Renal Medicine

We provide treatment for patients with kidney disease from Dundee, Angus, Perth and Kinross and the NE Fife. We operate a main unit at Ninewells Hospital which has 24 dialysis stations, a self-care unit with 6 stations which is also used for home haemodialysis training, a Peritoneal Dialysis unit and a 15 bed in patient ward (Ward 22). The unit is staffed by consultants, doctors in training and a skilled team of specialised nurses, a renal pharmacist and renal dieticians.

All in-patient Nephrology, including acute dialysis, is delivered at Ninewells Hospital. We provide satellite dialysis at Perth Royal Infirmary (12 stations) and Arbroath Royal Infirmary (10 Stations).

General Nephrology and Advanced Kidney Care Clinics are held at Ninewells Hospital, Perth Royal Infirmary, Arbroath Royal Infirmary and Whitehills Community Hospital in Forfar.

There is a weekly Transplant Clinic at Ninewells Hospital. Over 20 patients are transplanted annually. The implantation surgery is performed in Edinburgh Royal Infirmary but follow up after approximately one week is carried out at Ninewells Hospital. There is a proactive Live Donor Transplant programme supported by our transplant coordinators and REACH nurse.

The service has a strong belief in home dialysis and this is supported by a 6 station self care/home haemodialysis training unit at Ninewells which is supported by a dedicated nursing team.

There is a Renal Supportive Care Service with routine input from a Palliative Care Consultant and a dedicated Renal Supportive Care specialist nurses for patients who have elected to have conservative management and for patients on dialysis.

Please consider admission to AMU or discussion with the on-call renal doctor if there are the following clinical presentations:

Suspected acute kidney injury (AKI)

• Rapid and significant decline of renal function (unexplained, >30% and continuing rise in creatinine) over days to weeks in the absence of bladder outflow obstruction or volume depletion. The faster the rise the more urgent.
• Oliguria/anuria with renal impairment not caused by bladder outlet obstruction (where urological referral is usually more appropriate unless severe hyperkalaemia or acidosis).
• If new or symptomatic severe renal failure (eGFR <15ml/min) is present, discussion often useful even if renal replacement therapy is unlikely to be clinically appropriate.

Acute Kidney injury superimposed on chronic kidney disease– as for AKI
Accelerated phase hypertension
Marked elevation of BP, SBP >180mmHg or DBP >110 mmHg, with widespread acute arteriolar injury (severe hypertension with retinal haemorrhages/ exudates with renal impairment and dipstick urine abnormalities). This is likely to be managed by the Acute Medical or High Dependency Team.

Hyperkalaemia
Moderate hyperkalaemia in a patient not known to the Renal Services would usually be managed by the Acute Medical Team in the first instance. Renal input may be indicated if refractory/recurrent.

Hyperkalaemia for Community Bloods

Urgent Outpatient Referral

• New Advanced Kidney Disease

eGFR <15 ml/min without symptoms or
eGFR 15 to 30 ml/min with symptoms

• Proteinuria: Nephrotic syndrome

Urinary protein/creatinine ratio (uPCR) >300 mg/mmol or urinary albumin/creatinine ration (uACR) > 250 mg/mmol with low serum albumin (<30 g/L) and peripheral oedema.

• Haematuria

Proteinuria with haematuria and worsening renal function (likely underlying glomerulopathy)

• Systemic Illness

Multisystem disease with evidence of progressive renal involvement (renal dysfunction/urinary abnormality) e.g. lupus nephritis, myeloma and systemic vasculitis

Routine Outpatient Referral

• Stable, severe CKD or moderately severe CKD
• eGFR 15 to 30 ml/min
• eGFR 30 to 59 ml/min with complications:
  • Unexplained non-visible haematuria
  • Proteinuria (i.e. uACR > 70 or PCR > 100 mg/mmol)
  • Unexplained anaemia (Hb < 110 g/L), if eGFR < 45 (e.g. with negative GI investigations for iron deficiency, for example negative QFIT test)
• Abnormal potassium, or acidosis
• Abnormal calcium or phosphate
• PTH should be measured annually in stage 3 CKD, and 6 monthly in stages 4 and 5. Table below demonstrates PTH target ranges, and referral would be suggested if the PTH was above these target ranges

CKD stage (GFR) Target range	(pmol/l)	Target range (relative to upper limit of normal)
3 (30 – 60 ml/min)	Up to 13.8	Up to 2x
4 (15 – 30 ml/min)	6.9 to 27.6	1 – 4 x
5 (<15 ml/min or on dialysis)	13.8 to 62.1	2- 9 x

• Progressive renal impairment as defined by:
  • Sustained decrease in eGFR ≥ 25% AND a change in eGFR category within 12 months

OR
Sustained decrease in eGFR of ≥ 15 mls/min or 20% rise in serum creatinine within 12 months

Anaemia Guidelines for Patients with Chronic Kidney Disease
Chronic Kidney Disease Mineral and Bone Disorder Guidelines

Proteinuria

• uPCR > 100 or uACR > 70 mg/mmol
• uPCR > 50 or uACR > 30 mg/mmol if non-visible haematuria

Haematuria

• Visible haematuria with negative urological investigations with strong features of renal disease.
• Non-visible haematuria with uPCR > 50 or uACR > 30 mg/mmol

Hypertension

• Refractory hypertension if renal disease or renal artery stenosis suspected (e.g acute rise in creatinine >20% associated with ACEi or ARB or recurrent pulmonary oedema in absence of severe cardiac disease)
• Uncontrolled hypertension despite 4 agents at therapeutic doses in a patient with CKD.

Systemic Illness

• Known multisystem disease with minor and/or stable renal involvement
• Diabetes where progression of CKD is out of keeping with disease

Other

• Recurrent renal stones
• Possible familial renal disease including familial polycystic kidney disease

When to refer to the Renal Service_ According to Proteinuria
When to refer to the Renal Service_ According to eGFR

Any further questions for example on conditions listed below, could be made by SCI-GATEWAY or via telephone, for renal advice, but may be followed up in the community:

Isolated microscopic haematuria - (no hypertension or proteinuria)
Isolated proteinuria: Protein creatinine ratio <100mg/mmol in the absence of renal impairment or severe hypertension
Stages 1-2 CKD (eGFR 60+): Referral not required unless other evidence of kidney disease (e.g. likely genetic diagnosis, urinary abnormalities, or evidence of structural renal disease on ultrasound).

Recommended annual number of monitoring checks for people with CKD

Helpful information when referring
The kidney problem

• How discovered
• Any urinary symptoms now or previously

Medical history

• All significant illnesses
• Historical recordings of blood pressure and urine dipsticks (including pregnancy and insurance and other medical examinations) can be very helpful
• Risk factors/lifestyle including tobacco, alcohol

Drug history 

• All current drugs, and particularly others taken during the period before and since the renal problem is thought to have developed.

Urine dipstick results

• If proteinuria present, quantitation of protein/creatinine ratio is valuable

Blood pressure

• Recent and historical values on or off treatment

Imaging
• Renal ultrasound can reliably exclude obstruction, and show renal size (helpful in distinguishing acute/chronic kidney disease).

• Renal masses or complex renal cysts are managed by Urology who will often review the cases at their Urology MDT and organise follow up as required. Possible familial polycystic disease is appropriate to refer to Renal.
• Problems related to nephrostomies or ureteric stents are managed by Urology
• Visible and non-visible haematuria as per Urology guidance
• UTIs are very common. Nephrologists rarely have additional insights into the management of recurrent, uncomplicated UTI.
• In patients with advanced age, frailty, co-morbidity or with a reduced life expectancy, where the CKD is stable and the symptom burden is low, it is appropriate to manage these patients without direct input from the Renal services.

Guidance for Non-Visible Haematuria
Visible Haematuria
Antibiotic Prescribing for UTI in CKD

Routine, urgent and advice referral via SCI-Gateway.

There is 24 hour renal on-call service via the Ninewells Switchboard. (In hours, Monday to Friday, 9 am to 16.30 pm, page #4740. Renal SpR on call until 21.00 pm, Consultant on call overnight, both available via the hospital switchboard.

Chronic kidney disease | Health topics A to Z | CKS | NICE