



[4] Risk, injury, failure, loss, end stage renal disease, (p) refers to the paediatric classification.

[5] Acute Kidney Injury Network.

[6] Kidney disease: improving global outcomes.

[7] Where the rise is known (based on a prior blood test) or presumed (based on the patient history) to have occurred within 7 days.