Home Haemoglobin Monitoring for the Titration of Erythropoietin-Stimulating Agents in Chronic Kidney Disease: A Pragmatic Pilot Trial

Background. No trials of POCT device pathways have been published in the field of anaemia of CKD. We describe the results of a year of use of a novel POCT device with its associated eHealth pathway in the home monitoring of ESA therapy, with the aim of evaluating device performance and pathway feasibility. Methods: We used a POCT device designed for home self-testing, able to measure Hb from a drop of capillary blood (Luma, Entia, UK). Results were shared with HCPs via an associated mobile application. The pilot ran from August 2020 to March 2022 in a single UK renal centre. All adult non-dialysis-dependent-CKD patients on ESAs were eligible for inclusion. Participants were mailed the device and trained remotely. Participants were encouraged to self-test twice weekly for up to 1 year, with data collected on a pragmatic basis. Lab and Luma’s results were compared. Results: Seventeen participants returned comparable datasets (underwent ≥ 4 lab Hb measurements and self-tested for >5 months) with a mean testing frequency of 1.6 tests/wk. 1062 Luma and 113 lab Hb results were analysed. The coefficient of variation (CV) for raw results was 8.3% with a bias of −2.0% and SD 8.5. The percentage of Luma results differing by >10% lab results was 30.9%, dropping to 17.7% using an 8-point-moving-average. Participants stated they preferred Luma to traditional ESA monitoring and recommended the pathway to others. Conclusion: One year of home self-testing with Luma yielded comparable device utility to other POCT haematology analysers derived via HCP testing. Innovative pilot trials such as this form the basis for new empowering and home-based models of care required and desired by patients and HCPs

Point-of-care testing technologies for the home in chronic kidney disease: a narrative review

Abstract Point-of-care testing (POCT) performed by the patient at home, paired with eHealth technologies, offers a wealth of opportunities to develop individualized, empowering clinical pathways. The non-dialysis-dependent chronic kidney disease (CKD) patient who is at risk of or may already be suffering from a number of the associated complications of CKD represents an ideal patient group for the development of such initiatives. The current coronavirus disease 2019 pandemic and drive towards shielding vulnerable individuals have further highlighted the need for home testing pathways. In this narrative review we outline the evidence supporting remote patient management and the various technologies in use in the POCT setting. We then review the devices currently available for use in the home by patients in five key areas of renal medicine: anaemia, biochemical, blood pressure (BP), anticoagulation and diabetes monitoring. Currently there are few devices and little evidence to support the use of home POCT in CKD. While home testing in BP, anticoagulation and diabetes monitoring is relatively well developed, the fields of anaemia and biochemical POCT are still in their infancy. However, patients’ attitudes towards eHealth and home POCT are consistently positive and physicians also find this care highly acceptable. The regulatory and translational challenges involved in the development of new home-based care pathways are significant. Pragmatic and adaptable trials of a hybrid effectiveness–implementation design, as well as continued technological POCT device advancement, are required to deliver these innovative new pathways that our patients desire and deserve.</jats:p

P1363ON-LINE SURVEILLANCE OF ESTABLISHED HAEMODIALYSIS ARTERIOVENOUS FISTULA UTILISING FRESENIUS THERAPY MONITORING SYSTEM AND EUROPEAN CLINICAL DATA SYSTEM (EUCLID): THE SHUNT STUDY- BASELINE DEMOGRAPHICS OF PARTICIPANTS

Abstract Background and Aims The arteriovenous fistula (AVF) is well established as the preferred vascular access for haemodialysis (HD). However AVF remain prone to a number of complications, the most common of these being thrombosis, which usually occurs on the background of a developing stenosis. The development of stenosis can be detected and the lesion treated before thrombosis occurs; this forms the rationale behind monitoring and surveillance programs. Surveillance uses more resources than monitoring and has not been convincingly shown to improve outcomes such as access loss. The evidence supporting the use of the various monitoring techniques in AVF is in the main observational, under-powered, out of date and based on studies populations of predominantly arteriovenous grafts (AVG). Monitoring techniques have been shown in multiple studies to have higher utility in AVF than AVG. The modern, high efficiency dialysis machine with integrated on-line clearance monitoring (OCM) necessitates the reconsideration of the performance and utility of monitoring metrics such as Kt/V and access recirculation (AR). The lack of evidence surrounding monitoring techniques is recognised by KDOQI who recommend that further research is required to validate these indicators. In this study we aim to examine if changes in AR and Kt/V values obtained through OCM during HD can help predict AVF failure. Method SHUNT is a UK single-centre prospective cohort study with a 1-year follow-up of all study participants. The 100 participants are aged over 18 years receiving in-centre maintenance HD with through an established AVF. We use the Fresenius Therapy Data Monitoring System (F-TDMS) and EuCliD system to capture all dialysis treatment data from Fresenius 5008 machines. This will allow trend analysis for AR and Kt/V to assess the accuracy of these parameters in predicting access failure. The primary outcome measure is to determine whether changes in AR and Kt/V trends are able to predict AVF failure. Secondary outcome measures include assessment of the utility of AR and Kt/V alone to predict AVF failure, the comparison of AR and Kt/V trends pre- and post-intervention and the assessment of the number of patients referred for fistulograms, requiring AVF intervention and suffering access failure, VA related hospitalization and central line use. Results The planned 100 AVF patients have been recruited. Participants’ mean and median age is 63.07 and 63.32 years respectively with a standard deviation of 14.21. The patients are 59% male and the mean BMI is 28.27kg/m2. The mean vintage on HD is 3.41 years with a median of 2.32 years. The AVF are 37% brachiocephalic, 35% radiocephalic (65% of which are at the wrist), and 13% brachiobasilic transposition. Aetiology of primary renal disease is diabetic nephropathy in 22%, glomerulonephritis in 19%, unknown in 19%, obstructive in 15%, polycystic kidney disease in 11%, renovascular/hypertensive in 9% and assorted other pathology (eg. ATN, TIN) in 5%. Conclusion Our study participants are broadly representative of the UK’s AVF population as a whole. We hope that the SHUNT STUDY will provide representative, up-to-date and robust evidence for the utility of these basic monitoring tools in the prediction of AVF stenosis in the age of OCM. </jats:sec

Medicines optimisation review

A realist review of what works, for whom, in what contexts, for the teaching of medicines optimisation/review/deprescribing in undergraduate medical curricula

Reciprocal Relationship between Compliance with Post-Op Follow-Up and Weight Loss after Bariatric Surgery

Obesity is a large and growing health problem in the UK with high associated costs to the NHS. Bariatric surgery is proven as an effective treatment for obesity associated with long term weight loss and a reduction in obesity related comorbidities [1]. The NICE guidance highlights the importance of follow-up post-surgery [2]. The guidelines state that in order to be eligible for surgery the patient must commit to long term follow-up and that in order for a centre to offer bariatric surgery it must ensure that it can&nbsp; provide regular MDT post-op assessment and support for at least two years [2].</p

Persistent dysphagia and drowisness following collapse in an alcohol-dependent patient

A 58 year old man was brought to the emergency department with acute confusion after being found unconscious on his floor at home. He had a background of alcohol misuse with alcoholic liver disease. He was not taking any regular medications. On examination he smelt of alcohol and was tachycardic at 96 bpm with BP 110/70. The patient’s Glasgow Coma Score was 14, being drowsy but responsive with bilateral lower zone crepitations on auscultation of the chest. Neurological examination revealed generalized reduced muscle bulk but no focal deficits.</jats:p

Persistent dysphagia and drowisness following collapse in an alcohol-dependent patient (Answers)

This T2 weighted MRI scan demonstrates a hyperintense trident shaped lesion extending from the pontomedullary junction to the midbrain with peripheral sparing (figure 2 – abnormality indicated by white arrows).</jats:p