Background Patients with irreversible chronic kidney disease who require dialysis immediately are a subset of ultra late referrals for whom the term chronic kidney disease presenting acutely might usefully be applied. Although well known to nephrologists and recognised as a specific group with considerable problems, little has been written about them.

Objective To describe the presentation, clinical features and outcome of irreversible chronic kidney disease presenting acutely, with particular reference to nausea and vomiting as presenting symptoms.

Method and results Review of 202 consecutive patients with irreversible chronic kidney disease who had dialysis between 1996 and 2006 showed that 15 (7%) had required dialysis immediately or within 7 days of presentation. Analysis of 14 available case records showed eight avoidable late referrals: previous evidence of renal failure in six, and two patients with diabetes who had not had their renal function checked. Gastrointestinal symptoms were common and led to further delays in diagnosis, with three patients having endoscopy requested before their bloods were checked. Physical and psychological morbidity associated with this form of presentation was high.

Conclusions Chronic kidney disease presenting acutely is not uncommon, often avoidable and associated with adverse outcomes. The identification, follow-up and appropriate referral of patients with raised serum creatinine is likely to reduce its incidence. Nausea and vomiting may occur sufficiently frequently in advanced renal failure to justify measuring renal function before proceeding to endoscopy when patients present with gastrointestinal symptoms.