Consultant physicians working with patients - Royal College of ...

More documents

Recommendations

Info

2 Specialties Renal medicineRenal medicineDr Charles R V Tomson MA BMBCh FRCP DM Consultant nephrologistDr Philip D Mason BSc PhD MBBS FRCP Consultant nephrologist1 Description of the specialtyRenal medicine, or nephrology, involves the care ofpatients with all forms of kidney disease. Majorcomponents of the service are the management ofpatients with acute kidney injury (AKI; this term hasnow replaced the previous terminology of acute renalfailure) or advanced chronic kidney disease (CKD); thelatter is often used to assess workforce requirements. Inaddition, renal physicians provide care for patients withkidney diseases without impairment of excretory kidneyfunction, including proteinuria and nephroticsyndrome, kidney involvement in multisystem immunediseases such as systemic lupus erythematosus andvasculitis, and inherited and acquired tubular and othermetabolic disorders that affect the kidney. Renalphysicians work closely with urologists to provide carefor patients with haematuria, recurrent infections of theurinary tract, kidney stone disease, urinary tractobstruction and neurogenic bladder, and withobstetricians to manage kidney disorders in pregnancy,rheumatologists to manage systemic vasculitis andcardiologists to manage ‘cardiorenal syndrome’. Thecare of children with kidney disease is coordinated bypaediatric renal physicians, and particular support isrequired for the transition from paediatric to adult renalservices.A growing aspect of the work of renal physicians, inpartnership with primary care and some secondary carespecialties, involves the early detection of kidneyproblems and the prevention and management ofprogressive kidney disease.Who are the patients?It has become apparent in recent years that kidneydisease is more common than previously appreciated,although some controversies remain around thedefinition of CKD and, in particular, the extent to whichreduction in glomerular filtration rate is an inevitableand normal part of the ageing process, rather than beingcaused by avoidable microvascular disease. Kidneydisease is a long-term condition for many patients andcan impact on all aspects of life. The care, support andtreatment of patients with end-stage kidney failure areimportant aspects of renal service provision for adults.A coordinated approach involving a wide range ofhealthcare professionals is required to ensure thatnutritional, lifestyle, social and psychological needs aremet, alongside the management of biochemical andmetabolic disorders. The complexity of this carerequires integrated multiprofessional working toprovide a high-quality service.A sustained increase has been seen in the number ofpatients receiving renal replacement therapy (RRT) inthe UK. At the end of 2010, 50,965 patients werereceiving RRT in the UK, and prevalence per millionpopulation increased from 523 to 832 between 2000 and2010. 1,2 Acceptance rates for patients into RRT are lowerin the UK than in other comparable countries, whichmay be due partly to better prevention of progressivekidney disease in primary and secondary care, but couldalso be due to unmet need. The main growth in RRT inrecent years has been in hospital-based haemodialysis,with a gradual decline in the number of patientsreceiving home-based therapies (peritoneal dialysis andhome haemodialysis); current initiatives to enhancepatient choice and promote home therapies can beexpected to make some impact on this. In parallel,significant increases have been seen in the mean age andcomorbidities of patients accepted to RRT programmes.Rates of kidney transplantation have grown byincreasing use of transplantation from living kidneydonors, including spouses, friends, and altruisticdonors, from donation after circulatory death donors,and from ‘expanded criteria’ donors. Renaltransplantation across ABO blood group barriers oracross human leukocyte antigen (HLA)incompatibilities, traditionally rather uncommon in theUK, is becoming more widespread now that moderntechniques have led to improved results, but requiresadditional up-front funding. Renal physicians workclosely with transplant surgeons in the provision ofrenal transplant services, and are involved in theassessment of potential recipients, the evaluation ofpotential living donors, preoperative and postoperativeC○ Royal College of Physicians 2013 213
Consultant physicians working with patientscare, and the long-term follow-up of patients afterkidney transplantation.2 Organisation of the service and patternsof referralA typical serviceAccess to renal services is required at primary,secondary and tertiary levels at different stages in thejourney of a patient with kidney disease.Sources of referral from primary careThe early detection and prevention of CKD requireclose collaboration of primary care practitioners, renalphysicians and other specialists in secondary care.Awareness that CKD and/or proteinuria is a major riskfactor for vascular disease is increasing. Ascertainmentof kidney disease will undoubtedly be increased bystandardisation of assessment of excretory kidneyfunction using estimated glomerular filtration rate(eGFR) and by more widespread testing foralbuminuria. The eGFR is calculated from serumcreatinine, age, gender and ethnic origin, and is nowroutinely reported (after adjustment for interassaydifferences) by all NHS clinical biochemistrylaboratories whenever a serum creatinine concentrationis reported.Many people with CKD will not develop progressivekidney failure, and the emphasis should be on themanagement of their vascular risk factors in primarycare. An important minority of patients with CKD willprogress towards end-stage kidney failure, however, andlate referral of such patients remains a problem. Thosewith progressive CKD will benefit from specialistreferral for management to delay progression and tomanage the complications of progressive CKD,including anaemia, acidosis and bone disease.Guidelines on the detection, management and referralof patients with CKD in the UK provide clear guidanceon the management of CKD, including indications forreferral to a renal physician. 3 The National Institute forHealth and Care Excellence (NICE) has recentlypublished guidance on this topic(www.nice.org.uk/CG73). 4 Although detection of CKDin primary care is increasing, correct application ofthese guidelines has not resulted in a major sustainedincrease in the rates of outpatient referral to renalmedicine: many patients with stable, uncomplicatedCKD can safely be managed in primary care.Sources of referral from secondary andtertiary careThe provision of care for patients with advanced CKDand end-stage kidney failure is largely based in hospital.Referrals to secondary care arise from GPs and otherspecialists in secondary care, particularly diabetologists,cardiovascular physicians, rheumatologists andurologists.‘Acute kidney injury (AKI)’ is now the preferred termfor an acute change in kidney function, The change interminology is driven by the recognition that the earlystages of AKI are avoidable, primarily by the promptrecognition and treatment of sepsis, hypotension andhypovolaemia, together with the promptdiscontinuation (using ‘sick day rules’) of drugs thatmay impair renal autoregulation in the face of suchinsults – including drugs widely used in themanagement of chronic heart failure, hypertension andCKD (eg angiotensin-converting enzyme (ACE)inhibitors, angiotensin receptor blockers). Mostepisodes of AKI occur in other specialties (eg acutegeneral medicine, cardiology, general surgery), but renalphysicians have an important role to play in ensuringthat appropriate education and clinical systems (egautomated laboratory-based recognition of AKI) are inplace. Patients with later stages of AKI are eithermanaged by nephrologists (providing dialysis) or on anintensive care unit (usually with continuoushaemofiltration). Patients who have had an episode ofAKI are at greater risk of further episodes and ofdeveloping CKD, even if they appear initially to fullyrecover renal function.During the 1960s and 1970s, programmes for RRT inthe UK were provided by a small number of renal unitsbased in tertiary referral centres that covered largecatchment populations. In the 1980s and 1990s, asignificant increase in provision of dialysis was seen,provided to some extent by an increase in satellite unitsbut also by growth in the number of renal units.Currently there are 52 main adult renal units (notincluding satellite units) in England, 9 in Scotland, 5 inWales and 5 in Northern Ireland. There are 207 satellitedialysis units in the UK; 76 of these are operated byprivate companies under contract to the NHS, but, eventhough the nurses in these units are employed privately,medical supervision of the care of patients receivingdialysis in these units is provided by NHS nephrologists.A smaller number of these hospitals have renaltransplant units (RTUs), which also provide surgicaltransplant services: 19 in England, 23 in the UK.214 C○ Royal College of Physicians 2013
Page 1 and 2:
Consultant physiciansworking with p
Page 3 and 4:
The Royal College of PhysiciansThe
Page 5 and 6:
AcknowledgementsWe would like to th
Page 7:
AbbreviationsA&EAACsAMUsARCPCCGsCCS
Page 12 and 13:
1 Physicians in the NHS todaycan be
Page 15 and 16:
Consultant physicians working with
Page 17 and 18:
Page 19 and 20:
Page 22 and 23:
2 The work of the specialties2 The
Page 24 and 25:
2 Specialties Acute internal medici
Page 26 and 27:
Page 28 and 29:
Page 30 and 31:
Page 32:
Page 35 and 36:
Page 37 and 38:
Page 41 and 42:
Page 43 and 44:
Page 45 and 46:
Page 47 and 48:
Page 49 and 50:
Page 51 and 52:
Page 54 and 55:
2 Specialties Cardiovascular medici
Page 56 and 57:
Page 58 and 59:
Page 60 and 61:
Page 62 and 63:
Page 64 and 65:
Page 66 and 67:
2 Specialties Clinical geneticsClin
Page 68 and 69:
2 Specialties Clinical geneticsPati
Page 70 and 71:
2 Specialties Clinical genetics6 Cl
Page 72:
2 Specialties Clinical geneticswork
Page 75 and 76:
Page 77 and 78:
Page 80 and 81:
2 Specialties Clinical pharmacology
Page 82 and 83:
Page 84 and 85:
Page 86 and 87:
Page 88 and 89:
2 Specialties DermatologyDermatolog
Page 90 and 91:
2 Specialties Dermatology run monit
Page 92 and 93:
2 Specialties DermatologyDermatolog
Page 94 and 95:
2 Specialties DermatologyTable 1 Ex
Page 96:
2 Specialties Dermatology4 Parkin D
Page 99 and 100:
Page 101 and 102:
Page 103 and 104:
Page 106 and 107:
2 Specialties Gastroenterology and
Page 108 and 109:
Page 110 and 111:
Page 112 and 113:
Page 114 and 115:
Page 116:
Page 119 and 120:
Page 121 and 122:
Page 123 and 124:
Page 125 and 126:
Page 127 and 128:
Page 129 and 130:
Page 131 and 132:
Page 134 and 135:
2 Specialties HaematologyHaematolog
Page 136 and 137:
2 Specialties HaematologyTable 2 A
Page 138 and 139:
2 Specialties Haematologythey have
Page 140 and 141:
2 Specialties HaematologyTable 4 Sp
Page 142:
2 Specialties Haematology11 Departm
Page 145 and 146:
Page 147 and 148:
Page 149 and 150:
Page 151 and 152:
Page 153 and 154:
Page 155 and 156:
Page 157 and 158:
Page 160 and 161:
2 Specialties Medical oncologyMedic
Page 162 and 163:
2 Specialties Medical oncologyaroun
Page 164 and 165:
2 Specialties Medical oncologyset b
Page 166 and 167:
2 Specialties Medical oncologyTable
Page 168 and 169:
2 Specialties Medical ophthalmology
Page 170 and 171: 2 Specialties Medical ophthalmology
Page 172 and 173: 2 Specialties Medical ophthalmology
Page 174 and 175: 2 Specialties Metabolic medicineMet
Page 176 and 177: 2 Specialties Metabolic medicineof
Page 178: 2 Specialties Metabolic medicinemet
Page 181 and 182: Consultant physicians working with
Page 196 and 197: 2 Specialties Palliative medicinePa
Page 198 and 199: 2 Specialties Palliative medicine-
Page 200 and 201: 2 Specialties Palliative medicineA
Page 202 and 203: 2 Specialties Palliative medicineTa
Page 204: 2 Specialties Palliative medicine24
Page 212 and 213: 2 Specialties Rehabilitation medici
Page 222 and 223: 2 Specialties Renal medicineLocal a
Page 224 and 225: 2 Specialties Renal medicineInvolve
Page 226 and 227: 2 Specialties Renal medicineAcademi
Page 228 and 229: 2 Specialties Renal medicineTable 1
Page 230: 2 Specialties Renal medicinekidney
Page 270 and 271:
3 Supporting the delivery of high-q
Page 272 and 273:
Page 274 and 275:
Page 276 and 277:
Page 278 and 279:
Page 280:
show all

Consultant physicians working with patients - Royal College of ...

Create successful ePaper yourself

Delete template?

Save as template?