Scottish Renal Association – 29/30 November 2013 – Glasgow. Medical presentations 1. Anticipatory care planning in the renal unit Francesca Harvey, Ashley Pumphrey, Nicola Joss Renal Unit, Raigmore Hospital, Inverness Patients with chronic illnesses should have the opportunity to discuss future plans and wishes regarding end of life care. In the renal unit at Raigmore Hospital (excluding satellite units) we have been offering the opportunity for anticipatory care planning for haemodialysis patients since April 2011. A renal GP and renal nurse with Consultant support have spent time offering this service. A screening tool is used to identify patients who should be offered ACP. A patient symptom review leads into full ACP discussions. We present data on ACPs and deaths in the haemodialysis population between April 2011 and June 2013. 30 patients have had an ACP in place, 4 patients approached but have declined to have further discussions. This represents 26% of our prevalent HD patients between April 2011 and June 2013. Currently 12 patients have an ACP in place representing 22% of our prevalent patients. There were 29 deaths (18 male, 11 female, mean age 67.8) in the 27 month period. 24 patients had more than 5 comorbidities with only 5 patients having less than 5 comorbidities. The median time on dialysis for these 29 patients was 71 months (range 3-312 months). An ACP was in place for 18 patients, of these 16 had a DNA CPR order. There were 2 ACPs which specifically requested CPR and a further 2 patients who had no ACP but had a DNA CPR order. The mean age for patients with an ACP was 69.2 years. The mean age of the 11 patients who died without an ACP was 64.5 years. The causes of death were: cardiac arrest (n=8), planned withdrawal (n=8), myocardial infarction (n=5), pneumonia (n=2), post surgery (n=2), cardiac failure (n=1), haemorrhage from fistula (n=1), metastatic carcinoma(n=1) and IHD (n=1). Seventy two percent of deaths were expected (of these 71% had an ACP in place). Places of death were: hospital (n=14), home (n=9), public place (n=3), hospice (n=2) and nursing home (n=1). Withdrawal of dialysis occurred in 8 patients (5 died at home, 2 hospice, 1 hospital), 7 of these patients had an ACP. Of the unexpected deaths (n=8) 3 had a cardiac arrest in a public place, 2 died post access surgery, 1 died from haemorrhage from fistula at home, 2 died from presumed MI at home. Six of these patients had no ACP in place. 83.5% of patients who had an ACP in place had their wishes upheld. Anticipatory care planning is a time consuming but rewarding process. We are trying to identify patients who we think maybe in their final year of life. Sixty two percent of HD patients who died between April 2011 and June 2013 had an ACP in place. No conflicts of interest
Transcript
Scottish Renal Association – 29/30 November 2013 – Glasgow. Medical presentations
1. Anticipatory care planning in the renal unit
Francesca Harvey, Ashley Pumphrey, Nicola Joss
Renal Unit, Raigmore Hospital, Inverness
Patients with chronic illnesses should have the opportunity to discuss future plans and wishes regarding end of life care. In the renal unit at Raigmore Hospital (excluding satellite units) we have been offering the opportunity for anticipatory care planning for haemodialysis patients since April 2011. A renal GP and renal nurse with Consultant support have spent time offering this service. A screening tool is used to identify patients who should be offered ACP. A patient symptom review leads into full ACP discussions.
We present data on ACPs and deaths in the haemodialysis population between April 2011 and June 2013. 30 patients have had an ACP in place, 4 patients approached but have declined to have further discussions. This represents 26% of our prevalent HD patients between April 2011 and June 2013. Currently 12 patients have an ACP in place representing 22% of our prevalent patients.
There were 29 deaths (18 male, 11 female, mean age 67.8) in the 27 month period. 24 patients had more than 5 comorbidities with only 5 patients having less than 5 comorbidities. The median time on dialysis for these 29 patients was 71 months (range 3-312 months). An ACP was in place for 18 patients, of these 16 had a DNA CPR order. There were 2 ACPs which specifically requested CPR and a further 2 patients who had no ACP but had a DNA CPR order. The mean age for patients with an ACP was 69.2 years. The mean age of the 11 patients who died without an ACP was 64.5 years.
The causes of death were: cardiac arrest (n=8), planned withdrawal (n=8), myocardial infarction (n=5), pneumonia (n=2), post surgery (n=2), cardiac failure (n=1), haemorrhage from fistula (n=1), metastatic carcinoma(n=1) and IHD (n=1). Seventy two percent of deaths were expected (of these 71% had an ACP in place). Places of death were: hospital (n=14), home (n=9), public place (n=3), hospice (n=2) and nursing home (n=1). Withdrawal of dialysis occurred in 8 patients (5 died at home, 2 hospice, 1 hospital), 7 of these patients had an ACP. Of the unexpected deaths (n=8) 3 had a cardiac arrest in a public place, 2 died post access surgery, 1 died from haemorrhage from fistula at home, 2 died from presumed MI at home. Six of these patients had no ACP in place. 83.5% of patients who had an ACP in place had their wishes upheld.
Anticipatory care planning is a time consuming but rewarding process. We are trying to identify patients who we think maybe in their final year of life. Sixty two percent of HD patients who died between April 2011 and June 2013 had an ACP in place.
No conflicts of interest
2. Areas of clinical concern which contributed to or caused death in patients on RRT - a review of the Scottish Mortality Audit of Renal Replacement Therapy (SMARRT) data 2008-2012. Mark Findlay1, Jamie Traynor2, Wendy Metcalfe3 & Bruce Mackinnon1; 1 Glasgow Renal & Transplant Unit. 2Technical Director SRR. 3Chair SRR - On behalf of the SMARRT steering group Introduction After every death of a patient receiving RRT in Scotland their clinician considers the circumstances of death, recording the presence or absence of areas of concern using a five point scale. This ranges from “no areas of concern” through to “areas of concern which caused the death of this patient”. We present here demographic data on all deaths among RRT patients in Scotland between 2008 and 2012. Furthermore, a detailed analysis of those cases where areas of concern in management that have contributed to or caused death in undertaken. Methods Data on age, modality of RRT, circumstances, cause and location of death were collected via an audit form available to all renal units throughout Scotland and entered retrospectively into the SRR database. Where the management of the patient was categorised as contributing to or causing death further details of the circumstances of death were obtained. For deaths occurring in 2008 and 2009 this was undertaken by a group of consultant nephrologists performing a case note review. For deaths occurring in 2010 to 2012 further details were obtained from reports of morbidity and mortality meetings, critical incident reviews or investigations undertaken by procurators fiscal. From analysis of this additional information themes were identified. Each theme was further analysed to identify the recurrent issues for descriptive purposes. Results 2172 deaths occurred in the period 01 Jan 2008 – 31 Dec 2012. 1271 were male (58.5%). Median age at death was 71.8 years (18-98). Areas of clinical concern which may have contributed to or caused death were identified in 82 cases (3.8%). Seven themes were identified; hyperkalaemia, prescribing, systems of care, infection, vascular access, complications of intervention and other. Infection made up the largest single group (33%). Hyperkalaemic deaths tended to occur in younger patients (31 vs. 65.5 years). Analysis within each theme revealed line sepsis accounts for 44% of infection related concerns. Anticoagulant drugs, opioids and immunosuppressants were collectively responsible for 85% of prescribing related concerns. More than one third of the systems of care concerns were caused by delayed diagnoses (37%). Conclusions Significant areas of clinical concern are uncommon in this population accounting for <5% of all deaths over a 5 year period. The majority of adverse events, leading to death which affect patients receiving RRT are the result of commonly occurring problems such as infection, hyperkalaemia and the organisation of care rather than being related to the delivery of RRT itself. Efforts to improve patient safety should focus on these commonly identified areas of harm. Source of funding: None. Conflicts of interest: None
3. Fracture incidence in patients on Renal Replacement Therapy
T E Farrah1, V Dey2, J P Traynor3, E Spalding2, S Robertson4, C C Geddes 1
1 Glasgow Renal and Transplant Unit
2 Renal Unit, University Hospital Crosshouse
3 Renal Unit, Monklands Hospital
4 Renal Unit, Dumfries and Galloway Royal Infirmary
Introduction Patients on renal replacement therapy (RRT) are at increased risk of bone fracture because of altered bone metabolism termed Chronic Kidney Disease-Mineral and Bone Disorders (CKD-MBD). The true fracture incidence and consequent risk of fracture in prevalent RRT patients and the association with surrogate markers of CKD-MBD is poorly defined. Aim The aim was to quantify the incidence of radiologically proven bone fracture in prevalent RRT patients and compare renal transplant and dialysis patients. Methods We undertook a retrospective analysis of electronic patient records for all prevalent renal transplant (RT), haemodialysis (HD) and peritoneal dialysis (PD) patients across the West of Scotland. Our entry point was 7th July 2010 except for patients from Lanarkshire (01/07/2011) and patients were followed until August 2013. All radiology reports from all hospitals in the West of Scotland attached to patients’ records were included and searched to determine the number of fractures per 1000 patient days. The endpoint of follow up was defined by date of death or last documented biochemistry result. Results We identified 2096 patients on RRT at the start of the study. The prevalence of RRT modality at entry was: RT 1081 patients (51.6%), HD 907 patients (43.3%) and PD 108 patients (5.2%).The mean age of RT patients was 50.4 ±15.3 years, HD patients 61.8 ± 15.8 years, PD patients 57.9 ± 15.3 years. Median duration of follow up for RT patients was 1112 days, range 8-1155; HD patients 1086 days, range 4 – 1189, and PD patients 1126 days, range 13-1155. Fracture incidence for each RRT modality was RT: 0.10 fractures per 1000 patient days, HD: 0.28 fractures per 1000 patient days, PD: 0.17 per 1000 patient days. Conclusions Our study suggests that fracture incidence may be higher in patients on haemodialysis compared to renal transplant patients and patients on peritoneal dialysis. Further research is warranted to determine if the association between RRT modality and fracture incidence is independent of other risk factors for fracture
4. Fosfomycin – Is a second dose needed?
Authors: Ying Xuan Gue1, Dana Kidder1
Affiliations: 1 Renal Unit, Ninewells Hospital, Dundee, Scotland
Fosfomycin is a broad spectrum antibiotic commonly used to treat uncomplicated urinary tract infections (UTIs). It is usually administered orally as a single dose antibiotic. However, it is not clear if there is a difference between single and multiple dose treatment in terms of time to recurrence of UTI. Similar uncertainty exists with the use of Fosfomycin in renal transplant population.
Aim
In this single centre retrospective analysis we examined the use of Fosfomycin using dispensary records. The aim of this study was to examine the impact of single versus multiple doses of Fosfomycin on the time to recurrence of UTI.
Methods
Data on the use of Fosfomycin over the period from December 2010 to March 2013 were collected from the dispensary of Ninewells Hospital, Dundee, Scotland. Electronic data on age, sex, baseline eGFR and type of uropathogens were gathered. Patients were divided, broadly, into those with single versus multiple Fosfomycin doses. The time from treatment to the next positive urine culture was calculated in days for each patient.
Results
A total of 79 patients who received Fosfomycin therapy over the specified period were included in the analysis. Fifty patients had a single dose and twenty-nine patients had multiple doses. There was no significant statistical difference between both groups in the time to recurrence of UTI (p=0.89). Similarly, we could not demonstrate any advantage of multiple dosing in the renal transplant patients (11 versus 16, p =0.6).
Conclusion
There is no significant difference between single versus multiple Fosfomycin doses. Single dose treatment should be preferred as compliance will be improved whilst reducing adverse effects and costs.
5. Incidence and outcomes of Acute Kidney Injury requiring renal replacement therapy in Tayside
Huizinga TJW1, Bell S1 1 Ninewells Hospital, Dundee
Introduction: The incidence of Acute Kidney Injury (AKI) requiring dialysis is rising globally and is associated with high mortality and morbidity. KDIGO (Kidney Disease: Improving Global Outcomes) proposed a uniform standard to diagnose and classify AKI in 2007. The aim of this study was to compare the incidence of AKI requiring renal replacement therapy (RRT) during 2012 in Tayside with previous data, and determine the impact of RRT on morbidity, mortality and hospital stay.
Methods: We retrospectively examined all patients who underwent RRT in Ninewells Hospital from the 1st January 2012 to 31st December 2012. This included patients in the Intensive Care Unit (ICU), medical and surgical high dependency areas and the renal ward. Patients with known End-Stage-Renal-Disease (ESRD) established on dialysis were excluded. Conventional and electronic patient records were used to collect outcome data at discharge, 90 days and 12 months.
Results: We identified 179 individuals who received RRT during 2012.
The incidence of AKI requiring RRT was calculated as 430 per million population per year. Of all patients requiring RRT, 65% were male, 24% was diabetic and the mean age was 67 years (SD+ 14.68 years). 45% had pre-existent Chronic Kidney Disease (CKD) stage 3,4 or 5 (n=61, 13 and 2 respectively). Median length of hospital stay was 21 days (IQR of 9 to 38). In-patient mortality was 36%, with mortality at 90 days and 1 year 44% and 54% respectively. In-patient mortality was significantly higher in patients receiving their first dialysis in ICU or Higher care, compared to the ward (41.2% and 45.3% vs 6.2% respectively, p<0.001). Six percent of all patients remained dialysis dependent after discharge, half of these had CKD stage 3 or higher on admission. Only one third of all patients regained full renal function on discharge and at 90 days (29.9% and 31.6% respectively).
Conclusion: The incidence of AKI requiring RRT in our study is remarkably higher than estimated in previous studies performed in Scotland. AKI requiring RRT is associated with high mortality and impaired renal recovery in our population.
6. Hospital Mortality at the Weekend: Case-mix or Consultant Working?
R Haddock, C Deighan, P C Thomson. Western Infirmary Renal Unit, Glasgow.
Introduction: There are longstanding fundamental variations in National Health Service provision between weekend and weekday periods. This has been a highly publicised topic of political debate with a recent report suggesting a 10% increase in mortality of patients admitted at weekends. This study aims to assess in-patient mortality patterns by day of the week, in a tertiary referral renal unit with established 7-day consultant working, over a 2-year observation period.
Methods: All admissions to the Renal Unit at the Western Infirmary Glasgow from 1st August 2011 to 31st July 2013 were identified by searching the Strathclyde Electronic Renal Patient Record database. Mortality related to day of admission and related to day of death was analysed. Data on bed occupancy for each day of the week was collated. The typical caseload of the department was also assessed by detailing the circumstances of each patient’s admission over a concurrent 4-week period of observation.
Day of Admission Data. There were 46 deaths within 30 days of admission amongst patients admitted on a weekend day, compared with 107 deaths within 30 days of admission amongst patients admitted on a weekday. This equates to a 30-day mortality incidence of 46/208 = 0.22 deaths per weekend day, compared with 107/523 = 0.20 deaths per week-day. When expressed as a proportion of admissions, 30-day mortality was higher for those admitted on a weekend day 46/540 (8.5%) compared with those on a week day 107/2013 (5.3%) (RR 1.60, 95% CI 1.15 to 2.23, p=0.005).
Day of Death Data. There were 48 deaths within 30 days of admission over 8118 in-patient weekend days (48/8118=0.0059 deaths per patient weekend day) compared with 105 deaths within 30 days of admission over 21854 in-patient week days (105/21854=0.0048 deaths per patient week day). This provides a relative risk of 1.23 (95% CI from 0.88 to 1.73, p=0.23) with regard to risk of death on a weekend day.
When investigating case mix, we found a greater proportion of inter-hospital transfers occurred during weekend days than week-days. Notably over a 4 week sample of admissions, there were 10 acute kidney injury (AKI) admissions out of 8 observed weekend days (rate of 1.25/day) compared with 12 out of 20 observed weekdays (rate of 0.6/day). When expressed as a proportion of admissions, AKI accounted for 10/23 weekend admissions and 12/64 weekday admissions (43.5% and 18.8% respectively).
Discussion: Our results support previous research by indicating higher mortality for patients admitted on a weekend. When considering mortality on a given day of the week, we showed no significant difference in relative risk when comparing in-patients present at the weekend to those present on a weekday. These data are generated in a unit with 7-day consultant working.
6. Numerous variables from staffing, clinical resources and interval since dialysis may influence the mortality rate. Our data suggest that the population of patients admitted at the weekend is of a different demographic to those admitted during the working week. This study suggests that case-mix may be an important variable to consider when performing more detailed investigation on weekend admission mortality rates.
7. Mycofenolate mofetil therapy in IgA Nephropathy: Histological changes after treatment
Hannah Beckwith, Nicholas Medjeral-Thomas, Jack Galliford, Megan Griffith, Jeremy Levy, Liz Lightstone, Andrew Palmer, Candice Roufosse, H. Terence Cook and Tom Cairns.
Imperial College Kidney and Transplant Institute, London, UK.
Background:
Endocapillary hypercellularity independently predicts renal outcome in IgA Nephropathy (IgAN)1. Mycophenolate mofetil (MMF) treatment is offered to patients presenting to the Imperial College Kidney and Transplant Institute with IgAN and histological evidence of endocapillary inflammation. Clinical trials of MMF in IgAN have been inconclusive. Evidence of histological improvement following MMF treatment would support its therapeutic use. We therefore reviewed histological changes after MMF therapy in a cohort of IgAN patients.
Method:
Eleven IgAN patients with repeat native renal biopsies before and after MMF treatment were identified. Patients were excluded if they had received any other immunosuppression therapy, including corticosteroids. Based on the Oxford classification of IgAN1, we reviewed histological changes after MMF treatment.
Results:
Seven patients (60%) were male. At diagnostic renal biopsy, median age was 42 (range 19-67), serum creatinine was 127umol/L (56-233), and urine protein creatinine ratio (UPCR) was 157 mg/dl (67-224). The median time between biopsies was 29 months (14-41).
Following MMF treatment, repeat biopsy demonstrated statistically significant improvement in the mean percentage of glomeruli showing endocapillary hypercellularity and cellular/fibrocellular crescents. A significant reduction in IgA deposition (p=0.04) and a trend towards improved mesangial hypercellularity (p=0.05) was also demonstrated. There was no change in tubular atrophy. Median serum creatinine remained stable at 3 years follow-up at 110umol/L (59-421).
Conclusion:
MMF treatment is associated with histopathological improvement in IgAN.
References1. Cattran D, Coppo R, Cook T et al. The Oxford classification of IgA nephropathy: Rationale, clinicopathological correlations, and classification. Kidney Int 2009; 76: 546-556
Biopsy 1 Biopsy 2 p-value
Glomeruli with endocapillary hypercellularity, mean % (SD)
11.0 (14.3) 1.60 (4.03) <0.01
Tubular atrophy, mean % (SD) 21.8 (11.9) 18.1 (16.4) 0.23
Glomeruli with crescents, mean % (SD)
7.69 (8.77) 1.60 (3.25) <0.01
8. PHOSPHATE HAS DELETERIOUS EFFECTS ON VASCULAR FUNCTION
Kate Stevens, Rajan K. Patel, Laura Denby, Godfrey L. Smith, Marc Clancy, Christian Delles and Alan G. Jardine.
Renal Research Group, University of Glasgow, Glasgow, United Kingdom.
Background: Elevated serum phosphate is an independent risk factor for cardiovascular disease. Whether this is a direct effect of elevated phosphate or dependent on changes in intracellular calcium or calcium/phosphate product is unknown. We examined the direct effects of phosphate concentration in human resistance vessels and human umbilical vein endothelial cells (HUVECs).
Methods: Surplus adipose tissue was removed from patients with chronic kidney disease (CKD) stage 5 undergoing live donor transplantation and their normal donors. Resistance vessels were dissected and incubated in a physiological saline solution (PSS) with normal (1.18mM) or high phosphate concentration (2.5mM) for 16 hours, then mounted on a myograph. Vasoconstrictor responses to phenylepherine (PE) and vasorelaxation responses to carbachol and sodium nitroprusside (SNP) were measured. Concentration-response curves were constructed for PE, carbachol and SNP. Area under the curve (AUC) was calculated and comparisons were made using either a t test or an ANOVA. HUVECs were grown in normal (0.5mM) and high (3mM) phosphate medium. eNOS and nitrotyrosine expression were measured by Western blot and intracellular calcium concentration measured by epifluorescence with FURA 2 AM. Gene expression was studied with PCR.
Results: Vessels from patients with and without CKD incubated in high phosphate relax less well to carbachol (p<0.05). Vessels from patients without CKD relax less well to SNP (p<0.05); this difference is not seen in vessels from patients with CKD. Expression of total and phospho eNOS was reduced in HUVECs grown in high phosphate whilst nitrotyrosine expression was increased. Calcium concentration was not significantly different between HUVECs grown in high and normal phosphate. Genes involved in the cell cycle and growth were upregulated and expression of the phosphate transporters PiT1 and PiT2 was unchanged. HUVECs express Klotho and the FGF 1 receptor.
Conclusions: Elevated phosphate decreases endothelium dependent vasodilatation in patients with and without CKD. This may be a marker of endothelial dysfunction, supported by the reduced eNOS protein expression and increased nitrotyrosine expression seen in HUVECs. Elevated phosphate also impairs endothelial independent relaxation in vessels from healthy patients without CKD. These experiments indicate direct effects of elevated phosphate on the NO system, and on vascular function, and support the notion that phosphate has direct effects in uremia.
Funding: British Heart Foundation Junior Clinical Research Fellowship Conflicts of Interest: None
9. SUSTAINED PHOSPHATE LOADING IMPAIRS ENDOTHELIAL FUNCTION: A SINGLE BLIND CROSS OVER TRIAL
Kate Stevens, Rajan K. Patel, Patrick B. Mark, Christian Delles and Alan G. Jardine.
Renal Research Group, University of Glasgow, Glasgow, United Kingdom.
Background: Serum phosphate is linked with increased cardiovascular risk although the mechanism of action is unclear. The effect of sustained short term phosphate loading on endothelial function has not previously been studied. This study considers the effect of phosphate loading on endothelial function measured by flow mediated dilatation (FMD).
Methods: Healthy volunteers attended for a baseline and 2 subsequent visits. Blood was drawn for measures including bone biochemistry, vitamin D, FGF-23 and klotho. A 24-hour urine collection was performed prior to attendance and analysis included urinary cGMP and FGF-23 concentrations. FMD was recorded. Volunteers were randomized to take lanthanum carbonate (LC) or Phosphate Sandoz (PS) for 2 weeks prior to the next visit. After a wash out period, volunteers took the other drug and attended for a final visit. One individual, blinded to the order of drug ingestion, performed and analysed each FMD measure.
Results: Of 19 participants, 12 were female. At baseline, mean age was 42±14 years, eGFR 102±10ml/min, serum phosphate 1.05±0.18mmol/L and fractional excretion of phosphate (FeP) 14.3±3.4%. Median FMD was 8.4% (IQR 6.2-11.6%) post cuff inflation. After PS, there was a trend towards a higher serum phosphate within the normal range. FGF-23 and FeP rose significantly compared to baseline (p=0.013, p<0.001). FMD post cuff inflation reduced significantly (3.38% (IQR 2.57-5.26%), p<0.001). With LC, serum phosphate was unchanged. FeP fell (11.4±4.3, p<0.001). Post cuff inflation FMD fell (6.6% (IQR 3.4-10.3%), p=0.033). Randomization order had no effect. In a regression model, higher FeP was an independent predictor of attenuated post cuff inflation FMD (p=0.02). Urinary cGMP correlated negatively with serum phosphate (p=0.003).
Conclusions: This is the first study to demonstrate that sustained phosphate loading impairs endothelial function. The observed deleterious effect on FMD seen with PS may be explained by elevated total body phosphate with resultant elevated intra-cellular phosphate. FeP is likely a surrogate marker of total body phosphate. Urinary cGMP, as a marker of endothelial dysfunction negatively correlates with serum phosphate level. This study supports the hypothesis that phosphate increases cardiovascular risk by impairing endothelial function, possibly via the nitric oxide pathway. Sustained phosphate loading is directly detrimental to the vasculature even when serum phosphate remains within the normal range.
Funding: British Heart Foundation Junior Clinical Research Fellowship
Conflicts of Interest: None
10. Effects of Intravenous Ascorbic acid on Vascular Function and Oxidative Stress in Chronic Kidney Disease Keith Gillis*, Kathryn K. Stevens, Markus P. Schneider, Scott Morris, Christian Delles, Alan G. Jardine and Patrick B Mark Institute of Cardiovascular and Medical Sciences, University of Glasgow Background: Arterial stiffness is associated with excess premature cardiovascular disease in chronic kidney disease (CKD). Antioxidant therapy may represent a therapeutic intervention to improve vascular function and reduce cardiovascular risk. We studied the effect of intravenous ascorbic acid on arterial stiffness in patients with hypertension (HTN) and CKD. Methods: We performed a crossover study of administration of intravenous ascorbic acid and normal saline in patients with CKD or HTN and normal renal function. Arterial stiffness, and serum markers of oxidative stress were measured at each treatment time point. Arterial stiffness indicated by pulse wave velocity and augmentation index was assessed using the Sphygmocor system. Rate of reactive oxygen species (ROS) production was measured using electron paramagnetic resonance whilst total antioxidant capacity (TAC) was measured by a colorimetric assay. Results: 15 CKD and 15 HTN patients were recruited (mean age 57 years, BMI 29 kg/m2, blood pressure (BP) 144/89 mmHg). The CKD group had a mean eGFR of 28 ml/min/1.73m2 compared to 95 ml/min/1.73m2 in the HTN group. There was no significant difference in age, lipid profile, glycaemia or BP between groups, however use of ACE inhibitors, angiotensin receptor blockers, statins and allopurinol was higher in the CKD group. There was a significant reduction in adjusted augmentation index (Aix) after ascorbic acid in both CKD (26% to 16%; p < 0.001) and HTN (23% to 18%; p = 0.003), but no significant change in pulse wave velocity, and no significant differences between groups. There was a significant increase in rate of ROS production in both CKD (0.433 to 0.594; p < 0.001) and HTN (0.361 to 0.516; p <0.001) which fell to baseline after 60 minutes. Similarly, there was a significant increase in TAC in both CKD (0.642 to 1.173; p < 0.001) and HTN (0.579 to 1.151; p < 0.001) which had fallen to near baseline values at 60 minutes. Conclusions: Ascorbic acid ameliorates arterial stiffness, and causes a paradoxical increase in ROS production, in both CKD and HTN. Further study is required to determine the clinical implications and long term effects of this.
11. Habitual levels & patterns of physical activity in a Scottish haemodialysis population, and their relationship with markers of function and functional capacity. Smith S*, Rayson P*, Goddard J**, Davidson HIM*, *Queen Margaret University, Edinburgh, **Edinburgh Royal Infirmary, NHS Lothian Background: The benefits of targeted exercise interventions in haemodialysis patients are acknowledged (Heiwe et al 2011). However less is known about habitual levels & patterns of physical activity, particularly the prevalent Scottish population. In addition, in the general population, there is emerging evidence that levels of sedentary activity should be considered as a distinct entity from levels of physical activity & may be independently important for a number of risk factors. Aim: The primary aim was to examine levels & patterns of physical activity in a cohort of haemodialysis patients within Scotland. Secondary aims were to explore relationships between physical activity levels & markers of function/functional capacity along with markers of, nutritional, clinical status and quality of life. Only data relating to function/functional capacity is presented here. Methods & outcome measures: In this prospective observational study, all patients currently on dialysis in NHS Lothian, for > 3 months & able to give informed consent were eligible to participate. Habitual levels & patterns of physical activity were measured using an activPAL™ accelerometer, which detects & classifies an individual's free-living activity into periods spent sitting/lying, standing, stepping & number of steps taken. Patients were asked to wear the accelerometer for a continuous period of 5 days. Functional capacity was estimated using the six minute walk test & function was estimated using the 60 second sit to stand test (total number of sit to stands in 60 seconds), handgrip dynamometry & self-reported function was estimated using the KDQOL-PCS. Results: Provisional analysis of the data has been undertaken. 64 patients volunteered. Results are presented as mean (SD) unless otherwise stated for the 43 patients who had a minimum of 3 consecutive days of activPAL™ data (see table below). Activity levels across the 3 days were consistent. All patients
11. Significant positive relationships were observed between the number of steps and six minute walk, number of sit to stands, KDQOL-PCS, but not handgrip. No significant relationships were observed between time spent sitting/lying and standing with six minute walk, sit to stand or KDQOL-PCS. However there was a significant inverse relationship between time spent standing with handgrip & for time spent standing with six minute walk for men but not women.
Conclusion: The preliminary results, suggest that dialysis patients do not meet recommendations for the number of daily steps (10,000) & are sedentary for the majority of each day. Whilst further analysis & exploration of patterns of sedentary behaviour are necessary, this may provide the basis for simple low cost interventions, focusing on encouraging patients to sit less & walk more with a view to improving functional capacity, function & ultimately quality of life.
Heiwe S, Jacobson SH. Exercise training for adults with chronic kidney disease. Cochrane Database of Systematic Reviews 2011, Issue 10.
12. Possible factors influencing levels of physical activity in haemodialysis patients Smith S*, Rayson P*, Goddard J**, Davidson HIM*, *Queen Margaret University, Edinburgh, **Edinburgh Royal Infirmary, NHS Lothian Background: Lower levels of physical activity in haemodialysis patents in compared to age matched sedentary controls have been frequently reported. However little is known about the potential factors influencing levels of physical activity, which may be pertinent when designing targeted exercise interventions. Aim: The aim of this study was to explore levels of self-reported physical activity with levels of cognition, self-efficacy, barriers and motivators, quality of life in a cohort of Scottish haemodialysis patients. Methods: To obtain a representative sample of the current haemodialysis population in Lothian, all patients, who were able to provide informed consent, were eligible to participate. At the beginning of a dialysis session the Montreal cognitive assessment (MoCA) was administered along with one consolidated questionnaire (comprising demographics; Stanford self-efficacy; Exercise benefits/barriers scale; Stanford brief activity survey; LASA quality of life). Patients were classified into two groups (inactive or active) based on self-reported level of physical activity (derived from the Stanford brief physical activity survey component of the questionnaire). Differences between groups were determined using independent t-tests. Results: Results are based on data from 91 patients who volunteered. Results are presented as means (standard deviation) unless otherwise indicated. Mean age was 60 years (15.7). 57% were male, 16% worked, 16% smoked, 47% were married and 75% described their ethnic background as white Scottish. In the inactive group 34%
were classified as pre-contemplators & 42% as contemplators (readiness to change). Other results are provided in the table below. n Age MoCA
score Stanford self-efficacy score
Exercise Benefits/ Barriers total score
Barriers score
Benefits score
Quality of life score (LASA)
Inactive (29 men: 21 women)
50 60.5 (14.9)
23.0 (3.8)
5.6 (2.3)
97.8 (14.8)
33.5 (4.4)
67.3 (12.5) 6.4 (2.5)
Active (28 men: 13 women)
41 50.0 (15.1)
26.4 (2.4)
6.9 (1.6)
87.5 (13.3)
30.7 (5.1)
59.6 (10.6) 7.5 (1.7)
Inactive versus active p value
0.011 <0.01 0.001 0.001 0.006 0.002 0.017
Discussion & conclusion: The initial results of this study suggest those individuals who consider themselves as inactive are older, have lower than normal cognitive scores, have less confidence in their ability to exercise (lower levels of perceived self-efficacy) & a lower perceived quality of life. In addition, inactive patients are less likely to be thinking about becoming active (readiness to change). However those who were inactive positively perceived the benefits of exercise more than those who were active, but had a greater perception of barriers to exercise. Whilst further analysis is required, these initial results suggest that consideration should be given to such factors when encouraging or implementing exercise programmes.
13. Case of VRSE in Ayrshire and Arran. An audit of the use of vancomycin in haemodialysis patients
Porch K, Dunleavy A, Peters C, Spalding E. Renal Unit, Crosshouse Hospital
INTRODUCTION: Vancomycin resistance has been reported in clinical isolates of both coagulase-negative staphylococci and Staphylococcus aureus. The emerging threat of widespread vancomycin resistance poses a serious public health concern given the fact that vancomycin has long been the preferred treatment of antibiotic-resistant gram-positive organisms. Following the identification of vancomycin resistant staphylococcus epidermidis (VRSE) in a haemodialysis patient in Ayrshire and Arran the decision was taken to audit the use of vancomycin and adherence to the current vancomycin protocol in the renal unit.
METHODS: All haemodialysis patients in Ayrshire and Arran who had received IV vancomycin over a 6 month period were identified using SERPR. Patients who had received a single dose only were excluded from further analysis. Length of course, indication, vancomycin levels, dose given and compliance with protocol were recorded.
RESULTS: 61 courses of vancomycin were prescribed in 47 patients between 14/1/13 and 14/8/13. 10 prescriptions were for single doses only and were therefore excluded from further analysis. A total of 51 (n=51) courses of vancomycin were analysed. The mean length of treatment was 21.2 days (range 3-120). 282 levels were recorded with mean level 15.1mg/L (range<2-30.8). 489 doses of vancomycin were administered with mean dose 742.8mg (range 500-1000). All patients were loaded with 1000mg. 44 of 527 dosing decisions were not made according to protocol, of which 33 were due to lack of levels (not available in time, not sent or sent in incorrect bottle).
CONCLUSIONS: The majority of decisions regarding vancomycin dosing were made in accordance with the current protocol. Despite this levels are lower than target with 52% <15mg/L. It is widely accepted that sub therapeutic levels contribute to resistance primarily by allowing the organism to thicken its cell wall. This highlights the need for a new vancomycin protocol with higher loading doses and higher target levels. No conflicts of interest. No external funding.
14. Case report: use of bortezomib to treat chronic antibody-mediated rejection in a live related donor renal transplant recipient.
S Conlin, L Henderson, W Metcalfe
Antibody-mediated rejection (AMR) in renal transplant recipients is associated with deterioration in renal function and graft loss. Treatment with plasmapheresis, intravenous immunoglobulins (IVIG) and steroids has failed to substantially improve graft survival in chronic AMR. Bortezomib is a proteasome inhibitor that has been associated with reversal of histopathological changes and prolonged graft survival in chronic AMR. We report a case of bortezomib treatment in a patient with chronic AMR.
Our patient is a 35 year-old male with end stage renal disease secondary to chronic glomerulonephritis. He underwent a live related donor transplant in 2009 and was immune suppressed with prednisolone, mycophenolate mofetil (MMF) and ciclosporin. Day 8 biopsy was borderline for acute cellular rejection and he received pulsed intravenous methylprednisolone. He had been at a stable serum creatinine (SCr) of 200 and eGFR of 30 ml/min for almost four years when he presented in April 2013 with an acute rise in SCr in the context of sepsis and presumed ciclosporin-mediated toxicity, ciclosporin was withdrawn.
He went on to have a renal transplant biopsy in July 2013 which was stained C4d positive and he was found to have high titres of HLA Class I and II antibodies. Further biopsy in August 2013 showed chronic AMR and the patient was treated with methylprednisolone, plasmapheresis and IVIG. Repeat biopsy performed eight days later showed ongoing severe chronic AMR. After counseling the patient, Bortezomib therapy was commenced. The treatment regime consisted of two courses of intravenous bortezomib on days 1, 4, 8 and 11 two weeks apart supported throughout with plasmapheresis. On repeat biopsy at the end of the treatment course, there was evidence of ongoing chronic AMR. There was, however, reduced inflammation and the majority of glomeruli remained viable. C4d staining had decreased. SCr improved from 410 to around 340 during treatment and has remained stable. The HLA DQ antibody titre fell to one third of initial levels and remained stable. The patient suffered no bortezomib-associated complications.
We report on a case of late AMR treated with high-dose steroids, plasmapheresis with IVIG and bortezomib. The patient suffered from no major side effects to the treatment regime and showed early evidence of reduced inflammation and stasis of his chronic AMR on repeat biopsy. Serum HLA antibody titres were seen to fall. This case report shows some early efficacy of bortezomib in treating chronic AMR in a renal transplant recipient.
15. Combined eculizumab and bortezomib as additional therapies for early severe antibody mediated rejection in a highly sensitized renal transplant recipient.
Department of Renal Medicine, Aberdeen Royal Infirmary1 Department of Histocompatibility and Immunogenetics, Royal Infirmary of Edinburgh2, Department of Renal Medicine, Royal Infirmary of Edinburgh3
Introduction: The management of early severe acute antibody mediated rejection (AMR) is controversial. Eculizumab, a humanized anti C5-antibody that inhibits terminal complement and Bortezomib, a proteasome inhibitor, have been reported individually as effective treatments for severe AMR refractory to conventional therapy.
Case Summary: A 32 year-old woman with stage V CKD secondary to FSGS received a DCD renal transplant on 17th May 2013. She had received a previous renal transplant aged 15 which failed due to rejection at 18 months. As a result of her previous transplant and pregnancy, she was highly sensitized with a match score of 6, which had resulted in a waiting time of over 5000 days and no previous transplant offers. Pre-transplant crossmatch revealed a DPB1y DSA at 10,000 MFI. B flow crossmatch was positive and CDC crossmatch was negative.
Standard triple immunosuppression of tacrolimus, mycophenolate mofetil and prednisolone was supplemented with Campath induction and plasma exchange (PEX) with 100mg/kg intravenous immunoglobulin (IVIG) pre-transplant and then on alternate days post transplant. There was immediate graft function and creatinine fell to a nadir of 100umol/L before rising to 113umol/L at day 5 prompting a transplant biopsy. This demonstrated an acute severe thrombotic microangiopathy with diffuse C4d positivity. These findings, in conjunction with a rise in DPB1y DSA to 23,000 MFI with a de novo class I and class II DSA, (cumulative MFI 48,590) were consistent with severe AMR.
Biopsy was complicated by a haemaodynamically significant bleed accompanied by a rise in creatinine to 440 umol/L. She was pulsed with methyl prednisolone and PEX/IVIG frequency was increased to daily treatments once haemodynamically stable. Eculizumab commenced at day 8 for a total of 12 doses over 18 days. Despite on going PEX/IVIG and eculizumab, her cumulative DSA remained >20,000 (1:5 dilution) and creatinine plateaued at 200umol/L. She was given 3 doses of bortezomib and PEX/IVIG switched to alternate days. Cumulative DSA fell to <20,000. Serum creatinine peaked at 537 umol/L at day 10, falling to a nadir of 128 umol/L after the 1st cycle of bortezomib. Thrice weekly PEX/IVIG was continued and followed by a 2nd cycle of 4 doses of bortezomib before discontinuing PEX. Out-patient monitoring during the 3rd month post transplant revealed stable graft function with a creatinine ranging between 110-120umol/L. Elective biopsy on day 89 demonstrated resolution of the TMA with minimal inflammation though remained diffusely C4d positive. The patient remains under close follow-up with a current creatinine of 100umol/L and stable DSA titres.
Discussion: The dual strategy of eculizumab and bortezomib with PEX and IVIG has not been widely reported in the literature. In this case of severe TMA resulting from acute AMR, which would almost certainly have resulted in graft loss, we observed rapid recovery of graft function and a drop in cumulative DSA, permitting withdrawal of PEX with no evidence of relapse or transplant glomerulopathy at 3 months. The treatment was well tolerated with minimal adverse effects to date.
16. Renal function, serum phosphate, serum adjusted calcium and blood pressure following live donor nephrectomy.
Reid DJJ, Stevens KK, Clancy M, Geddes CC.
Background/Aim: Live donor nephrectomy is associated with compensatory hyperfiltration in the remaining kidney. In the general population, elevated serum phosphate, within the normal range, is associated with adverse cardiovascular outcomes. The effect of nephrectomy on serum phosphate is not well studied. The aim of this study was to quantify the effect of nephrectomy on glomerular filtration rate (GFR), serum phosphate, serum adjusted calcium and blood pressure in the first year after donation.
Method: Data were obtained from the electronic patient record. Patients with a recorded procedure of “live donor nephrectomy” between 2005 and 2013 were identified. GFR after donation was calculated using the formula ‘GFR = Preoperative Isotope GFR x (Serum creatinine/Preoperative Serum Creatinine)’, which is accurate assuming muscle mass does not change. Pre and post (three days, two weeks, three months and one year) donation serum creatinine, phosphate and adjusted calcium were recorded. Pre and post donation (three months and one year) blood pressure was recorded.
Results: One hundred and ninety-four consecutive donors were identified, of whom 9 had insufficient follow-up data for inclusion. The mean age was 46.1 ± 11.4 years and 47% (n=90) were male. Mean pre-donation isotope GFR was 97.8 ± 17.1 ml/min/1.73m2. Post donation calculated GFR was significantly lower at 72%, 70%, 71% and 75% of pre-donation GFR at 3 days, 2 weeks, 3 months and 1 year respectively (p < 0.001). Post donation serum phosphate was significantly lower at 3 days post-donation compared with pre-donation value (0.72 ± 0.16 vs 1.04 ± 0.16 mmol/l; p < 0.001). There was no significant difference in serum phosphate at 2 weeks, 3 months or 1 year post-donation. Mean pre-donation adjusted serum calcium was 2.40 mmol/l ± 0.08 mmol/l. Post donation adjusted serum calcium was significantly lower at one year compared with pre-donation values. (2.35 ± 0.13 vs 2.41 ± 0.08 mmol/l; p = 0.005). Mean pre-donation blood pressure was 132/78 ±16/10 mmHg. At three months BP was 129/77 mmHg ± 16/9 and at one year 131/79 ± 17/11 mmHg.
Conclusion: Individuals who undergo live donor nephrectomy have a GFR of 75% at one year compared to pre-donation GFR. Compensation in GFR occurs rapidly after nephrectomy. Post-donation serum phosphate and blood pressure are maintained at one year, whereas serum calcium falls significantly. This observation may relate to changes in the homeostatic regulation of calcium and phosphate.
17. How erythropoietin treatment targets affect quality of life, mortality and the risk of cardiovascular events in Chronic Kidney Disease: A review Weh Kiat Gan, Caitlin Hughes, Ylva Konsberg, Vui Yung Chieng, Catriona Niven, Matthew Saunders Supervisor: Dr. Angharad Marks, University of Aberdeen. Centre name: University of Aberdeen, Foresterhill Campus. Introduction: Chronic kidney disease (CKD) is a major public health problem with high morbidity and mortality. Anaemia due to reduced synthesis of erythropoietin, often develops in those with CKD and can be treated with erythropoietin stimulating agents. The current NICE guideline (Updated Feb 2011) recommends sub-normal target haemoglobin (Hb) level (10 -12 g/dl) for CKD patients. However, some observational studies suggest benefits of higher Hb target levels.
Aim: To evaluate current evidence as to whether erythropoietin treatment with a high target Hb level (versus low) is more effective for reducing mortality, cardiovascular events and improving quality of life in pre-dialysis CKD patients.
Methods: Medline and EMBASE literature searches (May 2013) using terms for chronic kidney disease, erythropoietin, anaemia, and the outcomes of interest (mortality, cardiovascular disease, and quality of life) were combined using Boolean operators “AND” or “OR”, as appropriate. Randomized control trials (RCTs) comparing the effects of high haemoglobin targets with low haemoglobin targets in pre-dialysis adult patients were included. Haemodialysis and peritoneal dialysis patients, paediatric studies, and studies which were not randomized controlled trials were excluded. The Critical Appraisal Skills Programme (CASP) was used for quality assessment. Scoring from 0 to 9 was given, where 9 being the best possible quality, fulfilling all the quality criteria (precision, blinding, appropriate intervention and comparison of study groups). Two reviewers appraised each study for inclusion or otherwise and extracted appropriate data from the studies. Results were expressed as hazard ratios with 95% confidence intervals (CI).
Results: The search generated 100 citations. 7 passed the inclusion and exclusion criteria. Of these 7 studies (6945 individuals in total), only Villar et al (May 2011), was not included in the NICE guideline review. The quality of the studies was variable. The CASP scores of the 7 studies ranged from 5 to 8. Five studies indicated higher all-cause-mortality risk in the high target Hb group, however the CI all crossed unity. Six studies reported on myocardial infarctions, but did not show significant difference between the Hb target groups. Three studies (n=4962) reporting on stroke noted a higher risk in the high Hb target group, but only one study (n=4038) reported it as statistically significant with hazard ratio of 1.92 (CI: 1.38-2.68). Five studies assessed quality of life as an outcome; three reported a significant improvement with higher Hb target level.
Conclusion: This review demonstrates that current evidence supports the 2011 NICE guideline recommending sub-normal target level for CKD patients. The quality of evidence is variable. CKD patients with high Hb target level generally report improved quality of life, however, also has increased risk of stroke. Ideally, future studies should look to stratify the risk of cardiovascular events and mortality in CKD patients with cardiovascular co-morbidities as well as the life expectancy in this group of patients to explore whether the increased quality of life outweighs the increased risk of stroke.
Funding and conflict of interest: None
18. The Concept of ‘Chronic Lithium Toxicity ‘: An Epidemiological Approach Stefan Clos MD, MSc student, Department of Biomedical Science and Public Health, Medical Research Institute, University of Dundee; Petra Rauchhaus BSc, Clinical Trials Statistician; Health Informatics Centre (HIC), University of Dundee; Alison Severn FRCP; PhD, Renal Unit, Ninewells Hospital and Medical School, Dundee; Peter T Donnan PhD, Dundee Epidemiology and Biostatistics Unit, Division of Population Health Sciences, Medical Research Institute, University of Dundee
Background For over 40 years there has been a debate about the long term effect of Lithium maintenance therapy on renal function. This population record-linkage study set out to assess whether there was evidence of this long-held belief.
Methods We used datasets from the University of Dundee’s Health Informatics Centre (HIC) to link laboratory data to community prescriptions for Tayside, Scotland. Primary outcome was the estimated Glomerular Filtration Rate (eGFR) using the CKD-EPI equation. A cohort of patients newly commenced on Lithium was constructed between Jan, 2000 and Jan, 2012. Patients with incidence exposure to other first line drugs (Quetiapine, Olanzapine, and Semisodium Valproate) provided a natural comparator group. Patients with glomerular/tubulo-interstitial disease or CKD stages 4/5 at baseline were excluded. Analysis of outcome utilised random coefficient models. Findings 1,120 patients (305 Lithium, 815 comparator drugs) aged 18-65 years qualified for inclusion providing 13,963 eGFR values over twelve years. Mean Lithium exposure length was 55 months (SD 42, min 6, max 144). Mean adjusted annual decline in eGFR was 1.5 ml/min/1.73m2 (SE 4.2 ml/min/1.73m2), with no difference between Lithium and comparator groups.The final model identified significant predictors for a decline in eGFR as age, baseline eGFR, diabetes, hypertension, co-prescriptions of nephrotoxic drugs (penicillinase-resistant penicillins at baseline; ACE inhibitors, diuretics and NSAIDs during F/U) and episodes of Lithium toxicity (> 1.5 mmol/L) but not Lithium exposure length or mean Lithium serum level. PROCEED Interpretation The analysis suggests no effect of Lithium maintenance therapy (Lithium levels in therapeutic range) on the rate of change in eGFR over time. The model, however, needs to be tested in a dataset other than the derivation data. Our results therefore contradict the concept that long-term Lithium therapy is associated with nephrotoxicity in the absence of episodes of acute intoxication and that duration of therapy and cumulative dose are the major determinants of toxicity. Previous publications inferring exposure length as being a predictor for renal decline in patients on long-term Lithium therapy will have been affected by inappropriate study design and associated bias and confounding. The concept of ‘Chronic lithium nephrotoxicity in the absence of episodes of acute intoxication’ may well be a modern medical myth.
19. Reducing Haemodialysis Bacteraemia Rates.
Murray E.C., Deighan C., Geddes C., Thomson P.C.
Renal Unit, Western Infirmary, Dumbarton Road, Glasgow, G11 6NT
Data on the quarterly incidence rates of all staphylococcal bacteraemic events in the NHS Greater Glasgow & Clyde and NHS Forth Valley haemodialysis population were collected for the period April 2011 to June 2013. This was achieved by a structured query language (SQL) interrogation of the renal unit electronic patient record (EPR) with the resulting output being processed by Microsoft Office Excel 2003. Consecutive blood culture results >14 days apart were regarded as separate events. Vascular access data were cross-checked by hand. Event rates were expressed as events per 1000 haemodialysis-exposed days for each vascular access type. Comparison between periods was made by student’s t-testing with a significance level set at α<0.05.
Results
261 bacteraemia events occurred over 427,836 HD days; 79 events in 289,456 AVF/AVG HD days, 160 events in 135,537 TCVC HD days, and 22 events in 2834 NTCVC HD days. Comparing the staphylococcal bacteraemia rate before and after the introduction of TauroHep500 in TCVCs demonstrated a reduction from 1.58/1000 HD days (95% confidence interval [CI] 1.12,2.03) to 0.74/1000 HD days (95% CI 0.20,1.28), p<0.01. In NTCVCs no corresponding reduction in staphylococcal bacteraemia rates was observed; 6.06/1000 HD days (95% CI 3.43,8.71) pre-Biopatch introduction, 10.36/1000 HD days (95% CI 3.10,17.62) following introduction, p=0.10. The staphylococcal bacteraemia rate in AVF/AVGs remained unchanged; 0.28/1000HD days pre-July 2012 (95% CI 0.16,0.41) versus 0.27/1000 HD days post-July 2012 (95% CI 0.18,0.36), p=0.87.
Conclusion
Using chlorhexidine impregnated foam patches on NTCVC exit sites failed to demonstrate any reduction in bacteraemia rates, though cumulative NTCVC HD days and incidence events were too low to draw any conclusion reliably. Replacing heparin 5000iU/mL with TauroHep500 as catheter lock solution in patients with TCVCs was associated with a statistically significant 47% reduction in staphylococcal bloodstream infection rates.
No funding was received. No conflict of interest.
19. References
1. Caskey F, Dawnay A, Farrington K, Feest T, Fogarty D, Inward C, Tomson CRV. UK Renal Registry 2010 Report. 13th Annual Report of the Renal Association. Nephron Clinical Practice Vol. 119, Suppl. 2, 2011.
2. Thomson PC, Stirling CM, Geddes CC, Morris ST, Mactier RA. Vascular access in haemodialysis patients: a modifiable risk factor for bacteraemia and death. QJM. 2007;100(7):415.
Benjamin Yong 1,2, Dana Kidder 2, Alison Severn 2, Vinodkumar P Sanu 2
1Department of Cardiology, Forth Valley Royal Hospital, Larbert 2Renal Unit, Ninewells Hospital and Medical School, Dundee.
Posterior reversible encephalopathy syndrome (PRES) is a clinical entity consisting reversible neurological clinical and radiological signs associated with cerebral vasogenic oedema and vascular endothelial dysfunction. The condition can occur in the context of systemic hypertension, eclampsia, sepsis, renal failure, connective tissue disorders, immunosuppression in solid organ transplant recipients and chemotherapeutic agents. We describe an interesting case of PRES in the setting of secondary hypokalemic hypertension.
Our patient is a 29-year-old male, previously well except for mild asthma, who initially presented to the department of urology in our hospital with left sided abdominal pain, vomiting, haemoproteinuria and an acute kidney injury with a creatinine of 268µmol/L. The urine protein/creatinine ratio was 67 mg/mmol. He was noted to be hypokalemic at 3.1mmol/L, in the absence of other electrolyte abnormalities.. The patient’s transtubular potassium gradient was inappropriately raised, with correlating low plasma and aldosterone concentrations.There was no clinical or biochemical evidence to suspect an underlying infective process. A CT urogram showed normal sized kidneys with good parenchymal width with no evidence of obstruction or renal calculi.
Subsequently, he developed a sudden onset severe fronto-occipital headache associated with an acute visual loss and a blood pressure of 174/99mmHg. Bedside fundoscopy was unremarkable. Emergency hypertension was treated with intravenous hydralazine. Magnetic resonance imaging of his brain showed bilateral high T2 signal return in the parietal and occipital lobes in keeping with a radiological diagnosis of PRES. Complete resolution of the patient’s symptoms followed management of his emergency hypertension with intravenous hydralazine and maintenance with an ACE inhibitor.
To our knowledge, this is the first reported case of PRES associated with low renin low aldosterone hypertension.
21. A retrospective study of first permanent vascular access outcomes in incident haemodialysis patients
Cameron Alexander1, Nicola Joss2
1.Medical student, University of Aberdeen 2 Consultant Nephrologist, Raigmore renal unit, Inverness
Background: The successful provision of vascular access is fundamental for
the effective delivery of haemodialysis (HD) in patients with established renal
failure. However, vascular accesses are susceptible to the development of a
range of complications. There is an immediate need to develop a greater
understanding of the factors that influence access-related outcomes. Aims: To determine the factors affecting first permanent vascular access outcomes
in patients starting HD. Methods: Data were retrospectively collected from the
hospital’s surgical, radiological and renal database systems on factors related
to patient characteristics and vascular access care for patients starting
haemodialysis between 01/01/2007 and 31/12/2012 at Raigmore Hospital.
The primary outcomes were primary and secondary survival of the first
surgically created permanent access. Univariate analysis of access survival
was undertaken for selected variables using the Kaplan-Meier method with
log-rank testing used to test for differences between subgroups. Results: Of
the 128 patients starting haemodialysis at Raigmore renal unit between
01/01/2007 and 31/12/2012, 107 met the selection criteria and were included
in the study. 25.2% (27/107) of included patients had previously failed
peritoneal dialysis and 74.8% (80/107) were starting RRT for the first time with
haemodialysis as their first treatment modality. In 96.3% (103/107) of patients,
a permanent access was surgically created, of which 26.2%, 54.4% and
10.7% were radiocephalic, brachiocephalic and transposed basilic fistulae,
respectively, and 8.7% were arteriovenous grafts. The reported complication
and intervention rates for first permanent accesses were 1.3 and 0.8 per
patient year on haemodialysis, respectively. Median primary survival of first
access was 21.2 months (95%CI 14.3, 28.1). Primary and secondary access
survival rates at 2 years was 45.9% and 73.4%, respectively. A primary renal
diagnosis of diabetes (p=0.022), previous use of a temporary catheter
(p=0.003), rope-ladder needling (p=0.013), and transposed basilic fistula or
arteriovenous graft (p<0.001) were predictive of significantly poorer
permanent access survival. Conclusion: The use of buttonhole needling may
improve access survival.
Funding/conflict of interest: none declared.
Nursing presentations:-
N1. The effects of a supported self blood pressure monitoring project on medication adherence, self management and self efficacy in individuals with CKD stage 3 – 4.
Author: Helen Rose RN MN NHS Grampian
Introduction / Background:
Optimum blood pressure control remains the cornerstone of treatment for Chronic Kidney Disease (CKD), most importantly in those presenting with proteinuria.
The author works as a CKD nurse specialist, a role which includes the exploration of nursing interventions to improve outcomes for individuals with mild to moderate CKD. Audit evidence from patients attending the CKD nurse led clinics suggests that the SIGN (2008) guideline for blood pressure was not being achieved in around 35% of the patient population.
A review of the literature indicated that when individuals are involved in their own long term condition management, health outcomes improve. When this rationale was explored in relation to hypertension management, small but statistically significant reductions in blood pressure were evident in systematic reviews of general hypertensive populations and in trials of individuals with CKD who participated in supported self blood pressure monitoring programmes.
Aim / Objective:
The project sought to pilot a self-management programme to improve target blood pressure adherence through the improvement of medication adherence, self-efficacy and self-management ability in individuals with co-existing CKD stage 3 – 4 and proteinuria. Qualitative patient preference for and experience of self monitoring was explored.
Method:
8 service users with co existing CKD 3 - 4, proteinuria and hypertension who were prescribed multiple antihypertensive agents, were selected to participate in the project.
All individuals received an automated blood pressure machine along with written literature in an information/self monitor record package. Each participant was trained to undertake self monitoring in relation to local NHS Grampian guidelines. Follow up support was provided by the CKD nurse.
Participants were required to complete questionnaires focusing on medication adherence and self management/self efficacy indices both pre and post project. In addition a semi structured interview was undertaken towards the end of the project timescale to explore patient experience.
Outcome / Results:
Despite a high degree of self reported medication adherence prior to the project, it appeared that incidents of forgetting to take medication did decrease during the project timescale. Participants suggested during the interview that self monitoring acted as an “aid memoire” for medication administration.
N1. Improvements in the self management and self efficacy indices were also noted; significantly individuals were more likely to take an interest in their blood pressure during clinic appointments, understand blood pressure targets and demonstrated increased confidence in discussing any issues with health care professionals.
A number of participants described innovative applications of self blood pressure monitoring which in one instance assisted with motivation for weight loss, and another in the self assessment of fluid overload.
The project highlighted a number of areas for further investigation including how to engage a wider number of service users in CKD self management, particularly when limited symptomology exists.
Reference: SCOTTISH INTERCOLLEGIATE GUIDELINE NETWORK (SIGN), 2008. Guideline 103. Diagnosis and Management of Chronic Kidney Disease. A national clinical guideline. Edinburgh: SIGN
N2. The Fight Against Infections in a Renal High Dependency
Nancy Bell, Lisa Jordan, Brenda Wardrop & Lindsay Dow
Crosshouse Hospital NHS Ayrshire & Arran
Introduction / Background:
Following the announced inspection to University Hospital Crosshouse in NHS Ayrshire & Arran from the Healthcare Environment Inspectorate (HEI) in August 2010 it was identified that essential improvements were required to provide a safe, effective and quality service to the service users in Ayrshire & Arran. On closer inspection Ward 2F, the Renal High Dependency Unit was identified as requiring urgent refurbishment of the facilities and improvement of clinical practice from all disciplines to address highlighted issues that were increasing the risks to our patients.
Aim / Objective:
To evidence a sustained improvement in infection rates of Hospital Acquired Infections with collaborative working within the professional Multi-disciplinary Team.
Method:
Quantitative data analysis of infection rates of Staphylococcus Aureus Bacteraemia (SAB), Clostridium Difficile and MRSA from April 2010 until June 2013.
Outcome / Results:
71% reduction in SAB rates with 100% reduction in central line infections in the first 5 months of 2013. 436 days since last acquired Clostridium Difficile infection. Reduction in time between MRSA acquisitions indicating need for further investigation and improvement action plan.
N3. Violence & Aggression in a Remote & Rural Dialysis Unit
Belford Hospital is a remote & rural general hospital which incorporates a
small out-patient haemodialysis satellite unit. The unit is open 3 days per
week with 1 full-time and 5 part-time nurses to provide dialysis for up to 12
patients. Over the past 18 months we have experienced regular aggressive
behaviour from one of our patients including verbal threats of physical
violence, with some staff being specifically targeted and facing daily
intimidation.
My presentation will focus on sharing our real lived experiences during this
time period. I aim to demonstrate this by using a timeline of events and
providing specific examples of violent & aggressive behaviour. I will then
progress to giving insights into how I managed this difficult and sensitive
situation and describe the effect this has had on the nursing staff, both
professionally and personally.
Aim / Objective: I would hope this experience may promote some thought and
discussion around how other units manage aggressive patients.
Key words – renal unit, violence and aggression, satellite dialysis unit
N4. Creative Prescribing
Authors – C Andrews / C McGuigan Monklands Hospital NHS Lanarkshire
Introduction / Background:
Patient questionnaires and research indicate high levels of isolation and depression in renal dialysis patients
Aim / Objective:
To increase mood and feeling of achievement in renal dialysis patients
Method:
Patient experience questionnaires and suggestions circulated to all RDU areas. Released CSW and qual nurse for 1 day per week each to drive project. Used combination of LEAN methodology and RTTC to support storage and time to support patients and staff.
Outcome / Results:
Positive patient experience. Increased mood and social interaction between patients. Reduction in anxiety.
N5. Green Nephrology Glasgow-Reduce, Reuse, Recycle and beyond
Author: Leigh Bainbridge Staff Nurse
Introduction / Background:
Within NHS GGC 505 people attend our chronic hospital haemodialysis programme equating to 78,780 resource intensive treatments per year in six renal dialysis units (RDUs). Small environmental and cost savings per treatment will translate into much larger savings overall. Thus targeting reduction of clinical waste and unnecessary consumable equipment use will be an effective method of reducing GHG emissions without impacting on the number or quality of treatments. Additionally an overall approach to reducing carbon emissions via Sustainable Action Planning (see below) has been developed
Aim / Objective:
To reduce the GHG emissions associated with resource intensive treatments such as dialysis
To engage good team working
To promote good environmental practice
To save money on equipment and waste disposal
Method:
The steps are detailed below:
1. Set up a Working Group: a. Identify keen local representatives from each RDU to promote, sustain and
develop an efficient waste management system and sustainable action plan as part of a coordinated waste management project within NHSGGC renal services.
b. Engage senior stakeholders to support the project including senior nursing and medical staff, Renal Services management team, the Education and Practice Development Nurse for Renal Services, the Estates department and the Sustainability Officer for NHS GGC.
2. Focus initially on “quick wins” to reduce clinical waste by diverting it into the domestic waste stream:
a. Use the Green Nephrology Programme as a model of good environmental practice and experience from the RDU at Queen Margaret Hospital, Fife.
b. Audit current patterns of consumable equipment use and disposal. c. Identify safe opportunities for reducing clinical waste. d. Identify equipment that could be safely removed from the dialysis process. e. Consider potential health and safety or infection control issues identified and
raise these with these departments as appropriate. f. Implement change and determine the cost and environmental savings by
weighing clinical and domestic waste from two dialysis sessions (using AV fistula and catheter methods) before and after planned waste reduction measures and estimating the change in weight overall.
g. Review annually to ensure change is maintained and any new improvements are adopted.
3. Develop an overall Sustainable Action Plan for each unit focusing on lighting, heating and cooling, water use, papers and printing and travel. This has started at the Vale of Leven RDU and will be extended to the other RDUs
4. Extend to inpatient dialysis facilities based in the Western Infirmary and look for additional opportunities e.g. reducing clinical waste for inpatient biopsy procedures (approximately 400 / year).
N5. Outcome / Results:
Each site has developed a strategy for reducing clinical waste. Clinical waste savings of 80 tonnes CO2e and £14,318 annually have been saved across all six RDUs. This excludes inpatient dialysis and procedures. Additionally, five sites use 1.7kg polyethylene Griff Bins® rather than orange clinical waste bags. By reverting to standard clinical waste bags (approximately 14,000 bins saved), 43 tonnes CO2e and £92,832 have been saved annually (£84,000 from purchasing and £8,592 from incineration costs). These estimates do not include supply chain emissions i.e. those generated from the manufacture and transport of the product to the RDU.
Benefits to patients:
Dialysis patients are not only more susceptible to CC effects such as heat waves and transport disruption, but they rely on the continued supply of drugs and disposable equipment. Reducing GHG emissions now will mitigate the effects of CC and reduce the financial burden associated with renal dialysis allowing redirection of funds into other areas of patient care including the predicted expansion of renal dialysis within NHS GGC. Savings at the Vale of Leven RDU are already seeing equipment gains to the unit locally.
Benefits to staff:
The use of a network of ground level representatives promotes good environmental practice at work and also engages staff in implementing change through seeing savings directly attributable to their actions quantified.
Benefits to NHS GGC:
In addition to cost and environmental savings for renal services, this project will contribute to institutional change by promoting lower carbon care on six acute hospital sites. Translating corporate environmental policies into operational practice remains a challenge for the NHS. The approach of using operational level networks of representatives to maintain and promote good environmental practice will generate lasting change and can be adapted to other high resource areas within NHS GGC such as theatres, ITUs and day case procedure areas with large potential savings.
N6. Supporting Staff with Dyslexia in the Renal Unit
Julie English (Clinical Educator) – Raigmore Hospital, NHS Highland
While working in NHS Highland as a clinical educator I have recently completed two modules relating to understanding dyslexia and supporting individuals with dyslexia in the workplace. In this presentation I will briefly discuss the traits associated with dyslexia, the impact this may have on working within a renal dialysis unit and offer suggestions to support staff.
During the process of supporting an individual with dyslexia in the dialysis unit a number of areas for improvement became evident.
These areas for improvement included -
• The need to raise awareness of dyslexia friendly learning amongst trainers, mentors and other education providers
• The level of support available for dyslexic staff within NHS Highland • The need to change existing documentation within the renal unit to aid users
with dyslexia
Making small adjustments to existing documents and provision of low cost aids have proven to be very beneficial to staff with dyslexia within our renal unit. In addition to this, other non dyslexic staff have benefited and compliance with some documentation has improved.
Keywords:-Dyslexia, Documentation, Renal Care, Staff Support
N7. The Development of Personal Health Information Logs (P.H.I.L)
Author: Marion McGinness NHS Greater Glasgow and Clyde
Introduction / Background:
Newly transplant patients previously given three separate paper information booklets totalling 53 pages containing some similar information, most of which was unnecessary and out of date and no longer fit for purpose.
Aim / Objective:
To replace the existing paper booklets with a sturdier product. Put all the relevant information in one place making it easier for the patient to use and understand. Promote self care and patient autonomy, through improved, clear concise information giving.
Method:
All necessary information gathered, developed tabbed design for the product so that the patient can go straight to the desired section. Several meetings involving renal pharmacist, clinical effectiveness team, printers, medical illustrations and getting the accessible information correct. Gaining financial support to fund the printing costs for the first 100 copies to allow a pilot test to go ahead.
Outcome / Results:
The product now known as Personal Health Information Log P.H.I.L has been given to newly transplanted patients since July 2013. An audit to assess qualitative outcomes of this; through a questionnaire given to patients at the transplant clinic, will be carried out once approval has been given. A separate audit for this is also being given to both nurses and doctors to assess their response and any ideas or improvements they feel could be made. To date over 40 have been issued with very positive verbal feedback given at ward level from patients prior to being discharged.
N8. Development of A Nurse Led Renal Day Ward, Renal Unit, Western Infirmary, Glasgow
Authors: Diane Wright1 Julie McKinlay1
Introduction / Background: As part of the redesign of renal services at the Western Infirmary, Glasgow it was recognised that certain procedures and treatments could be managed within a daycase setting . As the Renal Nurse Practitioner team are directly involved in the admission and management of patients it was determined that they should lead and implement this new development.
Aim / Objectives:
Reduce pressure on inpatient beds and provide new ways to care for patients which could better meet the demands of the service whilst continuing to provide safe and effective patient care.
Method:
Audit procedure and treatment data by analysing reports from the renal electronic patient record (EPR) and the nurse practitioner database.
Review outcomes of these procedures and treatments to target those suitable for day case.
Initiate patient referral pathway.
Develop protocols and day case documentation.
Create an electronic diary to schedule day case appointments.
Set up and manage processes within the electronic patient record to audit day case activity.
Consider level and number of staff required to manage and implement care within a day case area.
Outcome / Results:
Opening of designated day ward with 3 trolleys and 3 recliner chairs.
On completion of year one 1750 day case episodes recorded and 2050 year two.
Change in culture and acceptance for nurse-led care for targetted groups of patients.
Sucessfully demonstrate that Nurse Practitioners are able to lead care and make use of advanced nursing skills such as clinical examination and non medical prescribing.
Positive Patient feedback citing care as consistant, individually tailored and patient focused.
Recorded data is accurate and can clearly demonstrate the numbers and types of procedures taking place.
Simple and streamlined referral process
Reduced pressure on inpatient beds.
N9. Service Innovation and Safety of Nurse Led Day Case Renal Biopsy
This presentation will focus on how renal nurse practitioners in the western Infirmary manage and organise day case renal biopsies.
AIM
Percutaneous renal biopsy is an essential method of obtaining diagnostic renal tissue. It can also be useful for prognostic purposes, as well as helping to direct or change treatment. This includes elective/ urgent, native and transplant biopsies.
OBJECTIVE
I will describe in depth how the NP team streamline the care of the biopsy patient from the referral to discharge using a robust process to ensure a timely execution of the procedure.
The presentation will include patient numbers and type using retrospective data over a two year period. I will detail the exclusion criteria, the development of our biopsy protocol and procedure documentation. We will aim to demonstrate the impact of an innovative biopsy service in reducing pressure on inpatient beds and the benefits to nursing staff and also patient satisfaction.
In addition to the above, I will discuss how nurse practitioners are responsible for the safe handling, identification, dissection and distribution of tissue into the appropriate transport medium and how they work in close collaboration with the pathology technicians to ensure fast processing of urgent samples.
CHALLENGES TO SERVICE DELIVERY
Demand on renal trainees’ time commitments due to service pressures within the department.
Development of formal biopsy training course
An increasing demand for the service with limited resourses.
N10. Chronic Haemodialysis Care Planning
Authors: Helen Burton, NHS Lanarkshire
Introduction / Background:
New ICP introduced to the chronic dialysis outpatient areas as a means to improve nursing care on Hd.
Aim / Objective:
To incorporate aspects such as OPAC requirements.
Method:
Observational & documentation audit.
Outcome / Results:
Improved holistic care of those patients attending outpatient dialysis sessions.
N11. The Patient Police
Authors: C Andrews, Y Campbell, L Gourlay, J Traynor, NHS Lanarkshire
Introduction / Background:
Apparent high infection rates.
August 2011 work commenced to reduce same using improvement methodology.
Aim / Objective:
To reduce CVC related SABs to less than 300 days between SABs
Method:
Split into 2 workstreams. Used PDSA cycles to test new processes. Introduced bundles in temp lines. Used clocks and patient participation in perm lines in RDU.
Outcome / Results:
Nil temp CVC SAB since Dec 2011. 200 days since last perm CVC infection in RDU. Last 2 CVC SABs related to same patient with last line access in translumber site. If we excluded this gent last CVC SAB would be October 2012.
