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However, the incidence and absolute risk of ESRD remained quite low (Vivante, 2011) Renal ultrasound should be offered to all people with CKD who have: (i) progressive CKD (ii) visible or persistent non-visible haematuria (iii) symptoms of urinary tract obstruction, (iv) a family history of polycystic kidney disease and are over 20 years old (v) stage 4 or 5 CKD (vi) require a kidney biopsy • Doppler Ultrasound of the renal arteries may be useful in patients with uncontrolled hypertension, looking for renovascular disease. These patients often also have peripheral vascular disease, and AAA.Though this test has a significant false positive and negative rate.Until recently, the care of kidney patients has been largely under the domain of nephrologists in secondary care However, the increasing number of people diagnosed with chronic kidney disease (CKD; previously termed chronic renal failure) along with the more active treatment of end-stage renal disease (many more people have access to dialysis now than even a decade or so ago) means that: (i) more of the care has been streamlined into nurse-led clinics (ii) the earlier stages of renal disease are now being managed in the community by GPs This latter strategy means that an ever-wider group of healthcare professionals is obliged to have an understanding and basic knowledge of issues in relation to patients with CKD.The aim of this section is to discuss the prevalence, detection, evaluation and management of this condition Several epidemiologic studies have indicated that there is a high prevalence of CKD in the general population.A positive HIV test may suggest underlying HIV-associated nephropathy (HIVAN), which may present with renal impairment and proteinuria - and almost exclusively occurs in black people • Renal biopsy.In patients with renal impairment and/or proteinuria of more than 1 g/L (PCR 100), a renal biopsy may be required to elucidate the cause of underlying CKD, provided this is technically feasible.So the test should be called ' Haem' which is a more accurate term for what the test is detecting, rather than the term 'blood'.Haem is found within haemoglobin (free in the urine or within erythrocytes) or myoglobin.

Several glomerulonephritides may be driven by viruses and other infectious agents (eg Hep B, Hep C, HIV).

Persistence of asymptomatic NVH (defined as at least two out of three positive NVH dipsticks) is also considered significant.

Trace haematuria should be considered negative It is important to Investigate symptomatic and persistent asymptomatic haematuria by: (i) excluding UTIs or other transient causes (ii) checking creatinine/e GFR (iii) sending urine for ACR or PCR on a random sample (iv) measuring blood pressure (BP) (BAUS/RA 2008) Key Point: all patients with significant visible or symptomatic non-visible haematuria, and patients over the age of 40 years with symptomatic non-visible haematuria, should be referred to urology, to exclude carcinoma - using the 2 week cancer wait system An exception of referring directly to a nephrologist may be a young adult who has haematuria (cola-coloured!

In September 2008, the NICE guideline on CKD (NICE 2008) updated the staging of CKD.

The previous stage 3 (30–59 ml/min) was subdivided into stage 3A with an e GFR of between 45 and 59 ml/min/1.73m2, and stage 3B with an e GFR of between 30 and 44 m L/min/1.73m2 In addition, it recommended that the suffix ‘p’ be placed after the stage to denote the presence of proteinuria, where proteinuria is defined as urinary ACR 10 ml/min/1.73m2 within five years Proteinuria can be glomerular or tubular.

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End-stage renal disease is associated with considerable morbidity and a high mortality (UK Renal Registry 2009), as well as affecting quality of life Furthermore, the costs of ESRD are considerable.

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