The HSE is seeking additional funding to include chronic kidney disease (CKD) in the GP chronic disease management (CDM) programme in 2025, it has confirmed. The prevalence of CKD is significantly increasing in Ireland. Some 15.6 per cent of people aged 50 and over have CKD, but most are unaware, according to research published last year by TILDA and the National Renal Office (NRO).

The HSE has stated that recommendations from a review of the NRO are still being considered in the context of health service structural changes. The review was commissioned to examine the current and future work of the NRO, which was established in 2009 before the initiation of the HSE clinical programmes. Its original remit was end-stage kidney disease. The office now requires support for work in other areas, including preventative nephrology.

Commenting on the inclusion of CKD into the CDM programme, the Irish Kidney Association said: “We need to see the Government include provision for this positive development in the forthcoming Budget. We have seen the benefits for cardiac care as well as diabetes and hypertension management. Including CKD will be a significant move towards proactive health management in the general population. Remember, one-in-10 in the population has CKD, including one-in-seven of those over the age of 50.”

General practice completed 99,098 reviews of patients enrolled in the CDM programme in the first two months of 2024, according to figures provided to NiGP. The Department of Health also confirmed that it believes the programme is “the main contributing factor” in a reduction of chronic disease-related hospital admissions in recent years.

“The CDM programme forms part of the wider enhanced community care programme which has improved patient care and provided ongoing improvements to how health services are delivered,” said the Department’s spokesperson.

This reduction in hospital admissions was discussed at the Sláintecare programme board meeting in April. Board members were shown data that indicated a 16 per cent reduction in chronic disease-related hospital admissions as compared to a 3.5 per cent reduction in all other medical admissions per 100,000 population between 2019 and 2023.

The meeting was also told that 91 per cent of patients on the programme “are now fully managed routinely in primary care” and are not attending hospital for ongoing management of their condition. The CDM programme commenced in 2020. It has been rolled out on a phased basis to adult patients with a medical or GP visit card. Approximately 94 per cent of eligible GPs have signed up to providing the CDM programme.

Despite a range of enduring challenges, the future of kidney care and nephrology research in Ireland looks positive, according to Irish Nephrology Society (INS) President Prof Donal Reddan, Consultant Nephrologist and Honorary Professor at Galway University Hospital.

Speaking to Update, Prof Reddan discussed some of the most prominent problems in nephrology services and potential solutions to them, recent and ongoing developments at the INS and beyond, and his personal highlights from the recent INS Annual Scientific Meeting.

He said “it was great to see” so many of his colleagues from Northern Ireland as well as many senior Irish renal consultants at the meeting, which took place in the Gibson Hotel, Dublin, from 14-15 June, and said he is delighted with the growing cross-border relationships.

“The paediatric aspects were definitely a highlight,” Prof Reddan said in reference to the primary theme of the meeting, which celebrated 21 years of childhood transplants in Ireland.

He acknowledged the diverse range of speakers, clinicians, and guests that took part in the paediatric talks, including former international rugby player and Temple Street ambassador Brian O’Driscoll, and Consultant Transplant Surgeon Ms Dilly Little, National Kidney Transplant Service at Beaumont Hospital, Dublin, who Prof Reddan described as a “fantastic servant” to renal patients.

“It was also fantastic to see Dr Mary Waldron acknowledged for her significant contribution by her peers in paediatric nephrology,” he added. Commending all of the speakers and presenters for the “excellent quality” of the talks throughout, Prof Reddan said that “another big highlight” was the content related to genetics.

During the session entitled ‘Genetics in kidney disease – New frontiers’, Prof Catherine Quinlan, University of Melbourne, Australia, delivered an engaging talk entitled ‘Enhanced variant analysis in genetic kidney disease – Insights and practical applications’, and Prof Dervla Connaughton, Western University, Ontario, discussed genetic kidney disease and age.

“It’s exciting,” Prof Reddan said, “genetic testing will be able to identify a lot of reasons why people have kidney disease, as well as increase our understanding of kidney disease itself.”

Priorities for improvement

Describing the “big challenge” in nephrology, Prof Reddan highlighted the persistent and substantial rise in renal patients across the country, and the lack of “capacity to deal with the workload and the number of patients coming” into renal services. “Dialysis has gone up by 3 per cent consistently over the last 10-to-15 years, and we don’t have the resources in haemodialysis centres to cope with that,” he said.

Prof Reddan also described how fewer transplants occurred during Covid-19 and the impact this has had on patients. He went on to outline the “short-term solutions” currently being put in place, such as additional ‘twilight’ shifts and temporary additional dialysis spaces in centres that are already at full capacity.

“It’s a really big issue in the west where I work clinically, but all areas are affected and it reflects global trends,” he added, noting that these measures are impacting other services, such as home therapies, due to lack of actual space and staff to run them.

Prof Reddan went on to offer solutions, saying: “I think we need to push home therapies more.” He emphasised the work Prof George Mellotte, Consultant Nephrologist at St James’s Hospital and Tallaght University Hospital, Dublin, has done, and continues to do, in the development of home renal replacement services in his capacity as National Renal Office lead.

“We can’t start PD (peritoneal dialysis) or home haemodialysis in five minutes though,” Prof Reddan added, and stressed the need for more resources in the long-term, as well as short-term solutions until home therapies can be further developed across the country.

As well as improved access to home therapies, Prof Reddan also emphasised the importance of increasing transplant numbers. “We talk about home therapies, but if we did more transplants, we would have more room.

“We need more living donors and support. We have an excellent transplant service and we need to expand it… The new Human Tissue Bill is also very important.”

Prof Reddan also told Update that because of increasing longevity, a lot of older people with complex comorbidities are now starting on haemodialysis, many of whom “are not suitable candidates for kidney transplant or home dialysis”. These patients will remain on in-centre haemodialysis for the rest of their lives; therefore, capacity issues have to be addressed for this cohort, he said.

“It’s really a glass half full story more than half empty though. The interventions that we’re doing in nephrology, that are happening in cardiovascular health, in older persons care, across the board – they allow people to live longer.

People are living longer, so many of them develop chronic kidney disease, but the reality is that a lot of these patients wouldn’t have lived that long had they not received such excellent care.”

Cooperation and collaboration

Talking about developments in Irish nephrology, Prof Reddan told Update that there is “a big push and a lot of cooperation” taking place to establish a national renal registry, and to “coordinate and organise the data”. Prof Austin Stack, Consultant Nephrologist, University Hospital Limerick; Prof Peter Conlon, Consultant Nephrologist, Beaumont Hospital, Dublin; and Dr Conor Judge, Senior Lecturer and Consultant Nephrologist at Saolta University Health Care Group “have been very important, along with many other leaders and drivers”, he said.

“There has also been a lot of work going on behind the scenes within the INS, and by [Prof] George Mellotte at the National Renal Office, with support from the CCO Dr Colm Henry and several others to coordinate that sort of effort,” Prof Reddan added.

“It’s fantastic to see everybody collaborating, cooperating, and working together. This is so important. With a renal register, we can look for the resources and services our patients need, report the data, and compare ourselves with other European countries… One of the huge benefits we are going to see is if we have better data, we can get more resources.”

Renewed governance structures within the INS are also a “key development since the last [annual] meeting”, according to Prof Reddan. “There’s now formally a Board established for the INS,” he said, and added that former President Prof Liam Plant, Consultant Nephrologist, Cork University Hospital, “deserves a massive amount of credit” for his role in establishing the new system of governance. “It means we can plan for the future and have proper discussions about where we want to go.”

Returning to the strengthening of cross-border collaboration, Prof Reddan said that “on the Board, we have a number of subcommittees, as well as a person that specifically represents the interests of the people in the North and to make sure we are aligned with and supporting each other”.

“The primary objectives of the INS are to improve kidney care for patients in Ireland and to advocate for those patients, to advocate for research, and to build collaboration and teamwork with the Board. We also have a specific new research committee, and that committee is driving the register, a lot of collaboration, and a lot of other research…. Overall, I think things are looking up.”

Concluding, Prof Reddan acknowledged some of “the excellent and exciting” developments and research taking place in Ireland on both sides of the border. “I also see a lot of the big work happening in genetics and there’s more developments in the epidemiology and interventions of chronic kidney disease. There’s also very strong work from Prof Mark Little and his colleagues in vasculitis. It’s all looking positive.”