Web Correspondent Report on Nephrology in the United Kingdom

Web Correspondent Report on Nephrology in the United Kingdom

by David Goldsmith

History of Nephrology in the UK


Tower Bridge - London	White Tower - London

The UK Renal Association was founded in 1950 and as such is the second oldest renal specialist society in the world. Initially the interest and focus was nearly all physiological, concerning renal tubules.

However some of Kolff's machines had come to the UK, and in the 1950s there was acute dialysis in at the least the Hammersmith Hospital, and also in Leeds General Hospital.

The early to mid 1960s saw the emergence of a number of important and strong pioneering characters up and down the UK, as the challenge was thrown down to set up adult and shortly afterwards paediatric renal dialysis and transplantation services.

For the most part these individuals and services were based at major teaching / research institutions. It is interesting to note that the pattern of centres established in the 1960s has largely survived into the 21st century. Until the 1980s there were about 60 renal units; in 2003 there are about 70.

From the early 1960s there has been a steady underfunding of Health Care in the UK compared to most industrialised countries. Just at the time when a technological-dependent and expensive treatment modality was nascent. As a result of the lack of funding for regular dialysis, there was a major campaign in the UK for home haemodialysis in the 1960s and for CAPD in the 1970s and 1980s.

A review of services in England and Wales in 1975 estimated the need for 8000 dialysis spaces and 1500 transplants per year. The reality was 1900 and 542 respectively. Between 1980 and 1990 the acceptance rates onto chronic programmes increased from 25 ppm to 61 ppm, but still a long way behind other countries in Europe.
The National Renal review in 1992 highlighted major regional disparities in renal care provision. Between 1993 and 1998 the number of satellite units doubled. Whereas in the 1970s and 1980s over 50% of patients were on peritoneal dialysis, by 2001 the proportion on CAPD was about 32%. However the numbers on home haemodialysis have dwindled to just 2 - 3%

The latest reports from the UK Renal Registry suggest that 90 ppm is being achieved nationally, with higher rates in areas with higher proportion of older populations or racial minorities. This is still some 20 - 30 ppm short of calculated need. Sadly for diverse reasons the number of transplants has not increased, indeed may have fallen, despite some use of asystolic donors, and increasing use of live-related and unrelated donors.

Present Statistics

There are about 600 patients per million population in the UK on dialysis or with a transplant. This equates to about 35,000 patients.

There were 290 consultant posts in Nephrology in the UK in 2001 - of these the whole time equivalent was 206. It is estimated that 364 whole time equivalent posts are needed properly to manage patients as we are now, and that we will need a large expansion to cope with the large rise in dialysis stock. There about 200 trainees in renal medicine, and it is hoped that this number will be expanded by at least 100 - 150 over the next 10 years, most of that expansion taking place in the next 5 years.

Nephrology units for the main part are independent of Departments of Medicine. There are about 20 Professors of Renal Medicine / Medicine (Nephrology) in the UK.

There are about 70 dialysis units, and about 25 renal transplant centres in the UK. There are about 70 renal transplant surgeons, but only 13 are full time. There are very few surgical trainees. Few of these transplant centres transplant more than 100 kidneys per annum.

As with most of the Health Care in the UK, Nephrology is virtually all NHS and very little privately funded. However use has been made of the private sector in the development of satellite unit dialysis facilities.

Organisational Issues

The Renal Association represents Nephrologists and Allied Professionals, and is the main forum for presenting clinical and laboratory research. There are two two-three day meetings each year, one in London and one elsewhere. Abstracts are published in KI. Increasingly there are joint meetings with other societies in the UK and abroad. It publishes Standards and Audit Measures (3rd Edition 2002, published by the Royal College of Physicians, London), which is used as the audit benchmark to ensure compliance with reasonable clinical standards. The data from the UK Renal Registry (see below) are important also in this regard.
The RA also now sponsors and designs major trials.

The RA website has been recently redesigned and a visit will quickly enable an insight into the diverse activities of the Association. http://www.renal.org/

The Renal Registry (founded 1998) now compiles data from 75% of UK renal units, and this will be nearly 100% very shortly. The fifth annual report was published in December 2002. http://www.renalreg.com/

The British Renal Society (founded 1997) is a multi-disciplinary society which aims to bridge a potential gap between medical, nursing and allied professions in the care of renal patients. It emphasises the multi-disciplinary nature of renal care. http://www.britishrenal.org/

The National Kidney Federation (founded 1978) is a patients' association dedicated to improving the quality of care renal patients receive. http://www.kidney.org.uk/

The Kidney Alliance is a loose association of the Renal Association and the National Kidney Foundation (founded in 1998) dedicated to advancing the quality of care for renal patients. http://www.kidneyalliance.org.uk/

The National Kidney Research Foundation (NKRF) is the main funding charity for renal research in the UK. Traditionally it has emphasised laboratory-based research over clinical projects. http://www.nkrf.org.uk/

Challenges

Public Health - the massive rise in elderly and type II diabetic patients. The National Service Framework (http://www.doh.gov.uk/nsf/renal.htm) Initiatives are designed to try to level up the standard of care to achieve basic but important goals in prevention and in treatment of renal disease. Funding, and organisation of the commissioning of health care delivery, remain huge obstacles. Finding more trainees to permit a major expansion in consultant numbers is also challenging.