Quality standard
Quality statement 5: Referral for renal replacement therapy
Quality statement 5: Referral for renal replacement therapy
Quality statement
Children, young people and adults with acute kidney injury who meet the criteria for renal replacement therapy are referred immediately to a nephrologist or, if appropriate, a critical care specialist. [2014, updated 2023]
Rationale
It is important that people with acute kidney injury who need and wish to have renal replacement therapy, receive it in the right care setting, at the right time and that delays are avoided. This can be achieved by immediate referral to a nephrologist, or to a critical care specialist if intensive care is needed. Having effective referral and transfer protocols that prioritise people with the greatest need will help ensure that people receive timely treatment. Prompt access to renal replacement therapy offers potential benefits, including shorter hospital stays, reduced mortality and improved long-term outcomes.
Quality measures
The following measures can be used to assess the quality of care or service provision specified in the statement. They are examples of how the statement can be measured, and can be adapted and used flexibly.
Structure
Evidence that there is an agreed inter-hospital transfer standard in place to avoid delays in the transfer of people with acute kidney injury from referring hospitals to renal centres (where required).
Data source: Data can be collected from information recorded locally, such as a written transfer protocol.
Process
Proportion of children, young people and adults 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 children, young people and adults with acute kidney injury who meet the criteria for renal replacement therapy.
Data source: Data can be collected from information recorded locally by healthcare professionals and provider organisations, for example from patient records. Local areas may wish to add an exclusion for people who are in their last days of life.
Outcome
a) Time from referral of children, young people and adults with acute kidney injury who meet the criteria for renal replacement therapy to be seen by a nephrologist or critical care specialist.
Data source: Data can be collected from information recorded locally by healthcare professionals and provider organisations, for example from patient records.
b) 30-day mortality associated with acute kidney injury.
Data source: Mortality statistics from the Office for National Statistics.
What the quality statement means for different audiences
Service providers (such as district general hospitals and specialised renal centres) ensure that clear referral pathways and transfer protocols are in place for the immediate referral of children, young people and adults with acute kidney injury who meet the criteria for renal replacement therapy to a nephrologist or, if appropriate, a critical care specialist.
Healthcare professionals (such as doctors) immediately refer children, young people and adults with acute kidney injury who meet the criteria for renal replacement therapy to a nephrologist or, if appropriate, a critical care specialist, and transfer them according to local protocols. Before referral, they discuss and agree with the person, and their family and carers if appropriate, that renal replacement therapy is a suitable treatment for them.
Commissioners (integrated care boards and NHS England) ensure that secondary care providers have clear referral pathways and transfer protocols in place for the immediate referral of children, young people and adults 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.
Children, young people and adults with acute kidney injury who need renal replacement therapy (such as dialysis) discuss if it is suitable for them with their healthcare professional. If it is suitable and they wish to have the treatment, they are referred immediately to specialist services to avoid a delay in starting treatment.
Source guidance
Acute kidney injury: prevention, detection and management. NICE guideline NG148 (2019), recommendations 1.5.8 and 1.5.11
Definitions of terms used in this quality statement
Children, young people and adults with acute kidney injury
Acute kidney injury is detected in line with the (p)RIFLE (paediatric classification: risk, injury, failure, loss, end-stage renal disease), AKIN (Acute Kidney Injury Network) or KDIGO (Kidney Disease: Improving Global Outcomes) definitions, by using any of the following criteria:
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a rise in serum creatinine of 26 micromol/litre or greater within 48 hours
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a 50% or greater rise in serum creatinine known or presumed to have occurred within the past 7 days
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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
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a 25% or greater fall in estimated glomerular filtration rate (eGFR) in children and young people within the past 7 days.
[NICE's guideline on acute kidney injury, recommendation 1.3.1]
An NHS England endorsed algorithm for acute kidney injury standardises the definition of acute kidney injury.
Criteria for renal replacement therapy
If any of the following are not responding to medical management:
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hyperkalaemia
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metabolic acidosis
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symptoms or complications of uraemia (for example, pericarditis or encephalopathy)
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fluid overload
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pulmonary oedema.
[NICE's guideline on acute kidney injury, recommendation 1.5.8]
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 the National Early Warning Score (NEWS) 2 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. [Expert opinion]