eGFRsupport: Renal support : referral criteria to renal unit electronic guideline (685)

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Introduction

The Glasgow Renal and transplant unit is the largest renal unit in Scotland caring for approximately 600 patients receiving dialysis, over 1000 with a functioning renal transplant and serves the west of Scotland acute for renal transplantation. We have 42 general nephrology beds and 8 high acuity bed capable of providing renal and cardiovascular support.

We are happy to discuss all cases with referring clinicians and ask that referrals are placed using the following methods to allow appropriate prioritisation.

Routes of Referral

The Renal On-call Phone

The renal on-call registrar at the Queen Elizabeth Hospital is available on extension 82417 or external - 0141 452 2417. Three options are available by calling the renal on-call phone. By selecting option 1, 2 or 3 you will be connected to a renal pharmacist, secretary or the on-call registrar respectively. Due to the volume of calls received please select your option carefully to limit delays.

 

Option 1 – Renal Pharmacy  For renal specific pharmacy advice
Expert renal pharmacy advice is available via option 1. Advice relating to drug dosing, administration and interactions can be discussed. It is not appropriate to ask our pharmacy team to advise on clinical decisions e.g. whether a drug should be commenced or not. 2.

Option 2 – Renal SecretaryFor non-urgent issues
Renal secretarial staff will pass on non-urgent messages to our medical team for discussion. This option is most appropriate for patients known to the renal team, or for decisions on patient follow-up and is usually discussed with a consultant. A response will usually take 24-48 hours. 3.

Option 3 – Renal Registrar for Urgent Inpatient Referral - Instant access
All emergency cases, or cases which directly affect patient care (i.e. missed dialysis sessions) should be phoned directly to the renal on-call registrar at the Queen Elizabeth Hospital on extension 82417 or external 0141 452 2417.

Staffnet Intranet - For Generic Renal Advice
Generic advice is provided on investigations and initial management of AKI, nephrotic syndrome, care of the dialysis patient and care of the transplant patient within the GGC intranet guideline by searching for ‘eGFRsupport’ and selecting the relevant electronic guideline. We endeavour to expand on the ‘Electronic Guidelines for Renal Support’ with further advice in the future.

Referral examples

Renal Pharmacyrenal specific pharmacy advice

Examples of pharmacy referral include:

  • Drug dose calculation in those with renal dysfunction

  • Advice on drug interactions e.g. transplant medication

  • Antibiotic level monitoring in those on dialysis o Conversion of transplant medication in those nil by mouth

 

Renal Secretarynon-urgent referrals- usually 24-48 hours response

Examples of non-urgent referrals include:

  • Advice on need for/timing of out-patient follow-up

  • New referral on discharge (or simply copy IDL to renal)

  • Non-urgent treatment decisions e.g. changes to antihypertensives

 

Renal Registrar - Urgent Inpatient – immediate response

Examples of urgent inpatient referral include:

  • High suspicion of rapidly progressive glomerulonephritis

  • Indication for dialysis (refractory increase K+ >6.5mmol/L, or urea >30mmol/L and/or Cr >500micromol/L, tumour lysis syndrome, refractory volume overload, refractory acidosis pH <7.1, complications of uraemia, severe poisoning, severe hypothermia) or plasma exchange (pulmonary haemorrhage in a patient with suspected ANCA-associated vasculitis or anti-GBM disease).

  • Stage III AKI

  • Stage II AKI and unresponsive to treatment after 24-48 hours

  • Dialysis patient prior to admission

  • Renal transplant patient

Organising transfer

Emergency Transfer for AKI

Patient transfer is recognised to induce various physiological alterations which may impact on patient safety. Decision regarding appropriateness to transfer remains with the referring clinician

Important considerations in patient transfer are listed in box 1

Transfer considerations

* Hyperkalaemia – ideally <6.5mmol/L prior to transfer
* Risk of hypoglycaemia – from insulin/dextrose
* Oxygen requirement
* Cessation/Reversal of anticoagulants – to allow lines
* Cardiovascular stability
* Paramedic/Nursing escort

Box 1 – Important considerations in transferring patients with AKI

 

  • In patients with multi-organ failure or evidence of significant respiratory failure and AKI - we recommend discussing the case with local critical or intensive care units.

  • In all cases referred to the renal unit where the referring team believe transfer may be require, the referring doctor must ensure the consultant in charge of the patient’s care is aware of the referral.

  • It is the responsibility of the referring team to ensure that patients transferred for management of AKI from an area of specialist care organises ongoing input within the Queen Elizabeth (for example, patients developing AKI following orthopaedic surgery must have a named orthopaedic surgeon to contact on arrival to the Queen Elizabeth).

Last reviewed: 09 March 2022

Next review: 09 March 2025

Author(s): Mark Findlay

Version: Version 3

Approved By: Regional Services Directorate Clinical Governance Board

Document Id: 685