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

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