Inequalities in the Management of Diabetic Kidney Disease in UK Primary Care: :A Cross‐Sectional Analysis of A Large Primary Care Database

Aims: To determine differences in the management of diabetic kidney disease (DKD) relevant to patient sex, ethnicity and socio-economic group in UK primary care. Methods: A cross-sectional analysis as of January 1, 2019 was undertaken using the IQVIA Medical Research Data dataset, to determine the proportion of people with DKD managed in accordance with national guidelines, stratified by demographics. Robust Poisson regression models were used to calculate adjusted risk ratios (aRR) adjusting for age, sex, ethnicity and social deprivation. Results: Of the 2.3 million participants, 161,278 had type 1 or 2 diabetes, of which 32,905 had DKD. Of people with DKD, 60% had albumin creatinine ratio (ACR) measured, 64% achieved blood pressure (BP, <140/90 mmHg) target, 58% achieved glycosylated haemoglobin (HbA1c, <58 mmol/mol) target, 68% prescribed renin–angiotensin–aldosterone system (RAAS) inhibitor in the previous year. Compared to men, women were less likely to have creatinine: aRR 0.99 (95% CI 0.98–0.99), ACR: aRR 0.94 (0.92–0.96), BP: aRR 0.98 (0.97–0.99), HbA 1c: aRR 0.99 (0.98–0.99) and serum cholesterol: aRR 0.97 (0.96–0.98) measured; achieve BP: aRR 0.95 (0.94–0.98) or total cholesterol (<5 mmol/L) targets: aRR 0.86 (0.84–0.87); or be prescribed RAAS inhibitors: aRR 0.92 (0.90–0.94) or statins: aRR 0.94 (0.92–0.95). Compared to the least deprived areas, people from the most deprived areas were less likely to have BP measurements: aRR 0.98 (0.96–0.99); achieve BP: aRR 0.91 (0.8–0.95) or HbA 1c: aRR 0.88 (0.85–0.92) targets, or be prescribed RAAS inhibitors: aRR 0.91 (0.87–0.95). Compared to people of white ethnicity; those of black ethnicity were less likely to be prescribed statins aRR 0.91 (0.85–0.97). Conclusions: There are unmet needs and inequalities in the management of DKD in the UK. Addressing these could reduce the increasing human and societal cost of managing DKD

Survival for waitlisted kidney failure patients receiving transplantation versus remaining on waiting list:systematic review and meta-analysis

OBJECTIVES: To investigate the survival benefit of transplantation versus dialysis for waitlisted kidney failure patients with a priori stratification. DESIGN: Systematic review and meta-analysis. DATA SOURCES: Online databases MEDLINE, Ovid Embase, Web of Science, Cochrane Collection, and ClinicalTrials.gov were searched between database inception and 1 March 2021. INCLUSION CRITERIA: All comparative studies that assessed all cause mortality for transplantation versus dialysis in patients with kidney failure waitlisted for transplant surgery were included. Two independent reviewers extracted the data and assessed the risk of bias of included studies. Meta-analysis was done using the DerSimonian-Laird random effects model, with heterogeneity investigated by subgroup analyses, sensitivity analyses, and meta-regression. RESULTS: The search identified 48 observational studies with no randomised controlled trials (n=1 245 850 patients). In total, 92% (n=44/48) of studies reported a long term (at least one year) survival benefit associated with transplantation compared with dialysis. However, 11 of those studies identified stratums in which transplantation offered no statistically significant benefit over remaining on dialysis. In 18 studies suitable for meta-analysis, kidney transplantation showed a survival benefit (hazard ratio 0.45, 95% confidence interval 0.39 to 0.54; P<0.001), with significant heterogeneity even after subgroup/sensitivity analyses or meta-regression analysis. CONCLUSION: Kidney transplantation remains the superior treatment modality for most patients with kidney failure to reduce all cause mortality, but some subgroups may lack a survival benefit. Given the continued scarcity of donor organs, further evidence is needed to better inform decision making for patients with kidney failure. STUDY REGISTRATION: PROSPERO CRD42021247247

Exploring the Epidemiology of Cancer after Solid Organ Transplantation (EpCOT): an observational cohort study

Introduction Solid organ transplant patients are counselled regarding increased risk of cancer (principally due to their need for lifelong immunosuppression) and it ranks as one of their biggest self-reported worries. Post-transplantation cancer is common, associated with increased healthcare costs and emerging as a leading cause of post-transplant mortality. However, epidemiology of cancer post-transplantation remains poorly understood, with limitations including translating data from different countries and national data being siloed across different registries and/or data warehouses.Methods and analysis Study methodology for Epidemiology of Cancer after Solid Organ Transplantation involves record linkage between the UK Transplant Registry (from NHS Blood and Transplant), Hospital Episode Statistics (for secondary care episodes from NHS Digital), National Cancer Registry (from cancer registration data hosted by Public Health England) and the National Death Registry (from NHS Digital). Deterministic record linkage will be conducted by NHS Digital, with a fully anonymised linked dataset available for analysis by the research team. The study cohort will consist of up to 85 410 solid organ transplant recipients,who underwent a solid organ transplant in England between 1 January 1985 and 31 December 2015, with up-to-date outcome data.Ethics and dissemination This study has been approved by the Confidentiality Advisory Group (reference: 16/CAG/0121), Research Ethics Committee (reference: 15/YH/0320) and Institutional Review Board (reference: RRK5471). The results of this study will be presented at national and international conferences, and manuscripts with results will be submitted for publication in high-impact peer-reviewed journals. The information produced will also be used to develop national evidence-based clinical guidelines to inform risk stratification to enable risk-based clinical follow-up.Trial registration number NCT02991105

Seasonal mortality trends for hospitalised patients with acute kidney injury across England

Abstract Background Incidence of acute kidney injury (AKI) is known to peak in winter months. This is likely influenced by seasonality of commonly associated acute illnesses. We set out to assess seasonal mortality trends for patients who develop AKI across the English National Health Service (NHS) and to better understand associations with patient ‘case-mix’. Methods The study cohort included all hospitalised adult patients in England who triggered a biochemical AKI alert in 2017. We modelled the impact of season on 30-day mortality using multivariable logistic regression; adjusting for age, sex, ethnicity, index of multiple deprivation (IMD), primary diagnosis, comorbidity (RCCI), elective/emergency admission, peak AKI stage and community/hospital acquired AKI. Seasonal odds ratios for AKI mortality were then calculated and compared across individual NHS hospital trusts. Results The crude 30-day mortality for hospitalised AKI patients was 33% higher in winter compared to summer. Case-mix adjustment for a wide range of clinical and demographic factors did not fully explain excess winter mortality. The adjusted odds ratio of patients dying in winter vs. summer was 1.25 (1.22–1.29), this was higher than for Autumn and Spring vs. Summer, 1.09 (1.06–1.12) and 1.07 (1.04–1.11) respectively and varied across different NHS trusts (9 out of 90 centres outliers). Conclusion We have demonstrated an excess winter mortality risk for hospitalised patients with AKI across the English NHS, which could not be fully explained by seasonal variation in patient case-mix. Whilst the explanation for worse winter outcomes is not clear, unaccounted differences including ‘winter-pressures’ merit further investigation

Centre variation in mortality following post-hospitalisation acute kidney injury: Analysis of a large national cohort.

BACKGROUND Routine monitoring of outcomes for patients with Acute Kidney Injury (AKI) is important to drive ongoing quality improvement in patient care. In this study, we describe development of a case-mix adjusted 30-day mortality indicator for patients with post-hospitalisation AKI (H-AKI) across England, to facilitate identification of any unwarranted centre-variation in outcomes. METHODS We utilised a routinely collected national dataset of biochemically detected AKI cases, linked with national hospitals administrative and mortality data. 250,504 H-AKI episodes were studied in total, across 103 NHS hospital trusts, between January 2017 - December 2018. Standardised mortality ratios (SMRs) were calculated for each trust using logistic regression; adjusting for age, sex, primary diagnosis, comorbidity score, AKI severity, month of AKI, and admission method. RESULTS Mean 30-day mortality rate was high at 28.6%. SMRs for 23/103 trusts were classed as outliers, 12 above and 11 below the 95% control limits. Patients with H-AKI had mortality rates over 5 times higher than the overall hospitalised population in 90/136 diagnosis groups and over 10 times higher in 60/136 groups. Presentation at trusts with a co-located specialist nephrology service was associated with a lower mortality risk, as was South Asian or Black ethnicity. Deprivation, however, was associated with higher mortality. CONCLUSIONS This is the largest multi-centre analysis of mortality for patients with biochemically ascertained H-AKI to date, demonstrating once again the considerable risk associated with developing even mild elevations in serum creatinine. Mortality rates varied considerably across centres and those identified as outliers will now need to carefully interrogate local care pathways to understand and address reasons for this, with national policy required to tackle the identified health disparities