Home haemodialysis : trends in technology

Self management and home-based dialysis therapies offer the prospect of improved patient experience and outcomes. To allow more patients to realize these benefits requires changes in technology which focus on maximizing the ease and minimizing the burdens of undertaking home dialysis. These developments are underway.Peer reviewedFinal Published versio

Geriatric Assessment in Advanced Kidney Disease

Peer reviewe

A single weekly Kt/Vurea target for peritoneal dialysis patients does not provide an equal dialysis dose for all

Copyright © 2016 International Society of Nephrology. Published by Elsevier Inc. All rights reserved.Dialysis adequacy is traditionally based on urea clearance, adjusted for total body volume (Kt/Vurea), and clinical guidelines recommend a Kt/Vurea target for peritoneal dialysis. We wished to determine whether adjusting dialysis dose by resting and total energy expenditure would alter the delivered dialysis dose. The resting and total energy expenditures were determined by equations based on doubly labeled isotopic water studies and adjusted Kturea for resting energy expenditure and total energy expenditure in 148 peritoneal dialysis patients (mean age, 60.6 years; 97 male [65.5%]; 54 diabetic [36.5%]). The mean resting energy expenditure was 1534 kcal/d, and the total energy expenditure was 1974 kcal/day. Using a weekly target Kt/V of 1.7, Kt was calculated using V measured by bioimpedance and the significantly associated (r = 0.67) Watson equation for total body water. Adjusting Kt for resting energy expenditure showed a reduced delivered dialysis dose (ml/kcal per day) for women versus men (5.5 vs. 6.2), age under versus over 65 years (5.6 vs. 6.4), weight 80 kg (5.8 vs. 6.1), low versus high comorbidity (5.9 vs. 6.2), all of which were significant. Adjusting for the total energy expenditure showed significantly reduced dosing for those employed versus not employed (4.3 vs. 4.8), a low versus high frailty score (4.5 vs. 5.0) and nondiabetic versus diabetic (4.6 vs. 4.9). Thus, the current paradigm for a single target Kt/Vurea for all peritoneal dialysis patients does not take into account energy expenditure and metabolic rate and may lead to lowered dialysis delivery for the younger, more active female patient.Peer reviewedFinal Accepted Versio

Anti-CTLA-4 (CD 152) monoclonal antibody-induced autoimmune interstitial nephritis

Targeted immune-modulating agents are entering clinical practice in many specialties, providing novel therapeutic possibilities but introducing new potential toxicities. We present the first reported case, to our knowledge, of immune-mediated nephritis following the administration of Tremelimumab (CP-675, 206), an anti-cytotoxic T-lymphocyte-associated antigen 4 (CTLA-4) monoclonal antibody. High-dose steroid therapy led to a rapid improvement in renal function, avoiding the need for renal replacement therapy.Peer reviewe

UK Renal Registry 18th Annual Report : Chapter 12 Epidemiology of Reported Infections amongst Patients Receiving Dialysis for Established Renal Failure in England 2013 to 2014: a Joint Report from Public Health England and the UK Renal Registry

From 1st May 2013 to 30th April 2014 there were 35 episodes of Methicillin resistant Staphylococcus aureus (MRSA) bacteraemia in established renal failure patients on dialysis. This is now fairly stable year-on-year equating to a rate of 0.15 episodes per 100 dialysis patient years, following an initial decline in rates from 4.0 episodes per 100 dialysis patient years in 2005 when reporting began. Methicillin sensitive Staphylococcus aureus (MSSA) bacteraemia rates were slightly higher this year at 2.23 per 100 dialysis patient years (compared with 1.59 episodes per 100 dialysis patient years last year) with 526 episodes of blood stream infection reported. In 2005, the first year this was reported, there were 1,114 MSSA bacteraemias in 54 centres. There were 247 Clostridium difficile infection episodes with a rate of 1.05 per 100 dialysis patient years, slightly higher than last year at 0.55 episodes per 100 dialysis patient years. Escherichia coli infections occurred at a rate of 1.49 per 100 dialysis patient years, very similar to the rate reported last year (1.32 episodes per 100 dialysis patient years). This report has utilised a new methodology to identify cases, linking all established renal failure cases known to the UK Renal Registry (UKRR) with all infections reported to Public Health England and avoids the need for the local microbiology team to flag the patient as a renal patient. This may have increased the reliability of diagnosis at the UKRR level. In each infection for which access data were collected, the presence of a central venous catheter appeared to correlate with increased risk.Peer reviewedFinal Published versio

Successful use of steroids and ureteric stents in 24 patients with idiopathic retroperitoneal fibrosis : a retrospective study

Original article can be found at : http://content.karger.com/ Copyright Karger [Full text of this article is not available in the UHRA]Background/Aims: Retroperitoneal fibrosis (RPF) is a chronic inflammatory disorder causing obstructive nephropathy and renal failure. We reviewed our management of this condition. Method: All patients with RPF treated at a single center over a 15-year period were identified. A full review of notes and computer records was undertaken. Results: Data was available on 27 patients, 3 of which were excluded from later analysis. Diagnosis was based on clinical history and cross-sectional imaging. Retroperitoneal biopsy was undertaken in 3 patients. 96% had significant renal impairment at presentation with a mean serum creatinine of 688 μmol/l. 46% required emergency hemodialysis. All patients were treated with a combination of ureteric stents and/or steroids with an excellent clinical response. The mean best creatinine reached by the cohort was 136 μmol/l, and renal function remained stable in the long term. No patients required chronic dialysis. Ureteric stents were removed within 12 months and low-dose steroids were continued for a mean of 34 months. Recurrent disease was observed in 25% of patients, who all responded well to further steroid therapy. Mean duration of follow-up was 76 months. Conclusions: RPF is very effectively treated by a combination of ureteric stents and steroids, with excellent long-term results using this approach. Continued follow-up is advised because of the possibility of recurrent disease.Peer reviewe

How do patients from South Asian backgrounds experience life on haemodialysis in the UK? : A multicentre qualitative study

© Author(s) (or their employer(s)) 2018. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.OBJECTIVES: End-stage kidney disease disproportionately affects people of South Asian origin. This study aimed to uncover the lived experiences of this group of patients on centre-based haemodialysis (HD), the most prevalent dialysis modality. DESIGN: The study utilised a qualitative focus group methodology. Seven focus groups were conducted across four NHS Trusts in the UK including three in Gujarati and two each in Punjabi and Urdu. This provided an inclusive opportunity for South Asian patients to contribute in their language of origin. A total of 24 patients participated. Focus groups were facilitated by bilingual project workers and data were forward translated and analysed using thematic analysis. RESULTS: Four themes were identified. This included (1) 'treatment imposition', which comprised of the restrictive nature of HD, the effects of treatment and the feeling of being trapped in an endless process. (2) The 'patient-clinician relationship' centred around the impact of a perceived lack of staff time, and inadequacies in the quality of interactions. (3) 'Coping strategies' highlighted the role of cognitive reappraisal, living in the moment and family support networks in facilitating adjustment. (4) 'Pursuit of transplantation' included equating this form of treatment with restoring normality, alongside cultural factors limiting hopefulness for receiving an organ. CONCLUSIONS: In general, the experiences of South Asian patients receiving HD were not unique to this ethnic group. We did find distinct issues in relation to interactions with healthcare professionals, views on access to transplantation and the importance of family support networks. The study provides useful insights which may help enhance culturally tailored renal care.Peer reviewe

Initiating haemodialysis twice-weekly as part of an incremental programme may protect residual kidney function

© The Author(s) 2018. Published by Oxford University Press on behalf of ERA-EDTA. All rights reserved.Background: Initiating twice-weekly haemodialysis (2×HD) in patients who retain significant residual kidney function (RKF) may have benefits. We aimed to determine differences between patients initiated on twice- and thrice-weekly regimes, with respect to loss of kidney function, survival and other safety parameters. Methods: We conducted a single-centre retrospective study of patients initiating dialysis with a residual urea clearance (KRU) of ≥3 mL/min, over a 20-year period. Patients who had 2×HD for ≥3 months during the 12 months following initiation of 2×HD were identified for comparison with those dialysed thrice-weekly (3×HD). Results: The 2×HD group consisted of 154 patients, and the 3×HD group 411 patients. The 2×HD patients were younger (59 ± 15 versus 62 ± 15 years: P = 0.014) and weighed less (70 ± 16 versus 80 ± 18 kg: P < 0.001). More were females (34% versus 27%: P = 0.004). Fewer had diabetes (25% versus 34%: P = 0.04) and peripheral vascular disease (PVD) (13% versus 23%: P = 0.008). Baseline KRU was similar in both groups (5.3 ± 2.4 for 2 × HD versus 5.1 ± 2.8 mL/min for 3 × HD: P = 0.507). In a mixed effects model correcting for between-group differences in comorbidities and demographics, 3×HD was associated with increased rate of loss of KRU and separation of KRU. In separate mixed effects models, group (2×HD versus 3×HD) was not associated with differences in serum potassium or phosphate, and the groups did not differ with respect to total standard Kt/V. Survival, adjusted for age, gender, weight, baseline KRU and comorbidity (prevalence of diabetes, cardiac disease, PVD and malignancy) was greater in the 2×HD group (hazard ratio 0.755: P = 0.044). In sub-analyses, the survival benefit was confined to women, and those of less than median bodyweight. Conclusion: 2×HD initiation as part of an incremental programme with regular monthly monitoring of KRU was safe and associated with a reduced rate of loss of RKF early after dialysis initiation and improved survival. Randomized controlled trials of this approach are indicated.Peer reviewedFinal Accepted Versio

Time, timing, talking and training : findings from an exploratory action research study to improve quality of end of life care for minority ethnic kidney patients

Background. With an ageing and increasingly diverse population at risk from rising levels of obesity, diabetes and cardiovascular disease, including kidney complications, there is a need to provide quality care at all stages in the care pathway including at the end of life and to all patients. Aim. This study purposively explored South Asian patients' experiences of kidney end of life care to understand how services can be delivered in a way that meets diverse patient needs. Methods. Within an action research design 14 focus groups (45 care providers) of kidney care providers discussed the recruitment and analysis of individual interviews with 16 South Asian kidney patients (eight men, eight women). Emergent themes from the focus groups were analysed thematically. The research took place at four UK centres providing kidney care to diverse populations: West London, Luton, Leicester and Bradford. Results. Key themes related to time and the timing of discussions about end of life care and the factors that place limitations on patients and providers in talking about end of life care. Lack of time and confidence of nurses in areas of kidney care, individual attitudes and workforce composition influence whether and how patients have access to end of life care through kidney services. Conclusion. Training, team work and time to discuss overarching issues (including timing and communication about end of life) with colleagues could support service providers to facilitate access and delivery of end of life care to this group of patients.Peer reviewedFinal Published versio