INFORMATION RESOURCES ON RENAL DISEASE AND SERVICES

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Introduction

The East Midlands Public Health Observatory is the lead Public Health Observatory for renal health. To support this role these theme pages provide some background to renal disease and list useful resources and links both from Public Health Observatories and other sources.

Renal disease is disease of the kidney. A wide range of disease processes can damage kidney function. Where there is rapid loss of function (as in acute renal failure) recovery may be complete or leave some degree of chronic deficit. Kidney function may also be affected by chronic disease processes, accelerating the slow deterioration that comes with age (causing chronic renal failure). Chronic kidney disease is internationally classified into five different stages following guidance from the US National Kidney Foundation¹; stage five relates to the most severe form of kidney disease whilst stage one is the least severe. Estimates of glomerular filtration rate (GFR) - a measure of the flow rate through the kidney - are used to determine levels of chronic kidney disease (CKD), as outlined in the following table.

Table 1, from reference 1.

“CKD is a major public health problem”² and in 2006 reporting of stages three to five was introduced in the national Quality and Outcomes Framework³; this covers people with less than 60% of their kidney function. Only a small proportion of those with stages one or two progress to the more severe stages³, whilst timely, appropriate and effective investigation, treatment and follow-up of people with stages three and four CKD can reduce the risk of progression and complications.

The prevalence of CKD increases markedly with age; as both the English and East Midland populations are aging populations⁴, the prevalence of CKD is predicted to further increase.

Established renal failure (ERF) is an irreversible long-term condition. Until the 1960’s ERF always resulted in death⁷ because kidney function is essential for life⁵. People with renal failure (CKD stage 5) require some form of renal replacement therapy (RRT) such as peritoneal dialysis, haemodialysis or renal transplant. It is worth mentioning that people can be accepted onto transplants at any stage of CKD, for example in the UK in 2006, 24% and 59% of transplants were amongst patients with stages 1-2 and stage 3 respectively⁶.

In 2006 an estimated 5,062 patients were accepted for RRT in England, an incident rate of about 109 per million population⁶. There has been a progressive rise in acceptance rates since 1982, particularly amongst those in the over 65 years age group. The median age of commencement of RRT has increased from 63.3 in 1998 to 65.0 in 2006⁶.

There were almost 36,500 patients receiving RRT in total in England in 2006, a prevalence rate of 718 per million population6. Peak prevalence is in the 75-79 age band for men and the 65-74 age band for women⁶.

Rates of RRT can be taken as a proxy indication of rates of ERF. However, treatment rates are considerably higher in other comparable countries than in the UK: 3 times higher in the USA and twice as high in Germany⁷. Although this could possibly be explained by lower rates of ERF in the UK, it raises the possibility that there is unrecognised or unmet need.

There are also variations in treatment rates by region within the UK that are not fully explained by demographic differences. Some of the variation between Local Authority area rates has been attributed to ethnic mix⁶. South Asian and African Caribbean people are 3 to 5 times more likely to have kidney failure than white Caucasians⁸. However, in 2006 in England the crude acceptance rates in Local Authorities varied from 29 to 208 per million population⁶. The degree of variation suggests that other factors such as variable thresholds for treatment and access may be playing a part in determining treatment⁷. A Trent Regional study in 2001 showed a significant effect of deprivation and also distance from unit on haemodialysis rates⁹.

Renal Networks and Public Health Observatories have assessed local need^10-11. Changing patterns of demands have led to considerable strategic development over recent years (for example the development of satellite renal units to improve access and changes in workforce¹²). However, given the variability of provision, the validity of utilisation as a measure of underlying need remains uncertain. In the UK, work on identification of patients with renal disease in primary care is progressing and collection of renal data has been included in the latest Quality and Outcomes framework for primary care¹³.

Diabetes and high blood pressure are amongst the most common underlying causes of renal failure. About 13% of those requiring RRT in England have diabetes⁶. Screening for loss of renal function in high-risk groups has been proposed. However, there is some doubt as to whether this would be effective as an intervention because of the slow progression and relatively high rates of other serious illness (predominantly cardiovascular disease) in this group of patients^14;15.

Further data on care provided in the UK can be obtained from the UK Renal Registry.

References

1. K/DOQI Clinical Practice Guidelines for Chronic Kidney Disease: Evaluation, Classification, and Stratification. URL: www.kidney.org/professionals/Kdoqi/guidelines_ckd/p1_exec.htm
2. PE Stevens, DJ O'Donoghue, S de Lusignan, J Van Vlymen, B Klebe, R Middleton, N Hague, J New and CKT Farmer. Chronic Kidney disease management in the United Kingdom: NEOERICA project results. Kidney International (2007) 72, 92–99.
3. Revisions to the GMS contract 2006/07; Delivering investment in general practice. Available at www.nhsemployers.org
4. Sub-national Population Projections Unit, ONS: Crown Copyright.
5. NEPHO. Occasional Paper 05 - Implementation of the Renal NSF in the North East and Cumbria. Downloaded 06.07.08 URL: www.nepho.org.uk/
6. Ansell D, Feehally J, Feest TG, Tomson C, Williams AJ, Warwick G. UK Renal Registry Report 2007. UK Renal Registry, Bristol, UK.
7. DH Renal NSF Team. The National Service Framework for Renal Services Part One: Dialysis and Transplantation.  2004. London, Department of Health.
8. Lightstone, L. Preventing Kidney Disease: the Ethnic Challenge.  2001.
9. Fryers, P., Maheswaran, R., Meechan, D., and Jones, R. Socio-economic deprivation, ethnicity and travel distance and utilisation of renal replacement therapy in Trent Region.  2001. Sheffield, ScHARR / Trent Public Health Observatory.
10. Stribling, B. Service Implementation - Do Once and Share Renal Action Team Final Report.  2005. Leicester, East Midlands Renal Network.
11. Meechan, D., Jones, R., and Payne, N. Utilisation of Renal Replacement Therapy by Residents in the Trent Region.  2001. Sheffield, Trent Strategic Health Authority.
12. Royal College of Physicians. The changing face of renal medicine in the UK: the future of the specialty. Report of a Working Party.  2007. London, RCP.
13. de Lusignan S, Chan T, Stevens P, O'Donoghue D, Hague N, Dzregah B et al. Identifying patients with chronic kidney disease from general practice computer records. Family Practice 2005; 22:234-41.
14. Hallan SI, Dahl K, Oien CM, Grootendorst DC, Aasberg A, Holmen J. Screening strategies for chronic kidney disease in the general population: follow-up of cross sectional health survey. British Medical Journal 2006; 333:1047.
15. Clase M. Glomerular filtration rate - Screening cannot be recommended on the basis of current knowledge. British Medical Journal 2006; 333:1030-1.

If you have any queries on the renal disease and services home page please contact .

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PAGE CREATED: 28 November 2008