Renal Medicine

Dr Jess Selwood, ST5

What is Renal Medicine

Renal medicine is a fascinating specialty, encompassing multiple organ systems due to the array of conditions managed by nephrologists. Chronic kidney disease affects 1 in 10 people in the UK, and 1 in 5 in those aged over 80. Rates of CKD are expected to rise over the next decade with an ageing population and higher rates of comorbidity, alongside advances in technology and therefore an increased scope to treat more complex renal disease.

The specialty truly covers all aspects of medicine; from acute presentations to chronic conditions, children to elderly patients, and active intervention to conservative care. Patients with renal disease will frequently present to other specialties due to their comorbid nature, and so renal physicians often work closely with other teams. As such, there are many MDTs that you will be able to attend, including glomerulonephritis, transplantation and lupus, to name just a few.

Renal medicine offers a valuable experience and you will play a significant role in the patient journey as patients transition from outpatient clinics to regular dialysis and hopefully onto successful transplantation. The clinician acts as a patient advocate due to the regular contact, and you will be exposed to lots of general medicine as you care for patients with renal conditions. Because of this diversity, there are a huge range of opportunities for sub-specialisation, and most renal consultants have an area of interest, whether this be clinical, management, teaching or research.

Renal medicine also comes with opportunities to engage with procedures, including kidney biopsies, dialysis line insertion (both haemodialysis and peritoneal dialysis) and even fistula formation. There is a move towards the renal physician taking a more active role in procedures on the renal unit, integrating care and ensuring better services for patients. As such, procedural training forms a large part of the renal higher speciality training programme, and you are encouraged to get involved with biopsies and insertion of dialysis lines. However, not all renal trainees want to pursue this, and others develop an interest in procedures later on in their career, and these skills can be learned no matter what stage you are.

Overview of training programme

A new curriculum for dual training in Renal Medicine and General Internal Medicine was implemented in August 2022 following the Shape of Training review and the advent of the ‘junior registrar’ role taken on in IMT3. As such, most people enter renal training as an ST4, with one year of general medical experience under their belt. Other trainees may enter via alternative routes, for example ACCS-IM or the academic clinical fellow programme. Renal medicine is a 4-year training programme, generally with at least 12 months of dedicated general internal medicine training and 3 years covering general and specialist nephrology alongside acute transplantation experience. There are different ways in which this is delivered and this will depend on which deanery you undertake your training in, but you will be expected to act as both the renal and medical registrar on call throughout the 4 years. At the end of this 4-year programme, you obtain a dual CCT (certificate of completion of training) in renal and general internal medicine. You may also choose to accredit in intensive care medicine (ICM), resulting in a triple CCT. Adding on ICM extends your training to 8.5 – 9.5 years total.

A large proportion of trainees now work less-than-full-time (LTFT), either due to family/carer commitments, other roles or academic work. This is supported throughout the UK, and you may apply for this at any stage throughout your training once discussed with your training programme director.

Exam requirements

You need to have your full MRCP(UK) to apply for and be accepted onto renal medicine higher specialty training. Most people will have completed internal medicine training or ACCS-IM, although you may be able to apply without having done these specific training programmes (see the phstrecruitment.org.uk website for further information).

Before the end of your higher specialty training and prior to gaining your CCT, you are required to have sat and passed the European Specialty Examination in Nephrology (ESENeph).

Other requirements

As with all other specialties, you will need to stay up to date with your ePortfolio and curriculum requirements throughout your training for both renal and general internal medicine. This includes completing supervised learning events (SLEs), being involved with teaching and quality improvement projects, and developing leadership and management skills.

Despite the range of procedures available to you as a renal trainee, the only compulsory procedure that you will need to be signed off for is the insertion of a non-tunnelled catheter for dialysis. Most trainees will be signed off in their ST4 year, if not during internal medicine training, as a number of trainees will have had opportunities to do this earlier on in their training. There are also a number of procedures on the general internal medicine curriculum that need signing off and maintaining.

You are encouraged to become familiar with other procedures during your training, including insertion of tunnelled dialysis lines, native renal biopsy and transplant renal biopsy.

Opportunities for out of programme research

Renal medicine has a great reputation for encouraging OOPR for those trainees who are interested, with numerous routes to obtaining a higher degree (MD or PhD). Some units may have funded clinical research fellow roles, whilst other trainees may apply directly for funding from national charities, eg. Kidney Care UK.

Research within nephrology as a whole is incredibly active, with lots of consultants combining this alongside their clinical work. As such, there are plenty of registrars and consultants around for you to talk to about opportunities.

A typical day in the life of a Registrar

Working as a renal registrar can be very demanding. Often due to the ‘hub and spoke’ nature of renal services across the country, on call shifts can encounter a significant volume of referrals from other hospitals, which presents its own unique set of challenges. However, most renal units have ‘in-reach’ teams that review patients in other hospitals alongside teams in primary care, which can help with the referrals you take. Your overnight on calls may either be on-site or non-resident, and will differ between hospitals and deaneries.

When not on call, renal medicine has a great variety of clinics, which may include general nephrology, glomerulonephritis, lupus, pregnancy, dialysis and transplantation clinics. You will most likely work closely with other specialties in these clinics, for example rheumatology, respiratory and ENT.

Your day-to-day schedule will vary depending on whether you are in a tertiary renal unit or not, and whether your renal unit performs kidney and/or simultaneous pancreas/kidney transplants.

Your regular working days may include:

Ward rounds
- These may be either of general renal patients, or new transplant recipients
- Transplantation services may be run by or alongside the transplant surgical team, depending on your unit
Procedures
- Insertion of temporary dialysis catheters for those patients presenting acutely needing to start dialysis
- Renal biopsies of both native and transplanted kidneys
- Ultrasound scanning of new referrals
Inpatient reviews
- For example, patients with new AKIs on the acute medical take, or patients with established renal disease admitted under other specialties
Dialysis reviews
- Most hospitals will have an outpatient dialysis +/- home therapies (peritoneal dialysis and home haemodialysis) unit attached to them. Sometimes patients may need reviews for renal-related problems, or sometimes for other typically ‘non-renal’ conditions if the nursing staff are concerned

Your clinic days may be separate to this, or you may be expected to split your day with ward responsibilities in the morning and clinics in the afternoon. Some units may also designate you to a dialysis ‘block’ where you are attached to a specific dialysis team or unit, or you may be assigned a cohort of patients on dialysis to manage in conjunction with their lead consultant alongside your other clinical commitments.

There will undoubtedly be a vast array of meetings for you to attend as well. All renal units will have a regular histopathology MDT where renal biopsies are reviewed and diagnoses are discussed. This presents a fantastic learning opportunity, and is of use to your own clinical learning and the exam! Other MDTs will depend on the specialist services available at your unit, but can include vasculitis, lupus, pregnancy, transplantation and vascular access.

Pros and Cons of working in this specialty

Pros

Renal medicine is a fascinating speciality with lots of interesting conditions, necessitating thorough clinical decision making and team working.
It is a true multidisciplinary specialty and rich in interactions with other medical and surgical disciplines.
There have been huge advances in treatment and technology (eg. Plasma exchange, new glomerulonephritis treatments), and there is a great reward from seeing patients with improving symptoms and renal function due to interventions made.
Along with this, there is a huge scope for academia and research within nephrology, and trainees are encouraged to take time out of programme to pursue research interests should they wish.
You may also encounter patients enrolled in clinical trials whilst they are admitted to the wards eg. Anti-GBM disease and vasculitis studies, offering first-hand experience of research.
You will encompass the very young to the very old, and the very well to the very sick – there truly is the whole breadth of medicine available to you as a renal physician.
You will see all aspects of the patient journey, and may see someone through from advanced kidney care clinics, onto dialysis, and to transplantation and beyond.
There are opportunities to become involved in practical procedures and interventional nephrology.
There are plenty of opportunities for service delivery and design, including implementation of community and primary care resources and national guidelines.
Renal medicine is a fascinating speciality with lots of interesting conditions, necessitating thorough clinical decision making and team working.
It is a true multidisciplinary specialty and rich in interactions with other medical and surgical disciplines.
There have been huge advances in treatment and technology (eg. Plasma exchange, new glomerulonephritis treatments), and there is a great reward from seeing patients with improving symptoms and renal function due to interventions made.
Along with this, there is a huge scope for academia and research within nephrology, and trainees are encouraged to take time out of programme to pursue research interests should they wish.
You may also encounter patients enrolled in clinical trials whilst they are admitted to the wards eg. Anti-GBM disease and vasculitis studies, offering first-hand experience of research.
You will encompass the very young to the very old, and the very well to the very sick – there truly is the whole breadth of medicine available to you as a renal physician.
You will see all aspects of the patient journey, and may see someone through from advanced kidney care clinics, onto dialysis, and to transplantation and beyond.
There are opportunities to become involved in practical procedures and interventional nephrology.
There are plenty of opportunities for service delivery and design, including implementation of community and primary care resources and national guidelines.

Cons

Renal medicine is a demanding job with lots of referrals, making the on call shifts quite busy, however this means your diagnostic skills will be honed in no time!
You will be involved with important decision making on remote patients which can be challenging.
Patients with renal disease are often significantly comorbid and will present to other specialties. Other teams looking after them may not be expert at managing renal patients, therefore sometimes patients may be admitted under the renal team to facilitate their dialysis, for example. You also may have to optimise patients before they go for procedures, eg. coronary angiogram, which can sometimes take longer if patients aren’t under the direct care of that team.
Given the regular contact dialysis and transplant patients have with renal teams, you may often feel like you have taken on an additional role as the ‘renal unit GP’. In fact, renal physicians often know their patients better than a lot of GPs, and there is a significant level of trust that renal patients develop with their doctors and nurses – it truly is a privilege!

How this specialty differs to others and why I chose it

Renal medicine is one of the last true general medical specialties, and you will encounter a wide range of medical, surgical and psychological aspects to the patients you look after. As such, you will get the opportunity to work with a huge team, including dedicated renal dietitians and counsellors, dialysis and transplant nurses and doctors from other specialties in the hospital. The continuity aspect of nephrology is unique, and you will likely look after patients over many years as they transition through the service, which is a hugely rewarding job. Patients are able to trust and confide in you, and you are able to make a great impact on their lives and those of their families, for which they are truly grateful.

One of the main reasons I chose to pursue a career in renal medicine was because of the team I worked with during my internal medicine training. They were a fantastic group of people, all of whom had the utmost respect for their patients and one another, and all of the renal teams I have worked with since have been equally as fantastic colleagues.

Tips for success in applying for this specialty

Renal medicine may feel like a lot of unknowns unless you have had a rotation within the specialty. Even if you don’t have a job in nephrology, the acute medical take is full of renal patients and those with underlying autoimmune diseases, and so there are plenty of opportunities to increase your clinical knowledge.
You should approach consultants and/or registrars to show your interest, and you can also ask about getting involved with departmental quality improvement projects and/or audits. You may also want to get involved with procedures, including dialysis lines and biopsies.
There are plenty of opportunities outside of work for you to get involved with too, including presenting audit/QIPs at local and national conferences. The UK Kidney Association also run an annual conference and taster event which are fantastic experiences, and other conferences are held by relevant societies that you may wish to attend, eg. British Transplantation Society.