The patient population
The incidence and prevalence of chronic kidney disease (CKD) and the need for renal replacement therapy (RRT) in a given region are influenced by the age, gender, social deprivation and ethnicity of the local population. The UK has a growing and ageing population, with increasing numbers of people diagnosed with diabetes mellitus, and therefore diabetic renal disease. Research indicates that rates of starting RRT in the UK increase fourfold or more in patients from black and South Asian populations compared to Caucasians. This is thought to be related to an increased burden of hypertensive and diabetic renal disease, respectively in these populations. The age of patients starting RRT is significantly lower in both ethnic groups reflecting their population age structure. Both groups are more likely to be treated by haemodialysis (HD) than peritoneal dialysis (PD), and demonstrate lower transplantation rates (for a number of reasons including blood and tissue-type group differences, and low rates of retrieval and donation), and better survival rates on RRT programmes.
These differences will have clear implications on the commissioning of renal services. In England, the ratio of observed/expected rate of RRT, given the age and gender breakdown of any locality, varies between 0.66 and 2.15, according to the UK renal registry report.
Adjacent clinical commissioning groups (CCGs) can have widely different prevalence rates of established (RRT requiring) renal failure (ERF). Consortia commissioning of RRT by groups of CCGs, and network based strategic planning, is therefore essential to share the risks involved in resource allocation.
Attempts have been made to model future demand for RRT and the impact of factors such as acceptance rate, transplant supply and patient survival. One of the most cited studies of patients in England predicts a continued growth in patients receiving RRT, particularly in older people and those on HD, with a steady state not being reached until around 2030.
The Kidney Care Atlas, produced in collaboration with NHS Kidney Care and the UK Renal Registry, is a study of variation in kidney care in England. It is a themed component of the NHS Atlas of Variation in Healthcare. Data from datasets including the UK Renal Registry have been used to illustrate how aspects of healthcare specific to kidney disease vary. The Atlas highlights 18 indicators relating to kidney care, and represents a sample of the variation in value and quality in renal services across England.
Prevention of disease
Early detection and effective management of CKD, and appropriate referral of patients to specialist services, can help to delay progression of the disease. Supporting patients to exercise careful glycaemic control, optimal blood pressure control, avoidance of nephrotoxic medication, and good lifestyle choices (weight, smoking etc) are all important.
According to NICE commissioning guidance, it was anticipated that by diagnosing and treating kidney disease at an early stage, particularly among at-risk groups such as people with diabetes, cardiovascular disease or from ethnic minorities, that the likelihood of established renal failure (ERF) would be reduced, and therefore also the need for transplantation or lifelong dialysis treatment. Unfortunately there has been no change in the incidence of ERF in England in the last 8 years (reported in the 18th Renal Registry report – 2015), which remains constant after 10 years of mandatory estimated glomerular filtration rate (eGFR) reporting and 8 years after the incorporation of CKD management into the primary care payment for performance scheme (QOF) in 2006.
Good CKD management in primary care is important. It may well mitigate the hugely significant cardiac risk factors in patients with CKD.
Since 5–10 patients with progressive kidney failure die of a cardiovascular event for every one patient who survives to receive dialysis, lowering cardiovascular risk may increase survival in patients with CKD.
This is, however, likely to increase the numbers of people needing RRT, which needs to be taken into account when planning healthcare costs. This can be helped, however, by reductions brought about by prevention or slowing of CKD progression.
Planning effective services
There is a need for seamless commissioning of the whole patient pathway – for the management of patients developing acute kidney injury (especially in hospitals without an on-site renal service), from early chronic kidney disease right through to treatment by renal replacement therapy and end-of-life care. Such commissioning should appreciate the multidisciplinary nature of renal medicine, and the interconnectivities with other specialties and professions. Not taking these relationships into account can lead to fragmentation of care. Managed renal networks play an important role in promoting high-quality care.
Significant numbers of haemodialysis facilities have been passed from the NHS over to private sector management. It is chiefly the mechanistic aspects of haemodialysis that are outsourced, and much of the holistic support required by dialysis patients remains with renal units within NHS trusts. It can take years to build up the multidisciplinary teams (MDTs), who support dialysis patients. Their funding has historically derived indirectly from the dialysis tariff (and is usually not supported by private providers).
While private providers can deliver the mechanistic aspects of the dialysis service to the NHS to a high standard, the patient experience is critically dependent on support from renal specialist dieticians, counsellors, social workers, pharmacist, educators, and liaison nurses who deal with dialysis preparation, the support of patients with established renal failure (ERF) who choose not to dialyse (conservative management) and end-of-life issues in kidney failure. The continuing integrity of the MDTs is critical to patient-centred care.
The increasing numbers of patients who need treatment for kidney disease underline the importance of the renal physicians’ role in planning, with commissioners, for expansion and development of services and evaluating innovative approaches to service delivery. This includes the participation of renal physicians in regional and national work.