Kidney Research UK

Background

Founded in 1961, Kidney Research UK (formerly the National Kidney Research Fund) is the largest funder of research into the prevention, treatment and management of kidney disease. Our mission is to improve the quality of life of those with kidney disorders and to increase public awareness of kidney health.

We support the need for early detection and prevention in tackling the onset of kidney disease. In so doing, the likelihood of established renal failure is reduced, and therefore the need for transplantation or lifelong dialysis treatment. However, there is a significant minority of patients that do develop more advanced kidney disease and for them, it is important that services are designed to manage their condition and to prepare them for renal replacement therapy in the event of kidney failure.

Chronic Kidney Disease

Chronic Kidney Disease (CKD) is a long-term irreversible condition, which is sometimes progressive and irreversible. It implies an abnormality in one or both kidneys, involving a loss of kidney function, which may or may not also include kidney damage.

Kidney damage is caused by disease of the kidney itself e.g. glomerulonephritis or by diseases that effect many organs or systems including the kidney e.g diabetes mellitus. As kidney function starts to deteriorate, the risk of other complications start to increase as well, such as anaemia and renal bone disease.

In these very early stages, it can be almost undetectable; however, in a minority of people it will progress and establish renal failure (ERF), treatment for which is either dialysis or a transplant.

Stages of Chronic Kidney Disease

There are five recognised stages of kidney disease, based on levels of kidney function (GFR). GFR is the rate at which kidneys filter waste products. It is based on an international classification developed by the US National Kidney Foundation.

In stage 1 and 2 there is evidence of kidney damage e.g. protien in the urine but kidney function is normal (stage 1) or shortly reduced (stage 2). In stage 3 kidney function is defiantly abnormal but the consequences if any are mild. In stage 4 kidney function is markedly abnormal and complications are present, but dialysis is not needed. In stage 5 kidney function is so poor that the patient needs renal replacement (dialysis a transplant) or is already receiving it.

Managing patients with Stages 4-5 CKD

It is very important that patients in the early stages of CKD receive timely, appropriate and effective investigation, treatment and follow-up to reduce the risk of progression and complications. However, a number will unfortunately progress to Stages 4 and 5, where they are approaching, or have reached, ERF.

At this point, they should have been referred by their GP to a nephrology clinic, where their condition can be closely managed by a multi-disciplinary renal team, and preparation made for renal replacement therapy (RRT). The progression to Stages 4 and 5 of CKD is often slow enough for a renal team to predict when RRT will be required, and it is generally agreed that the optimum preparation time is one year in advance of this.

However, in around a third of cases, patients present to clinics less than three months before requiring RRT, which can affect their chances of survival and quality of life. It is important, therefore, that there is a clear patient pathway, extending from primary through to secondary care, which sets out how and when patients should be referred to nephrology clinics and the steps that should be taken to ensure they receive the appropriate care as their disease progresses.

We greatly welcomed the publication of the National Service Framework for Renal Services, which aimed to establish a structure for the development of such a pathway. We particularly welcomed its recommendation that patients should have access to appropriate information, individually tailored, that informs them of the choices they have at every stage of the pathway and enables them to work with their doctor to agree a care plan that meets their needs.

It is likely that some patients will already be receiving structured care for other, associated long-term conditions, such as cardiovascular disease and diabetes. This should be factored in to their care plan, along with the steps needed to manage their CKD and prepare them for RRT.

If CKD progresses, other conditions such as anaemia and renal bone disease can develop, which also need to be managed. For example, reducing phosphorus in the diet and taking vitamin D treatment in the early stages of CKD can help to reduce bone disease. In the case of anaemia, we support the recommendations of the National Institute for Health and Clinical Excellence’s clinical guideline on Anaemia Management in Chronic Kidney Disease, published in September.

Specific measures would include treatment for the management of complications associated with CKD progression, such as anaemia and renal bone disease, and of the impact of associated conditions such as hypertension and diabetes through anti-hypertensive and lipid-lowering treatment.

Alongside this, patients should have access to dietary and lifestyle advice, including support to help them stop smoking, improve their diet and increase exercise. Importantly, clinics should also provide access to counselling for patients to help them come to terms with the medical and psycho-social impacts of ERF, as well as what to expect from RRT.

Preparation for dialysis in patients with Stages 4-5 CKD should involve liaison with surgical teams to ensure that they have appropriate and timely vascular access surgery, ideally six months before starting treatment. The placement of peritoneal dialysis catheters should be carefully timed to avoid the need for bridging haemodialysis. Clinics should also ensure patients are tested for Hepatitis and are offered immunisation against Hepatitis B, Influenza and pnemococcus.

Finally, the renal team should discuss with patients their options with regard to transplantation. There can be a benefit to patients receiving a transplant before they commence dialysis. This avoids the need of access to be created.

Patients can be placed on the waiting list for a transplant up to six months before the start of their dialysis. Given that the average waiting time for a suitable organ is around 3 years, and the fact that finding a suitable organ depends on a number of factors, including blood group and genetic type, it is key that patients are given the opportunity to be put on the list as soon as they have been assessed for their suitability.

This assessment would take into account factors such as age, frailty, and general health, as some patients may not be physically up to transplant surgery. During this assessment, patients should also be invited to discuss other potential sources of organ donation, including live donation.

Kidney Research UK

April 2007