Quality statement 6: Referral for renal replacement therapy

Quality statement

People with acute kidney injury who meet the criteria for renal replacement therapy are referred immediately to a nephrologist or critical care specialist.

Rationale

It is important to ensure that people with acute kidney injury who need treatment receive it in the right care setting (such as an intensive care unit or renal unit) at the right time, and that delays in treatment that put people at risk are avoided. This can be achieved through immediate referral supported by effective referral and transfer protocols that prioritise people with the greatest need. Prompt treatment offers potential benefits that include preventing further deterioration of renal function, improving chances of renal recovery, shorter hospital stays, lower mortality and better long‑term outcomes.

Quality measures

Structure

Evidence of local arrangements to ensure that people with acute kidney injury who meet the criteria for renal replacement therapy are referred immediately to a nephrologist or critical care specialist and transferred according to local protocols.

Data source: Local data collection.

Process

Proportion of people with acute kidney injury who meet the criteria for renal replacement therapy who are referred immediately to a nephrologist or critical care specialist.

Numerator – the number in the denominator who are referred immediately to a nephrologist or critical care specialist.

Denominator – the number of people with acute kidney injury who meet the criteria for renal replacement therapy.

Data source: Local data collection.

Outcomes

a) Duration of renal replacement therapy for acute kidney injury.

Data source: Local data collection.

b) Mortality from acute kidney injury.

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

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

Service providers (district general hospitals and specialised renal centres) ensure that clear referral pathways and transfer protocols are in place for the immediate referral of people with acute kidney injury who meet the criteria for renal replacement therapy to a nephrologist or critical care specialist.

Healthcare professionals immediately refer people with acute kidney injury who meet the criteria for renal replacement therapy to a nephrologist or critical care specialist and transfer them according to local protocols.

Commissioners (clinical commissioning groups and NHS England) ensure that secondary care providers have clear referral pathways and transfer protocols in place for the immediate referral of people with acute kidney injury who meet the criteria for renal replacement therapy to a nephrologist or critical care specialist. Commissioners should work with NHS England when necessary to ensure that there is enough capacity within specialist nephrology teams for referrals.

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

People with acute kidney injury who need renal replacement therapy (such as dialysis) are referred immediately to specialist services so that delays in having the treatment are avoided.

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[8], AKIN[9] or KDIGO[10] 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.

Immediate referral

Immediate referral by healthcare professionals is needed to ensure timely initiation of therapy. Effective and timely referral should be made using locally developed referral and transfer protocols. These protocols should be based on local physiological early warning scores, which include urine output and parameters from the National Early Warning Score (NEWS), to ensure that people who meet the criteria for renal replacement therapy are seen by a suitable specialist and that there is appropriate triage of people with acute kidney injury, including those arriving from other hospitals. [Adapted from The Renal Association Acute kidney injury guideline 5.3 with expert opinion]

Criteria for renal replacement therapy

If any of the following are not responding to medical management:

  • hyperkalaemia

  • metabolic acidosis

  • symptoms or complications of uraemia (for example, pericarditis or encephalopathy)

  • fluid overload

  • pulmonary oedema.

[NICE guideline CG169, recommendation 1.5.8]



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

[9] Acute Kidney Injury Network.

[10] Kidney disease: improving global outcomes.