Access to renal services is required at primary, secondary and tertiary levels at different stages in the journey of a patient with kidney disease. Referrals come from GPs and other specialists in secondary care, particularly diabetologists, cardiovascular physicians, rheumatologists and urologists. Most episodes of acute kidney injury (AKI) arise while the patient is under the care of other specialists (eg acute general medicine, older people's care, cardiology, general surgery). Renal physicians have an important role to play in ensuring appropriate education, and that clinical systems (eg automated laboratory-based recognition of AKI) are in place.
Patients with advanced stages of AKI are either managed by nephrologists (providing dialysis) or on an intensive care unit (usually with continuous haemofiltration). Appropriate follow-up of patients with AKI is also required to monitor possible progression to chronic kidney disease (CKD).
The early detection and prevention of CKD require close collaboration between primary care practitioners, renal physicians and other specialists in secondary care.
The provision of care for patients with advanced CKD and end-stage kidney failure is largely hospital based. During the 1960s and 1970s, programmes for renal replacement therapy (RRT) in the UK were provided by a small number of renal units based in tertiary referral centres that covered large catchment populations. In the 1980s and 1990s, a significant increase in provision of dialysis was seen, provided to some extent by an increase in satellite units but also by growth in the number of renal units. Currently there are over 70 main adult renal units in the UK (not including satellite units); 56 in England, nine in Scotland, five in Wales and four in Northern Ireland. There are 207 satellite dialysis units in the UK. Just under half are operated by private companies under contract to the NHS. Although the nurses in these units are employed privately, medical supervision of patients receiving dialysis is provided by NHS nephrologists.
A smaller number of hospitals have renal transplant units (RTUs), which also provide surgical transplant services (23 in the UK, 19 in England). Patients are ideally referred at the stage of advancing CKD (aiming to achieve ‘pre-emptive’ transplantation), or once they are established on RRT programmes. Much of the pre-transplant workup occurs in non-transplanting renal units.