Nephrology emergencies

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1. Adult Nephrology
1. Chronic kidney disease
2. Electrolyte disorders
3. Hereditary kidney disease
4. Hypertension
5. Kidney transplant donor
6. Kidney transplant recipient
7. Recurrent kidney stones or urinary tract infections
2. ​Paediatric Nephrology
1. Congenital and other structural anomalies of the kidney and urinary tract
2. Elevated serum creatinine or urea
3. Haematuria or glomerular disease
4. Hypertension
5. Proteinuria or nephrotic syndrome

Adult patients (aged 16 years or over) ​

Chronic kidney disease

• Acute kidney injury (AKI) as indicated by any of the following features:
• Known or presumed to have occurred within the prior 7 days
• Rapidly declining eGFR
• Rapidly rising creatinine, oliguria or anuria over 24 hours
• Signs of acute glomerulonephritis (i.e. proteinuria and/or haematuria)
• Urine volume < 0.5 mL/Kg/h for 6 hours
• Nephrotic syndrome (i.e. proteinuria > 2 g over 24 hours or urine albumin to creatinine ratio > 200 mg/mmol) or lower with any of the following features to suggest glomerular disease or glomerulonephritis (e.g. IgA nephropathy, ANCA vasculitis, Lupus nephritis):
• Severe hypertension
• Significant peripheral oedema
• Signs of pulmonary oedema
• Signs of deep vein thrombosis (DVT) or pulmonary embolism (PE)
• Signs of infection or acute kidney injury
• Receiving dialysis with severe intercurrent illness (e.g. suspected peritonitis, acute infection)
• Renal transplant recipient with fever or intercurrent illness
• Severe electrolyte disorders (e.g. hyperkalaemia > 6.5 mmol/L, hypokalaemia < 2.5 mmol/L)
• Severe hypertension (i.e. blood pressure > 180/110 mmHg) associated with any of the following features:
• Acute kidney injury (AKI)
• Blurred vision
• Confusion
• Headache
• Proteinuria or albuminuria
• Retinal haemorrhage
• Reduced level of consciousness
• Seizures
• Signs of heart failure or chest pain
• Severe metabolic acidosis
• Stage 5 chronic kidney disease (CKD) eGFR < 15 mL/min/1.73m2 with signs or symptoms of uraemia or fluid overload needing urgent dialysis
• Suspected, severe pyelonephritis or urosepsis 

Electrolyte disorders

• Any electrolyte abnormality with any of the following features:
• Acute kidney injury
• Arrhythmia
• Rapidly changing levels
• Seizures
• Syncope
• Corrected serum calcium > 3.0 mmol/L with symptomatic hypercalcaemia (e.g. nausea and vomiting or volume depletion, alteration in mental status, or acute kidney injury)
• Corrected serum calcium > 3.5 mmol/L
• Corrected serum calcium < 1.9 mmol/L with symptomatic hypocalcaemia (e.g. seizures or tetany)
• Magnesium < 0.4 mmol/L with symptoms (e.g. neuromuscular irritability such as carpopedal spasm, seizure, and tremor, cardiovascular abnormalities such as arrythmias and vasoconstriction, and metabolic disorders such as insulin resistance and chondrocalcinosis)
• Potassium ≥ 6.5 mmol/L or < 2.5 mmol/L
• Sodium < 120 mmol/L or ≥ 160 mmol/L with or without acute symptomatic hyponatraemia (i.e. confusion, seizures)

Hereditary kidney disease

• Evidence of acute urinary obstruction (i.e. cystic disease and any of the clinical indications in the chronic kidney disease emergency statewide referral criteria)
• Heavy macroscopic haematuria (e.g. from cyst rupture); usually managed by urology
• Hypertensive emergencies, see Hypertension emergency statewide referral criteria
• Rapidly progressive kidney disease uremic symptoms (e.g. encephalopathy, pericarditis, pleuritis)
• Refractory electrolyte disturbances (e.g. hyperkalaemia, acidosis)
• Severe acute kidney injury
• Severe or refractory cyst pain with or without infectious symptoms

Hypertension

• Severe hypertension (i.e. blood pressure > 180/110 mmHg) with any of the following features:
• Acute kidney injury
• Blurred vision
• Confusion
• Headache
• Proteinuria or albuminuria
• Reduced level of consciousness
• Retinal haemorrhage
• Seizures
• Signs of heart failure or chest pain

Kidney transplant donor

Nil emergency criteria

Kidney transplant recipient

Kidney transplant recipient with fever or chronic kidney disease emergency statewide referral criteria

Recurrent kidney stones or urinary tract infections

Acute kidney stones (e.g. infection, obstruction) - Note: referral to urology is indicated

Paediatric patients (aged 0 to 15 years)

Congenital and other structural anomalies of the kidney and urinary tract

• Acute kidney injury in association with congenital anomalies of the kidney and urinary tract (CAKUT) 
• Febrile urinary tract infections with underlying CAKUT 
• Obstructed stone in association with CAKUT 
  Note: referral to paediatric urology is strongly indicated
• Poor urinary stream or suspected lower urinary tract obstruction in a neonate 
  Note: referral to paediatric urology is strongly indicated

Elevated serum creatinine

• Serum creatinine > 2 times above normal range for age and any one of the following features: 
• Elevated creatine kinase 
• Hypertension (i.e. blood pressure > 95^th centile for age and height)
  Note: refer to the American Academy of Pediatrics 2017 guideline
• Low urine output
• Serum potassium above normal range 
• Significant peripheral oedema (e.g. scrotal oedema, ascites, pleural effusions)
• Signs of pulmonary oedema 
• Systemically unwell 

Haematuria or glomerular disease

• Suspected glomerular disease (i.e. haematuria and proteinuria) with any of the following features: 
• Hypertension (i.e. blood pressure > 95^th centile for age and height)
  Note: refer to the American Academy of Pediatrics 2017 guideline
• Pre-existing conditions (e.g. lupus, other autoimmune conditions)
• Serum creatinine above normal age-related range 
• Where the patient is systemically unwell
  (e.g. rash, joint swelling and/or pain, breathlessness, haemoptysis, oedema or neurological impairment)

Hypertension

• Hypertension (i.e. blood pressure > 95^th centile for age and height) with any of the following features: 
• Absence of femoral pulses 
• Acute kidney injury 
• Blurred vision 
• Chest pain 
• Headache 
• Proteinuria > 2+ on urinalysis 
• Reduced level of consciousness or altered mentation
• Retinal haemorrhage or papilloedema 
• Seizures 
• Signs of heart failure

Note: refer to the American Academy of Pediatrics 2017 guideline

Proteinuria or nephrotic syndrome

• Proteinuria with any of the following features:
• Acute abdominal pain with tenderness and guarding (i.e. peritonitis)
• Elevated serum creatinine 
• Hypertension (i.e. blood pressure > 95^th centile for age and height)
  Note: refer to the American Academy of Pediatrics 2017 guideline
• Macroscopic haematuria 
• Significant peripheral oedema (e.g. scrotal oedema, ascites, pleural effusions)
• Signs of pulmonary oedema 
• Signs of venous thromboembolism 
• Systemic infection
• Systemically unwell