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

Guideline-aligned answer with reasoning, red flags and references. Clinically reviewed by Dr Kola Tytler MBBS CertHE MBA MRCGP.

Posted: 17 August 2025 Guideline-Aligned (High Confidence) Clinically Reviewed
Dr Kola Tytler MBBS CertHE MBA MRCGPClinical Lead • iatroX

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 ,.

  • Urgent Hospital Admission or Same-Day Referral is required if a patient has:
    • Likely stage 3 AKI ,.
    • 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) ,.
    • Evidence of hypovolaemia and a need for intravenous fluid replacement and monitoring ,.
    • A deterioration in clinical condition or a need for observation or monitoring that is impractical in primary care ,.
    • No identifiable cause for AKI ,.
    • An underlying cause requiring urgent hospital management, such as suspected urinary tract obstruction ,.
    • Sepsis ,.
  • 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) ,.
    • There is an inadequate response to treatment in primary care ,.
    • There is a history of renal transplant ,.
    • A possible diagnosis that may need specialist treatment, such as glomerulonephritis, is suspected ,.
  • Immediate Referral for Renal Replacement Therapy (RRT) is indicated if the patient has:
    • Hyperkalaemia not responding to medical management .
    • Metabolic acidosis not responding to medical management .
    • Symptoms or complications of uraemia (for example, pericarditis or encephalopathy) not responding to medical management .
    • Fluid overload or pulmonary oedema not responding to medical management .

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

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