How Does the Multi-Disciplinary Team Impact Chronic Kidney Disease Management?
Michael Fawzy1* and Baoying Huang2
1Faculty of urology, Renal consultant at Basildon University hospital, England
2Department of urology, Basildon University hospital, England
Submission: June 06, 2019; Published: July 11, 2019
*Corresponding author:Michael Fawzy, Faculty of urology, Renal consultant at Basildon University hospital, England
How to cite this article:Michael Fawzy, Baoying Huang. How Does the Multi-Disciplinary Team Impact Chronic Kidney Disease Management?. JOJ
uro & nephron. 2019; 6(5): 555697. DOI : 10.19080/JOJUN.2019.06.555697
Chronic kidney disease (CKD) is a condition where a gradual kidney function loss leads to a build-up of toxic waste products in the blood, increasing morbidity and premature deaths from enhanced risks of cardiovascular disease, stroke and mineral bone diseases. The most common causes of CKD include type II diabetes and hypertension, both accounting for two-thirds of all cases. CKD is asymptomatic in early stages and is only diagnosed via routine screening tests unless severe symptoms arise from advanced CKD. Management of CKD via multidisciplinary team (MDT) consisting of professionals from various disciplines has been hailed as the best modality in treating such a multi-faceted chronic disease, leading to positive impacts on patients’ experience and clinical outcomes.
More than 1.8 million people are diagnosed with CKD in England  where the advancing age is commonly associated with the higher incidence of CKD stage 3-5. Figure 1 is an illustration that on average, whilst there is only an estimation of 1.9% of the population having moderate to severe CKD, that figure is increased to 32.7% for those aged 75 and over. The latest guideline established that NHS England spent £1.45 billion in 2009-10 attributing to £1 in every £77 spent by NHS
in managing CKD and associated illnesses stemmed from the condition . Progression patterns and risk factors of CKD into end-stage kidney disease (ESKD) can be established well before the need to initiate renal replacement therapy (RRT). Therefore, proactive intervention strategies to prevent its progression form a basis of management of CKD which is mainly delivered via a multi-disciplinary team (MDT) to address all the various aspects and risk factors of CKD. This paper aims to explore and describe how effective this MDT approach is in treating CKD.
Chronic kidney disease (CKD) is a multi-factorial disease
leading to progressive worsening of kidney functions. Kidney biopsies
from most CKD patients will often show glomerulosclerosis,
tubular atrophy and interstitial fibrosis. Moreover, at the end
stage of kidney failure, they will feature a characteristic renal fibrosis
where the kidney undergoes unsuccessful wound healing
after chronic and sustained inflammation and injury to its tissues.
CKD can be classified into 5 stages based on an estimated
glomerular filtration rate (eGFR) which represents the amount of
fluid each functioning unit (nephron) of kidneys filters through,
per unit time. Figure 2 demonstrates the progression of CKD in
stages using eGFR and albumin to creatinine (ACR) ratios .
A consistently high level of kidney disease markers (illustrated
in Table 1) over a period of 3 months and a GFR at G3 stage are
two criteria that need to be met in diagnosing CKD. G5 of GFR is
termed as end-stage kidney disease (ESKD) where failure of kidney
can only be managed with renal replacement therapy (RRT)
including dialysis or kidney transplant unless the patient wishes
to undergo conservative management.
Exact aetiology of CKD is not fully understood; however,
older age, type II diabetes, and hypertension are associated with
diabetic glomerulosclerosis and hypertensive nephrosclerosis
both leading to CKD in Western world . Main causes of CKD in
developing countries include glomerular and tubulointerstitial
diseases due to infections, drug and toxin exposure. A small
percentage of CKDs also arises from congenital conditions such
as polycystic kidney disease. Gender difference plays a role
in CKD with males showing a more rapid and aggressive CKD
progression, suggesting the potential roles of sex hormones in
modulating synthesis of growth factors and chemical mediators
leading to CKD progression . Ethnicity and socioeconomic
status are also key modifiers in CKD prevalence and progression.
There is a 60% increased risk of worsening CKD in people of
the lowest social quartile when compared with their richer counterparts. This progression is highest in people with ethnic
minority backgrounds and can be attributed to having reduced
medical awareness and access to specialist nephrologist care in
both pre-dialysis and dialysis groups .
CKD is non-symptomatic in the earlier stages and most
diagnoses are made via routine tests unless patients present with
severe symptoms from advanced CKD. As the kidney gradually
loses its function from progressive disease, there is a rapid
accumulation of uraemic retention solutes in the body which can
then affect various parts of the body. Uraemic toxicity can lead to
vascular damage increasing the risk of cardiovascular diseases
and bleeding episodes, impaired inflammatory and immune
responses, and altered microflora in the digestive system .
Impairment to normal kidney functions can lead to proteinuria,
oedema, hypertension, hyperphosphatemia, hyperkalaemia,
anaemia and bleeding diathesis, renal osteodystrophy, congestive
heart failure, gastrointestinal disturbances and generalised
With medication compliance and adequate lifestyle changes
including keeping a normal weight, taking up exercise and
following a renal diet, CKD patients can remain as healthy as
possible. Management plan is aimed to treat primary pathological
diagnosis along with an intervention based on eGFR stages and
albuminuria to control hypertension, diabetes, dyslipidaemia
and anaemia to prevent episodes of acute kidney injury (AKI)
and reduce its complications. A referral to nephrology is to be
initiated when patients with poorly controlled hypertension
even after treatment with at least 4 anti-hypertensive drugs,
reach either G4 or G5 stage with decreasing GFR of less than
30ml/min/1.73m2 and an ACR of 10mg/mmol or higher .
A typical renal department provides inpatient and outpatient
services covering general nephrology, pre- and post-dialysis
review, low clearance clinics and transplant follow-up. The
department is made up of a team of professionals from various
disciplines including consultant nephrologists, clinical nurse
specialists (CNS) and dieticians. Joint clinics are typically run
in parallel with endocrinologists for diabetic patients with CKD,
with cardiologists to manage their cardiovascular health and
lastly with rheumatologists for patients with hyperuricemia to
manage their gout and joint pain associated with CKD.
In addition, a team of MDT managing CKD also includes
surgeons working together with interventional radiologists to
get an intravenous line in or to form fistulae for good vascular
access for dialysis. Interventional radiologists are valuable for the
team since they can also perform other key procedures such as
image-guided percutaneous renal biopsy allowing the clinicians
to treat the underlying causes. In addition, the maintenance of
fistulae and veins which allows good vascular access for future
dialysis is relied upon the great effort of vascular access CNS
who work alongside surgeons and radiologists to support the
patients regarding fistulae care.
There is a 57% increased mortality from cardiovascular
causes when patients reach a GFR of less than 60mL/min per
1.73m2 . In addition, CKD patients have 5-10-fold increased
risks of dying from other complications than progress into ESKD
. Keith , also published results from a longitudinal study
which concluded that CKD patients are twice likely to die from
CVD complications than develop ESKD. Therefore, one of the roles
of the consultant nephrologist is to prescribe anti-hypertensives
accordingly, and to monitor patients’ blood pressure and other
side effects arising from these therapies. Antagonists of reninangiotensin-
aldosterone system such as angiotensin convertingenzyme
inhibitors (ACEIs) or angiotensin II receptor blockers
(ARBs) are first-line choice of agents in CKD patients to reduce
proteinuria which is the main culprit for disease progression
. However, ARBs and ACEIs can also lead to hyperkalaemia
in CKD patients and therefore should be continuously monitored
for their blood potassium levels.
One of the main functions of kidney is to produce erythropoietin
(EPO) which is a hormone stimulating red blood cell
production. CKD patients typically present with hypo proliferative,
normocytic, and normochromic anaemia due to impaired
EPO production by the kidneys. CKD patients often have chronic
anaemia which reduces patients’ quality of life and puts them
at higher risks of deaths. There is a 29% increased chance of
hospitalisation in patients with haemoglobin (Hb) of <10 g/dl
than those with Hb between 11-12 g/dl . Therefore, iron and
derivatives of recombinant erythropoietin are commonly used
in treatment of anaemia, decreasing the need to transfuse blood
. Chronic anaemia is normally managed by anaemia CNS
who monitor patients’ iron levels and administer intravenous
iron and erythrocyte-stimulating agents (ESAs) to the patients,
as prescribed by the nephrologists. They are also important in
providing counselling sessions for pre-dialysis and dialysis patients
informing them of local and national treatment guidelines
to help decide their future treatment plan.
The kidneys regulate how calcium and phosphate are absorbed
in the intestine by regulating vitamin-D metabolism
which converts vitamin-D to calcitriol (activated vitamin D).
CKD patients can have abnormal serum concentrations of calcium,
phosphates and reduced calcitriol levels, leading to pain
in the bone or bone fragility due to increased osteoclast activity.
Management of CKD mineral bone diseases include renal diets
restricting phosphates and prescription of calcium or non-calcium
phosphate-binders and activated vitamin D in those with low serum calcitriol levels (>30 ng/mL) and normal parathyroid
hormone levels . In addition, CKD patients often have
high uric acid level (hyperuricemia) which can lead to acute or
chronic gout attacks for which uric acid lowering agents such as
allopurinol and febuxostat are used to manage hyperuricemia.
Therefore, it is the role of the renal dieticians to offer guidance
on which food to avoid and how to prepare an adequate meal for
good renal health, along with offering support and help to lose
weight, exercise more and quit smoking, if need be.
There is no universal definition or endpoint of CKD at which
ESKD can be diagnosed and renal replacement therapy (RRT) is
to be established since patients can have differing levels of comorbidities.
When the patients’ eGFRs start to approach 15%,
they are consulted to discuss and make timely arrangement
for further treatment plans including starting dialysis (either
peritoneal or haemodialysis), kidney transplant or undertaking
conservative treatment. However, a study supported by USA
National Kidney Foundation concluded that an acceptable
surrogate endpoint should be when a decrease of eGFR of 30-
40% within 2-3 years excluding causes of acute kidney injury
(AKI) . Generally, GFR of less than 15mL/min/1.73m2
along with presentation of uraemic symptoms can warrant a
consultation of RRT which involves either dialysis or kidney
RRT takes up a huge portion of NHS kidney budget and there
was an estimated total annual cost for both haemodialysis and
peritoneal dialysis of £505 million and a total annual cost for
all transplants was reported to be £225 million in 2009-2010
. Having a strong MDT team behind the patients makes an
important difference to ESKD patients regarding making lifechanging
decisions when considering RRT. There is a huge
burden for patients to consider whether to enlist for RRT or
undergo conservative management. A randomised control study
carried out by Cooper et. al., in Australia and New Zealand in
2010 (IDEAL study) did not find any difference or improvement
in survival outcomes and mortality rates when stage V CKD
patients were started on early or late dialytic treatments.
Therefore, it is paramount that a patient needs to be educated
and consulted on optimal timing of initiating dialysis, which
modality of dialysis to choose, extent of time waiting for the
matched donor kidney for transplantation and how to cope with
immunosuppressants and post-transplant complications.
Incorporation of MDT in CKD care has been supported widely
due to its positive outcomes from several studies published over
the years. A study by Lin , published in PLoS, found that
MDT increased quality of life adjusted years (QALYs) by 0.23 per
person, when compared with non-MDT care. Cost-effectiveness
of MDT has also been reported where MDT care leads to a
reduction of $1931 annually per patient from reduced RRT and
emergent need for dialysis since MDT was shown to slow eGFR
decline and infection-specific hospitalisation .
Furthermore, a prospective study led by Chen  in Taiwan,
also reported that patients under MDT care had a 51% reduced
mortality than patients under usual non-MDT care. Moreover, a
holistic approach provided via MDT care ensures that one will
be guaranteed with an individualised and targeted management
plan including health education and awareness of nephrotoxic
nonsteroidal anti-inflammatory drugs (NSAIDs) which are
contraindicated in CKD patients since they can lead to severe
renal injury and progression of CKD .
To conclude, CKD is a chronic disease associated with
multiple co-morbidities. To manage such a multi-faceted disease
accordingly, only a multi-disciplinary team with professionals
working towards the same goals and acting in the best interests
of patients, will be able to improve patients’ quality of life and
bring positive clinical outcomes. As CKD progresses, there is a
need for a more collaborative effort between members of the
MDT to address the increasing needs of the patients as they
present with more complications. However, integration of such
collaborative works may also need enhanced communication
between colleagues to provide optimal care for the patients.
Although effectiveness of providing a more integrated care
via MDT has been established, determination of one optimal
professional in an MDT has not been elucidated yet, requiring
more randomised studies to follow [20-22].
(2014) National institute of health and care excellence (NICE), Chronic kidney disease in adults: assessment and management [pdf] London: National institute of health and care excellence (NICE) Available.