Submission on behalf of
The Irish Nephrology Society
Joint Committee on Health and Children
Special reference to Primary Care
29.01.09
This executive Summary is based primarily on the report of the National renal
strategy review group that has been submitted to the HSE
The Irish Nephrology Society (INS) is comprised of doctors and scientists
working in the care of patients with kidney disease, either at a clinical or
research level. The mission of the Irish Nephrology Society is to ensure a high
quality care for patients with kidney disease by promoting the highest
standard of medical practice. It has an integral role in the education and
training of medical practitioners and advises the government, public and the
profession on health care issues relating to kidney disease.
Diseases of the Kidney are very common. Most international estimates are
that 1 in 10 adults in the world have some form of Kidney damage, most of
whom are unaware of that fact. In Ireland this translates in up to 400, 000
people. More significant kidney disease afflicts up to 180,000 patients – in
whom it is a very significant risk factor for cardiovascular disease and
premature death. The increased risk of cardiovascular death risk increases as
the kidney disease worsens. However patients have no or minimal symptoms,
(e.g. high blood pressure) until kidney disease is advanced. Yet screening for
kidney disease is easy, inexpensive and can be done in the primary care
setting. Dialysis is not the inevitable outcome for CKD patients. There are
many hidden risk factors that if managed appropriately, can prevent or slow
the progression of CKD
Over 100 different diseases affect the kidneys. The term renal disease
typically refers to diseases of the kidney other than cancers of either the
kidney or associated organs of the urinary tract (such as bladder and
prostate). These conditions have different presentations and treatments and
are cared for by urology services. Kidney disease is more common in selected
groups, One in three patients over the age of 50 that has either diabetes or
hypertension will have significant kidney disease.
The term renal replacement therapy (RRT) describes treatments for renal
failure in which removal of waste products from the body is achieved by
haemodialysis, peritoneal dialysis or renal transplantation. Drugs are used to
supplement other kidney functions.
Other disease processes almost always complicate renal failure. Some are
due to the primary disease (e.g. diabetes, the commonest cause of renal
failure, may additionally cause blindness, heart disease etc.). Others, such as
anaemia, bone disease and heart failure, are the consequences of renal
failure itself. In addition, many patients with renal failure have diseases
affecting the heart and blood vessels, particularly ischaemic heart disease
and peripheral vascular disease. The risk to a patient with renal failure thus
exceeds the sole consequences of the renal disease itself. In fact, most
patients with renal disease die prematurely because of the enormously
increased risk of heart disease that occurs in this condition.
Chronic renal failure (CRF) or chronic kidney disease (CKD) is where the
kidneys are slowly destroyed over months or years. In the earlier stages there
are few symptoms or signs. Many patients do not seek medical attention until
late in their disease, or even in its most advanced stages by which time they
are close to requiring long-term RRT. The severity of renal failure is graded
according to a measure known as the glomerular filtration rate (GFR). This
term refers to the ability of the kidneys to clear blood of waste products per
unit of time (usually expressed in mls/minute/1.73m2). Once a patient starts
on dialysis or receives a renal transplant they are described as having endstage kidney disease (ESKD).
Stratification of CKD by GFR
Stage
Description
1
Kidney damage with normal or  GFR
2
Mild  GFR
3
Moderate  GFR
4
Severe  GFR
5
Kidney Failure
GFR (ml/min/1.73m2)
>90
60-89
30-59
15-29
<15 or RRT
Renal transplantation is the optimum treatment for ESKD. Despite a relatively
high deceased donor organ transplant rate, transplantation has not kept pace
with the rise in prevalent dialysis patients. As the population ages, as the
prevalence of diabetes rises, and in common with the experience of other
countries, we can anticipate an increasing number of ESKD patients, with
very substantial attendant treatment costs (we already deliver over 175,000
haemodialysis (HD) treatments each year).
It is an increasing public health care problem both at primary care and in the
hospital setting. For example, 25% of health care budget for the elderly in
U.S.A. is spent on the management of kidney disease (USRDS 2007 report).
A detailed knowledge of the epidemiology together with effective management
of the complications of chronic renal disease, with maximal utilisation of
scarce resources at a national level, is of great importance to the INS.
The HSE commissioned a renal strategic review and has proposed the
creation of a National Renal Programme (NRP). The NRP will be responsible
for a number of initiatives designed to move planning of renal services from
multiple local, non-integrated activities to a strategic population-based model.
Key elements that impact on primary care include:
 Introducing an eGFR evaluation of kidney function, to simplify early
detection of renal disease throughout the country
 Disseminating guidelines to simplify and bring concordance to generic
management of kidney disease in the primary care setting
 Formulating intregrated national service plans, based on HSE Area
needs assessment, to anticipate increasing demand for services
 Integrating national renal-specific Patient Management Systems
 Commissioning a National Renal Registry to inform policy setting and
track patient outcomes
Prevention of renal disease
Many features of CKD make it a target for Public Health initiatives to prevent it
or its consequences, as a complement to the necessary deployment of clinical
resources to deal with its established consequences.
Chronic kidney disease:
 Places a large burden on society in terms of morbidity, mortality, quality
of life and cost
 Affects many people, has increased in prevalence, and is likely to
increase further in future
 Its burden is unequally distributed, with greater occurrence amongst
the elderly, those from specific ethnic backgrounds, and those already
with other chronic diseases
 There is evidence that upstream preventative strategies could reduce
the burden of the disease process
 These strategies are not yet deployed in a systematic fashion.
In the past, renal services have typically focused on the needs of patients who
are known to have ESKD. There are a large cohort of other patients who are
either at risk of renal failure, have unrecognised renal failure, or have not
been referred for specialist renal services, within the Irish population. The
Review of Renal services in Northern Ireland estimated that there were over
30 people with CKD in the community for every one individual with ESKD.
The early identification and management of patients with conditions
associated with the development of renal disease should ultimately reduce the
incidence and prevalence of ESKD.
Primary prevention
The aim of primary prevention is to prevent the occurrence of disease by
addressing causal risk factors. Appropriate interventions and education of the
general public and health professionals on the risk factors for CKD is required.
This can be achieved in combination with other prevention initiatives, as
primary prevention of renal disease is linked to the prevention of many other
illnesses.
Examples include
 Diabetes –
 Hypertension
 Smoking cessation
 Control of proteinuria
Early detection of renal disease
Patients should be confident that CKD can be detected at an early stage.
Prompt investigation, specific drug therapy and longer term medical
monitoring can significantly improve prognosis and reduce morbidity. Early
detection is possible in a primary care setting: blood pressure monitoring,
routine biochemical screening, and dipstick urine testing
Prompt detection facilitates early review at an appropriately located, equipped
and staffed renal unit. As well as slowing or halting the progression of
disease, early referral to a specialist unit presents an opportunity for
counselling, for evaluating more complex complications and for discussing the
targets for therapy and follow-up.
Primary care
The majority of patients with, and at risk of, CKD are primarily cared for by
general practitioners. It is not possible for all patients with CKD to be reviewed
by a nephrologist; this would overwhelm existing specialty services.
Therefore, general practitioners should be made aware of the correct
approach to CKD prevention, diagnosis and management and when to refer
patients for specialty care. Once a nephrologist has been involved, the
general practitioner and the nephrologist should share care. Regular
communication should take place.
Required action by general practitioners in the area of primary prevention is
related to the management of diabetes, cardiovascular disease, obesity and
smoking cessation. It is very important that they test for microalbuminuria,
proteinuria and serum creatinine levels as part of routine assessment in
patients at risks, particularly diabetics.
The Primary Care Strategy recommends that a community dietician link with
the Primary Care Network (population 7,000-21,000). This post would provide
a service to several primary care teams. Dietary intervention is required for all
stages of CKD and for the management of conditions that contribute to the
pathogenesis of CKD and influence the progression of CKD. These are in
particular hypertension, diabetes, obesity, dyslipidaemia and cardiovascular
disease. Patients at risk of CKD require dietary advice to maintain adequate
glucose control in diabetes, weight management, lipid lowering advice in
dyslipidaemia and salt restriction in hypertensive or oedematous patients.
The INS strongly supports the strategy outlined by the National Renal
Strategy Review Group.
The INS has been actively involved in implementing the two proposed
initiatives to help identify the patients at risk in the primary care setting.
1
Introducing an eGFR evaluation of kidney function, to simplify
early detection of renal disease throughout the country
Individual nephrologists have persuaded their local laboratories to configure
their reporting of kidney function tests to include eGFR. This has been rolled
out by a number of hospitals including Galway, Cavan, Sligo, Cork and some
Dublin hospitals but it is not yet universal or HSE policy. It does not require
additional expenditure as it involves manipulation of data generated by the
laboratory rather than additional testing.
2.
Disseminating guidelines to simplify and bring concordance to
generic management of kidney disease in the primary care setting
A sub-committee of the INS and the ICGP (Irish College of General
Practitioners) have developed Irish Guidelines. These have been published
with the support of a pharmaceutical company and are available on the
website of the INS (www.nephrology.ie). There is ongoing work to develop
software to facilitate referral as appropriate or give guidance to the primary
care physician as determined by the stage of CKD disease.
The focus of these guidelines is to provide a framework for G.P.’s to manage
early Stage 3 CKD. In the UK, primary care physicians are incentivised to
detect and manage early kidney disease.
Appendix 1
For information only
Terms explained
Haemodialysis is a hospital based system – original type of dialysis. Patients
attend hospital 3 times per week for a dialysis session. Each session lasts 45 hours, independent of travelling time. Each session has to be delivered at
specific times. Blood is taken from the body either by 2 needles are placed in
arm or vascular access device in neck and pumped through the
haemodialysis machine and cleaned by the artificial Kidney. A water treatment
unit is required for the ultra pure water needed by the artificial kidney.
Patients tend to travel for dialysis in taxis paid for by HSE
Dialysis slots are limited with fixed schedule 3 days/week, e.g. Mon – Wed –
Fri or Tue – Thur – Sat. Most units do 3 session/day though demand may
lead to a need for “night shifts” with session starting at 10 pm or 3am!
Peritoneal dialysis is a home based system. A catheter is embedded in the
abdomen and sterile dialysis fluid (supplied as 2 - 5L bags) is infused into the
peritoneal cavity 4-6 times per day, 365 days per year. It requires an area for
exchange in the home, a storage area for the fluid and equipment to heat the
bags. It is not suitable for most patients as it needs significant input from
patient.
Dialysis Services has expanded in Ireland considerably in Ireland and will
continue to do so. On average 10-15% of the dialysis population die each
year on dialysis yet the number of patients requiring dialysis in Ireland has
grown at a steady rate at approximately 17.5 patients per million population
(p.m.p). per annum since 2004, or 70 additional patients per year. On
average over 400 patients start dialysis each year.
The NRP projections are that 600 dialysis stations will be required by 2015
treating 3000 haemodialysis patients.
Incidence and prevalence of ESKD
1998
Take on rate
68 p.m.p.
Prevalence rate
ESRD
468 p.m.p.
Dialysis
182 p.m.p.
Number of patients on Dialysis
Total
638
HD
486
PD
152
2008
100+ p.m.p.
960 p.m.p.
366
1570
1370 (3x)
200 (1.5x)
=
=
Goal is for 5 treatments to be delivered per HD station per week and that most
patients receive dialysis within 1/2 hour travelling time of their home,