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2 Specialties Renal medicineLocal and regional servicesClinical networksThe level of renal service provision in different hospitalsvaries considerably. Some district general hospitals(DGHs) do not have a consultant renal physician.Others have a renal physician on a sessional basis,perhaps providing support for a satellite haemodialysisunit and outpatient clinic work, with 24-hour cover forrenal problems provided by the nearest renal unit. Agrowing number of DGHs have renal units that havesufficient consultant renal physicians to provide both24-hour specialist cover for renal medicine and on-callcover for general internal medicine (GIM), but requireaccess to a tertiary centre for renal transplantation.Continuous RRT (by haemofiltration or haemodiafiltration)for the urgent management of AKI can beperformed in many intensive care units (ICUs); patientswho require continuous RRT may need to betransferred to a renal unit if RRT is still needed whenintensive care is no longer required. Delay in transfer isassociated with poorer outcomes and there is increasingdemand for formal agreements between hospitals in aclinical network to ensure timely and safe transfer ofpatients with AKI.3 Working with patients: patient-centredcareWhat you do with patientsInvolving patients in decisions about theirtreatmentThe diagnosis of progressive CKD will be a majorlife-changing event. The needs of patients and theirfamilies and carers should be assessed on a regular basisto ensure that appropriate support is provided so thatthey can be involved in decisions about treatment. Theconsultant renal physician is central to ensuring thatoptimum support is provided by the multiprofessionalteam and that patients have access to the knowledge andexpertise that they require. Many decisions facingpatients with kidney disease are ‘preference sensitive’ –the choice depends not just on clinical outcomes butalso on the patient’s values and preferences. Elicitingthese, and ensuring that the patient ‘shares’ thedecision, rather than passively accepting a decisionmade by the healthcare team, requires specificconsultation skills. This is particularly important whenconsidering RRT for patients with end-stage kidneyfailure. Older patients with significant comorbidityother than CKD derive minimal or no survival benefitfrom dialysis: for such patients, the decision whether tostart dialysis is analogous to deciding whether to havechemotherapy to extend life in incurable cancer.Renal units provide information to patients and theircarers through direct discussions with members of themultiprofessional team – individually or in groupsessions – and through written and audiovisualmaterials. Patient decision aids are used as part of the‘shared decision-making approach’ and can be paper orweb based. Patients who feel ‘in control’ of their illnessdo better than those who feel that their illness controlsthem, so investment of effort to ‘empower’ patients payslarge dividends. Most UK renal units offer patientsaccess to their own test results and clinic letters usingRenal Patient View 5 – an award-winning, web-basedaccess system that so far is unique to renal medicine.Patients should be offered opportunities for self-carewhenever possible. Peritoneal dialysis and homehaemodialysis offer greater opportunities forindependence and self-determination, but decisionsabout treatment must take into account the impact oncarers and the patient’s home and family life.Patient choice: cultural considerationsPatients need time and expert advice to help them dealwith diverse choices, which may include opting forhome-based dialysis treatment, hospital-based dialysisor pre-emptive living donor transplant or, for some,choosing not to receive dialysis or a transplant whenkidney failure supervenes and instead opting forconservative care. Such discussions can be complex andtime-consuming. The need to provide information in arange of languages appropriate to the local populationandtotakeaccountofreligiousneeds–egwhenconsidering dietary advice – is widely recognised.Patient support groupsMany renal units have active kidney disease associationsthat provide local information and support. Thecontrolling council of the National Kidney Federation(NKF, www.kidney.org.uk) brings together 63 kidneypatients’ associations. The NKF campaigns forimprovements to renal provision and treatment, andprovides support and information for patients throughits website, information leaflets on kidney disease andthe National Kidney Patients’ Helpline. The BritishKidney Patient Association (www.britishkidney-pa.co.uk) provides support, information and grant aidboth to individuals and to renal centres, as well assupporting research that is likely to be of direct benefitC○ Royal College of Physicians 2013 215
Consultant physicians working with patientsto patients. There is an active discussion forum onwww.kidneypatientguide.org.uk. Kidney Research UKalso provides valuable patient information(www.kidneyresearch.uk.org).interventional skills for the provision and maintenanceof vascular access. Recommendations for theorganisation of services for vascular and peritonealaccess have recently been published. 6,74 Interspecialty and interdisciplinary liaisonMultidisciplinary team workingDuring the course of their illness, patients with kidneydisease encounter numerous healthcare professionals,who each contribute to their management and care.Patients’ varied needs may form the focus, at differenttimes, for a wide range of healthcare professionals withexpertise in kidney disease: renal physicians nurses and healthcare support assistants dietitians social workers clinical psychologists counsellors clinical technologists pharmacists occupational therapists and physiotherapists renal transplant and vascular surgeons transplant coordinators staff of the histocompatibility and immunogeneticsservice.Extended roles for clinicians other than doctors havelong been established practice in renal units – eg in theday-to-day care in haemodialysis units. Othercompetence-based extended roles – eg prescribing,nurse-led clinics and placement of vascular accesscatheters – are increasingly being developed.Renal unit managers and clerical and administrativestaff also have a key role in supporting patient care.The renal multiprofessional team that delivershealthcare to kidney patients is represented by a numberof professional bodies, which are coordinated throughthe British Renal Society (BRS, www.britishrenal.org).Access to the circulation or peritoneum forhaemodialysis and peritoneal dialysis, respectively, isessential for provision of dialysis. Access for dialysis isbest provided by a multiprofessional team whichincludes vascular and transplant surgeons, who areresponsible for the creation of access, renal physicians,renal nurses, and radiologists with vascular imaging andWorking with other specialistsRenal physicians often provide support for patients whodevelop kidney problems in other units and hospitals,particularly in ICUs, cardiothoracic units, liver unitsand vascular units, where AKI is common. Renalphysicians play a key educational role in settings inwhich improved clinical practice can reduce the risk ofAKI, and a recent National Confidential Enquiry intoPatient Outcome and Death (NCEPOD) reportemphasised the need for improvements. 8 Diabetes,microvascular and macrovascular disease, andimmune-mediated kidney diseases are the mostcommon causes of CKD, and renal physicians need towork closely with diabetologists and immunologists.Renal physicians also work closely with urologists,especially in the management of obstructive renaldisease. The multisystem consequences of kidneydisease – eg the increased risk of cardiovascular diseaseand metabolic bone disease – mean that patients withkidney failure require the support of many otherspecialists. The increasing number of elderly patients ondialysis programmes often requires the skills ofrehabilitation teams, and end-of-life issues requirepartnership with local palliative care services. Closeworking with renal transplant surgeons is essential fordelivery of a renal transplant service. Renal pathologistsprovide essential diagnostic input into renal andtransplant services.Working with non-consultant medicalpractitionersNon-consultant career grade (NCCG) practitioners playa key role in the provision of care in many renal units,especially for patients on maintenance haemodialysis.There are probably around 50 NCCGs working in UKrenal units, of whom two thirds are associate specialists.Many of these individuals are highly experienced.Provision of adequate training and study leaveopportunities for these doctors is currentlyunsatisfactory. New opportunities are offered throughArticle14oftheordergoverningthePostgraduateMedical Education and Training Board (PMETB),which describes how to secure a certificate of eligibilityfor specialist registration (CESR). By this means, anumber of NCCG doctors are being placed on thespecialist register.216 C○ Royal College of Physicians 2013
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