Professor Alan Salama, professor of nephrology and honorary consultant, UCL Centre for Nephrology at the Royal Free Hospital London, discusses the variety of the specialty, the challenges and changes within nephrology and what advice he would give to a newly qualified doctor.
Introduction to renal medicine
Renal medicine, or nephrology, involves the care of patients with all forms of kidney disease. A major part of the work of renal specialists is the management of patients with acute kidney injury or advanced chronic kidney disease. This may involve renal replacement therapy, by dialysis or kidney transplant.
In addition, renal physicians provide care for patients with kidney disease without impairment of kidney function, including proteinuria and nephrotic syndrome; patients who have kidney involvement in multisystem immune disease such as systemic lupus and vasculitis; and patients with tubular or other metabolic disorders affecting the kidney. Renal physicians work closely with urologists to provide care for patients with recurrent urinary tract infections and kidney stone disease, amongst other things, and with obstetricians to manage kidney disorders in pregnancy.
Nephrology has a strong multiprofessional approach, with close collaboration with transplant surgeons, and teamwork with specialist nurses, dieticians, psychologists, dialysis technicians etc. Also, prevention and early detection of kidney disease involves working with other hospital specialties (such as diabetic medicine and hypertension) and GPs.
Why did I choose renal medicine and why would I recommend it?
More than any other acute medical speciality the nephrologist maintains a life-long involvement in their patients’ journey, from initial presentation to death. You will guide them through diagnosis and initial management, and where no cure is available through the progression of their kidney disease to pre-dialysis counselling, care on dialysis and the life-transforming benefits of transplantation. The privilege of supporting your patients – and their families – through the many ups and downs of a life with kidney disease is a uniquely rewarding experience.
It requires a deep understanding of a wide range of pathophysiological mechanisms and processes, including immunobiology and human physiology of all the major organ systems, a strong feel for numerical measurement, and most of all an appreciation of the psychological aspects of living with long-term conditions. With a major reliance on dialysis nurses, technicians, dieticians, tissue typing experts, transplant and vascular surgeons that goes back many years, renal medicine more or less invented multidisciplinary team working as we know it today. The team is still growing and you will be, along with your patients, at its centre.
Professor Simon Davies, professor of nephrology and dialysis medicine at the Institute for Science and Technology in Medicine, Keele University and consultant nephrologist, University Hospital of North Midlands
Training and working in renal medicine
Five key facts about training in renal medicine:
- Entry is via CMT programme, having obtained the full MRCP diploma, and some renal experience during that time (or FY1/2) would be to your advantage.
- It is possible to obtain a CCT in renal medicine in 3 years (ST3 –St5) but most trainees broaden their experience by combining with another specialty, typically G(I)M (ST3–ST7) but other combinations are available eg ICU, clinical pharmacology.
- You will receive training in all aspects of nephrology including acute kidney injury, glomerular and interstitial diseases, chronic kidney disease and the management of kidney failure with dialysis and transplantation.
- An academic or educational period out of training [OOP] is strongly encouraged and supported within training programmes.
- The training has a strong emphasis on clinical leadership and multidisciplinary teamworking, with opportunities to undertake practical procedures eg renal biopsy.
You can find more information on the training pathway from the Joint Royal Colleges of Physicians Training Board. Learn more about the recruitment and interview process by visiting the ST3 recruitment page.
Renal medicine resources
- Renal Association
- BMJ articles
- The acute management of haemorrhage, surgery and overdose in patients receiving dabigatran: Emergency Medicine Journal (10.1136/emermed-2012-201976)
- Size of blood pressure reduction from renal denervation: insights from meta-analysis of antihypertensive drug trials of 4121 patients with focus on trial design: the CONVERGE report: Heart (10.1136/heartjnl-2013-304238)
- Prevention of renal disease in Henoch-Sch ö nlein purpura: clear evidence against steroids: Peter F Hoyer, Archives of Disease in Childhood (10.1136/archdischild-2013-303949)
- Chronic low level trimethyltin exposure and the risk of developing nephrolithiasis: Occupational and Environmental Medicine (10.1136/oemed-2012-101261)
- Residential proximity to major roadways and renal function: The Journal of Epidemiology and Community Health (10.1136/jech-2012-202307)
- Medical Care: Renal medicine
- Census of consultant physicians in the UK 2012 – Specialty report: renal medicine
- Clinical Medicine articles:
- Maynard-Smith L, Fernando B, Hopkins S, Harber M, Lipman M. Managing latent tuberculosis in UK renal transplant units: how does practice compare with published guidance? Clin Med , February 2014;14:26–29, doi:10.7861/clinmedicine.14-1-26.
- Jones RK, Hampton D, O’Sullivan DJ, Phillips AO. Diabetes and renal disease: who does what? Clin Med , October 2013;13:460–464, doi:10.7861/clinmedicine.13-5-460.
- Alston H. Conservative care for end-stage kidney disease: joint medical conference with the Renal Association, British Geriatrics Society and Association for Palliative Medicine . Clin Med , August 2013;13:383–386; doi:10.7861/clinmedicine.13-4-383.
- Palma-Reis I, Vais A, Nelson-Piercy C, Banerjee A. Renal disease and hypertension in pregnancy . Clin Med , February 2013;13:57–62, doi:10.7861/clinmedicine.13-1-57.
- Walsh SB, Unwin RJ. Renal tubular disorders . Clin Med , October 2012;12:476–479; doi:10.7861/clinmedicine.12-5-476;
- Kamesh L, Clapham M, Foggensteiner L. Developing a higher specialist training programme in renal medicine in the era of competence-based training . Clin Med , August 2012;12:338–341; doi:10.7861/clinmedicine.12-4-338;
- Connor A, Mortimer F, Higgins R. The follow-up of renal transplant recipients by telephone consultation: three years' experience from a single UK renal unit . Clin Med , June 2011;11:242–246, doi:10.7861/clinmedicine.11-3-242.
- CME renal medicine ( Clinical Medicine, October 2012 issue) articles included:
- Mathieson PW. Membranous nephropathy . Clin Med October 2012;12:461–466, doi:10.7861/clinmedicine.12-5-461.
- Dawson CH, Tomson CRV. Kidney stone disease: pathophysiology, investigation and medical treatment . Clin Med , October 2012;12:467–471; doi:10.7861/clinmedicine.12-5-467.
- Rodger RSC. Approach to the management of end-stage renal disease . Clin Med , October 2012; 12:472–475, doi:10.7861/clinmedicine.12-5-472.
- Walsh SB, Unwin RJ. Renal tubular disorders . Clin Med , October 2012;12:476–479; doi:10.7861/clinmedicine.12-5-476.
- Wylie EC, Satchell SC. Diabetic nephropathy . Clin Med , October 2012;12:480–482; doi:10.7861/clinmedicine.12-5-480.
Historical highlights from the library, archive and museum collection
Richard Bright, FRCP from 1832, was the first to discover that the link between albumins in urine would result in a disorder of the kidneys. Bright presented case histories of patients at Guy’s Hospital accompanied by notes on the treatments administered and illustrations of organs examined post mortem. His influential research on nephritis – bringing together the triad of dropsies, albuminuria, and kidney derangement – was published in the first volume of his Reports of medical cases selected with a view of illustrating the symptoms and cure of diseases by a reference to morbid anatomy , printed in 1827. The library holds the first edition, to be viewed by appointment, and a modern facsimile reprint is available for fellows and members to borrow. Other books by Bright, to be found on the library catalogue , include his travel writing. The RCP has a portrait of Richard Bright , commissioned after his death, and an obituary for Richard Bright within Munk’s Roll.
Also of note is the obituary of Marion Elizabeth Stevens , FRCP from 1995, who was both a renal specialist and a patient, and so had a unique perspective on the effects of renal failure.
- Oxford handbook of nephrology and hypertension
- ABC of kidney disease
- Managing the kidney when the heart is failing (added by member request)
- BMC nephrology journal
- American journal of nephrology (embargo 1 year).