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Kidney Disease

TWELVE

Kidney Disease

Which patients with kidney

disease need to be referred ?

The use of eGFR reporting, rather

than just serum, creatinine has been

widely adopted as a measure of

kidney function. Chronic Kidney

Disease (CKD) is divided into stages

with CKD1-2 having an eGFR >

60ml/min but proteinuria, haematuria

or other structural evidence of kidney

disease, CKD3 having an eGFR

< 60ml/min and CKD4 an eGFR

< 30 ml/min.This has led to significant

numbers of people becoming aware

that they may have CKD and it is

important to reassure, monitor or

refer them as appropriate. Many are

older people, and it is estimated that

40% of the UK population over 75

has CKD3-5. Clearly, nephrologists

do not need to see everyone with

CKD, and most can be monitored

in primary care, with attention to

cardiovascular risk, which is increased

in CKD.

A key question, therefore, is who

needs to be referred? NICE guidelines

have been developed, and are

designed to help identify those at

high risk of progression, and those

likely to develop end-stage kidney

disease.This includes most patients

with an eGFR < 30 ml/min and

those with a progressive fall in GFR.

It is important to appreciate that

CKD can only be diagnosed when

previous results are available. A patient

who is found to have abnormal

renal function, should be suspected

of having acute kidney disease until

proven otherwise.

It is vital to identify those patients

with an active disease such as

glomerulonephritis.With the

widespread recognition of CKD,

there is a real danger that people

with an acute and treatable kidney

disease will be labelled as having

CKD. Some features suggesting the

possibility of glomerulonephritis, and

indicating a need for referral, are

listed below:

• Isolated proteinuria (urine protein

creatinine ratio >100 mg/mmol)

• Proteinuria and microscopic

haematuria (urine protein

creatinine ratio >50 mg/mmol)

• Features to suggest an underlying

systemic illness, e.g. joint pains,

weight loss, fevers, haemoptysis,

rashes

Glomerulonephritis is a group

of diseases in which the immune

system attacks the kidneys.Types of

glomerulonephritis where Dr Robson

has particular interest are Systemic

Lupus Erythematosus (SLE), Anti-

Neutrophil Cytoplasmic Antibody

(ANCA) vasculitis.These are both

systemic diseases in which kidney

involvement may be the major feature

causing morbidity. In the early stages

GFR can be normal, despite the

presence of significant inflammation

and ongoing irreversible damage;

with proteinuria and haematuria

being the only signs of kidney disease.

Both of these conditions need urgent

treatment with drugs that suppress

the immune system in order to

Kidney Refe

Assessing I

Patients

Dr Michael Robson began his

medical studies at Oxford

University, where he obtained

a First Class undergraduate

degree, before moving to

London for clinical studies.

He trained in nephrology

at King’s College and Guy’s

Hospitals. Following the award

of an MRC clinical training

fellowship and research

into glomerulonephritis, he

gained a PhD from Imperial

College in 2000. He has been

a Consultant Nephrologist at

Guy’s and St Thomas’ since

2002. His clinical practice

covers all aspects of renal

medicine including nephrology,

dialysis and transplantation.

He has a particular expertise

in lupus, vasculitis and

glomerulonephritis, but

is happy to see and treat

patients with any form of

kidney disease. In addition to

clinical activities, Dr Robson

runs a laboratory-based

research programme in

glomerulonephritis. He was

awarded aWellcome Trust

Intermediate Fellowship in

2002, and his research has

continued with competitively

awarded funding from a

number of sources. He has

published many original

research papers, and is

seeking to understand disease

mechanisms and identify new

possibilities for therapy.

Dr Michael Robson

Consultant Nephrologist

BA (Oxon) MBBS PhD MRCP

Guy’s and St Thomas’

NHS FoundationTrust

Secretary: Kate Gill

T: 07925 856 001

F: 08721 117 747

[email protected] www.robsonrenal.co.uk www.robsonrenal.co.uk