When should I refer a patient to a nephrologist for consideration of renal replacement therapy?

Refer a patient to a nephrologist for consideration of renal replacement therapy (RRT) when:

• They have chronic kidney disease (CKD) with a 5-year risk of needing RRT as assessed by tools like the 4-variable Kidney Failure Risk Equation, to allow timely preparation and shared decision-making ¹.
• They have stage 4 or 5 CKD, or an estimated glomerular filtration rate (eGFR) around 5 to 7 ml/min/1.73 m², especially if symptoms of uraemia, uncontrollable fluid overload, or biochemical abnormalities are present ¹,³.
• They have acute kidney injury (AKI) with indications for RRT such as hyperkalaemia, metabolic acidosis, uraemic symptoms or complications (e.g., pericarditis, encephalopathy), fluid overload, or pulmonary oedema that are not responding to medical management ².
• They have stage 3 AKI or CKD stage 4 or 5, or an unclear cause of AKI, or inadequate response to treatment, or complications associated with AKI ².
• They require urgent discussion for RRT initiation, including those with significant comorbidities where the benefit of RRT needs multidisciplinary evaluation ².
• Assessment for RRT or conservative management should start at least 1 year before therapy is likely to be needed to allow clinical and psychosocial preparation and shared decision-making ³.

In summary, referral should be made early enough to allow patient education, preparation (such as vascular access or peritoneal catheter placement), and shared decision-making about treatment options and timing.