All patients with chronic renal failure
and a plasma creatinine above 150 umol/l and/or significant
proteinuria (>1gm/24hr) should be referred to specialist
nephrology.
Patients with creatinine >300 umol/l
should be referred urgently if there is no strong contraindication
to further treatment as a significant number will be approaching
or will have reached ESRF.
All patients with ESRF who, after discussion
between the multidisciplinary team, themselves and their
families, are deemed likely to benefit should be offered
RRT.
Commissioners should audit the number of
patients entering RRT as 'late' uraemic emergencies as
a first step to developing mechanisms to ensure the proportion
is reduced to a minimum.
Structured education and counselling of
patients approaching ESRF involving the multidisciplinary
team and other patients and carers should aim for the
seamless entry onto RRT using the patient's chosen modality.
Timely healthy initiation of appropriate
RRT demands unimpeded access to the main dialysis modalities,
which in turn requires planned expansion of facilities
in line with current prediction of need. There should
be no 'waiting list' for dialysis nor should any patient
be commenced on a therapy known to be inappropriate.
While it is accepted that the number of
transplant centres in the UK will not increase their staffing
should allow transplant surgeons, physicians and co-ordinators
to carry out clinics in autonomous renal centres to streamline
screening of potential recipients and to maximise morale,
local organ retrieval, live donation and pre-emptive transplantation.
Commissioners should be aware that the
benefits of erythropoietin therapy in
pre-dialysis patients (which is producing cost pressures
in the service) are based on increasingly firm evidence.
