What criteria should I use to determine whether a patient with rhabdomyolysis requires referral to secondary care?

Since rhabdomyolysis often leads to acute kidney injury (AKI), the criteria for referring a patient with rhabdomyolysis to secondary care are primarily based on the severity and complications of AKI ¹,².

• Urgent Hospital Admission or Same-Day Referral is required if a patient has:
  • Likely stage 3 AKI ¹,².
  • A suspected complication of AKI requiring urgent hospital management, such as pulmonary oedema, uraemic encephalopathy, pericarditis, or severe hyperkalaemia (serum potassium of 6.5 mmol/L or more) ¹,².
  • Evidence of hypovolaemia and a need for intravenous fluid replacement and monitoring ¹,².
  • A deterioration in clinical condition or a need for observation or monitoring that is impractical in primary care ¹,².
  • No identifiable cause for AKI ¹,².
  • An underlying cause requiring urgent hospital management, such as suspected urinary tract obstruction ¹,².
  • Sepsis ¹,².
• Liaison with a Nephrologist (as soon as possible and within 24 hours of detection) is necessary if:
  • The patient has stage 4 or 5 chronic kidney disease (CKD) ¹,².
  • There is an inadequate response to treatment in primary care ¹,².
  • There is a history of renal transplant ¹,².
  • A possible diagnosis that may need specialist treatment, such as glomerulonephritis, is suspected ¹,².
• Immediate Referral for Renal Replacement Therapy (RRT) is indicated if the patient has:
  • Hyperkalaemia not responding to medical management ³.
  • Metabolic acidosis not responding to medical management ³.
  • Symptoms or complications of uraemia (for example, pericarditis or encephalopathy) not responding to medical management ³.
  • Fluid overload or pulmonary oedema not responding to medical management ³.

The decision to start RRT should be based on the patient's overall condition, not just isolated lab values ³. Referral to a nephrologist, paediatric nephrologist, or critical care specialist should be immediate if RRT criteria are met ³.