Nephrology in the UK
This page provides an overview of nephrology and renal services in the UK. Specific and often topical information can be found on our pages from the departments of health of England (News from the Tsar), Scotland (News from Scotland), Wales (News from Wales) and Northern Ireland (News from Northern Ireland). See also our News pages. On this page:
- The National Service Framework and policy frameworks
- Key structures and bodies
- Organisation of renal services
- Level of renal replacement therapy
- Historical background
- Further information
Current policies in nephrological planning in England have been shaped by the publication of the National Service Framework for Renal Services.
- Part 1 covered Dialysis and Transplantation
- Part 2 covered Chronic Kidney Disease, Acute Renal Failure and End of Life Care
The Renal Services Information Strategy described the requirements for information systems to support the NSF. The NSF defined aims but few specific targets. A number of pieces of work have generated useful ways of assessing how these aims can be measured and met. Some are linked from the DH pages, other relevant documents are available from the Clinical Service page of this website.
Policy in Wales: in 2007 the Welsh Assembly Government published the document 'Designed to tackle renal disease in Wales: A policy statement and National Service Framework'. Together these will cover the whole spectrum of care for children and adults. Read the Welsh Renal NSF here. Linked to each standard there are key interventions which outline how that standard will be delivered.
Key structures and bodies
There are significant national differences within the UK in the organisation of the NHS.
In England, there is a Renal Policy team within the Department of Health (DH) comprised of Dr Donal O’Donoghue (‘Tsar’), Gerry Lynch, Monica Acheampong and Jane Hall. The Renal, Heart and Stroke team and Diabetes team form the Vascular Branch at the DH. The Children’s, Transplant, and End of Life Teams work in adjacent areas (are leaves on adjacent branches). See also News from the Tsar
In Northern Ireland, a series of local DH reviews have guided the development of renal services. A DH planning group oversees implementation of renal service review recommendations and this group influences regional commissioning policy. Consultant nephrologists, Professor Peter Maxwell and Dr John Harty, serve on the DH implementation group together with patient representatives.
In Scotland healthcare is managed by the Scottish Government Health Department. There is no formal policy document on kidney disease. However a Parliamentary Cross Party Group produced two documents with recommendations in 2004. See also News from Scotland.
In Wales, the Renal NSF programme sits within the Community Primary Care and Health Services Policy Division in the Dept Health and Social Services. The All-Wales Renal Advisory Group oversees the implementation of the NSF and Prof John Williams is the Lead Renal Clinician for Wales. See also News from Wales.
Some other organisations with important roles are mentioned under Joint Activities (menu to the left)
Organisation of renal services in the UK
There are about 75 main or 'hub' renal units in the UK (show map). These are units in which consultant nephrologists are permanently based and which have inpatient beds for renal patients. Hub units in the UK are on average much larger than is the pattern in most other countries. Almost all have several or many associated 'satellite' units, in which routine haemodialysis treatment of patients who live in the community is carried out by or under the supervision of nursing staff. These units are often but not always located on NHS sites that include other services, including District General or other hospital sites, but need not be. The aim is to provide treatments nearer to patients homes and in a lower intensity setting than at main units. Some satellite units are provided and staffed by commercial organisations, while medical care remains under the supervision of consultants from hub units. At present all hub units are staffed and administered by the NHS.
Care of patients on dialysis is carried out by multidisciplinary teams, with medical care supervised by approximately 360 consultant nephrologists, although the number of whole time equivalents (WTEs) is many fewer than this. Many UK nephrologists also undertake general internal medicine, and a proportion have part-time academic or other commitments.
Transplantation is based in about 25 units; this is fewer than some years ago, and it seems likely that further centralisation of transplantion may occur.
More information on individual dialysis and transplant units is available from our Renal Unit Database.
Levels of Renal Replacement Therapy (RRT)
About 40,000 patients in the UK are receiving dialysis or have functioning kidney transplants, which are grouped together as Renal Replacement Therapy, RRT. The take-on rate for patients onto RRT has risen progressively to about 110 per million population per annum (get the latest statistics from the Renal Registry). In some areas the take-on rate seems to have plateaued in recent years. However the survival of patients already on RRT means that even without further increases in take-on rate, the number of dialysis places needed will continue to rise. In fact take-on rates will need to rise because of the increasing number of elderly individuals in the population (there is a dramatic rise in risk of requiring RRT with age), and because of the age structure of some high-risk groups (diabetes, some racial minorities).
Although there continue to be intermittent severe stresses, particularly with adequate growth of haemodialysis provision in some regions, it is now generally true that long term dialysis is available for all those who need it in the UK. It is some decades since the elderly or patients with comorbid conditions were automatically refused, or simply not referred to renal units.
As well as delivering long term RRT, units also treat patients with acute renal failure (ARF). The number of cases requiring dialysis for ARF per year in any region is very approximately double the number of new patients starting long term RRT. They also diagnose and manage patients with earlier stages of kidney disease, often in collaboration with primary care. Almost all units offer outpatient consultations in local hospitals or other settings as well as at the hub unit. In centres that have transplant units, nephrologists share assessment and inpatient management of renal transplant patients. Most long term care of transplant patients is undertaken by renal units.
Chronic Kidney Disease (CKD)
The stages of chronic kidney disease (CKD) before dialysis have received greatly increased attention in the last few years, originally because of the desire to prevent the later stages of CKD and thence the need for dialysis and transplantation. In fact a much broader importance of CKD has been identified. Only some salient points are mentioned here
- According the the definition used, 5% or more of the population have some reduction in kidney function (CKD stage 3 or worse). Most of those affected are elderly.
- Most patients with CKD have stable kidney function and never develop end stage renal failure (ESRD) requiring RRT
- But their mortality is substantially increased, mostly through cardiovascular disease.
- Those at particular risk of progressing to ESRD should be assessed at a renal unit. They are a minority, but they can be quite simply identified.
- The UK CKD management guidelines support the management of CKD in the community, and referral of appropriate individuals to renal units.
- The Quality Outcomes Framework (QOF) component of the General Practice contract supports the identification and appropriate management of stage 3+ CKD.
See our pages on CKD and list of CKD resources.
Nephrology only became a substantial specialty in the UK with the spread of dialysis from about 1959, when 5 units opened, following the example set by Dr Frank Parsons in Leeds in 1956.
At first dialysis was only a short-term treatment to tide patients over acute renal failure, after the viability of dialysis treatment had been shown in the Korean War. It was slow to be adopted in the UK, where conservative dietary management had been the norm. However the very next year, at the first meeting of the International Society of Nephrology in Evian, France in 1960, Belding Scribner from Seattle reported using dialysis to prolong the lives of patients with irreversible kidney disease, instead of simply for recoverable acute renal failure. The first attempts to repeat this experience in the UK were both in London, at Charing Cross Hospital, led by Prof Hugh de Wardener, and the Royal Free Hospital, led by Dr Stanley Shaldon. The report of a group chaired by Hugh de Wardener led to the first wave of development of renal units in the UK.
Renal transplantation at that time was in its infancy, and although there were some remarkable successes, average survival figures were poor. Many patients died of infective complications and little long term dialysis was available in the event of failure. Some of the early dialysis units were set up to support transplantation, when it was not apparent that dialysis could be a viable long-term option.
During the following three decades there was a steady growth in dialysis and transplantation, and an improvement in safety and success rates of both. The number of patients kept alive by renal replacement therapy (RRT) rose steadily, but less quickly in the UK than in many other countries with similar living standards, and the number of patients per nephrologist was remarkably high, and still is. Financial constraints led to a period of a very high rate of peritoneal dialysis treatment (as CAPD), as this did not require new units to be built, or capital purchase and staffing of dialysis machines.
Serious outbreaks of hepatitis B in the late 60s and early 70s were important in steering the UK to use more home haemodialysis than most other countries, although this treatment was also associated with lower staff costs, and probably higher quality of life, in patients able to cope with it. In recent years it has declined for a number of reasons, but particularly because those patients who find it easiest are also the best candidates for renal transplantation, and because some of them can also also choose peritoneal dialysis, which is an easier treatment to set up at home.
The results of renal transplantation improved, particularly after the introduction of ciclosporin as an immunosuppressive drug in the 1980s. Transplantation is now the treatment of choice for all low to medium risk patients, and arguably could be advantageous to some higher risk patients if organ availability was unlimited. Organ availability is the major constraint however. The waiting list for a cadaver transplant continues to grow despite efforts to increase living organ donation and maximise cadaver organ donation.
Most of the long term survivors on RRT have experienced multiple different types of treatment. Almost all have had a kidney transplant for a large part of their lives, but there are a few patients who have survived over 30 or even rarely over 40 years of dialysis treatment.
More information on the history of dialysis and transplantation
History of the Renal Association
The recent document 'The Changing Face of Renal Medicine in the UK' (RA and RCP, 2007) is available from the JSC page