2017 abstract booklet - srr.scot.nhs.uk
TRANSCRIPT
Abstract Booklet26-27 October 2017
DoubleTree by Hilton Dunblane Hydro
A1 Adipose-derived regenerative cells administered via the renal artery for therapy in a novel rat transplant model Rashida Lathan 1 Ryan Ghita12 Dianne Hillyard1 Rhian M Touyz1 Patrick Mark12 Marc Clancy12
1Institute of Cardiovascular and Medical Sciences UNIVERSITY OF GLASGOW Glasgow UK 2Transplant Unit QUEEN ELIZABETH UNIVERSITY HOSPITAL Glasgow UK
Introduction Studies in our hybrid rat model of transplantationischemic reperfusion (IRI) have demonstrated improvement in kidney function post injection of adipose-derived regenerative cells (ADRCs) into the renal artery This technique has translational value in human transplant surgery as ADRCs provide a robust supply of cells from accessible tissue do not require culturing and can be generateddelivered at point of care during the time of transplant The mechanism on how these cells ameliorate IRI remains elusive
Objectives Our research aims to identify the active subsets of cells represented in the ADRC population their biodistribution mode of action and any potential deleterious effects Methods Flow cytometric analysis was performed on rat ADRCs extracted from inguinal (n=14) and perirenal tissue (n=6) and human perirenal ADRCs extracted from healthy donors (n=6) Cells were surveyed for markers that identify viability immune cells (CD45+) immune cell subsets (CD3+ CD3+CD4+ CD3+CD8+ CD11b+ cells) epithelial cells (CD45-CD31+) pericytes (CD45-CD146+) and mesenchymal stem cells (CD45-CD90+CD34-) Rat ADRC RNA expression for markers of repair and markers of inflammation was measured by real-time PCR ADRCs were extracted from inguinal fat of the Fisher 344 rat labelled with a near infrared lipophilic dye DiR and injected via the renal artery of the IRI rat model Whole body imaging was performed Organs (kidneys heart lung brain spleen liver) were removed and imaged at various time points Organs were processed for histological analysis and gene expression measured at 1 hour and 24 hours post renal injection Protein isolated from the kidney and serum at 24 hours post injection were surveyed with a proteome profile array
Results In the rat we show a 27-40 fraction of injected inguinal ADRCs were non-viable Cell subsets consisted of varying levels of immune cells (15-75) and varying levels of pericyte cells depending on the adipose tissue source (inguinal vs perirenal fat) Stem cell-like markers identified 12-22 of the total ADRC cell population Rat perirenal ADRC composition is similar to human perirenal ADRC composition with the exception that humans have higher levels of T-cells RNA expression from whole rat ADRCs indicate production of growth and repair factors angiogenin and matrix metallopeptidase-2 and chemokine CXCL1 A large accumulation of ADRCs appeared clustered in the glomeruli of the kidney 1 hour post injection of ADRCs At 24 hours cells remain visible within the kidney Histological analysis of the injected kidney identified labelled cells within the cortex (likely within the renal corpuscule) of the injected kidneys at 1 hour and 24 hours post injection Fluorescence was also detected within the liver at 1 hour and 24 hours at focal points in the periphery Gene expression studies performed on the kidneys at 1 hour and 24 hour post injection identified an upregulation of immunomodulatory repair and injury related genes when compared to sham-injected control Protein profiling indicated an upregulation of TIMP-1 and of ligands important in leukocyte trafficking
Discussion Rat ADRCs appear to be a pleomorphic cell suspension with multiple potential active subsets including T-cells macrophages and mesenchymal stem cells Collectively RNA of factors related to growth and repair are expressed Human perirenal ADRCs have a comparable composition as rat perirenal ADRCs After 24 hours the ADRCs persist within the kidney RNA data of the injected kidney suggests that ADRCs exert multiple effects on the surrounding tissue as shown by the increase in gene expression related to repair VEGFa Ang2 and immune modulation Csf2 CXCL1 CXCL2 Ifn- and IL-6 The change in RNA and protein levels of leukocyte trafficking-related factors suggest a major role for leukocytes
Funding UK Regenerative Medicine Platform Conflict of interest None
A2 The development of an online educational resource on AKI Ross Norris 1 Joanne Sloan 2 Samira Bell 2
1 School of Medicine University of Dundee Ninewells Hospital 2 Renal Unit Ninewells Hospital
Background Within NHS Tayside there are a number of resources and tools available to aid in the prompt detection and management of AKI such as primary amp secondary care E-Alert systems local guidelines and most recently lanyard cards These resources are supplemented by a regular AKI awareness week which involves delivery of formal amp informal education as well as distribution of a variety of resources However there was a lack of an easily accessible educational resource for both medical and nursing staff as well as medical students In light of this the aim of this project was to produce an educational resource that was engaging easily accessed and easily distributable
Development amp Production NHS Taysidersquos AKI guideline was used as the foundation for the content of the resource and animation was decided as the format in which the resource would be produced Animation was chosen because research has shown that multimedia is an effective method for delivering education and because an animated video provides an independent and easily accessible resource (1) Initial stages of development involved production of sketches and a script based on the guideline Following development of a working draft of both a focus group was held with staff from the renal department to gain constructive feedback In order to turn this concept into an animated video the team was expanded to include a local artist who used the initial sketches to produce illustrations on Adobe Photoshop and a videographer who developed a plan of how to approach the live drawing of each of the illustrations to maximise their visual impact To prepare for production a storyboard inclusive of the exact timings of each illustration and the coordinating part of the script was created Production involved live filming of the illustrations being drawn The footage obtained was then edited using Adobe Premier Pro reading of the script recorded and both combined to produce a fully narrated animated video
Distribution amp Utilization The resource has been made available to staff via upload to the intranet has been incorporated into FY1 induction and will be used as part of the next yearrsquos AKI awareness week Access to the video has been made open to enable use by medical students and professionals outside of Tayside via upload to NHS Taysidersquos YouTube Facebook and Twitter pages with current viewership being 1400
Link httpswwwyoutubecomwatchv=gW0pgXrIdgo
Funding amp Conflicts of Interest The renal endowment fund NHS Tayside No conflicts of interests to declare
References 1 Rolfe VE Gray D Are Multimedia Resources Effective in Life Science Education A Meta-Analysis Bioscience Education 201118(1)1-14
A3 Glucose dynamics and mortality in RRT patients an initial report
Matthew A Rutherford12 Gregory C Jones3 Alan G Jardine14 Patrick B Mark14 Peter C Thomson12 Christopher AR Sainsbury3
1 Glasgow Renal and Transplant Unit Queen Elizabeth University Hospital Glasgow UK 2 School of Medicine Dentistry and Nursing University of Glasgow UK 3 Diabetes Centre Gartnavel General Hospital Glasgow UK 4 Institute of Cardiovascular and Medical Sciences University of Glasgow UK
Background Glucose variability is increasingly being recognised for an association with adverse outcomes in populations with normal renal function For individuals with abnormal renal function this is less clear particularly for those with end stage renal failure undergoing renal replacement therapy (RRT) In RRT patients sustained extremes of glycaemia appear to be associated with worse survival however the effect of underlying glucose dynamics remains poorly understood Specifically there are few published studies which examine the influence of hypoglycaemic episodes on outcomes in RRT patients We sought to determine the relationship between inpatient hypoglycaemia and long-term mortality in a broad cohort of RRT patients
Methods Data for all incident and prevalent RRT patients within our catchment from July 2008 to December 2016 were extracted from the electronic patient record These were merged with a dataset of hospital capillary blood glucose (CBG) measurements Hospital contact episodes were identified from CBG timestamp data (a technique previously validated in other populations) Contacts with gt1 CBG measured within a 48 hour period were taken as admissions Those with at least one CBG lt4mmolL during the first recorded admission were compared with those without Age length of admission and number of measured CBGs were compared between groups A survival analysis was carried out over 85 years comparing groups A Cox proportional hazard model was used to compare time to death including age as a covariable
Results 367544 CBGs from 2215 individuals and 63559 hospital contact episodes were identified 31340 episodes from 831 individuals had gt1 CBG performed and were analysed as admissions 219 individuals had 1 or more CBGs lt4mmoll recorded This group experienced longer admission (36 vs 19 days plt0001) and had a higher number of recorded CBGs (13 vs 4 p lt 0001) On survival analysis hypoglycaemia was associated with a HR for death of 152 (95 CI 131-173 plt00001)
Discussion Hypoglycaemia is associated with prolonged admission and increased mortality in this broad population Further work investigating the impact of glucose variability RRT modality and presence or absence of diabetes is planned
A4 Vitamin K and Vascular Health A Systematic Review and Meta-Analysis Jennifer Lees12 Fiona Chapman2 Miles Witham3 Alan Jardine12 Patrick Mark12
1 Institute of Cardiovascular and Medical Sciences University of Glasgow 2 Glasgow Renal and Transplant Unit NHS Greater Glasgow and Clyde 3 University of Dundee
Background - Vascular stiffness and calcification occur prematurely in patients with chronic kidney disease (CKD) and are associated with increased mortality Activity of matrix Gla protein - an important regulator of vascular calcification - is dependent on adequate vitamin K intake vitamin K deficiency is prevalent in patients with CKD We conducted a systematic review and meta-analysis of the effect of vitamin K supplementation on vascular health and assessed the evidence that level of (inactive) dephosphorylated undercarboxylated Matrix Gla protein (dp-ucMGP) is associated with incident cardiovascular disease (CVD) or mortality
Methods - Two authors searched Medline and Embase databases Cochrane and ISRCTN registries in May 2017 for i) adult human studies of vitamin K supplementation versus control which measured effects on vascular calcification vascular stiffness or dp-ucMGP and ii) prospective observational studies assessing effect of baseline dp-ucMGP on incident CVD or mortality Random effects meta-analysis was conducted using meta and metafor packages for R statistical software package Egger regression and Trim-and-Fill analyses were used to assess for publication bias
Results ndash Nine intervention studies (n=952) and 13 observational studies (n=7495) met our pre-specified inclusion criteria Vitamin K led to a significant reduction in vascular calcification compared to placebo (-91 [95CI -177 -05] p=004) and a significant decrease in dp-ucMGP (-227pmolL [95CI -281 -173] plt0001) A non-significant improvement in vascular stiffness was evident (-37 [95CI -78 04] p=008) In observational studies with a follow up period of 70 + 40 years stepwise increase in dp-ucMGP was not associated with fatal or non-fatal CVD (log HR 005 [95CI -013 022] p=062) or mortality (log HR 004 [95CI -015 023] p=069) Egger regression and Trim-and-Fill analyses suggest possible publication bias in favour of positive results
Conclusion - Vitamin K supplementation significantly reduces dp-ucMGP level although dp-ucMGP is not associated with incident CVD or mortality Supplementation appears to reduce progression of vascular calcification with a trend towards improvement in vascular stiffness though there are limited data available Clinical trials of the effect of vitamin K supplementation on vascular health are warranted
Funding - JL is supported by a Kidney Research UK Training Fellowship
Conflicts of interest - MW and PM are currently running a BHF-funded trial of vitamin K supplementation in patients with CKD 3b4
A5 Review of management of patients with diabetic nephropathy Wan Shun Wonga Mohammed K Azharuddinb
aRenal and Transplant Unit Queen Elizabeth University Hospital Glasgow bDiabetes Unit Inverclyde Royal Hospital Greenock
Background ndash Diabetic nephropathy is a common and potentially life-threatening complication of both type 1 and type 2 diabetes and is now recognised as the leading cause of end-stage renal disease1 Studies have shown that early interventions can delay the onset and slow the progression of diabetic nephropathy2 The aim of our study was to review the management of patients with diabetic nephropathy at Inverclyde Royal Hospital in accordance to the guideline published by the National Institute for Health and Care Excellence (NICE)
Methods ndash Patients with diabetic nephropathy were identified on SCI-Diabetes Patient data was then extracted from renal electronic patient record SCI-Diabetes and Clinical Portal Clinical notes were also reviewed to determine the reason for cessation of angiotensin-converting-enzyme inhibitor (ACE-I) or angiotensin receptor blocker (ARB) Referral guidelines from the Renal Association were used to assess the eligibility for referral
Results ndash Data was collected from 255 patients with diabetes and urine ACR gt25 (for male) and gt35 (for female) Mean age was 625 years (SD 151) and 584 (n=149) were male 243 of patients (n=62) were classed as type 1 diabetes and 737 (n=188) as type 2 with further 20 (n=5) as others 949 (n=242) patients had an HbA1c recorded within the last year The mean HbA1c was 712 (SD 2052) 8 patients were on RRT (7 on HD and 1 on PD) Serum creatinine and urine ACRPCR were checked in 933 (n=238) and 612 (n=156) of patients in the last year respectively Blood pressure was measured within the past 12 months for 847 (n=216) of patients with 601 (n=146) having blood pressure higher than the target of 13080mmHg Mean systolic and diastolic blood pressures were 1339 mmHg (SD 1735) and 745 mmHg (SD 111) respectively 627 of patients were on ACE-IARB Of the 95 patients who were not on ACE-IARB 421 (n=40) were stopped due to side effects 116 (n=11) patients had their ACE-IARB discontinued but no reason could be found 379 (n=36) patients had never been on an ACE-IARB 157 (n=40) of patients met the criteria for referral to Renal Services and 7 patients had not been referred and all 7 of them recently developed CKD4
Conclusion ndash Our findings were consistent with the national data3 Urine PCR measurement has the lowest completion rate among all the recommended annual care processes Optimal blood pressure control remains a challenging issue for many of the patients with diabetes Further studies could be carried out to look at the reasons behind the low completion rate of urine PCR measurement as well as to devise ways to remind clinicians about starting patients on ACE-IARB and making referral to Renal Services when indicated
References 1 K Bennett B S Aditya An overview of diabetic nephropathy Epidemiology pathophysiology and treatment Journal of Diabetes Nursing 18 61-7 2 Molitch ME DeFronzo RA Franz MJ et al American Diabetes Association Nephropathy in diabetes Diabetes Care 200427(Suppl 1)S79-83 3 Scottish Diabetes Survey 2016 Scottish Diabetes Survey Monitoring Group NHS Scotland
Funding ndash None Conflict of Interest ndash None
A6 Analgesic Use in Dialysis Patients in a District General Hospital Setting
A McCallum L Dickson S Robertson A Almond N Rathnamalala M KellyT Muniraju
Renal Unit Dumfries and Galloway Royal Infirmary
Evidence shows around 50 of haemodialysis patients report pain with 83 describing this as moderate to severei Distinct variability also exists in levels of opiate prescribing between centres with studies showing incidence ranging from 5-50iiiii Consequently we sought to investigate the prevalence of both pain and opioid prescriptions in our local dialysis population as well as investigating whether there are any associations between co-morbidities and the use of opiates This information could then be used to identify new dialysis patients at high risk of pain as well as informing prescribing decisions
In order to achieve this a questionnaire was produced that incorporated validated pain and quality of life scores (the Brief Pain Index and Renal Palliative Care Outcome Scale) with a consent form to access electronic healthcare records Questionnaires were distributed to all our haemodialysis and peritoneal dialysis patients Results were transcribed into Microsoft Excel where they were analysed
Data was collected on 56 patients (46 haemodialysis patients 10 peritoneal dialysis patients) Results showed 46 described ldquopain other than everyday kindsrdquo on the day of survey completion The most common site of pain was in the legs and back On average patients were on 12 different medications of which 15 was for pain (range 0-5) 784 of these pain prescriptions were longstanding (gt3 month use) Amongst haemodialysis patients 45 were on a strong opioid ndash in 73 of cases this was a fentanyl patch Whilst scope exists to increase the use of simple analgesia and neuropathic agents in such patients analysis using the pain management index scale revealed use of opioid analgesia in such cases to be justified As in previous work no link was found between any one co-morbidity and the development of pain
Overall we have shown high rates of pain amongst our dialysis patients We also demonstrate high levels of chronic analgesia use and the overall tablet burden on our patient group is high This work adds to previously published literature and is being used locally to proactively minimise the burden of prescribed tablets and also increase awareness of the value of paracetamol and neuropathic agents in those with uncontrolled pain
Source of funding conflict of interest Nil
References i Davison SN Pain in hemodialysis patients prevalence cause severity and management Am J Kidney Dis 2003421239-1247 ii Butler AM Kshirsagar AV Brookhart MA Opioid Use in the US Hemodialysis Population Am J Kidney Dis 2014 63(1) 164-173 iii Wyne A Rai R Cuerden M Clark WF Suri RS Opioid and Benzodiazepine Use in End-Stage Renal Disease A Systematic Review Clin J Am Soc Nephrol 2011 6 326ndash333
A7 The Role of the Renal Supportive Care Service in Advanced Care Planning JM Sloan CA Douglas S Cathcart L Frame L Stage M Witham ME Lafferty
Renal Service Ninewells Hospital Dundee
Background In 2007 we established a Renal Supportive Care Service for patients with advanced chronic kidney disease who choose not to receive dialysis The service which includes a fortnightly Renal Supportive Care clinic is provided by a Consultant Nephrologist a Consultant Palliative Care Physician and a Renal Supportive Care Specialist nurse The focus of the service is on ongoing management of chronic kidney disease symptom control and improving quality of life while planning for end of life care
Methods We have undertaken a retrospective audit of our Renal Supportive Care Service on all patients known to the Renal Service for whom a conservative care management decision had been made We collected data over a 31-month period from April 2012 until October 2014 We collected data on demographics co-morbidities clinic attendance renal supportive care input anticipatory care planning performance status and mortality data
Results Of the 98 patients for conservative management 62 (6198) were female with a mean age of 837 years During the 31-month period there were 507 documented supportive care consultations with 36 (3598) of patients receiving domiciliary visits from the Renal Supportive care nurse Anticipatory Care Plans (ACP) were in place for 62 (61) of patients with a preferred place of death known for 56 (5598) 65 patients had a documented discussion about their DNACPR status which was communicated in writing to primary care For a further 13 it was not clear whether the discussion had taken place During the study period 61(62) patients died Of those patients with an ACP 29 (1138) died in an acute hospital versus 43 (1023) of those without (p=025) Similarly 24 (834) of patients with a documented preferred place of death died in an acute hospital versus 48 (1327) of those without (p=004)
Conclusions The role of the Renal Supportive Care team is invaluable in providing care and support to patients who have chosen conservative management By discussing and planning for end of life care the Renal Supportive Care team play a role in reducing the number of patients dying within an acute setting
Conflicts None
Funding The Renal Supportive Care Nurse post and one Palliative Care Consultant Programmed activity received 3 years of funding by British Kidney Patients Association
A8 Predictors of transplant failure in patients undergoing indication renal biopsy
Kate Stevens 1 Bruce Mackinnon1 David Kipgen1 Shana Coley1 Marc Clancy1 Colin Geddes1
1Renal and Transplant Unit QEUH NHS GGampC Glasgow United Kingdom
Introduction This study considers indication renal biopsies and factors which may be important
predictors of transplant loss and patient death
Objectives To identify the time line of histological diagnosis from transplant in our population
and to identify predictors of graft and patient survival in those undergoing indication renal biopsy
Methods All indication renal biopsies undertaken between 012011 and 122015 were identified
Demographic data including immunological and outcome data was recorded Statistical analysis
was undertaken in SPSS (v22)
Results 354 patients underwent 549 biopsies Mean patient and transplant age at time of biopsy
was 432 plusmn153 and 42plusmn58 years respectively 449 (n=247) of biopsies showed evidence of
Cell mediated rejection (CMR)ABMR or both 93 (n=51) demonstrated features of chronic
transplant glomerulopathy (CTG) DSA was present at the time of biopsy in 231 (n=127) In
transplants aged le 6 months old histological diagnosis was CMR in 325 (n=69) with ABMR seen
in 28 (n=6) In transplants aged ge10 years CTG was seen in 325 (n=26) with ABMR
accounting for 63 (n=5) 229 (n= 81) of transplants failed at a median of 182 days from most
recent biopsy On cox regression analysis peritubular capillary (PTC) C4d and CTG were
independent predictors of transplant failure Probability of transplant failure was 45 and 50 at
one year if mixed rejection or CTG were present 93 (n=33) patients died at a median of 227
days from most recent biopsy Independent predictors of death included deceased donor
transplant patient age and presence of ABMR on biopsy (plt005)
Conclusion Acute ABMR is a risk factor for patient loss whilst chronic ABMR is a risk factor for
transplant loss This association is independent of DSA but dependent upon PTC C4d staining
indicative of donor humoral activity ndash HLA or otherwise Histological diagnosis in an indication
biopsy is an important factor in predicting outcome This study is limited by the inherent bias in
patient selection with indication biopsy
Disclosure of Interest None Declared
A9 Renal Evaluation of Paediatric Patients with Tuberous Sclerosis Complex (TSC) in aNational TSC Multidisciplinary ClinicDr Jenny Patterson 1 Dr Shelagh Joss 1 Dr Ihab Shaheen 2
1 Clinical Genetics Queen Elizabeth University Hospital Glasgow 2 Paediatric Nephrology Royal Hospital for Sick Children Glasgow
Introduction Tuberous sclerosis complex (TSC) is a dominantly inherited multisystem disorder characterised by development of hamartomas (benign lesions) in multiple organs Previous studies have shown that renal manifestations are common in TSC and also the most frequent cause of TSC-related death in affected individuals With the recent discovery of targeted therapy with mTOR inhibitors early recognition of renal involvement allowing early surveillance and prompt therapy is now more important than ever
AimMethod To review a population of paediatric patients attending a large specialist TSC service in the UK both in terms of key clinical characteristics and current practice for renal radiological surveillance data were collected from electronic medical records pertaining to molecular diagnosis renal surveillance and presence or otherwise of sequelae affecting the renal or other systems Practice was compared to published surveillance recommendations of the International Tuberous Sclerosis Complex Consensus Group (2013)
Results Data were obtained for 41 children (18 males 23 females) Current age range 25 years to 14 years (mean 98 years) Twenty nine patients (707) were diagnosed lt1 year of age Genetic data were available for 29 patients Fifteen patients had a confirmed TSC1 mutation and 14 patients a confirmed TSC2 mutation including one contiguous PKD1 mutation Renal imaging (all US) within a year of diagnosis was documented in 2541(61) performed at a mean age of 3 years Renal symptoms at diagnosis were documented in 741(171) and 941(22) had renal abnormalities on baseline imaging There was wide variability in scanning interval and modality with 1041(243) having previous abdominal MRI with variable documented indication Seventeen (414) of the cohort mean age 102 years had documented renal lesions 917 angiomyolipomas 517 cysts and 317 both These lesions were diagnosed at a mean age of 6 years (range 02 years-142 years) Six patients (353) had normal baseline scans with a mean interval to lesion diagnosis of 1 year One patient had a lesion on MRI not detected on US that required subsequent biopsy Frequency of subsequent scanning ranged from intervals of 2 months to 1 year with a combination of MRIUS in an unclear pattern All patients except one with a contraindication were undergoing current brain surveillance by MRI
Conclusions Our results highlight the significant incidence of renal sequelae within our TSC cohort with renal manifestations ranging both in severity and age of onset International guidelines recommend MRI scanning for renal surveillance at diagnosis and throughout life Benefits of MRI include enhanced accuracy of sizing and characterisation of renal lesions The majority of our cohorts are already undergoing brain MRI surveillance It is our aim to combine and standardise MRI renal surveillance for this cohort to facilitate early and regular monitoring with a view to early intervention is possible
A10 Effect of blood temperature monitoring on intradialytic hypotension in patients with end stage renal disease requiring haemodialysis Heather Walker1 Susan McGeorge1 Drew Henderson2
1 Renal Unit Ninewells Hospital Dundee2 Regional Renal Centre Waikato Hospital Hamilton New Zealand
Background KDIGO define intradialytic hypotension (IDH) as a reduction in systolic bloodpressure (SBP) ge20mmHg or mean arterial pressure (MAP) ge 10mmHg with associatedsymptoms IDH is a common complication of haemodialysis (HD) and is associated with increasedmortality and morbidityStandard dialysis with a set temperature leads to thermal gain during the dialysis session Tocounteract this thermal gain vasodilation occurs and is postulated as one of the causes of IDHActive cooling of dialysis has been shown to reduce IDH but is not routinely applied across wholedialysis populations Isothermic dialysis can be achieved by controlling blood temperature on HDWe report here our experience of doing this using the Blood Temperature Monitoring (BTM)function on Fresenius 5008 dialysis machines
Methods An observational study was performed to assess the rates of IDH in patients with End Stage Kindey Disease (ESKD) undergoing regular satellite HD at NHS Tayside in July 2017 Rates of IDH were assessed (KDIGO definition) for two weeks prior to BTM settings being activated and for a two week study period after introduction SBP and MAP data was collected SBP data was grouped to either SBP decrease lt20mmHg or SBP decrease ge20mmHg compared with Pre HD BP Changes in MAP were also analysed at the same time points Patient reported symptoms related to initiation of BTM were also collected for the same time period
Results 402 dialysis sessions were evaluated in the pre intervention time period and 399 sessions post intervention
IDH 1072 vs 778 (Pre BTM vs Post BTM) p=015 gt20mmg SBP drop Pre vs Post BTM
Mean MAP Change (mmHg) Pre BTM vs Post BTM
1st BP 254 vs 204 (p=005) -522 vs +312 (plt001) 2nd BP 474 vs 435 (p=023) -1589 vs -886 (plt001) 3rd BP 515 vs 435 (p=003) -1862 vs -958 (plt001) Post HD 408 vs 338 (p=003) -1164 vs -077 (plt001)
Following the introduction of blood temperature monitoring only 08 of HD sessions reported experiencing cold or shivering symptoms
Conclusion The use of blood temperature monitoring was not associated with a statistically significant decrease in rates of IDH There was a significant reduction in the number of sessions where SBP decrease by gt20mmHg at the first and third HD BP and a reduction in MAP change across the study group Further evaluation of BTM is required assess its clinical utility in our HD population
Funding No funding was sought for this study
Conflicts of interest None
A11 Evaluating patient satisfaction and clinical outcomes of a new nurse-led dermatology clinic for patients attending the renal transplant clinic Campbell G Naismith K Neil A Rankin A Spalding E (joint first authors) Renal Unit University Hospital Crosshouse Kilmarnock UK
BACKGROUND National Guidelines advise that renal transplant recipients should receive annual skin surveillance to screen for skin cancer In August 2015 a specialist nurse-led dermatology clinic was set-up alongside the renal transplant clinic at University Hospital Crosshouse We aimed to evaluate the success of this joint clinic in terms of clinical outcomes and patient satisfaction
METHODS Clinical records were reviewed to determine the number of patients under dermatology follow-up before and after initiation of the joint clinic and to review cases that were referred for treatment of pathological skin lesions A questionnaire was also distributed to patients attending the new joint renal-dermatology transplant clinic The questionnaire consisted of 5 questions 2 for patient demographics 1 for current understanding of skin care advice and 2 to assess their satisfaction of the new joint clinic
RESULTS A total of 138 and 146 renal transplant recipients were registered on renal transplant clinic lists in 2015 and 2016 respectively Prior to initiation of the new joint-clinic 41 patients had attended dermatology (37 in NHS Ayrshire and Arran and 4 in NHS Greater Glasgow and Clyde) consisting of 30 of the transplant population In September 2016 13 months after initiation of the new clinic 60 patients had attended the new clinic increasing the proportion of patients meeting the national recommendation for skin surveillance to 41 Implementation of the new clinic resulted in patients being 65 more likely to have received the recommended skin checks (odds ratio 165 95 CI 101-270 p=004)
32 patients completed the questionnaire The median age of transplant was 90 years (IQR 38-153) 100 of patients knew to avoid sun exposure and 31 (96) knew to use sunscreen 29 (91) patients were aware of the advice to undergo annual skin surveillance by dermatology with 28 (88) having had a skin check in the last year 29 (91) patients reported that they found the new joint clinic useful although only 18 (56) had attended the clinic so far
CONCLUSIONS Implementation of a new nurse-led dermatology clinic running in parallel with the renal transplant clinic resulted in a considerable increase in the proportion of patients meeting national recommendations for annual skin surveillance The vast majority of patients also found the combined clinic to be useful There is still considerable room for improvement in order to achieve the target of 100 compliance with skin surveillance and ongoing clinical audit is required to assess progress We believe this model would be easily implementable at other units with similar benefits expected
A12 Pneumocystis pneumonia prophylaxis post-renal transplant increased duration of co-trimoxazole is safe and effective FA Chapman JE Dickerson M Clancy C Daly C Geddes Renal amp Transplant Unit Queen Elizabeth University Hospital Glasgow
Introduction All renal transplant recipients receive Pneumocystis jirovecii prophylaxis usually with co-trimoxazole Guidelines suggest this should be continued for 3 to 6 months Our unit previously prescribed 3 months however following an outbreak of Pneumocystis pneumonia (PCP) infection this was increased to 6 months Given its constituents of sulfamethoxazole and trimethoprim co-trimoxazole prophylaxis may influence the frequency of urinary tract infection (UTI) We aimed to compare the frequency of UTI between patients on 3 months vs 6 months prophylaxis and assess rates of multi-drug resistant organisms We also sought to establish if the increased duration of co-trimoxazole was adversely affecting renal function potassium concentration white cell and platelet count and dosing of mycophenolate mofetil
Methods A retrospective search of the West of Scotland Electronic Renal Patient Record was conducted for all renal transplant recipients between 1st January 2012 and 31st May 2016 Patients were grouped according to the intended duration of co-trimoxazole Data were extracted for baseline characteristics co-trimoxazole prescription mycophenolate mofetil (MMF) prescription laboratory results (creatinine potassium white cell count platelets) at 3 6 9 and 12 months post-transplant and microbiology results for 6 months post-transplant Results were analysed on an intention to treat (ITT) basis with a second analysis according to actual duration of co-trimoxazole treatment (AT) Subjects with transplant failure had laboratory results censored from the time of transplant failure and all of their microbiology results were excluded
Results 609 renal transplants were performed over the study period On ITT analysis there were 418 patients in group 1 (ITT1 3 months co-trimoxazole) with 15 transplant failures and 191 patients in group 2 (ITT2 6 months co-trimoxazole) with 12 transplant failures There was a significant difference in the number of patients with at least one UTI with fewer in ITT2 (ITT1 133403 vs ITT2 42179 p = 001) However this was not present when comparing actual treatment duration (AT1 111345 vs AT2 36149 p=007) Overall there was a similar spectrum of organisms cultured There were significantly fewer cultures of multi-resistant organisms in both ITT and AT analyses with 6 months of co-trimoxazole (ITT1 28376 vs ITT2 0106 p= 0004 AT1 22313 vs AT2 198 p = 002) There was no difference in estimated Glomerular Filtration Rate serum potassium concentration platelet count or MMF dose On AT analysis there was a significant difference in the total white cell count (WCC) and lymphocyte count at 6 months post-transplant (WCC 78 x10^5L vs 71 x10^5L p =004 lymphocytes 13 x10^5L vs 12 x10^5L p=002) There were 18 cases of PCP with 7 deaths attributable All cases occurred after cessation of co-trimoxazole prophylaxis (81 ndash 913 days after stopping co-trimoxazole)
Conclusion Although there is a significant difference in UTI frequency on ITT analysis this is not present on AT analysis suggesting no real co-trimoxazole effect There was no increase in frequency of multi-drug resistant organisms with a longer course of co-trimoxazole Renal function and serum potassium were unaffected Our findings support continuing co-trimoxazole prophylaxis for at least 6 months
A13 Kidney transplantation in the over 60rsquos in Scotland 1996-2015 TJW Rennie1 P Phelan1 J Campbell2 JP Traynor2 L Henderson1 W Metcalfe2 On behalf of the Scottish Renal Registry 1Renal transplant unit Royal Infirmary Edinburgh 2NHS National Services Scotland Introduction The proportion of older kidney transplant recipients has increased in the UK but
long term outcome data are scarce We aimed to evaluate patient and graft survival in patients
ge60 years of age receiving a first kidney only transplant in the last 20 years in Scotland
Methods Retrospective analysis of Scottish Renal Registry data of incident Renal Replacement
Therapy (RRT) patients and those in receipt of a kidney only transplant performed 1996-2015
(follow up until 311216) Patients were stratified by age 60-69 ge70 (group 1 and 2 respectively)
and decade of transplantation 1996-2005 2006-2015 (decades 1 and 2 respectively)
Results 6743 patients aged ge60 started RRT from 1996-2016 Of those 108 were ever
transplant-listed 54 had received a transplant by 311216 26 listed and 11 transplanted
were aged ge70
535 patients aged ge60 received a kidney only transplant in 1996-2015 90 patients (168) were
aged ge70 no patients were aged ge80 Mean time from wait listing until transplantation was 33plusmn24
years (plusmnSD) and from starting RRT until transplantation was 38plusmn26 years (plusmnSD) One and five
year graft survival was 97 and 87 in decade 1 95 and 89 in decade 2 (p=NS) there was
no difference in graft survival between age groups 1 and 2 One and five year patient survival was
94 and 78 in age group 1 85 and 56 in group 2 (plt0001) there was no difference in one
and five year patient survival between the two decades
Conclusion One and five year graft and patient survival in renal transplant recipients aged ge60
have not changed significantly in the last 20 years Recipient age ge70 is not associated with
reduced graft survival but patient survival from time of transplant is lower in this age group
compared to recipients aged 60-69
No conflict of interest to be declared No funding received
A14 High Mortality In Older Patients With Primary Nephrotic Syndrome Sarah Beverstock Wendy Metcalfe amp Robert W Hunter Department of Renal Medicine Royal Infirmary of Edinburgh
Introduction
Nephrotic syndrome can develop at any age and may be due to a primary glomerular lesion or secondary to systemic disease The natural history of glomerular disease can be different in older patients For instance minimal change disease (MCD) in children almost always remits promptly with steroid therapy in adulthood it typically remits only after many weeks of steroids or with adjunctive immunosuppression However there are remarkably few published data on the mortality of primary nephrotic syndrome in adults We aimed to study this in our centre
Methods
We enrolled all adult patients who had a kidney biopsy in order to investigate nephrotic syndrome over 38 consecutive months (01 Jan 2014 ndash 28 Feb 2017) We defined nephrotic syndrome as heavy proteinuria (urinary proteincreatinine ratio UPCR gt350 mgmmol or albumincreatinine ratio gt220 mgmmol) and hypoalbuminaemia (serum albumin lt35 gL) In our analysis we included all patients in whom nephrotic syndrome was attributed to a primary glomerular disease We excluded kidney transplant recipients and patients in whom biopsies were performed to follow up a known glomerular disease We collected laboratory data at baseline (time of biopsy) and at 6 and 12 months We assessed patient survival by Kaplan-Meier analysis
Results
Of the 117 patients biopsied for nephrotic syndrome 71 patients (61 ) met the inclusion criteria and were followed up for a median of 469 days We compared outcomes in patients aged under 60 years old (n = 35) with those aged over 60 (n = 36) Mortality was higher in the older group (37 vs 4 mortality at one year p lt005 by logrank test) There were no significant differences between the two groups in serum creatinine or UPCR at any time Serum albumin was similar in both groups at baseline and at 12 months but was lower in the older group at 6 months (27 vs 32 gL p lt 005) Baseline haemoglobin was lower in the older group (114 vs 130 gL p lt005 by unpaired t-test) Primary diagnoses were MCD (n = 10 in younger group amp n = 5 in older group) membranous nephropathy (5 amp 10) IgA nephropathy (9 amp 8) FSGS (5 amp 5) membranoproliferative glomerulonephritis or C3GN (4 amp 7) and other (2 amp 1) Therefore unsurprisingly there were relatively fewer cases of MCD and more cases of membranous nephropathy in the older group otherwise the causative glomerular lesions were similar in both groups In those patients with MCD mortality was significantly higher in the older group none of the 10 patients with MCD diagnosed under 60 yrs old died during the follow-up period whereas 4 of the 5 older patients died 3 patients in the younger group and 1 in the older group were on renal replacement therapy (dialysis or transplant) by the end of follow-up
Conclusions
Primary nephrotic syndrome is associated with high mortality in the over 60s (37 at one year) Mortality was high even for MCD a disease that follows a benign course in childhood and early adulthood The higher mortality in older patients was not associated with greater severity of renal disease at presentation (as assessed by basic blood and urine parameters) This work was not funded we declare no conflicts of interest
A15 Renal biopsies in patients with diabetes mellitus in Scotland
Udana Ratnapala 1 Nicola Joss 2 Colin Geddes 3 Dana Kidder 1
1 Renal Unit Aberdeen Royal Infirmary Aberdeen 2 Renal Unit Raigmore Hospital Inverness 3 Glasgow Renal and Transplant Unit Glasgow
Introduction Diabetes mellitus is the leading cause of end-stage kidney disease (ESKD) requiring renal replacement therapy The utility of renal biopsy in patients with diabetes mellitus is controversial Broadly renal biopsy findings in patients with DM can be divided into diabetic nephropathy (DN) alone DN with non-diabetic renal disease (NDRD) or NDRD alone Timely identification of patients with NDRD is important to provide appropriate therapeutic measures Previously published guidelines on clinical predictors of NDRD have limited specificity and sensitivity The frequency of NDRD in renal biopsies of patients with DM is unclear in ScotlandThis study aimed at identifying the frequency and the pathology spectrum of NDRD in diabetic patients underwent kidney biopsy in 3 renal units
Methods A retrospective observational study was performed on clinical-pathologic findings in all patients with diabetes mellitus who underwent renal biopsy between 01012010 and 31122016 in 3 renal units (Aberdeen Inverness and Greater Glasgow) Data were gathered from electronic patient record systems Scottish Index of Multiple Deprivation (SIMD) 2012 was used to analyse correlation with patient outcomes
Results 247 patients were included 150 men (607) 217 type 2 DM (879) mean age 621 years and mean serum creatinine at the time of renal biopsy of 261 micromolL (+-190 std) On biopsy 92 patients (372) had DN while 127 (514) had NDRD and 28(114) had NDRD superimposed on DN The commonest NDRD aetiologies were IgA nephropathy (187) tubulointerstitial nephritis (168) and idiopathic membranous nephropathy (103) Predictors of NDRD were age (OR 1027 95 CI 1002-1052 p=003) duration of DM (OR 094 95 CI 0900-0987 p=001) and absence of AKI as indication for biopsy (OR 022 95 CI 0059-0826 p=0025) There was no significance difference in renal or patient survival in DN and NDRD Finally no significant correlation was depicted between SIMD quintiles and renal or patient survival in both groups
Conclusions The majority of renal biopsies carried out in patients with DM revealed a NDRD In this study age at the time of biopsy duration of DM and AKI were the main pointers towards NDRD Renal and patient survival were not significantly different between DN and NDRD groups
A16 The Impact of Withdrawal of Maintenance Immunosuppression and Graft Nephrectomy on HLA Sensitisation Ailish Nimmo1 Sophie McIntyre1 Lorna Henderson1 Richard Battle2
(1 Department of Renal Medicine Royal Infirmary of Edinburgh 2 Histocompatibility and Immunogenetics Royal Infirmary of Edinburgh)
Background The development of HLA antibodies towards a failing renal allograft is a barrier to re-transplantation We previously demonstrated an increase in HLA antibodies and calculated reaction frequency (cRF) following nephrectomy but results were confounded by immunosuppression changes occurring in close time proximity We examined the formation of HLA donor specific antibodies (DSA) in patients with failed grafts that remained in situ and compared results with patients undergoing graft nephrectomy to further assess the relative impact of nephrectomy and immunosuppression weaning on sensitisation and chance of transplant
Methods We carried out a single centre retrospective study of all patients with failed grafts in Lothian from 2005 to 2015 Samples were tested for DSA pre-immunosuppression (IS) wean post-IS wean and post-IS cessation Nephrectomy patients also had samples tested for DSA before and after nephrectomy Data on other sensitising events including blood transfusion and rejection were collected cRF was determined at each time point and entered into the ODT chance of transplant calculator with other demographics based on the average patient from the Edinburgh centre
Results 62 grafts failed over this time period Blood samples were available 41 patients (24 with nephrectomy 17 with failed graft left in situ) Patient demographics were similar between groups There was a higher rate of antibody mediated rejection in the nephrectomy group (46 vs 18) 76 of patients with nephrectomy group had received a blood transfusion The pattern of immunosuppression weaning was similar but median time from start of IS wean to cessation was longer in the nephrectomy group (350 vs 298 days) The changes in cRF and chance of transplant (COT) with immunosuppression weaning are shown in Table 1
Pre-IS Wean Post-IS Wean
Failed graft in situ (n=17)
Mean CRF COT at 5
years 15 62 38 59
Nephrectomy (n=24)
Mean cRF COT at 5
years 54 54 69 46
Post-IS Stop 55 53 89 42 Table 1 Mean cRF and Chance of Transplant (COT) at 5 years with IS alterations
Discussion A stepwise increase in cRF with reduced chance of transplant was observed in both groups as immunosuppression was withdrawn with a similar pattern of change irrespective of graft nephrectomy cRF was higher in the nephrectomy group despite a more gradual wean which may reflect a higher rate of antibody mediated rejection and increased number of patients receiving a blood transfusion The risks and benefits of stopping immunosuppression need to be carefully considered on an individual basis to maximise chance of future transplant
The authors have no conflicts of interest No funding was required for this study
A17 Obesity is not associated with progression to end stage renal disease in patients withbiopsy-proven glomerular diseases
Benjamin Elyan Jennifer S Lees Bruce Mackinnon Jonathan G Fox Colin C Geddes Emily PMcQuarrie
Glasgow Renal and Transplant Unit Queen Elizabeth University Hospital Glasgow
Introduction - Addressing risk factors for renal progression is a key aspect of managing chronic kidney disease (CKD) Body mass index (BMI) has been shown to impact on renal progression in unspecified CKD The aim of this study was to evaluate if there was an association between BMI and progression to renal endpoints in patients with biopsy-proven primary glomerular disease (GN)
Methods - We included all adult patients diagnosed with biopsy-proven primary GN (excluding minimal change nephropathy) in Greater Glasgow amp Clyde and Forth Valley between 01012000 and 31122015 Biochemical and anthropometric data were extracted from the electronic patient record at time of biopsy with follow-up data until 20062017 BMI was calculated from height and weight at time of biopsy and categorised into groups BMI le25 kgm2 (G1) gt25 to le30 kgm2 (G2) and gt30 kgm2 (G3 - obese) We assessed factors associated with reaching a combined renal endpoint of CKD5 or renal replacement therapy (RRT) with competing risk of death using the Fine and Gray subdistribution hazard model Analyses were conducted using cmprsk package for R statistical software package and SPSS version 24
Results - 560 patients with primary GN and available BMI data were included The average age was 532 years and 339 were female There were 132 patients in G1 210 in G2 and 207 patients in G3 Those in G2 and G3 were older (p=002) with slightly higher diastolic blood pressure (p=002) than those in G1 There was a greater proportion of focal segmental glomerulosclerosis in G3 but similar proportions of other GN diagnoses across groups There was no significant difference in baseline serum creatinine (sCr) (p=034) or log uPCR (p=045) between BMI groups On multivariate analysis age systolic blood pressure BMI or GN diagnosis were not predictive of renal outcome Higher baseline sCr (SHR 1003 per 1 umoll increase in sCr 1001-1004 plt0001) and log uPCR (SHR 130 per unit increase in log uPCR 95 CI 105-160 p=002) were associated with progression to the combined renal endpoint accounting for competing risk of death BMI was not associated with reaching combined renal endpoint on univariate analysis whether considered as a continuous variable (SHR=100 95 CI 098-102 p=096) or categorised by BMI group
Conclusion - Contrary to our expectations there was no association between BMI and progression to a combined renal endpoint of CKD5 or RRT in this cohort of patients with primary GN Efforts should be directed to managing other known risk factors for CKD progression
Sources of FundingConflicts of Interest - None
A18 Factors influencing long term renal function after living kidney donation
Matthew A Rutherford Norman J Galbraith Marc Clancy Colin C Geddes
Glasgow Renal and Transplant Unit Queen Elizabeth University Hospital Glasgow UK
Background Following live donor nephrectomy the remaining kidney undergoes an increase in filtration capacity known as compensatory hypertrophy Few cohorts with follow up of renal function beyond 5 years have been reported The impact on long term renal function of variability in donor factors such as age sex pre-donation blood pressure and glomerular filtration rate (GFR) is unknown Increasingly kidney donors have potential risk factors for future poor renal function such as hypertension older age and obesity The aim of this study was to analyse factors influencing long-term renal function in living kidney donors from our centre
Method Data were obtained from the electronic patient record Patients with a recorded procedure of lsquolive donor nephrectomyrsquo between 2005 and 2017 were identified GFR after donation (calcGFR) was calculated using the formula lsquocalcGFR = Pre-donation Isotope GFR x (Pre-donation Serum creatinine Serum Creatinine)rsquo which is accurate assuming muscle mass does not change Pre and post donation serum creatinines (two days two weeks three months and one to ten year) were recorded We analysed the influence of age sex pre-donation GFR and blood pressure on post donation GFR compensation
Results 355 live donor nephrectomies were performed between January 2005 and December 2016 The mean age was 469 (plusmn 116) years and 504 (n=179) were female Mean pre-donation isotope GFR was 937 plusmn 156 mlmin173m2 Median follow up was 2 years (IQR 1 to 6 years with range 2 weeks to 10 years) The calculated percentage of pre-donation GFR at 2 days 2 weeks 3 months 1 year 5 years and 10 years were 698 691 712 730 801 and 950 respectively (p lt 0001) Patients aged lt50 y had not only a higher calcGFR (858 plusmn 29 mlmin173m2 compared with 671 plusmn 28 mlmin173m2 p lt 0001) at 5 years following donation but achieved a higher degree of compensation than donors gt 50 y (836 plusmn 16 compared with 756 plusmn 19 (p = 0002) Patients with pre-donation hypertension achieved 774 plusmn 53 of pre-donation GFR compared with 804 plusmn 32 in normotensive patients (p = 0998) Females had equivalent degree of renal compensation achieving 819 plusmn 19 compared with 780 plusmn 16 in males (p = 0131) at 5 years following donation Patients with pre-donation GFR gt 100 mlmin173m2 achieved 844 plusmn 23 of pre-donation function by 5 years compared with 777 plusmn 14 in those with pre-donation GFR lt 100 mlmin173m2 (p = 001)
Conclusion Following live donor nephrectomy renal function has a nadir of 691 at 2 weeks Compensation in GFR occurs rapidly and appears to be maintained regardless of sex and pre-donation blood pressure Younger age and higher pre-donation GFR were associated with a greater degree of compensation
A19 The utility of high-sensitivity cardiac troponin to stratify cardiovascular risk in patients with renal impairment
Eve Miller-Hodges Atul Anand Anoop S V Shah Nicholas L Mills Neeraj Dhaun
Background Cardiovascular disease is the most common outcome of chronic kidney disease1
Declining glomerular filtration rate (GFR) and proteinuria predict increased cardiovascular risk over the long term2 However there are currently no methods to stratify cardiovascular risk in the short or medium term in patients with renal impairment We have already shown that high-sensitivity cardiac troponin I concentrations (hs-cTnI) lt5ngL in patients presenting with symptoms of acute coronary syndrome identifies those at low risk of cardiac events within 30 days and over the next year3 However uncertainty remains over the role of hs-cTnI testing in patients with renal impairment This study investigated whether hs-cTnI could also stratify future cardiovascular risk in patients with renal impairment
Methods In a prospective study of consecutive patients presenting with suspected acute coronary syndrome we evaluated the performance of hs-cTnI in patients with and without renal impairment (estimated glomerular filtration rate lt60mLmin173m2) using an early risk stratification threshold of 5ngL to ldquorule outrdquo acute myocardial infarction at presentation and within 30 days and sex-specific 99th centile diagnostic thresholds for index type 1 myocardial infarction Subsequent type 1 myocardial infarction and cardiac death were reported at one year
Results Of 4726 patients identified 904 (19) had renal impairment Index diagnosis of type 1 and type 2 myocardial infarction was almost twice as likely in patients with renal impairment (30 vs 15) Performance of the early risk stratification threshold of 5ngL to identify patients at low risk of major cardiac events was similar in patients with (NPV 984 95CI 960-997 sensitivity 989 95CI 975-999) and without renal impairment (NPV 997 95CI 994-999 sensitivity 984 95CI 972-994) These patients continued to remain at low risk over the next year The PPV and specificity at the 99th centile for diagnosis of myocardial infarction were lower in patients with renal impairment at 500 (95CI 452-548) and 709 (95CI 675-742) respectively compared to 624 (95CI 588-659) and 921 (95CI 912-930) At one year 24 of patients with renal impairment and troponin gt99th centile regardless of index diagnosis had experienced further myocardial infarction or cardiac death compared with 10 of patients without
Conclusion In suspected acute coronary syndrome hs-cTnI can stratify risk in patients with renal impairment Irrespective of diagnosis patients with renal impairment and elevated cardiac troponin concentrations had two-fold greater risk of a major cardiac event compared to those with normal renal function and should be considered for further investigation and treatment
Funders Wellcome Trust British Heart Foundation and Chest Heart amp Stroke Scotland
1 Gansevoort RT Lancet 2013
2 Chronic Kidney Disease Prognosis Consortium Lancet 2010
3 Shah AS Lancet 2015
A20 lsquoDOES IT DIALYSE OUTrsquo - THE EFFECT OF RENAL REPLACEMENT THERAPY ON THE BRAIN Mark Findlay Jesse Dawson David Dickie Deborah McGlynn Patrick Mark Institute of Cardiovascular and Medical Science University of Glasgow amp Queen Elizabeth University Hospital Glasgow
Introduction Cerebrovascular disease is common in end-stage renal disease (ESRD) on renal replacement therapy (RRT) We investigated the effect of RRT on cerebral structure and cognitive function over 12 months Methods Observational cohort study in ESRD patients receiving HD Prior cognitive impairment or cerebrovascular disease were exclusion criteria Multi-domain cognitive testing was performed at baseline and at follow-up Transcranial Doppler was used to assess intra-dialysis related alterations in mean flow velocity (MFV) ndash a marker of cerebral blood flow MR imaging was performed at 0 and 12 months We performed T1 T2 FLAIR and DWI sequences and used volumetric software to calculate white matter hyperintensity (WMH) burden markers of atrophy mean diffusivity and fractional anisotropy (FA) to describe structural changes at 1 year Results 97 patients median age 59 years 412 female At follow-up 15 patients were transplanted 6 died 4 withdrew and the remainder continued HD Those who were transplanted were younger (median age 51 vs 60 years p=0019) and had been on dialysis for a shorter period (median 06 vs 21 years p=0003) MFV declined during HD median 475cms to 405cms plt0001 and correlated with lower scores of executive and frontal lobe function during HD (Rho 045 p lt0001 and Rho -0313 p lt001 respectively) In all patients MR imaging demonstrated a significant decline in frontal parietal and temporal lobe volume at follow-up Median WMH volume increased in those who remained on HD but not in transplanted patients (median change 023 vs -012ml p=0018) WMH burden correlated with worsening scores of frontal lobe tests Rho 0585 p0005 and worse mood Rho -0485 p0026 FA improved following renal transplant (028 to 029 p=0016) and correlated with improved executive function testing at follow-up Rho 089 p0019 Conclusion Cerebral blood flow is reduced during haemodialysis and correlates with a reduction in intradialytic executive function There is an improvement in FA following transplantation WMH volume increases in those who remain on dialysis and the degree of increase correlates with executive and frontal lobe function This suggests that haemodialysis is associated with clinically significant changes in the brain and that these may be ameliorated by transplantation
Source of fundingconflicts MF is funded by a KRUK fellowship
A21 Pathological classification of IgA nephropathy to predict renal outcomes ndash is there a better way to score tubulointerstitial inflammation
Alastair Rankin David Kipgen Bruce Mackinnon Jonathan Fox Colin Geddes Emily McQuarrie Glasgow Renal and Transplant Unit On behalf of the Scottish Renal Biopsy Registry
Background The Oxford pathological classification of IgA nephropathy (IgAN MEST-C score) is limited by the fact that individual features of the score are not all predictive and its utility in assisting clinical decision-making is questioned The addition of tubulointerstitial inflammation to the existing scoring system is appealing but is not currently included due to reportedly wide inter-observer variability We report a novel method to score percentage of cortex containing tubulo-interstitial inflammation in non-atrophic renal cortex (ATIN) in patients with IgAN similar to that used in transplant biopsy reporting and assess its utility to predict clinical outcomes
Methods All adult patients with a native renal biopsy diagnosis of IgAN between 2010 and 2015 in a unit serving 15 million people were identified Baseline characteristics biopsy reports and outcome data were collected ATIN was calculated by subtracting the percentage of atrophic cortex from the percentage of total cortex with tubulo-interstitial inflammation withge10 representing significant tubulo-interstitial inflammation in non-atrophic cortex The primary outcome was a composite of requiring renal replacement therapy (RRT) or doubling of serum creatinine (sCr)
Results 153 new cases of IgAN were identified 33 were excluded (24 had lt8 glomeruli on biopsy 6 inadequate biopsy for MEST scoring and 3 on RRT at time of biopsy) In addition patients with a tubular atrophy (T) score of 2 were also excluded (n=9) Of the remaining 111 patients 76 (68) were male Mean age at biopsy was 52 years (+- 167) and 18 (16) had a co-existing clinical diagnosis of henoch-schonlein purpura (HSP) Median sCr was 156 micromoll (IQR 101-212) and 54 (49) had ATIN on biopsy During a median follow-up of 23 years 34 (31) reached the primary outcome 20 (18) received immunosuppression and 16 (14) died On univariate Cox regression survival analysis ATIN was associated with a four-fold increase in the primary outcome (HR 49 (21-113)) On multivariate analysis mesangial hypercellularity (M) T and ATIN independently predicted renal outcome while endocapillary proliferation (E) and segmental sclerosis (S) did not (plt002 for ATIN) Excluding patients with HSP or those who received immunosuppression did not change the result
Conclusion Within our centre ATIN predicts renal outcome for IgAN independently of established histological features Assessment of inter-observer reproducibility and validation in other cohorts is still required but these results suggest ATIN could be a worthwhile addition to current pathological scoring systems for IgAN
Source of funding none Conflicts of interest none
P1 Polypharmacy in Renal Replacement Therapy Patients
Jason McMinn Colin Geddes Glasgow Renal and Transplant Unit Queen Elizabeth University Hospital
Introduction
Prescribing is often led by evidence from studies containing participants with single health conditions and without multimorbidity Polypharmacy is becoming increasingly recognised in patients with multiple chronic health conditions Additional medications are more likely to result in diminishing returns in benefit with an increased risk of harm Patients with established renal failure (ERF) are likely to be susceptible to medication-related harm A high pill burden is also likely to contribute adversely to an already restricted quality of life and has been associated with poor medication adherence The aim of this study was to analyse polypharmacy in all patients with ERF attending our service
Methods
We extracted medication records for all prevalent ERF patients attending the Glasgow Renal and Transplant Unit from the West of Scotland Electronic Renal Patient Record (SERPR) as of 01012017 The records were analysed to calculate the number of regular medications and total pill burden of each patient These medications were categorised as being lsquopreventativersquo or lsquosymptomaticrsquo We also analysed the prescription of specific drug classes to examine the prevalence of these medications
Results
We identified 1091 transplant follow-up 529 hospital haemodialysis and 46 peritoneal dialysis patients who were on a mean of 94 13 and 129 different medications respectively Overall pill burden was 139 tablets a day in transplant follow-up patients 141 in haemodialysis patients and 162 in peritoneal dialysis patients There were similar rates of prescribing between the different dialysis units and clinics within our service
The proportions of medications deemed as preventative rather than symptomatic were 76 in transplant 69 in haemodialysis and 60 in peritoneal dialysis
In transplant patients decreasing renal function was associated with a higher pill burden but even patients with a transplant eGFR gt 60 were on a mean of 126 tablets per day including a mean of 14 antihypertensives
Rates of antidepressant prescribing were 15 in transplant patients and 20 in hospital haemodialysis patients 53 of haemodialysis patients were on a statin 39 on aspirin 61 on a proton pump inhibitor and 7 were on warfarin
Conclusion
Patients undergoing all forms of renal replacement therapy are likely to be on a considerable number of medications Whilst these drugs are inevitably prescribed for valid reasons this data demonstrates the need for clinicians to engage with patients to explore opportunities to reduce pill burden
Conflict of Interest None Sources of Funding None
P2 An audit of Acute Kidney Injury (AKI) on an acute stroke ward before and after plannedinterventions to review and maintain hydration
Clare Harris1 Simon Hart2 Fiona Duthie3 1 University of Edinburgh Medical School 2 Stroke Unit Royal Infirmary of Edinburgh 3 Renal Unit Royal Infirmary of Edinburgh
Background Dehydration is an important factor in the development of acute kidney injury which is associated with increased morbidity and mortality particularly in the elderly population Poor fluid intake is common post stroke (1) and dehydration is associated with poorer outcomes 3 months post stroke (2) In late 2014 there was no system of identifying patients with poor oral intake on the stroke ward at the Royal Infirmary of Edinburgh a hydration protocol and education programme were implemented aiming to improve fluid balance This included the use of prescribed water either orally or by nasogastric tube An audit pre and post intervention demonstrated that hydration as measured by ureacreatinine ratio significantly improved after the protocol introduction (3) We aimed to determine whether the incidence of AKI by KDIGO criteria was also reduced as this could have implications for reducing patient morbidity and mortality in this elderly comorbid patient cohort
Method 150 inpatients to the acute stroke ward during JulAug 2014 and JulAug 2015 were selected (n= 80 2014 n=70 2015) Patient data and creatinine values were collected from the electronic patient record and medical notes and retrospectively analysed Baseline creatinine values were calculated and cases of AKI were identified and staged using KDIGO criteria (4) Chi-Squared tests were performed to determine P values Individual patient notes were reviewed for both quantitative and qualitative data of patient management
Results Incidence of AKI (of any stage) was 263 pre-protocol and 200 post-protocol (P=03646) Incidence of AKI stages 23 was 100 pre-protocol and 715 post-protocol (P=05374) In hospital post stroke mortality was 338 pre-protocol and 1286 post protocol (P=00028) AKI was also associated with increased length of stay
Conclusions Despite a trend in benefit there was no significant difference in incidence of AKI pre and post hydration protocol nor in incidence of severe AKI (stage 23) AKI is influenced by many factors one of which is hydration status Further studies are needed to determine whether the trend of benefit exhibited in this sample is significant in a greater sample size if this were the case such a protocol could have great benefit to patient care on stroke units and elsewhere There was a significant difference in inpatient post stroke mortality following introduction of the hydration protocol Further investigations are needed to explain underlying reasons for this factors other than hydration may play an important role
References 1 Whelan K Inadequate fluid intakes in dysphagic acute stroke Clinical Nutrition (2001) 20(5)
423-428 2 Bhalla A Sankaralingam S Dundas R Swaminathan R Wolfe CDA Rudd AG The influence of
raised plasma osmolality on clinical outcome after acute stroke Stroke (2000) 312043ndash2048 3 Hart SR Craig R Berry E Lane N Gad A Farrugia M Burton L Paquay A What Happens to
Acute Stroke Patientsrsquo Fluid Balance Renal Status and Dehydration in the First Two Weeks How Can They Be Markedly Improved doi 101111ijs12634_13
4 KDIGO Clinical Practice Guideline for Acute Kidney InjuryKidney international supplements (2012) 2(1) 1-138
No funding or conflict of interest to declare
P3NHS Highland-Improving the management of hyperkalaemia using a kit Initial resultsCantley N1 Abedin T2 Lambie S3
1FY2 NHS Highland 2ST4 Renal Medicine NHS Grampian 3Renal Consultant Renal unitRaigmore Hospital Inverness
Introduction The incidence of hyperkalaemia in hospitalised in patients is between 1 and 10 Guidelines in Northern Ireland promote the use of a Hyperkalaemia Kit to improve management of hyperkalaemia We assessed the management of hyperkalaemia in Raigmore Hospital including post-treatment monitoring of serum potassium and blood glucose at baseline and after the introduction of a lsquoHyperkalaemia Kitrsquo which contains a pro forma for the management of hyperkalaemia and all the relevant equipment and drugs for treatment
Method Between July and September 2016 an automated algorithm identified 34 patients with a potassium result 65 mmoll or above on laboratory results 12 received no specific treatment of these 6 results were spurious 4 patients died before treatment could be started and 2 patients were chronic haemodialysis patients We introduced the Hyperkalaemia Kit to the Acute Medical Admissions Unit in Raigmore Hospital Since then 15 patients have been identified with serum potassium measurements above 65 and the pro forma and kit was used with eight of these patients One of these patients proceeded straight to acute renal replacement therapy
Results Prior to our intervention all 22 patients that were actively treated received at least one prescription of appropriate doses of Insulin with Dextrose However only 16 patients received intravenous calcium and only 7 received nebulised Salbutamol Potassium was measured at 4 hours in 5 cases and by 12 hours in 17 cases Monitoring of any capillary blood glucose was only documented in 8 cases Of the 22 treated 2 needed acute renal replacement therapy 3 required further doses of insulin and dextrose 2 were treated with Calcium Resonium
Eight cases of hyperkalaemia have been managed with the use of the kit and pro-forma so far An initial ECG was performed in all eight and four patients had continuous cardiac monitoring Intravenous calcium was given in seven and nebulised Salbutamol was given in five out of the eight cases Six out of eight patients had at least three blood sugar measurements One had two measurements documented and one patient was stopped from further monitoring following senior review and decision to palliate Seven patients had appropriate monitoring of their serum potassium by 4h and 12h again one patient was not monitored due to palliation
Conclusion Baseline results showed very low rates of prescription of nebulised Salbutamol low rates of Calcium Gluconate use and very low monitoring of blood sugars and potassium post treatment This has the potential for serious adverse outcomes particularly the potential for iatrogenic hypoglycaemia Our initial data shows the use of a Hyperkalaemia pro forma and kit improves the rate of prescription of intravenous calcium and nebulised Salbutamol and the post-treatment monitoring of serum potassium and blood sugar levels
P4Rituximab as maintenance therapy in ANCA associated vasculitisndash a single centre experience Rathnamalala NK Mcmenamin J Robertson S Almond A Kelly M Muniraju T M Renal Unit Dumfries and Galloway Royal Infirmary NHS Dumfries and Galloway Background The introduction of Cyclophosphamide and high dose steroids transformed ANCA associate vasculitis (AAV) from a disease of high mortality to a relapsing remitting disease Maintenance of remission however still remains a major challenge A two randomised clinical trials have looked at the use of Rituximab in remission induction in AAV and reported similar remission rates between Cyclophosphamide and Rituximab 12 Both these trials used Azathioprine as maintenance therapy and in the follow up showed similar remission rates with either agent for induction The role of Rituximab for maintenance therapy after cyclophosphamide induction was studied in the MAINRITSAN trial 3 Rituximab was compared with azathioprine and found that the relapse rate was significantly lower in the Rituximab group There have been several other retrospective studies that have suggested regular Rituximab infusions are successful in maintaining remission however has not been thoroughly evaluated 4 5678910 Here we share our centrersquos experience using Rituximab for maintenance of remission of AAV Materials and methods We conducted a retrospective review of electronic medical records of all patients who had received Rituximab as maintenance therapy for 12 months or longer between January 2014 to July 2016 Disease activity was assessed using Birmingham Vasculitis Activity Score ( BVAS) Version 3 and complete remission was defined as a score of 0 and partial remission as a score of lt50 of the value at diagnosis Due to uncertainties associated with sub classification we did not assign specific diagnosis but broadly classified as ANCA associated vasculitis Results 6 patients received Rituximab as maintenance therapy during the study period 3 (50) of them had eye ear nose and upper airway manifestations consistent with Granulomatosis with Polyangitis (GPA) All patients were PR3 ANCA positive except for one at initial diagnosis The mean BVAS score at the time of initiation of Rituximab was 4 All patients were initiated on Rituximab for relapses while on maintenance therapy with Azathioprine 4 patients received 6 monthly doses of Rituximab while two received annual doses All of them were also maintained on 5-10 mg of Prednisolone The mean BVAS score by 6 months was 0 and remained 0 at 12 months The mean PR3 titre was 562 at the initiation of treatment while at 12 months it had come down to 68 All patients remained in complete clinical remission at the end of 12 months after initiation of therapy Rituximab was well tolerated by all patients except one who developed pyrexia during an administration
Conclusions All patients had sustained remission at 6 months and 12 months after initiating Rituximab Rituximab has a potential role as maintenance therapy in AAV
P5 Chronic Myelo-Monocytic Leukaemia (CMML) as a contraindication to renal biopsy Alastair Rankin Emily McQuarrie Jennifer Lees Bruce MacKinnon Glasgow Renal and Transplant Unit On behalf of the Scottish Renal Biopsy Registry
Abstract Chronic Myelo-Monocytic Leukaemia (CMML) is a relatively rare mixed myelodysplastic myeloproliferative disorder that predominately affects patients over the age of 65 years Renal impairment in patients with CMML is well described with several different mechanisms reported including tumour infiltration lysozyme-induced injury amyloid deposition and tubulointerstitial nephritis From anecdotal evidence within our centre we are concerned that patients with CMML have an excessive risk of clinically significant bleeding following native renal biopsy This risk appears disproportionate to the degree of any co-existing thrombocytopenia or coagulopathy
We review the cases of 4 patients with an existing diagnosis of CMML who were referred to the renal clinic with proteinuria and excretory renal dysfunction Two of these patients underwent renal biopsy with subsequent major haemorrhage post-procedure despite normal bleeding parameters pre-procedure Patient 1 presented with flank pain 8 days post-biopsy A CT confirmed peri-nephric haematoma with retroperitoneal extension A total of 6 units of packed red cells (PRCs) were transfused prior to successful CT-guided emoblisation Histology from the biopsy revealed chronic tubulointerstitial nephritis Patient 2 experienced haemodynamic instability and haematuria one hour post-biopsy A total of 11 units of PRCs 7 units of fresh frozen plasma 2 pools of platelets intravenous tranexamic acid and 2 attempts at CT-guided embolization were required until haemostasis was achieved Histology later showed evidence of tumour infiltration with associated vasculitis Patient 3 presented with renal impairment and proteinuria on the background of known CMML Following discussion with haematology the risk of bleeding following renal biopsy was considered unjustifiable despite their platelets and coagulation screen being within normal range The patient was treated for presumed renal tumour infiltration with hydroxycarbamide Patient 4 was referred to the renal clinic with acute onset nephrotic syndrome Urinary proteincreatinine ratio was elevated over 800 mgmmol with serum albumin of 23 gL but normal excretory renal function The patient attends the haematology clinic with suspected CMML and chronic thrombocytopenia but previously declined bone marrow biopsy Following discussion with the patient there are no plans to proceed with renal biopsy given potential risks These cases highlight that while CMML is rare these patients are being referred to renal clinics with features that would commonly justify renal biopsy in other settings but in whom there may be an increased risk of bleeding post-procedure Our in-centre risk of major bleeding is 2 therefore to have such extreme amounts of bleeding in 2 patients with this underlying diagnosis is remarkable This creates a dilemma for the clinician as there is a wide range of potential renal pathology associated with CMML some of which will have disease specific but relatively toxic treatments available
Source of funding none Conflicts of interest none
P6 NHS Highland-Prograf to Adoport switch McCulloch K1 Peel R2 Lambie S3
1Renal Pharmacist Renal unit Raigmore Hospital Inverness 23Renal Consultant Renal unit Raigmore Hospital Inverness
Introduction NHS Highland (NHSH) is the first health board in Scotland to implement a switch from Prograf to Adoport for renal transplant patients This will provide considerable cost savings Adoport meets the bioequivalence criteria for drugs with a narrow therapeutic index set by the European Medicines agency and studies indicate therapeutic equivalence1 with the proviso that brands are non- interchangeable unless the switch is overseen by a Renal Consultant and post-conversion therapeutic drug monitoring is conducted23 The switch has been undertaken by a majority of transplant centres in England the main difference being that they have undergone repatriation NHSH Patients receive their transplant primarily at Royal Infirmary of Edinburgh and occasionally at Queen Elizabeth University Hospital Glasgow Care is transferred to NHS Highland on discharge NHS Highland cares for approximately 170 renal transplant patients 110 being prescribed Prograf These patients may live as far as 110 miles from Raigmore Hospital Given that prescribing is carried out by primary care clear communication with patients GPs and community pharmacy is essential to avoid inadvertent switching between brands
Method Clinically it was agreed a switch could be safely undertaken A business case was submitted and funding secured for pharmacist time laboratory costs and primary care time GPs have been informed via GP subgroup and local prescribing bulletin lsquoThe Pink Onersquo Community pharmacies are being informed by phone A protocol has been agreed Eligible patients selected by Renal Consultant and Renal Pharmacist Patients sent letter signed by Renal Consultant and Renal pharmacist Patients phoned prior to clinic to agree Adoport start date and address concerns Patient seen by Renal Consultant and pharmacist + given 1 month of Adoport Tacrolimus level and UampEs checked 5-7 days after commencing Adoport and patient
contacted by phone to check if tolerated If stable letter sent to GP and community pharmacy to continue supply
Results and Evaluation Letters have been sent to all eligible patients Seven patients have been reviewed One has received a one month supply of Adoport and 5 others are due to switch One patient was deemed non-eligible at present as they have a 6 month surplus of Prograf A database will be maintained and analysed at the end and primary care savings will be monitored Extra pharmacist input will give us the opportunity to review how immunosuppression is managed and to evaluate the benefit of having a renal transplant pharmacist Conclusion The switch is at an early stage Ultimately we hope to show that the switch from Prograf to Adoport can be managed safely with extra pharmacist input to a remote and rural population with prescribing being conducted by primary care
Fundingconflicts of interest none 1 McDevitt-Potter LM Sadaka B Tichy EM Rogers CC Gabardi S Transplantation 2011 A multicenter experience with
generic tacrolimus conversion 2 Medicines and Health Products Regulatory Agency Drug Safety Update 2012 Accessed online via
wwwmhragovukSafetyinformationDrugSafetyUpdateCON1557563 ESPRIT Guidance on management of repatriation and immunosuppressant switches in transplant patients 2015
Accessed online via httpwwwespritorgukwp-contentuploads201508Switch-guidance-document-final-Aug-31-2015pdf
P7 NHS Highland-Tacrolimus baseline dataMcCulloch K1 Peel R2 Lambie S3
1Renal Pharmacist Renal unit Raigmore Hospital Inverness 2Renal Consultant Renal unitRaigmore Hospital Inverness 3Renal Consultant Renal unit Raigmore Hospital Inverness
BackgroundAs part of planning a switch from using tacrolimus Prograf to Adoport we assessed baseline data for our transplant patients currently using Prograf After converting patients to Adoport we will compare their tacrolimus levels to their individual target range We assessed our use of appropriate target ranges and our current performance in achieving tacrolimus levels within target range on Prograf therapy
Method 107 renal transplant patients taking Prograf were identified a sample of 19 of these were analysed using electronic patient records and results Time from transplant ranged from 1 month to 18 years All tacrolimus levels for the preceding year were analysed and compared to the target range specified at the time of the level being done The assay used has a Coefficient of Variation of lt5 at the lower limit of the assay
Results All 19 patients had a target range for tacrolimus clearly identified and recorded in clinic letterswhich are routinely copied to the patients themselves A variety of target ranges were specifiedThe commonest used was 5-8 microgramsl in 7 patients followed by 5-7 in a further 4 patientswith another 6 different target ranges being used for the remaining 8 patients The ranges usedhad a breadth of 3 microgramsl in 2 cases the rest had a breadth of 2 microgramslPatients had a median of 12 (range 3-72) tacrolimus levels over the preceding year Results werewithin specified target ranges for 54 +- 22 (Medan +- SD) of results checked
Conclusion We currently use a large number of different target ranges The majority of the ranges used had a breadth of just 2 microgramsl These factors help to account for the low proportion of test results which were within the specified target ranges This is important to bear in mind when interpreting whether tacrolimus levels are within target ranges after switching to Adoport We should consider aligning our target ranges and widening them
P8 Eculizumab use in Scottish paediatric dense deposit disease Stewart D1 David Hughes1 Lynne Riach2 Craig Oxley2 Athavale D1
1Royal Hospital for Children Glasgow 2Royal Aberdeen Childrenrsquos Hospital Aberdeen
Introduction The revised MPGN classification and increasing recognition of Dense Deposit Disease (DDD) a C3 glomerulopathy as an alternative complement pathway disorder suggests Eculizumab an anti-C5 monoclonal antibody may be beneficial in treatment However the experience of Eculizumab as an off-label and expensive treatment in children with DDD is limited with variable clinical response reported in the literature
Method We present the outcomes of the only 2 paediatric patients in Scotland who have received Eculizumab for the management of DDD
Results Case 1 A 10 year old male presented with proteinuria and haematuria resistant to steroid treatment with preserved renal function Initial biopsy confirmed DDD Conservative management with an angiotensin converting enzyme inhibitor and diuretics for symptom control continued until 14 years Due to worsening symptoms (oedema lethargy poor growth) and renal function deterioration along with elevated terminal complement complex (TCC) Eculizumab was commenced A repeat biopsy whilst suggestive of chronic irreversible damage showed 25 glomerular architecture preservation Symptom improvement was noted There was a reduction in proteinuria and renal function stabilisation fall in TCC and discontinuation of diuretics Eculizumab was discontinued after 24 months Progression of renal function decline was seen in the final months of Eculizumab therapy With recurrence of symptoms and increasing proteinuria following discontinuation Eculizumab was recommenced after 6 months Symptomatic improvement has since been noted
Case 2 A 5 year old girl presented with painless frank haematuria and proteinuria Initial biopsy confirmed DDD Proteinuria was unresponsive to steroid therapy and 5 months following diagnosis she rapidly progressed towards end stage renal disease despite the introduction of Mycophenolate Mofetil and plasmapheresis Haemodialysis was subsequently commenced TCC level was elevated and Eculizumab treatment was started 7 months after diagnosis Renal biopsy prior to treatment demonstrated continued severe pathological changes in all visible glomeruli However due to lack of clinical response Eculizumab was discontinued after 2 months and the patient remained dialysis dependent
Conclusions Our experience with Eculizumab in Scotland has demonstrated variable results in our 2 patients with one patient showing a positive response whilst the other experienced no improvement Eculizumab was administered to both patients at varying points in their clinical journey with differing progressive features on biopsy To date the outcomes of 9 paediatric patients with DDD treated with Eculizumab have been described in the literature with 8 experiencing some positive response to treatment including 2 patients who were able to stop renal replacement therapy within 12 weeks of treatment A role for Eculizumab in DDD may be guided by clinical and pathological features Well designed clinical trials will be necessary to define the role of complement inhibition therapy in DDD
No conflict of interest and no funding requested
P9 Examining markers of safety in the use of non-tunnelled central venous catheters
James WT Millar (Speciality Registrar) Scott W Oliver (Speciality Registrar) Peter C Thomson (Consultant Nephrologist) Glasgow Renal and Transplant Unit Queen Elizabeth University Hospital Glasgow
Background Non-tunnelled central venous catheters (NTCVC) remain an essential means of vascular access for incident haemodialysis Associated morbidity is well recognised for example in the form of Staphylococcus aureus bloodstream infections (SAB)[1]
Previous quality improvement initiatives in our unit have sought to both improve traditional markers of quality (such as SAB) and to identify additional areas of clinical risk In 2014 Oliver et al [2] suggested several additional quality measures including peri-procedure haemoglobin drop the need for a further NTCVC during the same clinical episode and the NTCVC insertion site This study further evaluated NTCVC related clinical practice within our unit
Methods The potential markers of clinical quality identified in a previous project were examined using prospectively collected data stored in the electronic patient record Identified cases of SAB significant peri-procedure haemoglobin drop and multiple NTCVC insertion were investigated by case note review
Results Between March 2016 and March 2017 a total of 222 patients received 346 NTCVC 54 patients (243) had more than one NTCVC inserted in a 21-day period (range 2-5) When considering NTCVC insertion site there were 159 (459) femoral vein catheters and 183 (541) internal jugular vein catheters No pneumothoraces were reported
15 SABrsquos were reported during this period equating to 43 of all NTCVC 5 arose in patients with femoral NTCVC (333) and 10 from internal jugular catheters (667) Mean time from line insertion to positive blood culture was 86 days 15 (67) patients had a drop in haemoglobin of greater than 20mgdl with no other source of blood loss identified on review of clinical notes
Discussion These data demonstrate that NTCVC-associated SAB rates remain low and significantly below Scottish government audit standards [3] Of interest is the continued trend towards the use of femoral catheters at 45 of lines compared with 38 in 2014 [2] Although traditionally thought of as having a higher incidence of infectious complications our data has shown fewer bacteraemia events associated with femoral catheters compared with internal jugular Our data also demonstrates a significant rate of peri-procedure haemorrhage arising in up to 1 in 20 cases Together these findings present opportunities to development practice and improve patient safety
References
[1] Murray E Deighan C Geddes CC Thomson PC Reducing haemodialysis bacteraemia rates Scottish Renal Association Glasgow November 2013 [2] Oliver SW Thomson PC Jardine AG defining safe effective and patient-centred dialysis catheter placement Scottish Renal Association Edinburgh September 2014 [3] The Staphylococcus aureus bacteraemia quarterly report of cumulative data from all NHS Boards in Scotland Health Protection Scotland January 2015
Sources of funding none Conflicts of interest none
P10 Prescribing of tolvaptan-The NHS Highland experience Lambie S1 McCulloch K2 Garrod J3
1Renal Consultant Renal unit Raigmore Hospital Inverness 2Renal Pharmacist Renal unit Raigmore Hospital Inverness 3Renal Pharmacist Renal unit Raigmore Hospital Inverness
Introduction Tolvaptan is a vasopressin antagonist It was accepted for use in Scotland by SMC in Jan 2016 to slow the progression of cyst development and renal insufficiency of autosomal dominant polycystic kidney disease in adults with chronic kidney disease (CKD) stage 1 to 3 at initiation of treatment with evidence of rapidly progressing disease1 Adverse effects related to aquaresis may affect patientsrsquo ability to achieve the optimum therapeutic dose and the risk of hepatic toxicity necessitates regular LFT monitoring The geography of NHS Highland required the implementation of novel methods of managing these patients and as a result a MDT approach with an emphasis on pharmacist input was adopted Consultant role Patient selection on the basis of evidence of rapidly progressing kidney disease declining
eGFR large volume kidneys on ultrasound and evidence of complications of PKD Side effects and potential benefits discussed Potential medication interactions reviewed Jinarc risk management prescriber training
Pharmacist role Undertook Jinarc risk management pharmacist training Prepares accurate drug history and reviews for potential drug interactions Carries out patient counselling and supplies patient education material sick day rules card
and lsquogot to gorsquo card Supplies GP education leaflet Provides advice on selection of new drug therapies eg for gout Manages stock and coordinates supply to patients
Results Prescribing commenced May 2016 patients currently prescribed tolvaptan 11 7 Female 4 male Number on target dose 73 n = 811 2 patients are still being titrated One patient did
not tolerate target dose due to aquaresis side effects and is being trialled on the middle dose
Withdrawals One patient has withdrawn due to agoraphobia and an inability to attend for monitoring and another is on hold due to having major surgery
Conclusion The MDT approach between the Renal Consultant and Pharmacist at Raigmore Hospital has enabled tolvaptan prescribing to be efficiently and safely implemented to patients living within a challenging geographical location
1 Scottish Medicines Consortium Detailed Advice Document tolvaptan 15mg 30mg 45mg 60mg and 90mg tablets (Jinarcreg) SMC No 111415 January 2016
NA1 Authors SCN Jacqueline Ross NHS Grampian
SCN Alan Somerville NHS Lanarkshire SCN Jane Humphrey NHS Lanarkshire
e- mail contact jacquelinerossnhsnet Alansommervillelanarkshirescotnhsuk
Janehumphreylanarkshirescotnhsuk
Phone contact 01224 552927 01236 712644
Title Sharing of Adverse Events in Renal Units across Scotland
Introduction Background The Scottish Renal Nurses Strategy Group (SRNSG) are a group of senior nurses from Renal
Units across Scotland who meet 3-4 times per year to discuss and implement best practice At the last meeting it was agreed that it would be good practice for each Health Board to share
their adverse events reported on the Datix System and deliver a presentation with an action plan to prevent incidents and improve patient safety across Scotland NHS Grampian and NHS Lanarkshire will be the first to deliver this presentation discussing adverse events from both Health Boards with an action plan
Top 5 adverse events over the past 12 months Renal Unit NHS Grampian 1 Violence and Aggression 2 Accidents including needlesticks slips trips and falls 3 Medication Errors 4 Infrastructure Staffing and Estates 5 Machines and Equipment
Top 5 adverse events over past 12 months Renal Unit NHS Lanarkshire
1 Slips Trips or Falls 2 Medicine errors 3 Treatment problems 4 Transfer problems 5 Breach of policy
The presentation will also focus on any serious adverse events which may not be in the top 5 categories
Aim Objective Each Health Board to share their adverse events with the aim to prevent them from occurring in other units to improve staff and patient safety and wellbeing across Scotland
Method Power Point Presentation
Outcome Results Sharing of adverse events resulting in the development of a national Action Plan to prevent these incidents improving safety and well being of staff and patients in Renal Units across Scotland
NA2
SRA Oct 2017 Abstract
BBV Never Event - The whats whys and hows
Staff Nurse Gillian Wilson Aberdeen Royal Infirmary
This presentation shares our experience of a never event that occurred and was not picked up for
a period of 18 months
Hepatitis C (HCV) positive antibodies were found in a previously negative patient
These results were a low positive with no biochemistry changes to suggest any liver damage
however steps were put immediately in place to isolate and investigate
Was it contamination from a dialysis machine was it related to a blood transfusion given prior to
first positive result was it faulty diagnostic tests in the laboratory
In Aberdeen we go over and above national guidelines and isolate all our BBV patients whether
they have positive blood results or are PCR negative
Further bloods tested at an external laboratory confirmed negative results
It highlighted that communication errors were to blame for the lack of speed in detecting this issue
Investigations concluded no real answers as to why this happened
NA3
Living Donation Scotland Changing attitudes towards living donor kidney transplantation
Jen Lumsdaine Julie Glen On behalf of the Living Donation Scotland Project Board
Background and aims
The rate of living donor transplantation has remained fairly static in Scotland over the past 10 years
Recent data has shown inequity of access to living donor transplantation throughout the UK so
there is potential to significantly increase this optimum form of treatment for patients with end-stage
renal failure in Scotland The Living Donation Project Board was formed in 2016 aiming to double
the number of living donor transplants by 2020
Method
The two key areas
1 Do recipients receive adequate and appropriate information at the right time about living
kidney donation
2 Informing the general public about altruistic donation
All patients active on the transplant list in Scotland were invited to an information event A follow-up
questionnaire was performed in the East of Scotland examining outcome or reasons for not
attending A scoping exercise looked at information provided by each unit was performed and link
nephrologists and low clearance nurses attended meeting to discuss strategies for early education
Outcome
An information pack containing both recipient and donor written information and short films on DVD
has been produced with the support of the Scottish Government for all recipients and potential
donors in Scotland A new website with comprehensive information both written and visual and
postcode finder to improve ease of access to local unit contact details has been developed
Two national media campaigns have been launched with a significant rise in the number of enquiries
from potential donors and actual increase in altruistic donor numbers
Nursing abstract ndash no conflict of interest
NA4Authors Susan Easson Charge Nurse Ward 4C QEUH Glasgow
e- mail contact SusanEassonggcscotnhsuk
Phone contact 0141 452 3300
Title A Conversational approach to find out ldquoWhat matters to yourdquo in a Renal Transplant ward
Introduction Background Finding out ldquo What Mattersrdquo to people using health and careservices is crucial to delivering safe effective and person centred care It is a simple yet profoundconcept and tries to get to the essence of person centred care by creating deeply personalengagements with patients and their families through a conversational approach However careexperience feedback all too often provides innumerable examples of where what really matters topatients and their family members is poorly understood or not addressed Using care experienceas the driver for change the nursing staff in Ward 4C used improvement approaches to explorehow to hold more meaningful ldquoWhat Matters to yourdquo conversations on a daily basis
Aim Objective To improve the patient experience by utilising a person centred approach
Method Using Care experience feedback What Matters to Me boards and the conversationalapproach
Outcome Results Improvements in patient experience will be shared using examples ofpractice and care experience feedback
There was no additional funding required for this project We worked in collaboration with theperson centred team whorsquos aim is to improve patient experience
NA5
The implementation of a renal education programme and its impact on clinical practice
The purpose was to implement a Renal Education Programme and to evaluate its impact on
clinical practise
It was identified that there was a need for an educational programme to be set up within Forth
Valley Royal Hospital There is no inpatient renal unit in FVRH on site for our renal patients they
attend Queen Elizabeth University Hospital We are an outpatient haemodialysis unit with
outpatient clinics on site Therefore it was identified that there was a need for nursing staff within
FVRH to be educated on all renal complexities for the benefit of our patients
This was done through a work-based learning approach which brought tangible benefits for our
patients However it did not come without pitfalls as educational programmes are often seen as
making very little difference to clinical practise
T
his study describes what methods were used and examines the advantages and disadvantages in
setting up an educational programme and evaluating its impact on clinical practise
NA6
Nursing Abstract ndash SRA Meeting ndash 26 October 2017
Chris McGee Tonya Broe Ken Weir
Renal Unit Forth Valley Royal Hospital
Use of the Therapy Monitor Haemodialysis Patient Record System Can we aim for a paper-
free dialysis unit
We are trialling a new haemodialysis patient monitoring system to work in conjunction with SERPR
and which is intended to supersede the Finesse system used previously
We are in the early stages of this process but with continuing staff education and regular tech
support we are hoping to gather sufficient evidence to evaluate whether the use of paper case
notes needs to continue
Is it a realistic goal to aim for a completely paper-free unit
NA7
THE CLINICAL USES OF APHERESIS WITHIN NHS TAYSIDE
Laura Thomson CN
Ninewells Hospital Dundee
NHS Tayside took over the apheresis service from BTS in 2012 The service has since expanded
with the benefits of carrying out this treatment has been widely recognised within NHS Tayside
and is now more commonly being offered to treat a wider range of conditions with the number of
treatments carried out each year rising
This presentation will highlight the progression of the apheresis service within NHS Tayside We
will identify the various conditions it is currently being used to treat and also identify the decision
making process involved in carrying out these treatments ie which replacement fluid will be used
anticoagulation medication administered
We will highlight the benefits and challenges we face in providing this expanding service within the
Renal Service
NA8Authors Linda McDougall Renal Physiotherapist NHS Highland
e- mail contact lindamcdougall1nhsnet
Phone contact 01463 706022
Title lsquoExercise on Haemodialysis- Keeping the Wheels in Motionrsquo
Introduction Background The impact of CKD on physical fitness functional ability independence amp ultimately quality of life cannot be underestimated Current national guidelines recommend that all individuals with CKD are encouraged to participate in regular exercise programmes between or during dialysis sessions if on HD Following a successful pilot study funding was approved to establish an lsquoExercise on Dialysisrsquo (EOD) programme across NHS Highland through the appointment of a dedicated renal physiotherapist in 2008 A successful programme was soon established but for several years post-vacancies and increasing in-patient demands limited the physiotherapy servicersquos ability to deliver the programme The need to improve the long-term sustainability of the service was recognised and in late 2016 funding was approved to develop a Band 4 PT HCSW role for this purpose
Aim ObjectiveTo optimise the sustainability and continuity of the lsquoExercise on Dialysisrsquo service across NHSHighland through development of a Band 4 PT HCSW role
Method The potential parameters of the role and limits of autonomy were scoped out using current NES resources and guidelines Service and task analysis was then carried out to establish which components of the EOD protocol could be undertaken by a Band 4 A series of competencies were developed in line with the clinical protocol and one-to-one training and supervision provided to the post-holder to ensure competency achieved in delivering the programme
Outcome Results A 10 WTE Band 4 PT HCSW was appointed in Jan 2017 with a dual role between the renal unit and acute medical wards Although training is not yet complete the post-holder is already running the day-to-day delivery and monthly audit of the EOD service with senior physiotherapist input only required for individual patient safety queries and general discussion around patientsrsquo progress and goals The benefit to the unit has been considerable as the band 4 is available to support patients and staff with EOD provision 5 days a week This allows for one-to-one supervision of patients who need more support to participate in EOD regular feedback on performance and reviews of outcome measures and goals to maintain motivation levels Feedback on the post has been very positive and its scope will only continue to expand as we look to further develop renal rehabilitation services across NHS Highland
NA9Authors Nadine Lyall and Kerry Guthrie
e- mail contact nadinelyallbordersscotnhsuk kerryguthriebordersscotnhsuk
Phone contact 01896 826637
Title The Developing Role of the NMP in a Satellite Dialysis Unit
Introduction Background
We have been practising as NMPrsquos for nearly 3 years working in the dialysis unit at the BGH The unit is a satellite unit of the ERI and we have expanded over the last 6 years The unit provides haemodialysis for 12 patients at any one time 3 sessions a day 6 days a week We are nurse-led and have 2 renal consultants who are based at the ERI
We saw an opportunity to use our knowledge and experience to develop our role By becoming NMPrsquos we have enhanced our professional development and we feel we meet the changing needs of the dialysis patient in a more holistic manner
Aim Objective
Our aim is to deliver effective care as we are better placed to deal with issues that often arise byacting swiftly this in turn is cost effective and convenient For example good anaemia and bonemanagement is important for their health wellbeing and lifespanTo help understand our role we will use a power point presentation highlighting issues we dealwith and the drugs we prescribe under the following headings Cardiovascular infection painanticoagulant disequilibrium diet renal bone disease and renal anaemia
Method Power point
Outcome Results
In the future we hope to further develop and have greater autonomy in our role We have great support from our renal consultants and have already built up a great relationship with our patients We hope to undertake the Clinical Decision Making course and this in turn will allow us to deal effectively with acute illness giving the dialysis patient better care We are keen to get feedback from other renal nurses in Scotland to enable us to develop our role further and in turn raise awareness of the NMP role in a dialysis unit We record all our prescribing decisions and keep the consultants up to date regularly Currently we are working on auditing our prescribing practice so that we can improve the service we can provide
NA10 Title Komunikacja w szkoleniu dializy ortzewnowej
Author Senior Charge Nurse Rhoda Bell
Address Raigmore Hospital Old Perth Road Inverness IV2 3UJ
Email rhodabellnhsnet Telephone 01463706023
Introduction Background Case study on lady with Polish as her first language she has some English but requires an interpreter to carry out Peritoneal Dialysis training and attend clinic She had some gynaecological issues that we were not aware of which impacted on the functionality of PD and therefore the success of treatment There were areas of concern in low clearance clinic with signs the patient had a reluctance to engage in decision making
AimObjective
Methods Discussion through the case study highlighted issues with communication between different PD staff and patients Areas of concern include different staffing techniques environment factors on training success Also language and communication issues the patient had were not fully apparent so training could not be individualised
Results We plan to trial training at home and have more individualised training schedule for patients The training step by step guides have been reviewed and practise standardised In collaboration with low clearance nurse we have developed a check list which will highlight concerns before the transition to PD ie language issues and need for training aids in another language gynaecological conditions
Conclusions Everyone learns differently and training methodsaids must be individualised for all It may not be apparent until training has commenced that there are concerns Having one to one training with the same nurse will consolidate training and build confidence in the patient Having a close working relationship with members of the MDT will help make a supportive PD journey
Would we do things differently if we knew about prolapse or lack of English both spoken and written
Key words - Peritoneal dialysis patient training communication
N11
Telehealth amp PDAudrey Jones
Advantages
Information on a daily basis about treatment weight and blood pressure
Change programme remotely via computer or mobile
Earlier intervention for machineprogramme issues
Reduction in home visits ie patient trained but still requires volume increases
No need to download cards to see what problems have been
Can have more detailed information available at clinics
Disadvantages
Relying on patient input data correctly
Machine is noisy especially first wave of machine
Still the same bag connection system and patient connection system (difficult for manual
dexterity problems)
Relying on patient having good signal
Modem problems
NA12Autosomal Dominant Polycystic Kidney Disease A cruel inheritance but new hopeAlistair Lawrie Renal Unit Victoria Hospital KirkcaldySadaf Arshad Corry Dunnigan Paul Phelan Neil Turner Renal Unit Royal Infirmary of Edinburgh
Background Autosomal Dominant Polycystic Kidney Disease (ADPKD) is the most prevalent single gene human genetic disorder and the most common of the inherited cystic and interstitial kidney diseases It is estimated to affect 1 in every 1000 individuals worldwide with over 50 of sufferers eventually developing end stage kidney disease and requiring dialysis or transplantation Symptoms include spasmodic severe pain hypertension haematuria infection and kidney failure There is currently no cure for ADPKD Management of the condition has traditionally involved lifestyle modification BP control and analgesia however a recent study (Torres et al 2012) demonstrated that treatment with V2-receptor antagonist drugs slowed increase in total kidney volume reduced the rate of functional decline and showed a reduced incidence of kidney pain
Aim Provision of a tolvaptan prescribing and monitoring service
Methods Experiential finding report of initial twelve months period of multidisciplinary ADPKDtolvaptan clinic
Results Early results are comparable with TEMPO study outcomes
Conclusion Due to the long term nature of this treatment results available at this time are showing only the earliest benefits of the intervention More quantifiable results such as increased time before the necessity for RRT will only be evident in coming years Torres VE et al (2012) Tolvaptan in Patients with Autosomal Dominant Polycystic Kidney Disease New England Journal of Medicine 367 pp 2407-2418 DOI 101056NEJMoa1205311
No funding requirement No conflict of interest
A1 Adipose-derived regenerative cells administered via the renal artery for therapy in a novel rat transplant model Rashida Lathan 1 Ryan Ghita12 Dianne Hillyard1 Rhian M Touyz1 Patrick Mark12 Marc Clancy12
1Institute of Cardiovascular and Medical Sciences UNIVERSITY OF GLASGOW Glasgow UK 2Transplant Unit QUEEN ELIZABETH UNIVERSITY HOSPITAL Glasgow UK
Introduction Studies in our hybrid rat model of transplantationischemic reperfusion (IRI) have demonstrated improvement in kidney function post injection of adipose-derived regenerative cells (ADRCs) into the renal artery This technique has translational value in human transplant surgery as ADRCs provide a robust supply of cells from accessible tissue do not require culturing and can be generateddelivered at point of care during the time of transplant The mechanism on how these cells ameliorate IRI remains elusive
Objectives Our research aims to identify the active subsets of cells represented in the ADRC population their biodistribution mode of action and any potential deleterious effects Methods Flow cytometric analysis was performed on rat ADRCs extracted from inguinal (n=14) and perirenal tissue (n=6) and human perirenal ADRCs extracted from healthy donors (n=6) Cells were surveyed for markers that identify viability immune cells (CD45+) immune cell subsets (CD3+ CD3+CD4+ CD3+CD8+ CD11b+ cells) epithelial cells (CD45-CD31+) pericytes (CD45-CD146+) and mesenchymal stem cells (CD45-CD90+CD34-) Rat ADRC RNA expression for markers of repair and markers of inflammation was measured by real-time PCR ADRCs were extracted from inguinal fat of the Fisher 344 rat labelled with a near infrared lipophilic dye DiR and injected via the renal artery of the IRI rat model Whole body imaging was performed Organs (kidneys heart lung brain spleen liver) were removed and imaged at various time points Organs were processed for histological analysis and gene expression measured at 1 hour and 24 hours post renal injection Protein isolated from the kidney and serum at 24 hours post injection were surveyed with a proteome profile array
Results In the rat we show a 27-40 fraction of injected inguinal ADRCs were non-viable Cell subsets consisted of varying levels of immune cells (15-75) and varying levels of pericyte cells depending on the adipose tissue source (inguinal vs perirenal fat) Stem cell-like markers identified 12-22 of the total ADRC cell population Rat perirenal ADRC composition is similar to human perirenal ADRC composition with the exception that humans have higher levels of T-cells RNA expression from whole rat ADRCs indicate production of growth and repair factors angiogenin and matrix metallopeptidase-2 and chemokine CXCL1 A large accumulation of ADRCs appeared clustered in the glomeruli of the kidney 1 hour post injection of ADRCs At 24 hours cells remain visible within the kidney Histological analysis of the injected kidney identified labelled cells within the cortex (likely within the renal corpuscule) of the injected kidneys at 1 hour and 24 hours post injection Fluorescence was also detected within the liver at 1 hour and 24 hours at focal points in the periphery Gene expression studies performed on the kidneys at 1 hour and 24 hour post injection identified an upregulation of immunomodulatory repair and injury related genes when compared to sham-injected control Protein profiling indicated an upregulation of TIMP-1 and of ligands important in leukocyte trafficking
Discussion Rat ADRCs appear to be a pleomorphic cell suspension with multiple potential active subsets including T-cells macrophages and mesenchymal stem cells Collectively RNA of factors related to growth and repair are expressed Human perirenal ADRCs have a comparable composition as rat perirenal ADRCs After 24 hours the ADRCs persist within the kidney RNA data of the injected kidney suggests that ADRCs exert multiple effects on the surrounding tissue as shown by the increase in gene expression related to repair VEGFa Ang2 and immune modulation Csf2 CXCL1 CXCL2 Ifn- and IL-6 The change in RNA and protein levels of leukocyte trafficking-related factors suggest a major role for leukocytes
Funding UK Regenerative Medicine Platform Conflict of interest None
A2 The development of an online educational resource on AKI Ross Norris 1 Joanne Sloan 2 Samira Bell 2
1 School of Medicine University of Dundee Ninewells Hospital 2 Renal Unit Ninewells Hospital
Background Within NHS Tayside there are a number of resources and tools available to aid in the prompt detection and management of AKI such as primary amp secondary care E-Alert systems local guidelines and most recently lanyard cards These resources are supplemented by a regular AKI awareness week which involves delivery of formal amp informal education as well as distribution of a variety of resources However there was a lack of an easily accessible educational resource for both medical and nursing staff as well as medical students In light of this the aim of this project was to produce an educational resource that was engaging easily accessed and easily distributable
Development amp Production NHS Taysidersquos AKI guideline was used as the foundation for the content of the resource and animation was decided as the format in which the resource would be produced Animation was chosen because research has shown that multimedia is an effective method for delivering education and because an animated video provides an independent and easily accessible resource (1) Initial stages of development involved production of sketches and a script based on the guideline Following development of a working draft of both a focus group was held with staff from the renal department to gain constructive feedback In order to turn this concept into an animated video the team was expanded to include a local artist who used the initial sketches to produce illustrations on Adobe Photoshop and a videographer who developed a plan of how to approach the live drawing of each of the illustrations to maximise their visual impact To prepare for production a storyboard inclusive of the exact timings of each illustration and the coordinating part of the script was created Production involved live filming of the illustrations being drawn The footage obtained was then edited using Adobe Premier Pro reading of the script recorded and both combined to produce a fully narrated animated video
Distribution amp Utilization The resource has been made available to staff via upload to the intranet has been incorporated into FY1 induction and will be used as part of the next yearrsquos AKI awareness week Access to the video has been made open to enable use by medical students and professionals outside of Tayside via upload to NHS Taysidersquos YouTube Facebook and Twitter pages with current viewership being 1400
Link httpswwwyoutubecomwatchv=gW0pgXrIdgo
Funding amp Conflicts of Interest The renal endowment fund NHS Tayside No conflicts of interests to declare
References 1 Rolfe VE Gray D Are Multimedia Resources Effective in Life Science Education A Meta-Analysis Bioscience Education 201118(1)1-14
A3 Glucose dynamics and mortality in RRT patients an initial report
Matthew A Rutherford12 Gregory C Jones3 Alan G Jardine14 Patrick B Mark14 Peter C Thomson12 Christopher AR Sainsbury3
1 Glasgow Renal and Transplant Unit Queen Elizabeth University Hospital Glasgow UK 2 School of Medicine Dentistry and Nursing University of Glasgow UK 3 Diabetes Centre Gartnavel General Hospital Glasgow UK 4 Institute of Cardiovascular and Medical Sciences University of Glasgow UK
Background Glucose variability is increasingly being recognised for an association with adverse outcomes in populations with normal renal function For individuals with abnormal renal function this is less clear particularly for those with end stage renal failure undergoing renal replacement therapy (RRT) In RRT patients sustained extremes of glycaemia appear to be associated with worse survival however the effect of underlying glucose dynamics remains poorly understood Specifically there are few published studies which examine the influence of hypoglycaemic episodes on outcomes in RRT patients We sought to determine the relationship between inpatient hypoglycaemia and long-term mortality in a broad cohort of RRT patients
Methods Data for all incident and prevalent RRT patients within our catchment from July 2008 to December 2016 were extracted from the electronic patient record These were merged with a dataset of hospital capillary blood glucose (CBG) measurements Hospital contact episodes were identified from CBG timestamp data (a technique previously validated in other populations) Contacts with gt1 CBG measured within a 48 hour period were taken as admissions Those with at least one CBG lt4mmolL during the first recorded admission were compared with those without Age length of admission and number of measured CBGs were compared between groups A survival analysis was carried out over 85 years comparing groups A Cox proportional hazard model was used to compare time to death including age as a covariable
Results 367544 CBGs from 2215 individuals and 63559 hospital contact episodes were identified 31340 episodes from 831 individuals had gt1 CBG performed and were analysed as admissions 219 individuals had 1 or more CBGs lt4mmoll recorded This group experienced longer admission (36 vs 19 days plt0001) and had a higher number of recorded CBGs (13 vs 4 p lt 0001) On survival analysis hypoglycaemia was associated with a HR for death of 152 (95 CI 131-173 plt00001)
Discussion Hypoglycaemia is associated with prolonged admission and increased mortality in this broad population Further work investigating the impact of glucose variability RRT modality and presence or absence of diabetes is planned
A4 Vitamin K and Vascular Health A Systematic Review and Meta-Analysis Jennifer Lees12 Fiona Chapman2 Miles Witham3 Alan Jardine12 Patrick Mark12
1 Institute of Cardiovascular and Medical Sciences University of Glasgow 2 Glasgow Renal and Transplant Unit NHS Greater Glasgow and Clyde 3 University of Dundee
Background - Vascular stiffness and calcification occur prematurely in patients with chronic kidney disease (CKD) and are associated with increased mortality Activity of matrix Gla protein - an important regulator of vascular calcification - is dependent on adequate vitamin K intake vitamin K deficiency is prevalent in patients with CKD We conducted a systematic review and meta-analysis of the effect of vitamin K supplementation on vascular health and assessed the evidence that level of (inactive) dephosphorylated undercarboxylated Matrix Gla protein (dp-ucMGP) is associated with incident cardiovascular disease (CVD) or mortality
Methods - Two authors searched Medline and Embase databases Cochrane and ISRCTN registries in May 2017 for i) adult human studies of vitamin K supplementation versus control which measured effects on vascular calcification vascular stiffness or dp-ucMGP and ii) prospective observational studies assessing effect of baseline dp-ucMGP on incident CVD or mortality Random effects meta-analysis was conducted using meta and metafor packages for R statistical software package Egger regression and Trim-and-Fill analyses were used to assess for publication bias
Results ndash Nine intervention studies (n=952) and 13 observational studies (n=7495) met our pre-specified inclusion criteria Vitamin K led to a significant reduction in vascular calcification compared to placebo (-91 [95CI -177 -05] p=004) and a significant decrease in dp-ucMGP (-227pmolL [95CI -281 -173] plt0001) A non-significant improvement in vascular stiffness was evident (-37 [95CI -78 04] p=008) In observational studies with a follow up period of 70 + 40 years stepwise increase in dp-ucMGP was not associated with fatal or non-fatal CVD (log HR 005 [95CI -013 022] p=062) or mortality (log HR 004 [95CI -015 023] p=069) Egger regression and Trim-and-Fill analyses suggest possible publication bias in favour of positive results
Conclusion - Vitamin K supplementation significantly reduces dp-ucMGP level although dp-ucMGP is not associated with incident CVD or mortality Supplementation appears to reduce progression of vascular calcification with a trend towards improvement in vascular stiffness though there are limited data available Clinical trials of the effect of vitamin K supplementation on vascular health are warranted
Funding - JL is supported by a Kidney Research UK Training Fellowship
Conflicts of interest - MW and PM are currently running a BHF-funded trial of vitamin K supplementation in patients with CKD 3b4
A5 Review of management of patients with diabetic nephropathy Wan Shun Wonga Mohammed K Azharuddinb
aRenal and Transplant Unit Queen Elizabeth University Hospital Glasgow bDiabetes Unit Inverclyde Royal Hospital Greenock
Background ndash Diabetic nephropathy is a common and potentially life-threatening complication of both type 1 and type 2 diabetes and is now recognised as the leading cause of end-stage renal disease1 Studies have shown that early interventions can delay the onset and slow the progression of diabetic nephropathy2 The aim of our study was to review the management of patients with diabetic nephropathy at Inverclyde Royal Hospital in accordance to the guideline published by the National Institute for Health and Care Excellence (NICE)
Methods ndash Patients with diabetic nephropathy were identified on SCI-Diabetes Patient data was then extracted from renal electronic patient record SCI-Diabetes and Clinical Portal Clinical notes were also reviewed to determine the reason for cessation of angiotensin-converting-enzyme inhibitor (ACE-I) or angiotensin receptor blocker (ARB) Referral guidelines from the Renal Association were used to assess the eligibility for referral
Results ndash Data was collected from 255 patients with diabetes and urine ACR gt25 (for male) and gt35 (for female) Mean age was 625 years (SD 151) and 584 (n=149) were male 243 of patients (n=62) were classed as type 1 diabetes and 737 (n=188) as type 2 with further 20 (n=5) as others 949 (n=242) patients had an HbA1c recorded within the last year The mean HbA1c was 712 (SD 2052) 8 patients were on RRT (7 on HD and 1 on PD) Serum creatinine and urine ACRPCR were checked in 933 (n=238) and 612 (n=156) of patients in the last year respectively Blood pressure was measured within the past 12 months for 847 (n=216) of patients with 601 (n=146) having blood pressure higher than the target of 13080mmHg Mean systolic and diastolic blood pressures were 1339 mmHg (SD 1735) and 745 mmHg (SD 111) respectively 627 of patients were on ACE-IARB Of the 95 patients who were not on ACE-IARB 421 (n=40) were stopped due to side effects 116 (n=11) patients had their ACE-IARB discontinued but no reason could be found 379 (n=36) patients had never been on an ACE-IARB 157 (n=40) of patients met the criteria for referral to Renal Services and 7 patients had not been referred and all 7 of them recently developed CKD4
Conclusion ndash Our findings were consistent with the national data3 Urine PCR measurement has the lowest completion rate among all the recommended annual care processes Optimal blood pressure control remains a challenging issue for many of the patients with diabetes Further studies could be carried out to look at the reasons behind the low completion rate of urine PCR measurement as well as to devise ways to remind clinicians about starting patients on ACE-IARB and making referral to Renal Services when indicated
References 1 K Bennett B S Aditya An overview of diabetic nephropathy Epidemiology pathophysiology and treatment Journal of Diabetes Nursing 18 61-7 2 Molitch ME DeFronzo RA Franz MJ et al American Diabetes Association Nephropathy in diabetes Diabetes Care 200427(Suppl 1)S79-83 3 Scottish Diabetes Survey 2016 Scottish Diabetes Survey Monitoring Group NHS Scotland
Funding ndash None Conflict of Interest ndash None
A6 Analgesic Use in Dialysis Patients in a District General Hospital Setting
A McCallum L Dickson S Robertson A Almond N Rathnamalala M KellyT Muniraju
Renal Unit Dumfries and Galloway Royal Infirmary
Evidence shows around 50 of haemodialysis patients report pain with 83 describing this as moderate to severei Distinct variability also exists in levels of opiate prescribing between centres with studies showing incidence ranging from 5-50iiiii Consequently we sought to investigate the prevalence of both pain and opioid prescriptions in our local dialysis population as well as investigating whether there are any associations between co-morbidities and the use of opiates This information could then be used to identify new dialysis patients at high risk of pain as well as informing prescribing decisions
In order to achieve this a questionnaire was produced that incorporated validated pain and quality of life scores (the Brief Pain Index and Renal Palliative Care Outcome Scale) with a consent form to access electronic healthcare records Questionnaires were distributed to all our haemodialysis and peritoneal dialysis patients Results were transcribed into Microsoft Excel where they were analysed
Data was collected on 56 patients (46 haemodialysis patients 10 peritoneal dialysis patients) Results showed 46 described ldquopain other than everyday kindsrdquo on the day of survey completion The most common site of pain was in the legs and back On average patients were on 12 different medications of which 15 was for pain (range 0-5) 784 of these pain prescriptions were longstanding (gt3 month use) Amongst haemodialysis patients 45 were on a strong opioid ndash in 73 of cases this was a fentanyl patch Whilst scope exists to increase the use of simple analgesia and neuropathic agents in such patients analysis using the pain management index scale revealed use of opioid analgesia in such cases to be justified As in previous work no link was found between any one co-morbidity and the development of pain
Overall we have shown high rates of pain amongst our dialysis patients We also demonstrate high levels of chronic analgesia use and the overall tablet burden on our patient group is high This work adds to previously published literature and is being used locally to proactively minimise the burden of prescribed tablets and also increase awareness of the value of paracetamol and neuropathic agents in those with uncontrolled pain
Source of funding conflict of interest Nil
References i Davison SN Pain in hemodialysis patients prevalence cause severity and management Am J Kidney Dis 2003421239-1247 ii Butler AM Kshirsagar AV Brookhart MA Opioid Use in the US Hemodialysis Population Am J Kidney Dis 2014 63(1) 164-173 iii Wyne A Rai R Cuerden M Clark WF Suri RS Opioid and Benzodiazepine Use in End-Stage Renal Disease A Systematic Review Clin J Am Soc Nephrol 2011 6 326ndash333
A7 The Role of the Renal Supportive Care Service in Advanced Care Planning JM Sloan CA Douglas S Cathcart L Frame L Stage M Witham ME Lafferty
Renal Service Ninewells Hospital Dundee
Background In 2007 we established a Renal Supportive Care Service for patients with advanced chronic kidney disease who choose not to receive dialysis The service which includes a fortnightly Renal Supportive Care clinic is provided by a Consultant Nephrologist a Consultant Palliative Care Physician and a Renal Supportive Care Specialist nurse The focus of the service is on ongoing management of chronic kidney disease symptom control and improving quality of life while planning for end of life care
Methods We have undertaken a retrospective audit of our Renal Supportive Care Service on all patients known to the Renal Service for whom a conservative care management decision had been made We collected data over a 31-month period from April 2012 until October 2014 We collected data on demographics co-morbidities clinic attendance renal supportive care input anticipatory care planning performance status and mortality data
Results Of the 98 patients for conservative management 62 (6198) were female with a mean age of 837 years During the 31-month period there were 507 documented supportive care consultations with 36 (3598) of patients receiving domiciliary visits from the Renal Supportive care nurse Anticipatory Care Plans (ACP) were in place for 62 (61) of patients with a preferred place of death known for 56 (5598) 65 patients had a documented discussion about their DNACPR status which was communicated in writing to primary care For a further 13 it was not clear whether the discussion had taken place During the study period 61(62) patients died Of those patients with an ACP 29 (1138) died in an acute hospital versus 43 (1023) of those without (p=025) Similarly 24 (834) of patients with a documented preferred place of death died in an acute hospital versus 48 (1327) of those without (p=004)
Conclusions The role of the Renal Supportive Care team is invaluable in providing care and support to patients who have chosen conservative management By discussing and planning for end of life care the Renal Supportive Care team play a role in reducing the number of patients dying within an acute setting
Conflicts None
Funding The Renal Supportive Care Nurse post and one Palliative Care Consultant Programmed activity received 3 years of funding by British Kidney Patients Association
A8 Predictors of transplant failure in patients undergoing indication renal biopsy
Kate Stevens 1 Bruce Mackinnon1 David Kipgen1 Shana Coley1 Marc Clancy1 Colin Geddes1
1Renal and Transplant Unit QEUH NHS GGampC Glasgow United Kingdom
Introduction This study considers indication renal biopsies and factors which may be important
predictors of transplant loss and patient death
Objectives To identify the time line of histological diagnosis from transplant in our population
and to identify predictors of graft and patient survival in those undergoing indication renal biopsy
Methods All indication renal biopsies undertaken between 012011 and 122015 were identified
Demographic data including immunological and outcome data was recorded Statistical analysis
was undertaken in SPSS (v22)
Results 354 patients underwent 549 biopsies Mean patient and transplant age at time of biopsy
was 432 plusmn153 and 42plusmn58 years respectively 449 (n=247) of biopsies showed evidence of
Cell mediated rejection (CMR)ABMR or both 93 (n=51) demonstrated features of chronic
transplant glomerulopathy (CTG) DSA was present at the time of biopsy in 231 (n=127) In
transplants aged le 6 months old histological diagnosis was CMR in 325 (n=69) with ABMR seen
in 28 (n=6) In transplants aged ge10 years CTG was seen in 325 (n=26) with ABMR
accounting for 63 (n=5) 229 (n= 81) of transplants failed at a median of 182 days from most
recent biopsy On cox regression analysis peritubular capillary (PTC) C4d and CTG were
independent predictors of transplant failure Probability of transplant failure was 45 and 50 at
one year if mixed rejection or CTG were present 93 (n=33) patients died at a median of 227
days from most recent biopsy Independent predictors of death included deceased donor
transplant patient age and presence of ABMR on biopsy (plt005)
Conclusion Acute ABMR is a risk factor for patient loss whilst chronic ABMR is a risk factor for
transplant loss This association is independent of DSA but dependent upon PTC C4d staining
indicative of donor humoral activity ndash HLA or otherwise Histological diagnosis in an indication
biopsy is an important factor in predicting outcome This study is limited by the inherent bias in
patient selection with indication biopsy
Disclosure of Interest None Declared
A9 Renal Evaluation of Paediatric Patients with Tuberous Sclerosis Complex (TSC) in aNational TSC Multidisciplinary ClinicDr Jenny Patterson 1 Dr Shelagh Joss 1 Dr Ihab Shaheen 2
1 Clinical Genetics Queen Elizabeth University Hospital Glasgow 2 Paediatric Nephrology Royal Hospital for Sick Children Glasgow
Introduction Tuberous sclerosis complex (TSC) is a dominantly inherited multisystem disorder characterised by development of hamartomas (benign lesions) in multiple organs Previous studies have shown that renal manifestations are common in TSC and also the most frequent cause of TSC-related death in affected individuals With the recent discovery of targeted therapy with mTOR inhibitors early recognition of renal involvement allowing early surveillance and prompt therapy is now more important than ever
AimMethod To review a population of paediatric patients attending a large specialist TSC service in the UK both in terms of key clinical characteristics and current practice for renal radiological surveillance data were collected from electronic medical records pertaining to molecular diagnosis renal surveillance and presence or otherwise of sequelae affecting the renal or other systems Practice was compared to published surveillance recommendations of the International Tuberous Sclerosis Complex Consensus Group (2013)
Results Data were obtained for 41 children (18 males 23 females) Current age range 25 years to 14 years (mean 98 years) Twenty nine patients (707) were diagnosed lt1 year of age Genetic data were available for 29 patients Fifteen patients had a confirmed TSC1 mutation and 14 patients a confirmed TSC2 mutation including one contiguous PKD1 mutation Renal imaging (all US) within a year of diagnosis was documented in 2541(61) performed at a mean age of 3 years Renal symptoms at diagnosis were documented in 741(171) and 941(22) had renal abnormalities on baseline imaging There was wide variability in scanning interval and modality with 1041(243) having previous abdominal MRI with variable documented indication Seventeen (414) of the cohort mean age 102 years had documented renal lesions 917 angiomyolipomas 517 cysts and 317 both These lesions were diagnosed at a mean age of 6 years (range 02 years-142 years) Six patients (353) had normal baseline scans with a mean interval to lesion diagnosis of 1 year One patient had a lesion on MRI not detected on US that required subsequent biopsy Frequency of subsequent scanning ranged from intervals of 2 months to 1 year with a combination of MRIUS in an unclear pattern All patients except one with a contraindication were undergoing current brain surveillance by MRI
Conclusions Our results highlight the significant incidence of renal sequelae within our TSC cohort with renal manifestations ranging both in severity and age of onset International guidelines recommend MRI scanning for renal surveillance at diagnosis and throughout life Benefits of MRI include enhanced accuracy of sizing and characterisation of renal lesions The majority of our cohorts are already undergoing brain MRI surveillance It is our aim to combine and standardise MRI renal surveillance for this cohort to facilitate early and regular monitoring with a view to early intervention is possible
A10 Effect of blood temperature monitoring on intradialytic hypotension in patients with end stage renal disease requiring haemodialysis Heather Walker1 Susan McGeorge1 Drew Henderson2
1 Renal Unit Ninewells Hospital Dundee2 Regional Renal Centre Waikato Hospital Hamilton New Zealand
Background KDIGO define intradialytic hypotension (IDH) as a reduction in systolic bloodpressure (SBP) ge20mmHg or mean arterial pressure (MAP) ge 10mmHg with associatedsymptoms IDH is a common complication of haemodialysis (HD) and is associated with increasedmortality and morbidityStandard dialysis with a set temperature leads to thermal gain during the dialysis session Tocounteract this thermal gain vasodilation occurs and is postulated as one of the causes of IDHActive cooling of dialysis has been shown to reduce IDH but is not routinely applied across wholedialysis populations Isothermic dialysis can be achieved by controlling blood temperature on HDWe report here our experience of doing this using the Blood Temperature Monitoring (BTM)function on Fresenius 5008 dialysis machines
Methods An observational study was performed to assess the rates of IDH in patients with End Stage Kindey Disease (ESKD) undergoing regular satellite HD at NHS Tayside in July 2017 Rates of IDH were assessed (KDIGO definition) for two weeks prior to BTM settings being activated and for a two week study period after introduction SBP and MAP data was collected SBP data was grouped to either SBP decrease lt20mmHg or SBP decrease ge20mmHg compared with Pre HD BP Changes in MAP were also analysed at the same time points Patient reported symptoms related to initiation of BTM were also collected for the same time period
Results 402 dialysis sessions were evaluated in the pre intervention time period and 399 sessions post intervention
IDH 1072 vs 778 (Pre BTM vs Post BTM) p=015 gt20mmg SBP drop Pre vs Post BTM
Mean MAP Change (mmHg) Pre BTM vs Post BTM
1st BP 254 vs 204 (p=005) -522 vs +312 (plt001) 2nd BP 474 vs 435 (p=023) -1589 vs -886 (plt001) 3rd BP 515 vs 435 (p=003) -1862 vs -958 (plt001) Post HD 408 vs 338 (p=003) -1164 vs -077 (plt001)
Following the introduction of blood temperature monitoring only 08 of HD sessions reported experiencing cold or shivering symptoms
Conclusion The use of blood temperature monitoring was not associated with a statistically significant decrease in rates of IDH There was a significant reduction in the number of sessions where SBP decrease by gt20mmHg at the first and third HD BP and a reduction in MAP change across the study group Further evaluation of BTM is required assess its clinical utility in our HD population
Funding No funding was sought for this study
Conflicts of interest None
A11 Evaluating patient satisfaction and clinical outcomes of a new nurse-led dermatology clinic for patients attending the renal transplant clinic Campbell G Naismith K Neil A Rankin A Spalding E (joint first authors) Renal Unit University Hospital Crosshouse Kilmarnock UK
BACKGROUND National Guidelines advise that renal transplant recipients should receive annual skin surveillance to screen for skin cancer In August 2015 a specialist nurse-led dermatology clinic was set-up alongside the renal transplant clinic at University Hospital Crosshouse We aimed to evaluate the success of this joint clinic in terms of clinical outcomes and patient satisfaction
METHODS Clinical records were reviewed to determine the number of patients under dermatology follow-up before and after initiation of the joint clinic and to review cases that were referred for treatment of pathological skin lesions A questionnaire was also distributed to patients attending the new joint renal-dermatology transplant clinic The questionnaire consisted of 5 questions 2 for patient demographics 1 for current understanding of skin care advice and 2 to assess their satisfaction of the new joint clinic
RESULTS A total of 138 and 146 renal transplant recipients were registered on renal transplant clinic lists in 2015 and 2016 respectively Prior to initiation of the new joint-clinic 41 patients had attended dermatology (37 in NHS Ayrshire and Arran and 4 in NHS Greater Glasgow and Clyde) consisting of 30 of the transplant population In September 2016 13 months after initiation of the new clinic 60 patients had attended the new clinic increasing the proportion of patients meeting the national recommendation for skin surveillance to 41 Implementation of the new clinic resulted in patients being 65 more likely to have received the recommended skin checks (odds ratio 165 95 CI 101-270 p=004)
32 patients completed the questionnaire The median age of transplant was 90 years (IQR 38-153) 100 of patients knew to avoid sun exposure and 31 (96) knew to use sunscreen 29 (91) patients were aware of the advice to undergo annual skin surveillance by dermatology with 28 (88) having had a skin check in the last year 29 (91) patients reported that they found the new joint clinic useful although only 18 (56) had attended the clinic so far
CONCLUSIONS Implementation of a new nurse-led dermatology clinic running in parallel with the renal transplant clinic resulted in a considerable increase in the proportion of patients meeting national recommendations for annual skin surveillance The vast majority of patients also found the combined clinic to be useful There is still considerable room for improvement in order to achieve the target of 100 compliance with skin surveillance and ongoing clinical audit is required to assess progress We believe this model would be easily implementable at other units with similar benefits expected
A12 Pneumocystis pneumonia prophylaxis post-renal transplant increased duration of co-trimoxazole is safe and effective FA Chapman JE Dickerson M Clancy C Daly C Geddes Renal amp Transplant Unit Queen Elizabeth University Hospital Glasgow
Introduction All renal transplant recipients receive Pneumocystis jirovecii prophylaxis usually with co-trimoxazole Guidelines suggest this should be continued for 3 to 6 months Our unit previously prescribed 3 months however following an outbreak of Pneumocystis pneumonia (PCP) infection this was increased to 6 months Given its constituents of sulfamethoxazole and trimethoprim co-trimoxazole prophylaxis may influence the frequency of urinary tract infection (UTI) We aimed to compare the frequency of UTI between patients on 3 months vs 6 months prophylaxis and assess rates of multi-drug resistant organisms We also sought to establish if the increased duration of co-trimoxazole was adversely affecting renal function potassium concentration white cell and platelet count and dosing of mycophenolate mofetil
Methods A retrospective search of the West of Scotland Electronic Renal Patient Record was conducted for all renal transplant recipients between 1st January 2012 and 31st May 2016 Patients were grouped according to the intended duration of co-trimoxazole Data were extracted for baseline characteristics co-trimoxazole prescription mycophenolate mofetil (MMF) prescription laboratory results (creatinine potassium white cell count platelets) at 3 6 9 and 12 months post-transplant and microbiology results for 6 months post-transplant Results were analysed on an intention to treat (ITT) basis with a second analysis according to actual duration of co-trimoxazole treatment (AT) Subjects with transplant failure had laboratory results censored from the time of transplant failure and all of their microbiology results were excluded
Results 609 renal transplants were performed over the study period On ITT analysis there were 418 patients in group 1 (ITT1 3 months co-trimoxazole) with 15 transplant failures and 191 patients in group 2 (ITT2 6 months co-trimoxazole) with 12 transplant failures There was a significant difference in the number of patients with at least one UTI with fewer in ITT2 (ITT1 133403 vs ITT2 42179 p = 001) However this was not present when comparing actual treatment duration (AT1 111345 vs AT2 36149 p=007) Overall there was a similar spectrum of organisms cultured There were significantly fewer cultures of multi-resistant organisms in both ITT and AT analyses with 6 months of co-trimoxazole (ITT1 28376 vs ITT2 0106 p= 0004 AT1 22313 vs AT2 198 p = 002) There was no difference in estimated Glomerular Filtration Rate serum potassium concentration platelet count or MMF dose On AT analysis there was a significant difference in the total white cell count (WCC) and lymphocyte count at 6 months post-transplant (WCC 78 x10^5L vs 71 x10^5L p =004 lymphocytes 13 x10^5L vs 12 x10^5L p=002) There were 18 cases of PCP with 7 deaths attributable All cases occurred after cessation of co-trimoxazole prophylaxis (81 ndash 913 days after stopping co-trimoxazole)
Conclusion Although there is a significant difference in UTI frequency on ITT analysis this is not present on AT analysis suggesting no real co-trimoxazole effect There was no increase in frequency of multi-drug resistant organisms with a longer course of co-trimoxazole Renal function and serum potassium were unaffected Our findings support continuing co-trimoxazole prophylaxis for at least 6 months
A13 Kidney transplantation in the over 60rsquos in Scotland 1996-2015 TJW Rennie1 P Phelan1 J Campbell2 JP Traynor2 L Henderson1 W Metcalfe2 On behalf of the Scottish Renal Registry 1Renal transplant unit Royal Infirmary Edinburgh 2NHS National Services Scotland Introduction The proportion of older kidney transplant recipients has increased in the UK but
long term outcome data are scarce We aimed to evaluate patient and graft survival in patients
ge60 years of age receiving a first kidney only transplant in the last 20 years in Scotland
Methods Retrospective analysis of Scottish Renal Registry data of incident Renal Replacement
Therapy (RRT) patients and those in receipt of a kidney only transplant performed 1996-2015
(follow up until 311216) Patients were stratified by age 60-69 ge70 (group 1 and 2 respectively)
and decade of transplantation 1996-2005 2006-2015 (decades 1 and 2 respectively)
Results 6743 patients aged ge60 started RRT from 1996-2016 Of those 108 were ever
transplant-listed 54 had received a transplant by 311216 26 listed and 11 transplanted
were aged ge70
535 patients aged ge60 received a kidney only transplant in 1996-2015 90 patients (168) were
aged ge70 no patients were aged ge80 Mean time from wait listing until transplantation was 33plusmn24
years (plusmnSD) and from starting RRT until transplantation was 38plusmn26 years (plusmnSD) One and five
year graft survival was 97 and 87 in decade 1 95 and 89 in decade 2 (p=NS) there was
no difference in graft survival between age groups 1 and 2 One and five year patient survival was
94 and 78 in age group 1 85 and 56 in group 2 (plt0001) there was no difference in one
and five year patient survival between the two decades
Conclusion One and five year graft and patient survival in renal transplant recipients aged ge60
have not changed significantly in the last 20 years Recipient age ge70 is not associated with
reduced graft survival but patient survival from time of transplant is lower in this age group
compared to recipients aged 60-69
No conflict of interest to be declared No funding received
A14 High Mortality In Older Patients With Primary Nephrotic Syndrome Sarah Beverstock Wendy Metcalfe amp Robert W Hunter Department of Renal Medicine Royal Infirmary of Edinburgh
Introduction
Nephrotic syndrome can develop at any age and may be due to a primary glomerular lesion or secondary to systemic disease The natural history of glomerular disease can be different in older patients For instance minimal change disease (MCD) in children almost always remits promptly with steroid therapy in adulthood it typically remits only after many weeks of steroids or with adjunctive immunosuppression However there are remarkably few published data on the mortality of primary nephrotic syndrome in adults We aimed to study this in our centre
Methods
We enrolled all adult patients who had a kidney biopsy in order to investigate nephrotic syndrome over 38 consecutive months (01 Jan 2014 ndash 28 Feb 2017) We defined nephrotic syndrome as heavy proteinuria (urinary proteincreatinine ratio UPCR gt350 mgmmol or albumincreatinine ratio gt220 mgmmol) and hypoalbuminaemia (serum albumin lt35 gL) In our analysis we included all patients in whom nephrotic syndrome was attributed to a primary glomerular disease We excluded kidney transplant recipients and patients in whom biopsies were performed to follow up a known glomerular disease We collected laboratory data at baseline (time of biopsy) and at 6 and 12 months We assessed patient survival by Kaplan-Meier analysis
Results
Of the 117 patients biopsied for nephrotic syndrome 71 patients (61 ) met the inclusion criteria and were followed up for a median of 469 days We compared outcomes in patients aged under 60 years old (n = 35) with those aged over 60 (n = 36) Mortality was higher in the older group (37 vs 4 mortality at one year p lt005 by logrank test) There were no significant differences between the two groups in serum creatinine or UPCR at any time Serum albumin was similar in both groups at baseline and at 12 months but was lower in the older group at 6 months (27 vs 32 gL p lt 005) Baseline haemoglobin was lower in the older group (114 vs 130 gL p lt005 by unpaired t-test) Primary diagnoses were MCD (n = 10 in younger group amp n = 5 in older group) membranous nephropathy (5 amp 10) IgA nephropathy (9 amp 8) FSGS (5 amp 5) membranoproliferative glomerulonephritis or C3GN (4 amp 7) and other (2 amp 1) Therefore unsurprisingly there were relatively fewer cases of MCD and more cases of membranous nephropathy in the older group otherwise the causative glomerular lesions were similar in both groups In those patients with MCD mortality was significantly higher in the older group none of the 10 patients with MCD diagnosed under 60 yrs old died during the follow-up period whereas 4 of the 5 older patients died 3 patients in the younger group and 1 in the older group were on renal replacement therapy (dialysis or transplant) by the end of follow-up
Conclusions
Primary nephrotic syndrome is associated with high mortality in the over 60s (37 at one year) Mortality was high even for MCD a disease that follows a benign course in childhood and early adulthood The higher mortality in older patients was not associated with greater severity of renal disease at presentation (as assessed by basic blood and urine parameters) This work was not funded we declare no conflicts of interest
A15 Renal biopsies in patients with diabetes mellitus in Scotland
Udana Ratnapala 1 Nicola Joss 2 Colin Geddes 3 Dana Kidder 1
1 Renal Unit Aberdeen Royal Infirmary Aberdeen 2 Renal Unit Raigmore Hospital Inverness 3 Glasgow Renal and Transplant Unit Glasgow
Introduction Diabetes mellitus is the leading cause of end-stage kidney disease (ESKD) requiring renal replacement therapy The utility of renal biopsy in patients with diabetes mellitus is controversial Broadly renal biopsy findings in patients with DM can be divided into diabetic nephropathy (DN) alone DN with non-diabetic renal disease (NDRD) or NDRD alone Timely identification of patients with NDRD is important to provide appropriate therapeutic measures Previously published guidelines on clinical predictors of NDRD have limited specificity and sensitivity The frequency of NDRD in renal biopsies of patients with DM is unclear in ScotlandThis study aimed at identifying the frequency and the pathology spectrum of NDRD in diabetic patients underwent kidney biopsy in 3 renal units
Methods A retrospective observational study was performed on clinical-pathologic findings in all patients with diabetes mellitus who underwent renal biopsy between 01012010 and 31122016 in 3 renal units (Aberdeen Inverness and Greater Glasgow) Data were gathered from electronic patient record systems Scottish Index of Multiple Deprivation (SIMD) 2012 was used to analyse correlation with patient outcomes
Results 247 patients were included 150 men (607) 217 type 2 DM (879) mean age 621 years and mean serum creatinine at the time of renal biopsy of 261 micromolL (+-190 std) On biopsy 92 patients (372) had DN while 127 (514) had NDRD and 28(114) had NDRD superimposed on DN The commonest NDRD aetiologies were IgA nephropathy (187) tubulointerstitial nephritis (168) and idiopathic membranous nephropathy (103) Predictors of NDRD were age (OR 1027 95 CI 1002-1052 p=003) duration of DM (OR 094 95 CI 0900-0987 p=001) and absence of AKI as indication for biopsy (OR 022 95 CI 0059-0826 p=0025) There was no significance difference in renal or patient survival in DN and NDRD Finally no significant correlation was depicted between SIMD quintiles and renal or patient survival in both groups
Conclusions The majority of renal biopsies carried out in patients with DM revealed a NDRD In this study age at the time of biopsy duration of DM and AKI were the main pointers towards NDRD Renal and patient survival were not significantly different between DN and NDRD groups
A16 The Impact of Withdrawal of Maintenance Immunosuppression and Graft Nephrectomy on HLA Sensitisation Ailish Nimmo1 Sophie McIntyre1 Lorna Henderson1 Richard Battle2
(1 Department of Renal Medicine Royal Infirmary of Edinburgh 2 Histocompatibility and Immunogenetics Royal Infirmary of Edinburgh)
Background The development of HLA antibodies towards a failing renal allograft is a barrier to re-transplantation We previously demonstrated an increase in HLA antibodies and calculated reaction frequency (cRF) following nephrectomy but results were confounded by immunosuppression changes occurring in close time proximity We examined the formation of HLA donor specific antibodies (DSA) in patients with failed grafts that remained in situ and compared results with patients undergoing graft nephrectomy to further assess the relative impact of nephrectomy and immunosuppression weaning on sensitisation and chance of transplant
Methods We carried out a single centre retrospective study of all patients with failed grafts in Lothian from 2005 to 2015 Samples were tested for DSA pre-immunosuppression (IS) wean post-IS wean and post-IS cessation Nephrectomy patients also had samples tested for DSA before and after nephrectomy Data on other sensitising events including blood transfusion and rejection were collected cRF was determined at each time point and entered into the ODT chance of transplant calculator with other demographics based on the average patient from the Edinburgh centre
Results 62 grafts failed over this time period Blood samples were available 41 patients (24 with nephrectomy 17 with failed graft left in situ) Patient demographics were similar between groups There was a higher rate of antibody mediated rejection in the nephrectomy group (46 vs 18) 76 of patients with nephrectomy group had received a blood transfusion The pattern of immunosuppression weaning was similar but median time from start of IS wean to cessation was longer in the nephrectomy group (350 vs 298 days) The changes in cRF and chance of transplant (COT) with immunosuppression weaning are shown in Table 1
Pre-IS Wean Post-IS Wean
Failed graft in situ (n=17)
Mean CRF COT at 5
years 15 62 38 59
Nephrectomy (n=24)
Mean cRF COT at 5
years 54 54 69 46
Post-IS Stop 55 53 89 42 Table 1 Mean cRF and Chance of Transplant (COT) at 5 years with IS alterations
Discussion A stepwise increase in cRF with reduced chance of transplant was observed in both groups as immunosuppression was withdrawn with a similar pattern of change irrespective of graft nephrectomy cRF was higher in the nephrectomy group despite a more gradual wean which may reflect a higher rate of antibody mediated rejection and increased number of patients receiving a blood transfusion The risks and benefits of stopping immunosuppression need to be carefully considered on an individual basis to maximise chance of future transplant
The authors have no conflicts of interest No funding was required for this study
A17 Obesity is not associated with progression to end stage renal disease in patients withbiopsy-proven glomerular diseases
Benjamin Elyan Jennifer S Lees Bruce Mackinnon Jonathan G Fox Colin C Geddes Emily PMcQuarrie
Glasgow Renal and Transplant Unit Queen Elizabeth University Hospital Glasgow
Introduction - Addressing risk factors for renal progression is a key aspect of managing chronic kidney disease (CKD) Body mass index (BMI) has been shown to impact on renal progression in unspecified CKD The aim of this study was to evaluate if there was an association between BMI and progression to renal endpoints in patients with biopsy-proven primary glomerular disease (GN)
Methods - We included all adult patients diagnosed with biopsy-proven primary GN (excluding minimal change nephropathy) in Greater Glasgow amp Clyde and Forth Valley between 01012000 and 31122015 Biochemical and anthropometric data were extracted from the electronic patient record at time of biopsy with follow-up data until 20062017 BMI was calculated from height and weight at time of biopsy and categorised into groups BMI le25 kgm2 (G1) gt25 to le30 kgm2 (G2) and gt30 kgm2 (G3 - obese) We assessed factors associated with reaching a combined renal endpoint of CKD5 or renal replacement therapy (RRT) with competing risk of death using the Fine and Gray subdistribution hazard model Analyses were conducted using cmprsk package for R statistical software package and SPSS version 24
Results - 560 patients with primary GN and available BMI data were included The average age was 532 years and 339 were female There were 132 patients in G1 210 in G2 and 207 patients in G3 Those in G2 and G3 were older (p=002) with slightly higher diastolic blood pressure (p=002) than those in G1 There was a greater proportion of focal segmental glomerulosclerosis in G3 but similar proportions of other GN diagnoses across groups There was no significant difference in baseline serum creatinine (sCr) (p=034) or log uPCR (p=045) between BMI groups On multivariate analysis age systolic blood pressure BMI or GN diagnosis were not predictive of renal outcome Higher baseline sCr (SHR 1003 per 1 umoll increase in sCr 1001-1004 plt0001) and log uPCR (SHR 130 per unit increase in log uPCR 95 CI 105-160 p=002) were associated with progression to the combined renal endpoint accounting for competing risk of death BMI was not associated with reaching combined renal endpoint on univariate analysis whether considered as a continuous variable (SHR=100 95 CI 098-102 p=096) or categorised by BMI group
Conclusion - Contrary to our expectations there was no association between BMI and progression to a combined renal endpoint of CKD5 or RRT in this cohort of patients with primary GN Efforts should be directed to managing other known risk factors for CKD progression
Sources of FundingConflicts of Interest - None
A18 Factors influencing long term renal function after living kidney donation
Matthew A Rutherford Norman J Galbraith Marc Clancy Colin C Geddes
Glasgow Renal and Transplant Unit Queen Elizabeth University Hospital Glasgow UK
Background Following live donor nephrectomy the remaining kidney undergoes an increase in filtration capacity known as compensatory hypertrophy Few cohorts with follow up of renal function beyond 5 years have been reported The impact on long term renal function of variability in donor factors such as age sex pre-donation blood pressure and glomerular filtration rate (GFR) is unknown Increasingly kidney donors have potential risk factors for future poor renal function such as hypertension older age and obesity The aim of this study was to analyse factors influencing long-term renal function in living kidney donors from our centre
Method Data were obtained from the electronic patient record Patients with a recorded procedure of lsquolive donor nephrectomyrsquo between 2005 and 2017 were identified GFR after donation (calcGFR) was calculated using the formula lsquocalcGFR = Pre-donation Isotope GFR x (Pre-donation Serum creatinine Serum Creatinine)rsquo which is accurate assuming muscle mass does not change Pre and post donation serum creatinines (two days two weeks three months and one to ten year) were recorded We analysed the influence of age sex pre-donation GFR and blood pressure on post donation GFR compensation
Results 355 live donor nephrectomies were performed between January 2005 and December 2016 The mean age was 469 (plusmn 116) years and 504 (n=179) were female Mean pre-donation isotope GFR was 937 plusmn 156 mlmin173m2 Median follow up was 2 years (IQR 1 to 6 years with range 2 weeks to 10 years) The calculated percentage of pre-donation GFR at 2 days 2 weeks 3 months 1 year 5 years and 10 years were 698 691 712 730 801 and 950 respectively (p lt 0001) Patients aged lt50 y had not only a higher calcGFR (858 plusmn 29 mlmin173m2 compared with 671 plusmn 28 mlmin173m2 p lt 0001) at 5 years following donation but achieved a higher degree of compensation than donors gt 50 y (836 plusmn 16 compared with 756 plusmn 19 (p = 0002) Patients with pre-donation hypertension achieved 774 plusmn 53 of pre-donation GFR compared with 804 plusmn 32 in normotensive patients (p = 0998) Females had equivalent degree of renal compensation achieving 819 plusmn 19 compared with 780 plusmn 16 in males (p = 0131) at 5 years following donation Patients with pre-donation GFR gt 100 mlmin173m2 achieved 844 plusmn 23 of pre-donation function by 5 years compared with 777 plusmn 14 in those with pre-donation GFR lt 100 mlmin173m2 (p = 001)
Conclusion Following live donor nephrectomy renal function has a nadir of 691 at 2 weeks Compensation in GFR occurs rapidly and appears to be maintained regardless of sex and pre-donation blood pressure Younger age and higher pre-donation GFR were associated with a greater degree of compensation
A19 The utility of high-sensitivity cardiac troponin to stratify cardiovascular risk in patients with renal impairment
Eve Miller-Hodges Atul Anand Anoop S V Shah Nicholas L Mills Neeraj Dhaun
Background Cardiovascular disease is the most common outcome of chronic kidney disease1
Declining glomerular filtration rate (GFR) and proteinuria predict increased cardiovascular risk over the long term2 However there are currently no methods to stratify cardiovascular risk in the short or medium term in patients with renal impairment We have already shown that high-sensitivity cardiac troponin I concentrations (hs-cTnI) lt5ngL in patients presenting with symptoms of acute coronary syndrome identifies those at low risk of cardiac events within 30 days and over the next year3 However uncertainty remains over the role of hs-cTnI testing in patients with renal impairment This study investigated whether hs-cTnI could also stratify future cardiovascular risk in patients with renal impairment
Methods In a prospective study of consecutive patients presenting with suspected acute coronary syndrome we evaluated the performance of hs-cTnI in patients with and without renal impairment (estimated glomerular filtration rate lt60mLmin173m2) using an early risk stratification threshold of 5ngL to ldquorule outrdquo acute myocardial infarction at presentation and within 30 days and sex-specific 99th centile diagnostic thresholds for index type 1 myocardial infarction Subsequent type 1 myocardial infarction and cardiac death were reported at one year
Results Of 4726 patients identified 904 (19) had renal impairment Index diagnosis of type 1 and type 2 myocardial infarction was almost twice as likely in patients with renal impairment (30 vs 15) Performance of the early risk stratification threshold of 5ngL to identify patients at low risk of major cardiac events was similar in patients with (NPV 984 95CI 960-997 sensitivity 989 95CI 975-999) and without renal impairment (NPV 997 95CI 994-999 sensitivity 984 95CI 972-994) These patients continued to remain at low risk over the next year The PPV and specificity at the 99th centile for diagnosis of myocardial infarction were lower in patients with renal impairment at 500 (95CI 452-548) and 709 (95CI 675-742) respectively compared to 624 (95CI 588-659) and 921 (95CI 912-930) At one year 24 of patients with renal impairment and troponin gt99th centile regardless of index diagnosis had experienced further myocardial infarction or cardiac death compared with 10 of patients without
Conclusion In suspected acute coronary syndrome hs-cTnI can stratify risk in patients with renal impairment Irrespective of diagnosis patients with renal impairment and elevated cardiac troponin concentrations had two-fold greater risk of a major cardiac event compared to those with normal renal function and should be considered for further investigation and treatment
Funders Wellcome Trust British Heart Foundation and Chest Heart amp Stroke Scotland
1 Gansevoort RT Lancet 2013
2 Chronic Kidney Disease Prognosis Consortium Lancet 2010
3 Shah AS Lancet 2015
A20 lsquoDOES IT DIALYSE OUTrsquo - THE EFFECT OF RENAL REPLACEMENT THERAPY ON THE BRAIN Mark Findlay Jesse Dawson David Dickie Deborah McGlynn Patrick Mark Institute of Cardiovascular and Medical Science University of Glasgow amp Queen Elizabeth University Hospital Glasgow
Introduction Cerebrovascular disease is common in end-stage renal disease (ESRD) on renal replacement therapy (RRT) We investigated the effect of RRT on cerebral structure and cognitive function over 12 months Methods Observational cohort study in ESRD patients receiving HD Prior cognitive impairment or cerebrovascular disease were exclusion criteria Multi-domain cognitive testing was performed at baseline and at follow-up Transcranial Doppler was used to assess intra-dialysis related alterations in mean flow velocity (MFV) ndash a marker of cerebral blood flow MR imaging was performed at 0 and 12 months We performed T1 T2 FLAIR and DWI sequences and used volumetric software to calculate white matter hyperintensity (WMH) burden markers of atrophy mean diffusivity and fractional anisotropy (FA) to describe structural changes at 1 year Results 97 patients median age 59 years 412 female At follow-up 15 patients were transplanted 6 died 4 withdrew and the remainder continued HD Those who were transplanted were younger (median age 51 vs 60 years p=0019) and had been on dialysis for a shorter period (median 06 vs 21 years p=0003) MFV declined during HD median 475cms to 405cms plt0001 and correlated with lower scores of executive and frontal lobe function during HD (Rho 045 p lt0001 and Rho -0313 p lt001 respectively) In all patients MR imaging demonstrated a significant decline in frontal parietal and temporal lobe volume at follow-up Median WMH volume increased in those who remained on HD but not in transplanted patients (median change 023 vs -012ml p=0018) WMH burden correlated with worsening scores of frontal lobe tests Rho 0585 p0005 and worse mood Rho -0485 p0026 FA improved following renal transplant (028 to 029 p=0016) and correlated with improved executive function testing at follow-up Rho 089 p0019 Conclusion Cerebral blood flow is reduced during haemodialysis and correlates with a reduction in intradialytic executive function There is an improvement in FA following transplantation WMH volume increases in those who remain on dialysis and the degree of increase correlates with executive and frontal lobe function This suggests that haemodialysis is associated with clinically significant changes in the brain and that these may be ameliorated by transplantation
Source of fundingconflicts MF is funded by a KRUK fellowship
A21 Pathological classification of IgA nephropathy to predict renal outcomes ndash is there a better way to score tubulointerstitial inflammation
Alastair Rankin David Kipgen Bruce Mackinnon Jonathan Fox Colin Geddes Emily McQuarrie Glasgow Renal and Transplant Unit On behalf of the Scottish Renal Biopsy Registry
Background The Oxford pathological classification of IgA nephropathy (IgAN MEST-C score) is limited by the fact that individual features of the score are not all predictive and its utility in assisting clinical decision-making is questioned The addition of tubulointerstitial inflammation to the existing scoring system is appealing but is not currently included due to reportedly wide inter-observer variability We report a novel method to score percentage of cortex containing tubulo-interstitial inflammation in non-atrophic renal cortex (ATIN) in patients with IgAN similar to that used in transplant biopsy reporting and assess its utility to predict clinical outcomes
Methods All adult patients with a native renal biopsy diagnosis of IgAN between 2010 and 2015 in a unit serving 15 million people were identified Baseline characteristics biopsy reports and outcome data were collected ATIN was calculated by subtracting the percentage of atrophic cortex from the percentage of total cortex with tubulo-interstitial inflammation withge10 representing significant tubulo-interstitial inflammation in non-atrophic cortex The primary outcome was a composite of requiring renal replacement therapy (RRT) or doubling of serum creatinine (sCr)
Results 153 new cases of IgAN were identified 33 were excluded (24 had lt8 glomeruli on biopsy 6 inadequate biopsy for MEST scoring and 3 on RRT at time of biopsy) In addition patients with a tubular atrophy (T) score of 2 were also excluded (n=9) Of the remaining 111 patients 76 (68) were male Mean age at biopsy was 52 years (+- 167) and 18 (16) had a co-existing clinical diagnosis of henoch-schonlein purpura (HSP) Median sCr was 156 micromoll (IQR 101-212) and 54 (49) had ATIN on biopsy During a median follow-up of 23 years 34 (31) reached the primary outcome 20 (18) received immunosuppression and 16 (14) died On univariate Cox regression survival analysis ATIN was associated with a four-fold increase in the primary outcome (HR 49 (21-113)) On multivariate analysis mesangial hypercellularity (M) T and ATIN independently predicted renal outcome while endocapillary proliferation (E) and segmental sclerosis (S) did not (plt002 for ATIN) Excluding patients with HSP or those who received immunosuppression did not change the result
Conclusion Within our centre ATIN predicts renal outcome for IgAN independently of established histological features Assessment of inter-observer reproducibility and validation in other cohorts is still required but these results suggest ATIN could be a worthwhile addition to current pathological scoring systems for IgAN
Source of funding none Conflicts of interest none
P1 Polypharmacy in Renal Replacement Therapy Patients
Jason McMinn Colin Geddes Glasgow Renal and Transplant Unit Queen Elizabeth University Hospital
Introduction
Prescribing is often led by evidence from studies containing participants with single health conditions and without multimorbidity Polypharmacy is becoming increasingly recognised in patients with multiple chronic health conditions Additional medications are more likely to result in diminishing returns in benefit with an increased risk of harm Patients with established renal failure (ERF) are likely to be susceptible to medication-related harm A high pill burden is also likely to contribute adversely to an already restricted quality of life and has been associated with poor medication adherence The aim of this study was to analyse polypharmacy in all patients with ERF attending our service
Methods
We extracted medication records for all prevalent ERF patients attending the Glasgow Renal and Transplant Unit from the West of Scotland Electronic Renal Patient Record (SERPR) as of 01012017 The records were analysed to calculate the number of regular medications and total pill burden of each patient These medications were categorised as being lsquopreventativersquo or lsquosymptomaticrsquo We also analysed the prescription of specific drug classes to examine the prevalence of these medications
Results
We identified 1091 transplant follow-up 529 hospital haemodialysis and 46 peritoneal dialysis patients who were on a mean of 94 13 and 129 different medications respectively Overall pill burden was 139 tablets a day in transplant follow-up patients 141 in haemodialysis patients and 162 in peritoneal dialysis patients There were similar rates of prescribing between the different dialysis units and clinics within our service
The proportions of medications deemed as preventative rather than symptomatic were 76 in transplant 69 in haemodialysis and 60 in peritoneal dialysis
In transplant patients decreasing renal function was associated with a higher pill burden but even patients with a transplant eGFR gt 60 were on a mean of 126 tablets per day including a mean of 14 antihypertensives
Rates of antidepressant prescribing were 15 in transplant patients and 20 in hospital haemodialysis patients 53 of haemodialysis patients were on a statin 39 on aspirin 61 on a proton pump inhibitor and 7 were on warfarin
Conclusion
Patients undergoing all forms of renal replacement therapy are likely to be on a considerable number of medications Whilst these drugs are inevitably prescribed for valid reasons this data demonstrates the need for clinicians to engage with patients to explore opportunities to reduce pill burden
Conflict of Interest None Sources of Funding None
P2 An audit of Acute Kidney Injury (AKI) on an acute stroke ward before and after plannedinterventions to review and maintain hydration
Clare Harris1 Simon Hart2 Fiona Duthie3 1 University of Edinburgh Medical School 2 Stroke Unit Royal Infirmary of Edinburgh 3 Renal Unit Royal Infirmary of Edinburgh
Background Dehydration is an important factor in the development of acute kidney injury which is associated with increased morbidity and mortality particularly in the elderly population Poor fluid intake is common post stroke (1) and dehydration is associated with poorer outcomes 3 months post stroke (2) In late 2014 there was no system of identifying patients with poor oral intake on the stroke ward at the Royal Infirmary of Edinburgh a hydration protocol and education programme were implemented aiming to improve fluid balance This included the use of prescribed water either orally or by nasogastric tube An audit pre and post intervention demonstrated that hydration as measured by ureacreatinine ratio significantly improved after the protocol introduction (3) We aimed to determine whether the incidence of AKI by KDIGO criteria was also reduced as this could have implications for reducing patient morbidity and mortality in this elderly comorbid patient cohort
Method 150 inpatients to the acute stroke ward during JulAug 2014 and JulAug 2015 were selected (n= 80 2014 n=70 2015) Patient data and creatinine values were collected from the electronic patient record and medical notes and retrospectively analysed Baseline creatinine values were calculated and cases of AKI were identified and staged using KDIGO criteria (4) Chi-Squared tests were performed to determine P values Individual patient notes were reviewed for both quantitative and qualitative data of patient management
Results Incidence of AKI (of any stage) was 263 pre-protocol and 200 post-protocol (P=03646) Incidence of AKI stages 23 was 100 pre-protocol and 715 post-protocol (P=05374) In hospital post stroke mortality was 338 pre-protocol and 1286 post protocol (P=00028) AKI was also associated with increased length of stay
Conclusions Despite a trend in benefit there was no significant difference in incidence of AKI pre and post hydration protocol nor in incidence of severe AKI (stage 23) AKI is influenced by many factors one of which is hydration status Further studies are needed to determine whether the trend of benefit exhibited in this sample is significant in a greater sample size if this were the case such a protocol could have great benefit to patient care on stroke units and elsewhere There was a significant difference in inpatient post stroke mortality following introduction of the hydration protocol Further investigations are needed to explain underlying reasons for this factors other than hydration may play an important role
References 1 Whelan K Inadequate fluid intakes in dysphagic acute stroke Clinical Nutrition (2001) 20(5)
423-428 2 Bhalla A Sankaralingam S Dundas R Swaminathan R Wolfe CDA Rudd AG The influence of
raised plasma osmolality on clinical outcome after acute stroke Stroke (2000) 312043ndash2048 3 Hart SR Craig R Berry E Lane N Gad A Farrugia M Burton L Paquay A What Happens to
Acute Stroke Patientsrsquo Fluid Balance Renal Status and Dehydration in the First Two Weeks How Can They Be Markedly Improved doi 101111ijs12634_13
4 KDIGO Clinical Practice Guideline for Acute Kidney InjuryKidney international supplements (2012) 2(1) 1-138
No funding or conflict of interest to declare
P3NHS Highland-Improving the management of hyperkalaemia using a kit Initial resultsCantley N1 Abedin T2 Lambie S3
1FY2 NHS Highland 2ST4 Renal Medicine NHS Grampian 3Renal Consultant Renal unitRaigmore Hospital Inverness
Introduction The incidence of hyperkalaemia in hospitalised in patients is between 1 and 10 Guidelines in Northern Ireland promote the use of a Hyperkalaemia Kit to improve management of hyperkalaemia We assessed the management of hyperkalaemia in Raigmore Hospital including post-treatment monitoring of serum potassium and blood glucose at baseline and after the introduction of a lsquoHyperkalaemia Kitrsquo which contains a pro forma for the management of hyperkalaemia and all the relevant equipment and drugs for treatment
Method Between July and September 2016 an automated algorithm identified 34 patients with a potassium result 65 mmoll or above on laboratory results 12 received no specific treatment of these 6 results were spurious 4 patients died before treatment could be started and 2 patients were chronic haemodialysis patients We introduced the Hyperkalaemia Kit to the Acute Medical Admissions Unit in Raigmore Hospital Since then 15 patients have been identified with serum potassium measurements above 65 and the pro forma and kit was used with eight of these patients One of these patients proceeded straight to acute renal replacement therapy
Results Prior to our intervention all 22 patients that were actively treated received at least one prescription of appropriate doses of Insulin with Dextrose However only 16 patients received intravenous calcium and only 7 received nebulised Salbutamol Potassium was measured at 4 hours in 5 cases and by 12 hours in 17 cases Monitoring of any capillary blood glucose was only documented in 8 cases Of the 22 treated 2 needed acute renal replacement therapy 3 required further doses of insulin and dextrose 2 were treated with Calcium Resonium
Eight cases of hyperkalaemia have been managed with the use of the kit and pro-forma so far An initial ECG was performed in all eight and four patients had continuous cardiac monitoring Intravenous calcium was given in seven and nebulised Salbutamol was given in five out of the eight cases Six out of eight patients had at least three blood sugar measurements One had two measurements documented and one patient was stopped from further monitoring following senior review and decision to palliate Seven patients had appropriate monitoring of their serum potassium by 4h and 12h again one patient was not monitored due to palliation
Conclusion Baseline results showed very low rates of prescription of nebulised Salbutamol low rates of Calcium Gluconate use and very low monitoring of blood sugars and potassium post treatment This has the potential for serious adverse outcomes particularly the potential for iatrogenic hypoglycaemia Our initial data shows the use of a Hyperkalaemia pro forma and kit improves the rate of prescription of intravenous calcium and nebulised Salbutamol and the post-treatment monitoring of serum potassium and blood sugar levels
P4Rituximab as maintenance therapy in ANCA associated vasculitisndash a single centre experience Rathnamalala NK Mcmenamin J Robertson S Almond A Kelly M Muniraju T M Renal Unit Dumfries and Galloway Royal Infirmary NHS Dumfries and Galloway Background The introduction of Cyclophosphamide and high dose steroids transformed ANCA associate vasculitis (AAV) from a disease of high mortality to a relapsing remitting disease Maintenance of remission however still remains a major challenge A two randomised clinical trials have looked at the use of Rituximab in remission induction in AAV and reported similar remission rates between Cyclophosphamide and Rituximab 12 Both these trials used Azathioprine as maintenance therapy and in the follow up showed similar remission rates with either agent for induction The role of Rituximab for maintenance therapy after cyclophosphamide induction was studied in the MAINRITSAN trial 3 Rituximab was compared with azathioprine and found that the relapse rate was significantly lower in the Rituximab group There have been several other retrospective studies that have suggested regular Rituximab infusions are successful in maintaining remission however has not been thoroughly evaluated 4 5678910 Here we share our centrersquos experience using Rituximab for maintenance of remission of AAV Materials and methods We conducted a retrospective review of electronic medical records of all patients who had received Rituximab as maintenance therapy for 12 months or longer between January 2014 to July 2016 Disease activity was assessed using Birmingham Vasculitis Activity Score ( BVAS) Version 3 and complete remission was defined as a score of 0 and partial remission as a score of lt50 of the value at diagnosis Due to uncertainties associated with sub classification we did not assign specific diagnosis but broadly classified as ANCA associated vasculitis Results 6 patients received Rituximab as maintenance therapy during the study period 3 (50) of them had eye ear nose and upper airway manifestations consistent with Granulomatosis with Polyangitis (GPA) All patients were PR3 ANCA positive except for one at initial diagnosis The mean BVAS score at the time of initiation of Rituximab was 4 All patients were initiated on Rituximab for relapses while on maintenance therapy with Azathioprine 4 patients received 6 monthly doses of Rituximab while two received annual doses All of them were also maintained on 5-10 mg of Prednisolone The mean BVAS score by 6 months was 0 and remained 0 at 12 months The mean PR3 titre was 562 at the initiation of treatment while at 12 months it had come down to 68 All patients remained in complete clinical remission at the end of 12 months after initiation of therapy Rituximab was well tolerated by all patients except one who developed pyrexia during an administration
Conclusions All patients had sustained remission at 6 months and 12 months after initiating Rituximab Rituximab has a potential role as maintenance therapy in AAV
P5 Chronic Myelo-Monocytic Leukaemia (CMML) as a contraindication to renal biopsy Alastair Rankin Emily McQuarrie Jennifer Lees Bruce MacKinnon Glasgow Renal and Transplant Unit On behalf of the Scottish Renal Biopsy Registry
Abstract Chronic Myelo-Monocytic Leukaemia (CMML) is a relatively rare mixed myelodysplastic myeloproliferative disorder that predominately affects patients over the age of 65 years Renal impairment in patients with CMML is well described with several different mechanisms reported including tumour infiltration lysozyme-induced injury amyloid deposition and tubulointerstitial nephritis From anecdotal evidence within our centre we are concerned that patients with CMML have an excessive risk of clinically significant bleeding following native renal biopsy This risk appears disproportionate to the degree of any co-existing thrombocytopenia or coagulopathy
We review the cases of 4 patients with an existing diagnosis of CMML who were referred to the renal clinic with proteinuria and excretory renal dysfunction Two of these patients underwent renal biopsy with subsequent major haemorrhage post-procedure despite normal bleeding parameters pre-procedure Patient 1 presented with flank pain 8 days post-biopsy A CT confirmed peri-nephric haematoma with retroperitoneal extension A total of 6 units of packed red cells (PRCs) were transfused prior to successful CT-guided emoblisation Histology from the biopsy revealed chronic tubulointerstitial nephritis Patient 2 experienced haemodynamic instability and haematuria one hour post-biopsy A total of 11 units of PRCs 7 units of fresh frozen plasma 2 pools of platelets intravenous tranexamic acid and 2 attempts at CT-guided embolization were required until haemostasis was achieved Histology later showed evidence of tumour infiltration with associated vasculitis Patient 3 presented with renal impairment and proteinuria on the background of known CMML Following discussion with haematology the risk of bleeding following renal biopsy was considered unjustifiable despite their platelets and coagulation screen being within normal range The patient was treated for presumed renal tumour infiltration with hydroxycarbamide Patient 4 was referred to the renal clinic with acute onset nephrotic syndrome Urinary proteincreatinine ratio was elevated over 800 mgmmol with serum albumin of 23 gL but normal excretory renal function The patient attends the haematology clinic with suspected CMML and chronic thrombocytopenia but previously declined bone marrow biopsy Following discussion with the patient there are no plans to proceed with renal biopsy given potential risks These cases highlight that while CMML is rare these patients are being referred to renal clinics with features that would commonly justify renal biopsy in other settings but in whom there may be an increased risk of bleeding post-procedure Our in-centre risk of major bleeding is 2 therefore to have such extreme amounts of bleeding in 2 patients with this underlying diagnosis is remarkable This creates a dilemma for the clinician as there is a wide range of potential renal pathology associated with CMML some of which will have disease specific but relatively toxic treatments available
Source of funding none Conflicts of interest none
P6 NHS Highland-Prograf to Adoport switch McCulloch K1 Peel R2 Lambie S3
1Renal Pharmacist Renal unit Raigmore Hospital Inverness 23Renal Consultant Renal unit Raigmore Hospital Inverness
Introduction NHS Highland (NHSH) is the first health board in Scotland to implement a switch from Prograf to Adoport for renal transplant patients This will provide considerable cost savings Adoport meets the bioequivalence criteria for drugs with a narrow therapeutic index set by the European Medicines agency and studies indicate therapeutic equivalence1 with the proviso that brands are non- interchangeable unless the switch is overseen by a Renal Consultant and post-conversion therapeutic drug monitoring is conducted23 The switch has been undertaken by a majority of transplant centres in England the main difference being that they have undergone repatriation NHSH Patients receive their transplant primarily at Royal Infirmary of Edinburgh and occasionally at Queen Elizabeth University Hospital Glasgow Care is transferred to NHS Highland on discharge NHS Highland cares for approximately 170 renal transplant patients 110 being prescribed Prograf These patients may live as far as 110 miles from Raigmore Hospital Given that prescribing is carried out by primary care clear communication with patients GPs and community pharmacy is essential to avoid inadvertent switching between brands
Method Clinically it was agreed a switch could be safely undertaken A business case was submitted and funding secured for pharmacist time laboratory costs and primary care time GPs have been informed via GP subgroup and local prescribing bulletin lsquoThe Pink Onersquo Community pharmacies are being informed by phone A protocol has been agreed Eligible patients selected by Renal Consultant and Renal Pharmacist Patients sent letter signed by Renal Consultant and Renal pharmacist Patients phoned prior to clinic to agree Adoport start date and address concerns Patient seen by Renal Consultant and pharmacist + given 1 month of Adoport Tacrolimus level and UampEs checked 5-7 days after commencing Adoport and patient
contacted by phone to check if tolerated If stable letter sent to GP and community pharmacy to continue supply
Results and Evaluation Letters have been sent to all eligible patients Seven patients have been reviewed One has received a one month supply of Adoport and 5 others are due to switch One patient was deemed non-eligible at present as they have a 6 month surplus of Prograf A database will be maintained and analysed at the end and primary care savings will be monitored Extra pharmacist input will give us the opportunity to review how immunosuppression is managed and to evaluate the benefit of having a renal transplant pharmacist Conclusion The switch is at an early stage Ultimately we hope to show that the switch from Prograf to Adoport can be managed safely with extra pharmacist input to a remote and rural population with prescribing being conducted by primary care
Fundingconflicts of interest none 1 McDevitt-Potter LM Sadaka B Tichy EM Rogers CC Gabardi S Transplantation 2011 A multicenter experience with
generic tacrolimus conversion 2 Medicines and Health Products Regulatory Agency Drug Safety Update 2012 Accessed online via
wwwmhragovukSafetyinformationDrugSafetyUpdateCON1557563 ESPRIT Guidance on management of repatriation and immunosuppressant switches in transplant patients 2015
Accessed online via httpwwwespritorgukwp-contentuploads201508Switch-guidance-document-final-Aug-31-2015pdf
P7 NHS Highland-Tacrolimus baseline dataMcCulloch K1 Peel R2 Lambie S3
1Renal Pharmacist Renal unit Raigmore Hospital Inverness 2Renal Consultant Renal unitRaigmore Hospital Inverness 3Renal Consultant Renal unit Raigmore Hospital Inverness
BackgroundAs part of planning a switch from using tacrolimus Prograf to Adoport we assessed baseline data for our transplant patients currently using Prograf After converting patients to Adoport we will compare their tacrolimus levels to their individual target range We assessed our use of appropriate target ranges and our current performance in achieving tacrolimus levels within target range on Prograf therapy
Method 107 renal transplant patients taking Prograf were identified a sample of 19 of these were analysed using electronic patient records and results Time from transplant ranged from 1 month to 18 years All tacrolimus levels for the preceding year were analysed and compared to the target range specified at the time of the level being done The assay used has a Coefficient of Variation of lt5 at the lower limit of the assay
Results All 19 patients had a target range for tacrolimus clearly identified and recorded in clinic letterswhich are routinely copied to the patients themselves A variety of target ranges were specifiedThe commonest used was 5-8 microgramsl in 7 patients followed by 5-7 in a further 4 patientswith another 6 different target ranges being used for the remaining 8 patients The ranges usedhad a breadth of 3 microgramsl in 2 cases the rest had a breadth of 2 microgramslPatients had a median of 12 (range 3-72) tacrolimus levels over the preceding year Results werewithin specified target ranges for 54 +- 22 (Medan +- SD) of results checked
Conclusion We currently use a large number of different target ranges The majority of the ranges used had a breadth of just 2 microgramsl These factors help to account for the low proportion of test results which were within the specified target ranges This is important to bear in mind when interpreting whether tacrolimus levels are within target ranges after switching to Adoport We should consider aligning our target ranges and widening them
P8 Eculizumab use in Scottish paediatric dense deposit disease Stewart D1 David Hughes1 Lynne Riach2 Craig Oxley2 Athavale D1
1Royal Hospital for Children Glasgow 2Royal Aberdeen Childrenrsquos Hospital Aberdeen
Introduction The revised MPGN classification and increasing recognition of Dense Deposit Disease (DDD) a C3 glomerulopathy as an alternative complement pathway disorder suggests Eculizumab an anti-C5 monoclonal antibody may be beneficial in treatment However the experience of Eculizumab as an off-label and expensive treatment in children with DDD is limited with variable clinical response reported in the literature
Method We present the outcomes of the only 2 paediatric patients in Scotland who have received Eculizumab for the management of DDD
Results Case 1 A 10 year old male presented with proteinuria and haematuria resistant to steroid treatment with preserved renal function Initial biopsy confirmed DDD Conservative management with an angiotensin converting enzyme inhibitor and diuretics for symptom control continued until 14 years Due to worsening symptoms (oedema lethargy poor growth) and renal function deterioration along with elevated terminal complement complex (TCC) Eculizumab was commenced A repeat biopsy whilst suggestive of chronic irreversible damage showed 25 glomerular architecture preservation Symptom improvement was noted There was a reduction in proteinuria and renal function stabilisation fall in TCC and discontinuation of diuretics Eculizumab was discontinued after 24 months Progression of renal function decline was seen in the final months of Eculizumab therapy With recurrence of symptoms and increasing proteinuria following discontinuation Eculizumab was recommenced after 6 months Symptomatic improvement has since been noted
Case 2 A 5 year old girl presented with painless frank haematuria and proteinuria Initial biopsy confirmed DDD Proteinuria was unresponsive to steroid therapy and 5 months following diagnosis she rapidly progressed towards end stage renal disease despite the introduction of Mycophenolate Mofetil and plasmapheresis Haemodialysis was subsequently commenced TCC level was elevated and Eculizumab treatment was started 7 months after diagnosis Renal biopsy prior to treatment demonstrated continued severe pathological changes in all visible glomeruli However due to lack of clinical response Eculizumab was discontinued after 2 months and the patient remained dialysis dependent
Conclusions Our experience with Eculizumab in Scotland has demonstrated variable results in our 2 patients with one patient showing a positive response whilst the other experienced no improvement Eculizumab was administered to both patients at varying points in their clinical journey with differing progressive features on biopsy To date the outcomes of 9 paediatric patients with DDD treated with Eculizumab have been described in the literature with 8 experiencing some positive response to treatment including 2 patients who were able to stop renal replacement therapy within 12 weeks of treatment A role for Eculizumab in DDD may be guided by clinical and pathological features Well designed clinical trials will be necessary to define the role of complement inhibition therapy in DDD
No conflict of interest and no funding requested
P9 Examining markers of safety in the use of non-tunnelled central venous catheters
James WT Millar (Speciality Registrar) Scott W Oliver (Speciality Registrar) Peter C Thomson (Consultant Nephrologist) Glasgow Renal and Transplant Unit Queen Elizabeth University Hospital Glasgow
Background Non-tunnelled central venous catheters (NTCVC) remain an essential means of vascular access for incident haemodialysis Associated morbidity is well recognised for example in the form of Staphylococcus aureus bloodstream infections (SAB)[1]
Previous quality improvement initiatives in our unit have sought to both improve traditional markers of quality (such as SAB) and to identify additional areas of clinical risk In 2014 Oliver et al [2] suggested several additional quality measures including peri-procedure haemoglobin drop the need for a further NTCVC during the same clinical episode and the NTCVC insertion site This study further evaluated NTCVC related clinical practice within our unit
Methods The potential markers of clinical quality identified in a previous project were examined using prospectively collected data stored in the electronic patient record Identified cases of SAB significant peri-procedure haemoglobin drop and multiple NTCVC insertion were investigated by case note review
Results Between March 2016 and March 2017 a total of 222 patients received 346 NTCVC 54 patients (243) had more than one NTCVC inserted in a 21-day period (range 2-5) When considering NTCVC insertion site there were 159 (459) femoral vein catheters and 183 (541) internal jugular vein catheters No pneumothoraces were reported
15 SABrsquos were reported during this period equating to 43 of all NTCVC 5 arose in patients with femoral NTCVC (333) and 10 from internal jugular catheters (667) Mean time from line insertion to positive blood culture was 86 days 15 (67) patients had a drop in haemoglobin of greater than 20mgdl with no other source of blood loss identified on review of clinical notes
Discussion These data demonstrate that NTCVC-associated SAB rates remain low and significantly below Scottish government audit standards [3] Of interest is the continued trend towards the use of femoral catheters at 45 of lines compared with 38 in 2014 [2] Although traditionally thought of as having a higher incidence of infectious complications our data has shown fewer bacteraemia events associated with femoral catheters compared with internal jugular Our data also demonstrates a significant rate of peri-procedure haemorrhage arising in up to 1 in 20 cases Together these findings present opportunities to development practice and improve patient safety
References
[1] Murray E Deighan C Geddes CC Thomson PC Reducing haemodialysis bacteraemia rates Scottish Renal Association Glasgow November 2013 [2] Oliver SW Thomson PC Jardine AG defining safe effective and patient-centred dialysis catheter placement Scottish Renal Association Edinburgh September 2014 [3] The Staphylococcus aureus bacteraemia quarterly report of cumulative data from all NHS Boards in Scotland Health Protection Scotland January 2015
Sources of funding none Conflicts of interest none
P10 Prescribing of tolvaptan-The NHS Highland experience Lambie S1 McCulloch K2 Garrod J3
1Renal Consultant Renal unit Raigmore Hospital Inverness 2Renal Pharmacist Renal unit Raigmore Hospital Inverness 3Renal Pharmacist Renal unit Raigmore Hospital Inverness
Introduction Tolvaptan is a vasopressin antagonist It was accepted for use in Scotland by SMC in Jan 2016 to slow the progression of cyst development and renal insufficiency of autosomal dominant polycystic kidney disease in adults with chronic kidney disease (CKD) stage 1 to 3 at initiation of treatment with evidence of rapidly progressing disease1 Adverse effects related to aquaresis may affect patientsrsquo ability to achieve the optimum therapeutic dose and the risk of hepatic toxicity necessitates regular LFT monitoring The geography of NHS Highland required the implementation of novel methods of managing these patients and as a result a MDT approach with an emphasis on pharmacist input was adopted Consultant role Patient selection on the basis of evidence of rapidly progressing kidney disease declining
eGFR large volume kidneys on ultrasound and evidence of complications of PKD Side effects and potential benefits discussed Potential medication interactions reviewed Jinarc risk management prescriber training
Pharmacist role Undertook Jinarc risk management pharmacist training Prepares accurate drug history and reviews for potential drug interactions Carries out patient counselling and supplies patient education material sick day rules card
and lsquogot to gorsquo card Supplies GP education leaflet Provides advice on selection of new drug therapies eg for gout Manages stock and coordinates supply to patients
Results Prescribing commenced May 2016 patients currently prescribed tolvaptan 11 7 Female 4 male Number on target dose 73 n = 811 2 patients are still being titrated One patient did
not tolerate target dose due to aquaresis side effects and is being trialled on the middle dose
Withdrawals One patient has withdrawn due to agoraphobia and an inability to attend for monitoring and another is on hold due to having major surgery
Conclusion The MDT approach between the Renal Consultant and Pharmacist at Raigmore Hospital has enabled tolvaptan prescribing to be efficiently and safely implemented to patients living within a challenging geographical location
1 Scottish Medicines Consortium Detailed Advice Document tolvaptan 15mg 30mg 45mg 60mg and 90mg tablets (Jinarcreg) SMC No 111415 January 2016
NA1 Authors SCN Jacqueline Ross NHS Grampian
SCN Alan Somerville NHS Lanarkshire SCN Jane Humphrey NHS Lanarkshire
e- mail contact jacquelinerossnhsnet Alansommervillelanarkshirescotnhsuk
Janehumphreylanarkshirescotnhsuk
Phone contact 01224 552927 01236 712644
Title Sharing of Adverse Events in Renal Units across Scotland
Introduction Background The Scottish Renal Nurses Strategy Group (SRNSG) are a group of senior nurses from Renal
Units across Scotland who meet 3-4 times per year to discuss and implement best practice At the last meeting it was agreed that it would be good practice for each Health Board to share
their adverse events reported on the Datix System and deliver a presentation with an action plan to prevent incidents and improve patient safety across Scotland NHS Grampian and NHS Lanarkshire will be the first to deliver this presentation discussing adverse events from both Health Boards with an action plan
Top 5 adverse events over the past 12 months Renal Unit NHS Grampian 1 Violence and Aggression 2 Accidents including needlesticks slips trips and falls 3 Medication Errors 4 Infrastructure Staffing and Estates 5 Machines and Equipment
Top 5 adverse events over past 12 months Renal Unit NHS Lanarkshire
1 Slips Trips or Falls 2 Medicine errors 3 Treatment problems 4 Transfer problems 5 Breach of policy
The presentation will also focus on any serious adverse events which may not be in the top 5 categories
Aim Objective Each Health Board to share their adverse events with the aim to prevent them from occurring in other units to improve staff and patient safety and wellbeing across Scotland
Method Power Point Presentation
Outcome Results Sharing of adverse events resulting in the development of a national Action Plan to prevent these incidents improving safety and well being of staff and patients in Renal Units across Scotland
NA2
SRA Oct 2017 Abstract
BBV Never Event - The whats whys and hows
Staff Nurse Gillian Wilson Aberdeen Royal Infirmary
This presentation shares our experience of a never event that occurred and was not picked up for
a period of 18 months
Hepatitis C (HCV) positive antibodies were found in a previously negative patient
These results were a low positive with no biochemistry changes to suggest any liver damage
however steps were put immediately in place to isolate and investigate
Was it contamination from a dialysis machine was it related to a blood transfusion given prior to
first positive result was it faulty diagnostic tests in the laboratory
In Aberdeen we go over and above national guidelines and isolate all our BBV patients whether
they have positive blood results or are PCR negative
Further bloods tested at an external laboratory confirmed negative results
It highlighted that communication errors were to blame for the lack of speed in detecting this issue
Investigations concluded no real answers as to why this happened
NA3
Living Donation Scotland Changing attitudes towards living donor kidney transplantation
Jen Lumsdaine Julie Glen On behalf of the Living Donation Scotland Project Board
Background and aims
The rate of living donor transplantation has remained fairly static in Scotland over the past 10 years
Recent data has shown inequity of access to living donor transplantation throughout the UK so
there is potential to significantly increase this optimum form of treatment for patients with end-stage
renal failure in Scotland The Living Donation Project Board was formed in 2016 aiming to double
the number of living donor transplants by 2020
Method
The two key areas
1 Do recipients receive adequate and appropriate information at the right time about living
kidney donation
2 Informing the general public about altruistic donation
All patients active on the transplant list in Scotland were invited to an information event A follow-up
questionnaire was performed in the East of Scotland examining outcome or reasons for not
attending A scoping exercise looked at information provided by each unit was performed and link
nephrologists and low clearance nurses attended meeting to discuss strategies for early education
Outcome
An information pack containing both recipient and donor written information and short films on DVD
has been produced with the support of the Scottish Government for all recipients and potential
donors in Scotland A new website with comprehensive information both written and visual and
postcode finder to improve ease of access to local unit contact details has been developed
Two national media campaigns have been launched with a significant rise in the number of enquiries
from potential donors and actual increase in altruistic donor numbers
Nursing abstract ndash no conflict of interest
NA4Authors Susan Easson Charge Nurse Ward 4C QEUH Glasgow
e- mail contact SusanEassonggcscotnhsuk
Phone contact 0141 452 3300
Title A Conversational approach to find out ldquoWhat matters to yourdquo in a Renal Transplant ward
Introduction Background Finding out ldquo What Mattersrdquo to people using health and careservices is crucial to delivering safe effective and person centred care It is a simple yet profoundconcept and tries to get to the essence of person centred care by creating deeply personalengagements with patients and their families through a conversational approach However careexperience feedback all too often provides innumerable examples of where what really matters topatients and their family members is poorly understood or not addressed Using care experienceas the driver for change the nursing staff in Ward 4C used improvement approaches to explorehow to hold more meaningful ldquoWhat Matters to yourdquo conversations on a daily basis
Aim Objective To improve the patient experience by utilising a person centred approach
Method Using Care experience feedback What Matters to Me boards and the conversationalapproach
Outcome Results Improvements in patient experience will be shared using examples ofpractice and care experience feedback
There was no additional funding required for this project We worked in collaboration with theperson centred team whorsquos aim is to improve patient experience
NA5
The implementation of a renal education programme and its impact on clinical practice
The purpose was to implement a Renal Education Programme and to evaluate its impact on
clinical practise
It was identified that there was a need for an educational programme to be set up within Forth
Valley Royal Hospital There is no inpatient renal unit in FVRH on site for our renal patients they
attend Queen Elizabeth University Hospital We are an outpatient haemodialysis unit with
outpatient clinics on site Therefore it was identified that there was a need for nursing staff within
FVRH to be educated on all renal complexities for the benefit of our patients
This was done through a work-based learning approach which brought tangible benefits for our
patients However it did not come without pitfalls as educational programmes are often seen as
making very little difference to clinical practise
T
his study describes what methods were used and examines the advantages and disadvantages in
setting up an educational programme and evaluating its impact on clinical practise
NA6
Nursing Abstract ndash SRA Meeting ndash 26 October 2017
Chris McGee Tonya Broe Ken Weir
Renal Unit Forth Valley Royal Hospital
Use of the Therapy Monitor Haemodialysis Patient Record System Can we aim for a paper-
free dialysis unit
We are trialling a new haemodialysis patient monitoring system to work in conjunction with SERPR
and which is intended to supersede the Finesse system used previously
We are in the early stages of this process but with continuing staff education and regular tech
support we are hoping to gather sufficient evidence to evaluate whether the use of paper case
notes needs to continue
Is it a realistic goal to aim for a completely paper-free unit
NA7
THE CLINICAL USES OF APHERESIS WITHIN NHS TAYSIDE
Laura Thomson CN
Ninewells Hospital Dundee
NHS Tayside took over the apheresis service from BTS in 2012 The service has since expanded
with the benefits of carrying out this treatment has been widely recognised within NHS Tayside
and is now more commonly being offered to treat a wider range of conditions with the number of
treatments carried out each year rising
This presentation will highlight the progression of the apheresis service within NHS Tayside We
will identify the various conditions it is currently being used to treat and also identify the decision
making process involved in carrying out these treatments ie which replacement fluid will be used
anticoagulation medication administered
We will highlight the benefits and challenges we face in providing this expanding service within the
Renal Service
NA8Authors Linda McDougall Renal Physiotherapist NHS Highland
e- mail contact lindamcdougall1nhsnet
Phone contact 01463 706022
Title lsquoExercise on Haemodialysis- Keeping the Wheels in Motionrsquo
Introduction Background The impact of CKD on physical fitness functional ability independence amp ultimately quality of life cannot be underestimated Current national guidelines recommend that all individuals with CKD are encouraged to participate in regular exercise programmes between or during dialysis sessions if on HD Following a successful pilot study funding was approved to establish an lsquoExercise on Dialysisrsquo (EOD) programme across NHS Highland through the appointment of a dedicated renal physiotherapist in 2008 A successful programme was soon established but for several years post-vacancies and increasing in-patient demands limited the physiotherapy servicersquos ability to deliver the programme The need to improve the long-term sustainability of the service was recognised and in late 2016 funding was approved to develop a Band 4 PT HCSW role for this purpose
Aim ObjectiveTo optimise the sustainability and continuity of the lsquoExercise on Dialysisrsquo service across NHSHighland through development of a Band 4 PT HCSW role
Method The potential parameters of the role and limits of autonomy were scoped out using current NES resources and guidelines Service and task analysis was then carried out to establish which components of the EOD protocol could be undertaken by a Band 4 A series of competencies were developed in line with the clinical protocol and one-to-one training and supervision provided to the post-holder to ensure competency achieved in delivering the programme
Outcome Results A 10 WTE Band 4 PT HCSW was appointed in Jan 2017 with a dual role between the renal unit and acute medical wards Although training is not yet complete the post-holder is already running the day-to-day delivery and monthly audit of the EOD service with senior physiotherapist input only required for individual patient safety queries and general discussion around patientsrsquo progress and goals The benefit to the unit has been considerable as the band 4 is available to support patients and staff with EOD provision 5 days a week This allows for one-to-one supervision of patients who need more support to participate in EOD regular feedback on performance and reviews of outcome measures and goals to maintain motivation levels Feedback on the post has been very positive and its scope will only continue to expand as we look to further develop renal rehabilitation services across NHS Highland
NA9Authors Nadine Lyall and Kerry Guthrie
e- mail contact nadinelyallbordersscotnhsuk kerryguthriebordersscotnhsuk
Phone contact 01896 826637
Title The Developing Role of the NMP in a Satellite Dialysis Unit
Introduction Background
We have been practising as NMPrsquos for nearly 3 years working in the dialysis unit at the BGH The unit is a satellite unit of the ERI and we have expanded over the last 6 years The unit provides haemodialysis for 12 patients at any one time 3 sessions a day 6 days a week We are nurse-led and have 2 renal consultants who are based at the ERI
We saw an opportunity to use our knowledge and experience to develop our role By becoming NMPrsquos we have enhanced our professional development and we feel we meet the changing needs of the dialysis patient in a more holistic manner
Aim Objective
Our aim is to deliver effective care as we are better placed to deal with issues that often arise byacting swiftly this in turn is cost effective and convenient For example good anaemia and bonemanagement is important for their health wellbeing and lifespanTo help understand our role we will use a power point presentation highlighting issues we dealwith and the drugs we prescribe under the following headings Cardiovascular infection painanticoagulant disequilibrium diet renal bone disease and renal anaemia
Method Power point
Outcome Results
In the future we hope to further develop and have greater autonomy in our role We have great support from our renal consultants and have already built up a great relationship with our patients We hope to undertake the Clinical Decision Making course and this in turn will allow us to deal effectively with acute illness giving the dialysis patient better care We are keen to get feedback from other renal nurses in Scotland to enable us to develop our role further and in turn raise awareness of the NMP role in a dialysis unit We record all our prescribing decisions and keep the consultants up to date regularly Currently we are working on auditing our prescribing practice so that we can improve the service we can provide
NA10 Title Komunikacja w szkoleniu dializy ortzewnowej
Author Senior Charge Nurse Rhoda Bell
Address Raigmore Hospital Old Perth Road Inverness IV2 3UJ
Email rhodabellnhsnet Telephone 01463706023
Introduction Background Case study on lady with Polish as her first language she has some English but requires an interpreter to carry out Peritoneal Dialysis training and attend clinic She had some gynaecological issues that we were not aware of which impacted on the functionality of PD and therefore the success of treatment There were areas of concern in low clearance clinic with signs the patient had a reluctance to engage in decision making
AimObjective
Methods Discussion through the case study highlighted issues with communication between different PD staff and patients Areas of concern include different staffing techniques environment factors on training success Also language and communication issues the patient had were not fully apparent so training could not be individualised
Results We plan to trial training at home and have more individualised training schedule for patients The training step by step guides have been reviewed and practise standardised In collaboration with low clearance nurse we have developed a check list which will highlight concerns before the transition to PD ie language issues and need for training aids in another language gynaecological conditions
Conclusions Everyone learns differently and training methodsaids must be individualised for all It may not be apparent until training has commenced that there are concerns Having one to one training with the same nurse will consolidate training and build confidence in the patient Having a close working relationship with members of the MDT will help make a supportive PD journey
Would we do things differently if we knew about prolapse or lack of English both spoken and written
Key words - Peritoneal dialysis patient training communication
N11
Telehealth amp PDAudrey Jones
Advantages
Information on a daily basis about treatment weight and blood pressure
Change programme remotely via computer or mobile
Earlier intervention for machineprogramme issues
Reduction in home visits ie patient trained but still requires volume increases
No need to download cards to see what problems have been
Can have more detailed information available at clinics
Disadvantages
Relying on patient input data correctly
Machine is noisy especially first wave of machine
Still the same bag connection system and patient connection system (difficult for manual
dexterity problems)
Relying on patient having good signal
Modem problems
NA12Autosomal Dominant Polycystic Kidney Disease A cruel inheritance but new hopeAlistair Lawrie Renal Unit Victoria Hospital KirkcaldySadaf Arshad Corry Dunnigan Paul Phelan Neil Turner Renal Unit Royal Infirmary of Edinburgh
Background Autosomal Dominant Polycystic Kidney Disease (ADPKD) is the most prevalent single gene human genetic disorder and the most common of the inherited cystic and interstitial kidney diseases It is estimated to affect 1 in every 1000 individuals worldwide with over 50 of sufferers eventually developing end stage kidney disease and requiring dialysis or transplantation Symptoms include spasmodic severe pain hypertension haematuria infection and kidney failure There is currently no cure for ADPKD Management of the condition has traditionally involved lifestyle modification BP control and analgesia however a recent study (Torres et al 2012) demonstrated that treatment with V2-receptor antagonist drugs slowed increase in total kidney volume reduced the rate of functional decline and showed a reduced incidence of kidney pain
Aim Provision of a tolvaptan prescribing and monitoring service
Methods Experiential finding report of initial twelve months period of multidisciplinary ADPKDtolvaptan clinic
Results Early results are comparable with TEMPO study outcomes
Conclusion Due to the long term nature of this treatment results available at this time are showing only the earliest benefits of the intervention More quantifiable results such as increased time before the necessity for RRT will only be evident in coming years Torres VE et al (2012) Tolvaptan in Patients with Autosomal Dominant Polycystic Kidney Disease New England Journal of Medicine 367 pp 2407-2418 DOI 101056NEJMoa1205311
No funding requirement No conflict of interest
A2 The development of an online educational resource on AKI Ross Norris 1 Joanne Sloan 2 Samira Bell 2
1 School of Medicine University of Dundee Ninewells Hospital 2 Renal Unit Ninewells Hospital
Background Within NHS Tayside there are a number of resources and tools available to aid in the prompt detection and management of AKI such as primary amp secondary care E-Alert systems local guidelines and most recently lanyard cards These resources are supplemented by a regular AKI awareness week which involves delivery of formal amp informal education as well as distribution of a variety of resources However there was a lack of an easily accessible educational resource for both medical and nursing staff as well as medical students In light of this the aim of this project was to produce an educational resource that was engaging easily accessed and easily distributable
Development amp Production NHS Taysidersquos AKI guideline was used as the foundation for the content of the resource and animation was decided as the format in which the resource would be produced Animation was chosen because research has shown that multimedia is an effective method for delivering education and because an animated video provides an independent and easily accessible resource (1) Initial stages of development involved production of sketches and a script based on the guideline Following development of a working draft of both a focus group was held with staff from the renal department to gain constructive feedback In order to turn this concept into an animated video the team was expanded to include a local artist who used the initial sketches to produce illustrations on Adobe Photoshop and a videographer who developed a plan of how to approach the live drawing of each of the illustrations to maximise their visual impact To prepare for production a storyboard inclusive of the exact timings of each illustration and the coordinating part of the script was created Production involved live filming of the illustrations being drawn The footage obtained was then edited using Adobe Premier Pro reading of the script recorded and both combined to produce a fully narrated animated video
Distribution amp Utilization The resource has been made available to staff via upload to the intranet has been incorporated into FY1 induction and will be used as part of the next yearrsquos AKI awareness week Access to the video has been made open to enable use by medical students and professionals outside of Tayside via upload to NHS Taysidersquos YouTube Facebook and Twitter pages with current viewership being 1400
Link httpswwwyoutubecomwatchv=gW0pgXrIdgo
Funding amp Conflicts of Interest The renal endowment fund NHS Tayside No conflicts of interests to declare
References 1 Rolfe VE Gray D Are Multimedia Resources Effective in Life Science Education A Meta-Analysis Bioscience Education 201118(1)1-14
A3 Glucose dynamics and mortality in RRT patients an initial report
Matthew A Rutherford12 Gregory C Jones3 Alan G Jardine14 Patrick B Mark14 Peter C Thomson12 Christopher AR Sainsbury3
1 Glasgow Renal and Transplant Unit Queen Elizabeth University Hospital Glasgow UK 2 School of Medicine Dentistry and Nursing University of Glasgow UK 3 Diabetes Centre Gartnavel General Hospital Glasgow UK 4 Institute of Cardiovascular and Medical Sciences University of Glasgow UK
Background Glucose variability is increasingly being recognised for an association with adverse outcomes in populations with normal renal function For individuals with abnormal renal function this is less clear particularly for those with end stage renal failure undergoing renal replacement therapy (RRT) In RRT patients sustained extremes of glycaemia appear to be associated with worse survival however the effect of underlying glucose dynamics remains poorly understood Specifically there are few published studies which examine the influence of hypoglycaemic episodes on outcomes in RRT patients We sought to determine the relationship between inpatient hypoglycaemia and long-term mortality in a broad cohort of RRT patients
Methods Data for all incident and prevalent RRT patients within our catchment from July 2008 to December 2016 were extracted from the electronic patient record These were merged with a dataset of hospital capillary blood glucose (CBG) measurements Hospital contact episodes were identified from CBG timestamp data (a technique previously validated in other populations) Contacts with gt1 CBG measured within a 48 hour period were taken as admissions Those with at least one CBG lt4mmolL during the first recorded admission were compared with those without Age length of admission and number of measured CBGs were compared between groups A survival analysis was carried out over 85 years comparing groups A Cox proportional hazard model was used to compare time to death including age as a covariable
Results 367544 CBGs from 2215 individuals and 63559 hospital contact episodes were identified 31340 episodes from 831 individuals had gt1 CBG performed and were analysed as admissions 219 individuals had 1 or more CBGs lt4mmoll recorded This group experienced longer admission (36 vs 19 days plt0001) and had a higher number of recorded CBGs (13 vs 4 p lt 0001) On survival analysis hypoglycaemia was associated with a HR for death of 152 (95 CI 131-173 plt00001)
Discussion Hypoglycaemia is associated with prolonged admission and increased mortality in this broad population Further work investigating the impact of glucose variability RRT modality and presence or absence of diabetes is planned
A4 Vitamin K and Vascular Health A Systematic Review and Meta-Analysis Jennifer Lees12 Fiona Chapman2 Miles Witham3 Alan Jardine12 Patrick Mark12
1 Institute of Cardiovascular and Medical Sciences University of Glasgow 2 Glasgow Renal and Transplant Unit NHS Greater Glasgow and Clyde 3 University of Dundee
Background - Vascular stiffness and calcification occur prematurely in patients with chronic kidney disease (CKD) and are associated with increased mortality Activity of matrix Gla protein - an important regulator of vascular calcification - is dependent on adequate vitamin K intake vitamin K deficiency is prevalent in patients with CKD We conducted a systematic review and meta-analysis of the effect of vitamin K supplementation on vascular health and assessed the evidence that level of (inactive) dephosphorylated undercarboxylated Matrix Gla protein (dp-ucMGP) is associated with incident cardiovascular disease (CVD) or mortality
Methods - Two authors searched Medline and Embase databases Cochrane and ISRCTN registries in May 2017 for i) adult human studies of vitamin K supplementation versus control which measured effects on vascular calcification vascular stiffness or dp-ucMGP and ii) prospective observational studies assessing effect of baseline dp-ucMGP on incident CVD or mortality Random effects meta-analysis was conducted using meta and metafor packages for R statistical software package Egger regression and Trim-and-Fill analyses were used to assess for publication bias
Results ndash Nine intervention studies (n=952) and 13 observational studies (n=7495) met our pre-specified inclusion criteria Vitamin K led to a significant reduction in vascular calcification compared to placebo (-91 [95CI -177 -05] p=004) and a significant decrease in dp-ucMGP (-227pmolL [95CI -281 -173] plt0001) A non-significant improvement in vascular stiffness was evident (-37 [95CI -78 04] p=008) In observational studies with a follow up period of 70 + 40 years stepwise increase in dp-ucMGP was not associated with fatal or non-fatal CVD (log HR 005 [95CI -013 022] p=062) or mortality (log HR 004 [95CI -015 023] p=069) Egger regression and Trim-and-Fill analyses suggest possible publication bias in favour of positive results
Conclusion - Vitamin K supplementation significantly reduces dp-ucMGP level although dp-ucMGP is not associated with incident CVD or mortality Supplementation appears to reduce progression of vascular calcification with a trend towards improvement in vascular stiffness though there are limited data available Clinical trials of the effect of vitamin K supplementation on vascular health are warranted
Funding - JL is supported by a Kidney Research UK Training Fellowship
Conflicts of interest - MW and PM are currently running a BHF-funded trial of vitamin K supplementation in patients with CKD 3b4
A5 Review of management of patients with diabetic nephropathy Wan Shun Wonga Mohammed K Azharuddinb
aRenal and Transplant Unit Queen Elizabeth University Hospital Glasgow bDiabetes Unit Inverclyde Royal Hospital Greenock
Background ndash Diabetic nephropathy is a common and potentially life-threatening complication of both type 1 and type 2 diabetes and is now recognised as the leading cause of end-stage renal disease1 Studies have shown that early interventions can delay the onset and slow the progression of diabetic nephropathy2 The aim of our study was to review the management of patients with diabetic nephropathy at Inverclyde Royal Hospital in accordance to the guideline published by the National Institute for Health and Care Excellence (NICE)
Methods ndash Patients with diabetic nephropathy were identified on SCI-Diabetes Patient data was then extracted from renal electronic patient record SCI-Diabetes and Clinical Portal Clinical notes were also reviewed to determine the reason for cessation of angiotensin-converting-enzyme inhibitor (ACE-I) or angiotensin receptor blocker (ARB) Referral guidelines from the Renal Association were used to assess the eligibility for referral
Results ndash Data was collected from 255 patients with diabetes and urine ACR gt25 (for male) and gt35 (for female) Mean age was 625 years (SD 151) and 584 (n=149) were male 243 of patients (n=62) were classed as type 1 diabetes and 737 (n=188) as type 2 with further 20 (n=5) as others 949 (n=242) patients had an HbA1c recorded within the last year The mean HbA1c was 712 (SD 2052) 8 patients were on RRT (7 on HD and 1 on PD) Serum creatinine and urine ACRPCR were checked in 933 (n=238) and 612 (n=156) of patients in the last year respectively Blood pressure was measured within the past 12 months for 847 (n=216) of patients with 601 (n=146) having blood pressure higher than the target of 13080mmHg Mean systolic and diastolic blood pressures were 1339 mmHg (SD 1735) and 745 mmHg (SD 111) respectively 627 of patients were on ACE-IARB Of the 95 patients who were not on ACE-IARB 421 (n=40) were stopped due to side effects 116 (n=11) patients had their ACE-IARB discontinued but no reason could be found 379 (n=36) patients had never been on an ACE-IARB 157 (n=40) of patients met the criteria for referral to Renal Services and 7 patients had not been referred and all 7 of them recently developed CKD4
Conclusion ndash Our findings were consistent with the national data3 Urine PCR measurement has the lowest completion rate among all the recommended annual care processes Optimal blood pressure control remains a challenging issue for many of the patients with diabetes Further studies could be carried out to look at the reasons behind the low completion rate of urine PCR measurement as well as to devise ways to remind clinicians about starting patients on ACE-IARB and making referral to Renal Services when indicated
References 1 K Bennett B S Aditya An overview of diabetic nephropathy Epidemiology pathophysiology and treatment Journal of Diabetes Nursing 18 61-7 2 Molitch ME DeFronzo RA Franz MJ et al American Diabetes Association Nephropathy in diabetes Diabetes Care 200427(Suppl 1)S79-83 3 Scottish Diabetes Survey 2016 Scottish Diabetes Survey Monitoring Group NHS Scotland
Funding ndash None Conflict of Interest ndash None
A6 Analgesic Use in Dialysis Patients in a District General Hospital Setting
A McCallum L Dickson S Robertson A Almond N Rathnamalala M KellyT Muniraju
Renal Unit Dumfries and Galloway Royal Infirmary
Evidence shows around 50 of haemodialysis patients report pain with 83 describing this as moderate to severei Distinct variability also exists in levels of opiate prescribing between centres with studies showing incidence ranging from 5-50iiiii Consequently we sought to investigate the prevalence of both pain and opioid prescriptions in our local dialysis population as well as investigating whether there are any associations between co-morbidities and the use of opiates This information could then be used to identify new dialysis patients at high risk of pain as well as informing prescribing decisions
In order to achieve this a questionnaire was produced that incorporated validated pain and quality of life scores (the Brief Pain Index and Renal Palliative Care Outcome Scale) with a consent form to access electronic healthcare records Questionnaires were distributed to all our haemodialysis and peritoneal dialysis patients Results were transcribed into Microsoft Excel where they were analysed
Data was collected on 56 patients (46 haemodialysis patients 10 peritoneal dialysis patients) Results showed 46 described ldquopain other than everyday kindsrdquo on the day of survey completion The most common site of pain was in the legs and back On average patients were on 12 different medications of which 15 was for pain (range 0-5) 784 of these pain prescriptions were longstanding (gt3 month use) Amongst haemodialysis patients 45 were on a strong opioid ndash in 73 of cases this was a fentanyl patch Whilst scope exists to increase the use of simple analgesia and neuropathic agents in such patients analysis using the pain management index scale revealed use of opioid analgesia in such cases to be justified As in previous work no link was found between any one co-morbidity and the development of pain
Overall we have shown high rates of pain amongst our dialysis patients We also demonstrate high levels of chronic analgesia use and the overall tablet burden on our patient group is high This work adds to previously published literature and is being used locally to proactively minimise the burden of prescribed tablets and also increase awareness of the value of paracetamol and neuropathic agents in those with uncontrolled pain
Source of funding conflict of interest Nil
References i Davison SN Pain in hemodialysis patients prevalence cause severity and management Am J Kidney Dis 2003421239-1247 ii Butler AM Kshirsagar AV Brookhart MA Opioid Use in the US Hemodialysis Population Am J Kidney Dis 2014 63(1) 164-173 iii Wyne A Rai R Cuerden M Clark WF Suri RS Opioid and Benzodiazepine Use in End-Stage Renal Disease A Systematic Review Clin J Am Soc Nephrol 2011 6 326ndash333
A7 The Role of the Renal Supportive Care Service in Advanced Care Planning JM Sloan CA Douglas S Cathcart L Frame L Stage M Witham ME Lafferty
Renal Service Ninewells Hospital Dundee
Background In 2007 we established a Renal Supportive Care Service for patients with advanced chronic kidney disease who choose not to receive dialysis The service which includes a fortnightly Renal Supportive Care clinic is provided by a Consultant Nephrologist a Consultant Palliative Care Physician and a Renal Supportive Care Specialist nurse The focus of the service is on ongoing management of chronic kidney disease symptom control and improving quality of life while planning for end of life care
Methods We have undertaken a retrospective audit of our Renal Supportive Care Service on all patients known to the Renal Service for whom a conservative care management decision had been made We collected data over a 31-month period from April 2012 until October 2014 We collected data on demographics co-morbidities clinic attendance renal supportive care input anticipatory care planning performance status and mortality data
Results Of the 98 patients for conservative management 62 (6198) were female with a mean age of 837 years During the 31-month period there were 507 documented supportive care consultations with 36 (3598) of patients receiving domiciliary visits from the Renal Supportive care nurse Anticipatory Care Plans (ACP) were in place for 62 (61) of patients with a preferred place of death known for 56 (5598) 65 patients had a documented discussion about their DNACPR status which was communicated in writing to primary care For a further 13 it was not clear whether the discussion had taken place During the study period 61(62) patients died Of those patients with an ACP 29 (1138) died in an acute hospital versus 43 (1023) of those without (p=025) Similarly 24 (834) of patients with a documented preferred place of death died in an acute hospital versus 48 (1327) of those without (p=004)
Conclusions The role of the Renal Supportive Care team is invaluable in providing care and support to patients who have chosen conservative management By discussing and planning for end of life care the Renal Supportive Care team play a role in reducing the number of patients dying within an acute setting
Conflicts None
Funding The Renal Supportive Care Nurse post and one Palliative Care Consultant Programmed activity received 3 years of funding by British Kidney Patients Association
A8 Predictors of transplant failure in patients undergoing indication renal biopsy
Kate Stevens 1 Bruce Mackinnon1 David Kipgen1 Shana Coley1 Marc Clancy1 Colin Geddes1
1Renal and Transplant Unit QEUH NHS GGampC Glasgow United Kingdom
Introduction This study considers indication renal biopsies and factors which may be important
predictors of transplant loss and patient death
Objectives To identify the time line of histological diagnosis from transplant in our population
and to identify predictors of graft and patient survival in those undergoing indication renal biopsy
Methods All indication renal biopsies undertaken between 012011 and 122015 were identified
Demographic data including immunological and outcome data was recorded Statistical analysis
was undertaken in SPSS (v22)
Results 354 patients underwent 549 biopsies Mean patient and transplant age at time of biopsy
was 432 plusmn153 and 42plusmn58 years respectively 449 (n=247) of biopsies showed evidence of
Cell mediated rejection (CMR)ABMR or both 93 (n=51) demonstrated features of chronic
transplant glomerulopathy (CTG) DSA was present at the time of biopsy in 231 (n=127) In
transplants aged le 6 months old histological diagnosis was CMR in 325 (n=69) with ABMR seen
in 28 (n=6) In transplants aged ge10 years CTG was seen in 325 (n=26) with ABMR
accounting for 63 (n=5) 229 (n= 81) of transplants failed at a median of 182 days from most
recent biopsy On cox regression analysis peritubular capillary (PTC) C4d and CTG were
independent predictors of transplant failure Probability of transplant failure was 45 and 50 at
one year if mixed rejection or CTG were present 93 (n=33) patients died at a median of 227
days from most recent biopsy Independent predictors of death included deceased donor
transplant patient age and presence of ABMR on biopsy (plt005)
Conclusion Acute ABMR is a risk factor for patient loss whilst chronic ABMR is a risk factor for
transplant loss This association is independent of DSA but dependent upon PTC C4d staining
indicative of donor humoral activity ndash HLA or otherwise Histological diagnosis in an indication
biopsy is an important factor in predicting outcome This study is limited by the inherent bias in
patient selection with indication biopsy
Disclosure of Interest None Declared
A9 Renal Evaluation of Paediatric Patients with Tuberous Sclerosis Complex (TSC) in aNational TSC Multidisciplinary ClinicDr Jenny Patterson 1 Dr Shelagh Joss 1 Dr Ihab Shaheen 2
1 Clinical Genetics Queen Elizabeth University Hospital Glasgow 2 Paediatric Nephrology Royal Hospital for Sick Children Glasgow
Introduction Tuberous sclerosis complex (TSC) is a dominantly inherited multisystem disorder characterised by development of hamartomas (benign lesions) in multiple organs Previous studies have shown that renal manifestations are common in TSC and also the most frequent cause of TSC-related death in affected individuals With the recent discovery of targeted therapy with mTOR inhibitors early recognition of renal involvement allowing early surveillance and prompt therapy is now more important than ever
AimMethod To review a population of paediatric patients attending a large specialist TSC service in the UK both in terms of key clinical characteristics and current practice for renal radiological surveillance data were collected from electronic medical records pertaining to molecular diagnosis renal surveillance and presence or otherwise of sequelae affecting the renal or other systems Practice was compared to published surveillance recommendations of the International Tuberous Sclerosis Complex Consensus Group (2013)
Results Data were obtained for 41 children (18 males 23 females) Current age range 25 years to 14 years (mean 98 years) Twenty nine patients (707) were diagnosed lt1 year of age Genetic data were available for 29 patients Fifteen patients had a confirmed TSC1 mutation and 14 patients a confirmed TSC2 mutation including one contiguous PKD1 mutation Renal imaging (all US) within a year of diagnosis was documented in 2541(61) performed at a mean age of 3 years Renal symptoms at diagnosis were documented in 741(171) and 941(22) had renal abnormalities on baseline imaging There was wide variability in scanning interval and modality with 1041(243) having previous abdominal MRI with variable documented indication Seventeen (414) of the cohort mean age 102 years had documented renal lesions 917 angiomyolipomas 517 cysts and 317 both These lesions were diagnosed at a mean age of 6 years (range 02 years-142 years) Six patients (353) had normal baseline scans with a mean interval to lesion diagnosis of 1 year One patient had a lesion on MRI not detected on US that required subsequent biopsy Frequency of subsequent scanning ranged from intervals of 2 months to 1 year with a combination of MRIUS in an unclear pattern All patients except one with a contraindication were undergoing current brain surveillance by MRI
Conclusions Our results highlight the significant incidence of renal sequelae within our TSC cohort with renal manifestations ranging both in severity and age of onset International guidelines recommend MRI scanning for renal surveillance at diagnosis and throughout life Benefits of MRI include enhanced accuracy of sizing and characterisation of renal lesions The majority of our cohorts are already undergoing brain MRI surveillance It is our aim to combine and standardise MRI renal surveillance for this cohort to facilitate early and regular monitoring with a view to early intervention is possible
A10 Effect of blood temperature monitoring on intradialytic hypotension in patients with end stage renal disease requiring haemodialysis Heather Walker1 Susan McGeorge1 Drew Henderson2
1 Renal Unit Ninewells Hospital Dundee2 Regional Renal Centre Waikato Hospital Hamilton New Zealand
Background KDIGO define intradialytic hypotension (IDH) as a reduction in systolic bloodpressure (SBP) ge20mmHg or mean arterial pressure (MAP) ge 10mmHg with associatedsymptoms IDH is a common complication of haemodialysis (HD) and is associated with increasedmortality and morbidityStandard dialysis with a set temperature leads to thermal gain during the dialysis session Tocounteract this thermal gain vasodilation occurs and is postulated as one of the causes of IDHActive cooling of dialysis has been shown to reduce IDH but is not routinely applied across wholedialysis populations Isothermic dialysis can be achieved by controlling blood temperature on HDWe report here our experience of doing this using the Blood Temperature Monitoring (BTM)function on Fresenius 5008 dialysis machines
Methods An observational study was performed to assess the rates of IDH in patients with End Stage Kindey Disease (ESKD) undergoing regular satellite HD at NHS Tayside in July 2017 Rates of IDH were assessed (KDIGO definition) for two weeks prior to BTM settings being activated and for a two week study period after introduction SBP and MAP data was collected SBP data was grouped to either SBP decrease lt20mmHg or SBP decrease ge20mmHg compared with Pre HD BP Changes in MAP were also analysed at the same time points Patient reported symptoms related to initiation of BTM were also collected for the same time period
Results 402 dialysis sessions were evaluated in the pre intervention time period and 399 sessions post intervention
IDH 1072 vs 778 (Pre BTM vs Post BTM) p=015 gt20mmg SBP drop Pre vs Post BTM
Mean MAP Change (mmHg) Pre BTM vs Post BTM
1st BP 254 vs 204 (p=005) -522 vs +312 (plt001) 2nd BP 474 vs 435 (p=023) -1589 vs -886 (plt001) 3rd BP 515 vs 435 (p=003) -1862 vs -958 (plt001) Post HD 408 vs 338 (p=003) -1164 vs -077 (plt001)
Following the introduction of blood temperature monitoring only 08 of HD sessions reported experiencing cold or shivering symptoms
Conclusion The use of blood temperature monitoring was not associated with a statistically significant decrease in rates of IDH There was a significant reduction in the number of sessions where SBP decrease by gt20mmHg at the first and third HD BP and a reduction in MAP change across the study group Further evaluation of BTM is required assess its clinical utility in our HD population
Funding No funding was sought for this study
Conflicts of interest None
A11 Evaluating patient satisfaction and clinical outcomes of a new nurse-led dermatology clinic for patients attending the renal transplant clinic Campbell G Naismith K Neil A Rankin A Spalding E (joint first authors) Renal Unit University Hospital Crosshouse Kilmarnock UK
BACKGROUND National Guidelines advise that renal transplant recipients should receive annual skin surveillance to screen for skin cancer In August 2015 a specialist nurse-led dermatology clinic was set-up alongside the renal transplant clinic at University Hospital Crosshouse We aimed to evaluate the success of this joint clinic in terms of clinical outcomes and patient satisfaction
METHODS Clinical records were reviewed to determine the number of patients under dermatology follow-up before and after initiation of the joint clinic and to review cases that were referred for treatment of pathological skin lesions A questionnaire was also distributed to patients attending the new joint renal-dermatology transplant clinic The questionnaire consisted of 5 questions 2 for patient demographics 1 for current understanding of skin care advice and 2 to assess their satisfaction of the new joint clinic
RESULTS A total of 138 and 146 renal transplant recipients were registered on renal transplant clinic lists in 2015 and 2016 respectively Prior to initiation of the new joint-clinic 41 patients had attended dermatology (37 in NHS Ayrshire and Arran and 4 in NHS Greater Glasgow and Clyde) consisting of 30 of the transplant population In September 2016 13 months after initiation of the new clinic 60 patients had attended the new clinic increasing the proportion of patients meeting the national recommendation for skin surveillance to 41 Implementation of the new clinic resulted in patients being 65 more likely to have received the recommended skin checks (odds ratio 165 95 CI 101-270 p=004)
32 patients completed the questionnaire The median age of transplant was 90 years (IQR 38-153) 100 of patients knew to avoid sun exposure and 31 (96) knew to use sunscreen 29 (91) patients were aware of the advice to undergo annual skin surveillance by dermatology with 28 (88) having had a skin check in the last year 29 (91) patients reported that they found the new joint clinic useful although only 18 (56) had attended the clinic so far
CONCLUSIONS Implementation of a new nurse-led dermatology clinic running in parallel with the renal transplant clinic resulted in a considerable increase in the proportion of patients meeting national recommendations for annual skin surveillance The vast majority of patients also found the combined clinic to be useful There is still considerable room for improvement in order to achieve the target of 100 compliance with skin surveillance and ongoing clinical audit is required to assess progress We believe this model would be easily implementable at other units with similar benefits expected
A12 Pneumocystis pneumonia prophylaxis post-renal transplant increased duration of co-trimoxazole is safe and effective FA Chapman JE Dickerson M Clancy C Daly C Geddes Renal amp Transplant Unit Queen Elizabeth University Hospital Glasgow
Introduction All renal transplant recipients receive Pneumocystis jirovecii prophylaxis usually with co-trimoxazole Guidelines suggest this should be continued for 3 to 6 months Our unit previously prescribed 3 months however following an outbreak of Pneumocystis pneumonia (PCP) infection this was increased to 6 months Given its constituents of sulfamethoxazole and trimethoprim co-trimoxazole prophylaxis may influence the frequency of urinary tract infection (UTI) We aimed to compare the frequency of UTI between patients on 3 months vs 6 months prophylaxis and assess rates of multi-drug resistant organisms We also sought to establish if the increased duration of co-trimoxazole was adversely affecting renal function potassium concentration white cell and platelet count and dosing of mycophenolate mofetil
Methods A retrospective search of the West of Scotland Electronic Renal Patient Record was conducted for all renal transplant recipients between 1st January 2012 and 31st May 2016 Patients were grouped according to the intended duration of co-trimoxazole Data were extracted for baseline characteristics co-trimoxazole prescription mycophenolate mofetil (MMF) prescription laboratory results (creatinine potassium white cell count platelets) at 3 6 9 and 12 months post-transplant and microbiology results for 6 months post-transplant Results were analysed on an intention to treat (ITT) basis with a second analysis according to actual duration of co-trimoxazole treatment (AT) Subjects with transplant failure had laboratory results censored from the time of transplant failure and all of their microbiology results were excluded
Results 609 renal transplants were performed over the study period On ITT analysis there were 418 patients in group 1 (ITT1 3 months co-trimoxazole) with 15 transplant failures and 191 patients in group 2 (ITT2 6 months co-trimoxazole) with 12 transplant failures There was a significant difference in the number of patients with at least one UTI with fewer in ITT2 (ITT1 133403 vs ITT2 42179 p = 001) However this was not present when comparing actual treatment duration (AT1 111345 vs AT2 36149 p=007) Overall there was a similar spectrum of organisms cultured There were significantly fewer cultures of multi-resistant organisms in both ITT and AT analyses with 6 months of co-trimoxazole (ITT1 28376 vs ITT2 0106 p= 0004 AT1 22313 vs AT2 198 p = 002) There was no difference in estimated Glomerular Filtration Rate serum potassium concentration platelet count or MMF dose On AT analysis there was a significant difference in the total white cell count (WCC) and lymphocyte count at 6 months post-transplant (WCC 78 x10^5L vs 71 x10^5L p =004 lymphocytes 13 x10^5L vs 12 x10^5L p=002) There were 18 cases of PCP with 7 deaths attributable All cases occurred after cessation of co-trimoxazole prophylaxis (81 ndash 913 days after stopping co-trimoxazole)
Conclusion Although there is a significant difference in UTI frequency on ITT analysis this is not present on AT analysis suggesting no real co-trimoxazole effect There was no increase in frequency of multi-drug resistant organisms with a longer course of co-trimoxazole Renal function and serum potassium were unaffected Our findings support continuing co-trimoxazole prophylaxis for at least 6 months
A13 Kidney transplantation in the over 60rsquos in Scotland 1996-2015 TJW Rennie1 P Phelan1 J Campbell2 JP Traynor2 L Henderson1 W Metcalfe2 On behalf of the Scottish Renal Registry 1Renal transplant unit Royal Infirmary Edinburgh 2NHS National Services Scotland Introduction The proportion of older kidney transplant recipients has increased in the UK but
long term outcome data are scarce We aimed to evaluate patient and graft survival in patients
ge60 years of age receiving a first kidney only transplant in the last 20 years in Scotland
Methods Retrospective analysis of Scottish Renal Registry data of incident Renal Replacement
Therapy (RRT) patients and those in receipt of a kidney only transplant performed 1996-2015
(follow up until 311216) Patients were stratified by age 60-69 ge70 (group 1 and 2 respectively)
and decade of transplantation 1996-2005 2006-2015 (decades 1 and 2 respectively)
Results 6743 patients aged ge60 started RRT from 1996-2016 Of those 108 were ever
transplant-listed 54 had received a transplant by 311216 26 listed and 11 transplanted
were aged ge70
535 patients aged ge60 received a kidney only transplant in 1996-2015 90 patients (168) were
aged ge70 no patients were aged ge80 Mean time from wait listing until transplantation was 33plusmn24
years (plusmnSD) and from starting RRT until transplantation was 38plusmn26 years (plusmnSD) One and five
year graft survival was 97 and 87 in decade 1 95 and 89 in decade 2 (p=NS) there was
no difference in graft survival between age groups 1 and 2 One and five year patient survival was
94 and 78 in age group 1 85 and 56 in group 2 (plt0001) there was no difference in one
and five year patient survival between the two decades
Conclusion One and five year graft and patient survival in renal transplant recipients aged ge60
have not changed significantly in the last 20 years Recipient age ge70 is not associated with
reduced graft survival but patient survival from time of transplant is lower in this age group
compared to recipients aged 60-69
No conflict of interest to be declared No funding received
A14 High Mortality In Older Patients With Primary Nephrotic Syndrome Sarah Beverstock Wendy Metcalfe amp Robert W Hunter Department of Renal Medicine Royal Infirmary of Edinburgh
Introduction
Nephrotic syndrome can develop at any age and may be due to a primary glomerular lesion or secondary to systemic disease The natural history of glomerular disease can be different in older patients For instance minimal change disease (MCD) in children almost always remits promptly with steroid therapy in adulthood it typically remits only after many weeks of steroids or with adjunctive immunosuppression However there are remarkably few published data on the mortality of primary nephrotic syndrome in adults We aimed to study this in our centre
Methods
We enrolled all adult patients who had a kidney biopsy in order to investigate nephrotic syndrome over 38 consecutive months (01 Jan 2014 ndash 28 Feb 2017) We defined nephrotic syndrome as heavy proteinuria (urinary proteincreatinine ratio UPCR gt350 mgmmol or albumincreatinine ratio gt220 mgmmol) and hypoalbuminaemia (serum albumin lt35 gL) In our analysis we included all patients in whom nephrotic syndrome was attributed to a primary glomerular disease We excluded kidney transplant recipients and patients in whom biopsies were performed to follow up a known glomerular disease We collected laboratory data at baseline (time of biopsy) and at 6 and 12 months We assessed patient survival by Kaplan-Meier analysis
Results
Of the 117 patients biopsied for nephrotic syndrome 71 patients (61 ) met the inclusion criteria and were followed up for a median of 469 days We compared outcomes in patients aged under 60 years old (n = 35) with those aged over 60 (n = 36) Mortality was higher in the older group (37 vs 4 mortality at one year p lt005 by logrank test) There were no significant differences between the two groups in serum creatinine or UPCR at any time Serum albumin was similar in both groups at baseline and at 12 months but was lower in the older group at 6 months (27 vs 32 gL p lt 005) Baseline haemoglobin was lower in the older group (114 vs 130 gL p lt005 by unpaired t-test) Primary diagnoses were MCD (n = 10 in younger group amp n = 5 in older group) membranous nephropathy (5 amp 10) IgA nephropathy (9 amp 8) FSGS (5 amp 5) membranoproliferative glomerulonephritis or C3GN (4 amp 7) and other (2 amp 1) Therefore unsurprisingly there were relatively fewer cases of MCD and more cases of membranous nephropathy in the older group otherwise the causative glomerular lesions were similar in both groups In those patients with MCD mortality was significantly higher in the older group none of the 10 patients with MCD diagnosed under 60 yrs old died during the follow-up period whereas 4 of the 5 older patients died 3 patients in the younger group and 1 in the older group were on renal replacement therapy (dialysis or transplant) by the end of follow-up
Conclusions
Primary nephrotic syndrome is associated with high mortality in the over 60s (37 at one year) Mortality was high even for MCD a disease that follows a benign course in childhood and early adulthood The higher mortality in older patients was not associated with greater severity of renal disease at presentation (as assessed by basic blood and urine parameters) This work was not funded we declare no conflicts of interest
A15 Renal biopsies in patients with diabetes mellitus in Scotland
Udana Ratnapala 1 Nicola Joss 2 Colin Geddes 3 Dana Kidder 1
1 Renal Unit Aberdeen Royal Infirmary Aberdeen 2 Renal Unit Raigmore Hospital Inverness 3 Glasgow Renal and Transplant Unit Glasgow
Introduction Diabetes mellitus is the leading cause of end-stage kidney disease (ESKD) requiring renal replacement therapy The utility of renal biopsy in patients with diabetes mellitus is controversial Broadly renal biopsy findings in patients with DM can be divided into diabetic nephropathy (DN) alone DN with non-diabetic renal disease (NDRD) or NDRD alone Timely identification of patients with NDRD is important to provide appropriate therapeutic measures Previously published guidelines on clinical predictors of NDRD have limited specificity and sensitivity The frequency of NDRD in renal biopsies of patients with DM is unclear in ScotlandThis study aimed at identifying the frequency and the pathology spectrum of NDRD in diabetic patients underwent kidney biopsy in 3 renal units
Methods A retrospective observational study was performed on clinical-pathologic findings in all patients with diabetes mellitus who underwent renal biopsy between 01012010 and 31122016 in 3 renal units (Aberdeen Inverness and Greater Glasgow) Data were gathered from electronic patient record systems Scottish Index of Multiple Deprivation (SIMD) 2012 was used to analyse correlation with patient outcomes
Results 247 patients were included 150 men (607) 217 type 2 DM (879) mean age 621 years and mean serum creatinine at the time of renal biopsy of 261 micromolL (+-190 std) On biopsy 92 patients (372) had DN while 127 (514) had NDRD and 28(114) had NDRD superimposed on DN The commonest NDRD aetiologies were IgA nephropathy (187) tubulointerstitial nephritis (168) and idiopathic membranous nephropathy (103) Predictors of NDRD were age (OR 1027 95 CI 1002-1052 p=003) duration of DM (OR 094 95 CI 0900-0987 p=001) and absence of AKI as indication for biopsy (OR 022 95 CI 0059-0826 p=0025) There was no significance difference in renal or patient survival in DN and NDRD Finally no significant correlation was depicted between SIMD quintiles and renal or patient survival in both groups
Conclusions The majority of renal biopsies carried out in patients with DM revealed a NDRD In this study age at the time of biopsy duration of DM and AKI were the main pointers towards NDRD Renal and patient survival were not significantly different between DN and NDRD groups
A16 The Impact of Withdrawal of Maintenance Immunosuppression and Graft Nephrectomy on HLA Sensitisation Ailish Nimmo1 Sophie McIntyre1 Lorna Henderson1 Richard Battle2
(1 Department of Renal Medicine Royal Infirmary of Edinburgh 2 Histocompatibility and Immunogenetics Royal Infirmary of Edinburgh)
Background The development of HLA antibodies towards a failing renal allograft is a barrier to re-transplantation We previously demonstrated an increase in HLA antibodies and calculated reaction frequency (cRF) following nephrectomy but results were confounded by immunosuppression changes occurring in close time proximity We examined the formation of HLA donor specific antibodies (DSA) in patients with failed grafts that remained in situ and compared results with patients undergoing graft nephrectomy to further assess the relative impact of nephrectomy and immunosuppression weaning on sensitisation and chance of transplant
Methods We carried out a single centre retrospective study of all patients with failed grafts in Lothian from 2005 to 2015 Samples were tested for DSA pre-immunosuppression (IS) wean post-IS wean and post-IS cessation Nephrectomy patients also had samples tested for DSA before and after nephrectomy Data on other sensitising events including blood transfusion and rejection were collected cRF was determined at each time point and entered into the ODT chance of transplant calculator with other demographics based on the average patient from the Edinburgh centre
Results 62 grafts failed over this time period Blood samples were available 41 patients (24 with nephrectomy 17 with failed graft left in situ) Patient demographics were similar between groups There was a higher rate of antibody mediated rejection in the nephrectomy group (46 vs 18) 76 of patients with nephrectomy group had received a blood transfusion The pattern of immunosuppression weaning was similar but median time from start of IS wean to cessation was longer in the nephrectomy group (350 vs 298 days) The changes in cRF and chance of transplant (COT) with immunosuppression weaning are shown in Table 1
Pre-IS Wean Post-IS Wean
Failed graft in situ (n=17)
Mean CRF COT at 5
years 15 62 38 59
Nephrectomy (n=24)
Mean cRF COT at 5
years 54 54 69 46
Post-IS Stop 55 53 89 42 Table 1 Mean cRF and Chance of Transplant (COT) at 5 years with IS alterations
Discussion A stepwise increase in cRF with reduced chance of transplant was observed in both groups as immunosuppression was withdrawn with a similar pattern of change irrespective of graft nephrectomy cRF was higher in the nephrectomy group despite a more gradual wean which may reflect a higher rate of antibody mediated rejection and increased number of patients receiving a blood transfusion The risks and benefits of stopping immunosuppression need to be carefully considered on an individual basis to maximise chance of future transplant
The authors have no conflicts of interest No funding was required for this study
A17 Obesity is not associated with progression to end stage renal disease in patients withbiopsy-proven glomerular diseases
Benjamin Elyan Jennifer S Lees Bruce Mackinnon Jonathan G Fox Colin C Geddes Emily PMcQuarrie
Glasgow Renal and Transplant Unit Queen Elizabeth University Hospital Glasgow
Introduction - Addressing risk factors for renal progression is a key aspect of managing chronic kidney disease (CKD) Body mass index (BMI) has been shown to impact on renal progression in unspecified CKD The aim of this study was to evaluate if there was an association between BMI and progression to renal endpoints in patients with biopsy-proven primary glomerular disease (GN)
Methods - We included all adult patients diagnosed with biopsy-proven primary GN (excluding minimal change nephropathy) in Greater Glasgow amp Clyde and Forth Valley between 01012000 and 31122015 Biochemical and anthropometric data were extracted from the electronic patient record at time of biopsy with follow-up data until 20062017 BMI was calculated from height and weight at time of biopsy and categorised into groups BMI le25 kgm2 (G1) gt25 to le30 kgm2 (G2) and gt30 kgm2 (G3 - obese) We assessed factors associated with reaching a combined renal endpoint of CKD5 or renal replacement therapy (RRT) with competing risk of death using the Fine and Gray subdistribution hazard model Analyses were conducted using cmprsk package for R statistical software package and SPSS version 24
Results - 560 patients with primary GN and available BMI data were included The average age was 532 years and 339 were female There were 132 patients in G1 210 in G2 and 207 patients in G3 Those in G2 and G3 were older (p=002) with slightly higher diastolic blood pressure (p=002) than those in G1 There was a greater proportion of focal segmental glomerulosclerosis in G3 but similar proportions of other GN diagnoses across groups There was no significant difference in baseline serum creatinine (sCr) (p=034) or log uPCR (p=045) between BMI groups On multivariate analysis age systolic blood pressure BMI or GN diagnosis were not predictive of renal outcome Higher baseline sCr (SHR 1003 per 1 umoll increase in sCr 1001-1004 plt0001) and log uPCR (SHR 130 per unit increase in log uPCR 95 CI 105-160 p=002) were associated with progression to the combined renal endpoint accounting for competing risk of death BMI was not associated with reaching combined renal endpoint on univariate analysis whether considered as a continuous variable (SHR=100 95 CI 098-102 p=096) or categorised by BMI group
Conclusion - Contrary to our expectations there was no association between BMI and progression to a combined renal endpoint of CKD5 or RRT in this cohort of patients with primary GN Efforts should be directed to managing other known risk factors for CKD progression
Sources of FundingConflicts of Interest - None
A18 Factors influencing long term renal function after living kidney donation
Matthew A Rutherford Norman J Galbraith Marc Clancy Colin C Geddes
Glasgow Renal and Transplant Unit Queen Elizabeth University Hospital Glasgow UK
Background Following live donor nephrectomy the remaining kidney undergoes an increase in filtration capacity known as compensatory hypertrophy Few cohorts with follow up of renal function beyond 5 years have been reported The impact on long term renal function of variability in donor factors such as age sex pre-donation blood pressure and glomerular filtration rate (GFR) is unknown Increasingly kidney donors have potential risk factors for future poor renal function such as hypertension older age and obesity The aim of this study was to analyse factors influencing long-term renal function in living kidney donors from our centre
Method Data were obtained from the electronic patient record Patients with a recorded procedure of lsquolive donor nephrectomyrsquo between 2005 and 2017 were identified GFR after donation (calcGFR) was calculated using the formula lsquocalcGFR = Pre-donation Isotope GFR x (Pre-donation Serum creatinine Serum Creatinine)rsquo which is accurate assuming muscle mass does not change Pre and post donation serum creatinines (two days two weeks three months and one to ten year) were recorded We analysed the influence of age sex pre-donation GFR and blood pressure on post donation GFR compensation
Results 355 live donor nephrectomies were performed between January 2005 and December 2016 The mean age was 469 (plusmn 116) years and 504 (n=179) were female Mean pre-donation isotope GFR was 937 plusmn 156 mlmin173m2 Median follow up was 2 years (IQR 1 to 6 years with range 2 weeks to 10 years) The calculated percentage of pre-donation GFR at 2 days 2 weeks 3 months 1 year 5 years and 10 years were 698 691 712 730 801 and 950 respectively (p lt 0001) Patients aged lt50 y had not only a higher calcGFR (858 plusmn 29 mlmin173m2 compared with 671 plusmn 28 mlmin173m2 p lt 0001) at 5 years following donation but achieved a higher degree of compensation than donors gt 50 y (836 plusmn 16 compared with 756 plusmn 19 (p = 0002) Patients with pre-donation hypertension achieved 774 plusmn 53 of pre-donation GFR compared with 804 plusmn 32 in normotensive patients (p = 0998) Females had equivalent degree of renal compensation achieving 819 plusmn 19 compared with 780 plusmn 16 in males (p = 0131) at 5 years following donation Patients with pre-donation GFR gt 100 mlmin173m2 achieved 844 plusmn 23 of pre-donation function by 5 years compared with 777 plusmn 14 in those with pre-donation GFR lt 100 mlmin173m2 (p = 001)
Conclusion Following live donor nephrectomy renal function has a nadir of 691 at 2 weeks Compensation in GFR occurs rapidly and appears to be maintained regardless of sex and pre-donation blood pressure Younger age and higher pre-donation GFR were associated with a greater degree of compensation
A19 The utility of high-sensitivity cardiac troponin to stratify cardiovascular risk in patients with renal impairment
Eve Miller-Hodges Atul Anand Anoop S V Shah Nicholas L Mills Neeraj Dhaun
Background Cardiovascular disease is the most common outcome of chronic kidney disease1
Declining glomerular filtration rate (GFR) and proteinuria predict increased cardiovascular risk over the long term2 However there are currently no methods to stratify cardiovascular risk in the short or medium term in patients with renal impairment We have already shown that high-sensitivity cardiac troponin I concentrations (hs-cTnI) lt5ngL in patients presenting with symptoms of acute coronary syndrome identifies those at low risk of cardiac events within 30 days and over the next year3 However uncertainty remains over the role of hs-cTnI testing in patients with renal impairment This study investigated whether hs-cTnI could also stratify future cardiovascular risk in patients with renal impairment
Methods In a prospective study of consecutive patients presenting with suspected acute coronary syndrome we evaluated the performance of hs-cTnI in patients with and without renal impairment (estimated glomerular filtration rate lt60mLmin173m2) using an early risk stratification threshold of 5ngL to ldquorule outrdquo acute myocardial infarction at presentation and within 30 days and sex-specific 99th centile diagnostic thresholds for index type 1 myocardial infarction Subsequent type 1 myocardial infarction and cardiac death were reported at one year
Results Of 4726 patients identified 904 (19) had renal impairment Index diagnosis of type 1 and type 2 myocardial infarction was almost twice as likely in patients with renal impairment (30 vs 15) Performance of the early risk stratification threshold of 5ngL to identify patients at low risk of major cardiac events was similar in patients with (NPV 984 95CI 960-997 sensitivity 989 95CI 975-999) and without renal impairment (NPV 997 95CI 994-999 sensitivity 984 95CI 972-994) These patients continued to remain at low risk over the next year The PPV and specificity at the 99th centile for diagnosis of myocardial infarction were lower in patients with renal impairment at 500 (95CI 452-548) and 709 (95CI 675-742) respectively compared to 624 (95CI 588-659) and 921 (95CI 912-930) At one year 24 of patients with renal impairment and troponin gt99th centile regardless of index diagnosis had experienced further myocardial infarction or cardiac death compared with 10 of patients without
Conclusion In suspected acute coronary syndrome hs-cTnI can stratify risk in patients with renal impairment Irrespective of diagnosis patients with renal impairment and elevated cardiac troponin concentrations had two-fold greater risk of a major cardiac event compared to those with normal renal function and should be considered for further investigation and treatment
Funders Wellcome Trust British Heart Foundation and Chest Heart amp Stroke Scotland
1 Gansevoort RT Lancet 2013
2 Chronic Kidney Disease Prognosis Consortium Lancet 2010
3 Shah AS Lancet 2015
A20 lsquoDOES IT DIALYSE OUTrsquo - THE EFFECT OF RENAL REPLACEMENT THERAPY ON THE BRAIN Mark Findlay Jesse Dawson David Dickie Deborah McGlynn Patrick Mark Institute of Cardiovascular and Medical Science University of Glasgow amp Queen Elizabeth University Hospital Glasgow
Introduction Cerebrovascular disease is common in end-stage renal disease (ESRD) on renal replacement therapy (RRT) We investigated the effect of RRT on cerebral structure and cognitive function over 12 months Methods Observational cohort study in ESRD patients receiving HD Prior cognitive impairment or cerebrovascular disease were exclusion criteria Multi-domain cognitive testing was performed at baseline and at follow-up Transcranial Doppler was used to assess intra-dialysis related alterations in mean flow velocity (MFV) ndash a marker of cerebral blood flow MR imaging was performed at 0 and 12 months We performed T1 T2 FLAIR and DWI sequences and used volumetric software to calculate white matter hyperintensity (WMH) burden markers of atrophy mean diffusivity and fractional anisotropy (FA) to describe structural changes at 1 year Results 97 patients median age 59 years 412 female At follow-up 15 patients were transplanted 6 died 4 withdrew and the remainder continued HD Those who were transplanted were younger (median age 51 vs 60 years p=0019) and had been on dialysis for a shorter period (median 06 vs 21 years p=0003) MFV declined during HD median 475cms to 405cms plt0001 and correlated with lower scores of executive and frontal lobe function during HD (Rho 045 p lt0001 and Rho -0313 p lt001 respectively) In all patients MR imaging demonstrated a significant decline in frontal parietal and temporal lobe volume at follow-up Median WMH volume increased in those who remained on HD but not in transplanted patients (median change 023 vs -012ml p=0018) WMH burden correlated with worsening scores of frontal lobe tests Rho 0585 p0005 and worse mood Rho -0485 p0026 FA improved following renal transplant (028 to 029 p=0016) and correlated with improved executive function testing at follow-up Rho 089 p0019 Conclusion Cerebral blood flow is reduced during haemodialysis and correlates with a reduction in intradialytic executive function There is an improvement in FA following transplantation WMH volume increases in those who remain on dialysis and the degree of increase correlates with executive and frontal lobe function This suggests that haemodialysis is associated with clinically significant changes in the brain and that these may be ameliorated by transplantation
Source of fundingconflicts MF is funded by a KRUK fellowship
A21 Pathological classification of IgA nephropathy to predict renal outcomes ndash is there a better way to score tubulointerstitial inflammation
Alastair Rankin David Kipgen Bruce Mackinnon Jonathan Fox Colin Geddes Emily McQuarrie Glasgow Renal and Transplant Unit On behalf of the Scottish Renal Biopsy Registry
Background The Oxford pathological classification of IgA nephropathy (IgAN MEST-C score) is limited by the fact that individual features of the score are not all predictive and its utility in assisting clinical decision-making is questioned The addition of tubulointerstitial inflammation to the existing scoring system is appealing but is not currently included due to reportedly wide inter-observer variability We report a novel method to score percentage of cortex containing tubulo-interstitial inflammation in non-atrophic renal cortex (ATIN) in patients with IgAN similar to that used in transplant biopsy reporting and assess its utility to predict clinical outcomes
Methods All adult patients with a native renal biopsy diagnosis of IgAN between 2010 and 2015 in a unit serving 15 million people were identified Baseline characteristics biopsy reports and outcome data were collected ATIN was calculated by subtracting the percentage of atrophic cortex from the percentage of total cortex with tubulo-interstitial inflammation withge10 representing significant tubulo-interstitial inflammation in non-atrophic cortex The primary outcome was a composite of requiring renal replacement therapy (RRT) or doubling of serum creatinine (sCr)
Results 153 new cases of IgAN were identified 33 were excluded (24 had lt8 glomeruli on biopsy 6 inadequate biopsy for MEST scoring and 3 on RRT at time of biopsy) In addition patients with a tubular atrophy (T) score of 2 were also excluded (n=9) Of the remaining 111 patients 76 (68) were male Mean age at biopsy was 52 years (+- 167) and 18 (16) had a co-existing clinical diagnosis of henoch-schonlein purpura (HSP) Median sCr was 156 micromoll (IQR 101-212) and 54 (49) had ATIN on biopsy During a median follow-up of 23 years 34 (31) reached the primary outcome 20 (18) received immunosuppression and 16 (14) died On univariate Cox regression survival analysis ATIN was associated with a four-fold increase in the primary outcome (HR 49 (21-113)) On multivariate analysis mesangial hypercellularity (M) T and ATIN independently predicted renal outcome while endocapillary proliferation (E) and segmental sclerosis (S) did not (plt002 for ATIN) Excluding patients with HSP or those who received immunosuppression did not change the result
Conclusion Within our centre ATIN predicts renal outcome for IgAN independently of established histological features Assessment of inter-observer reproducibility and validation in other cohorts is still required but these results suggest ATIN could be a worthwhile addition to current pathological scoring systems for IgAN
Source of funding none Conflicts of interest none
P1 Polypharmacy in Renal Replacement Therapy Patients
Jason McMinn Colin Geddes Glasgow Renal and Transplant Unit Queen Elizabeth University Hospital
Introduction
Prescribing is often led by evidence from studies containing participants with single health conditions and without multimorbidity Polypharmacy is becoming increasingly recognised in patients with multiple chronic health conditions Additional medications are more likely to result in diminishing returns in benefit with an increased risk of harm Patients with established renal failure (ERF) are likely to be susceptible to medication-related harm A high pill burden is also likely to contribute adversely to an already restricted quality of life and has been associated with poor medication adherence The aim of this study was to analyse polypharmacy in all patients with ERF attending our service
Methods
We extracted medication records for all prevalent ERF patients attending the Glasgow Renal and Transplant Unit from the West of Scotland Electronic Renal Patient Record (SERPR) as of 01012017 The records were analysed to calculate the number of regular medications and total pill burden of each patient These medications were categorised as being lsquopreventativersquo or lsquosymptomaticrsquo We also analysed the prescription of specific drug classes to examine the prevalence of these medications
Results
We identified 1091 transplant follow-up 529 hospital haemodialysis and 46 peritoneal dialysis patients who were on a mean of 94 13 and 129 different medications respectively Overall pill burden was 139 tablets a day in transplant follow-up patients 141 in haemodialysis patients and 162 in peritoneal dialysis patients There were similar rates of prescribing between the different dialysis units and clinics within our service
The proportions of medications deemed as preventative rather than symptomatic were 76 in transplant 69 in haemodialysis and 60 in peritoneal dialysis
In transplant patients decreasing renal function was associated with a higher pill burden but even patients with a transplant eGFR gt 60 were on a mean of 126 tablets per day including a mean of 14 antihypertensives
Rates of antidepressant prescribing were 15 in transplant patients and 20 in hospital haemodialysis patients 53 of haemodialysis patients were on a statin 39 on aspirin 61 on a proton pump inhibitor and 7 were on warfarin
Conclusion
Patients undergoing all forms of renal replacement therapy are likely to be on a considerable number of medications Whilst these drugs are inevitably prescribed for valid reasons this data demonstrates the need for clinicians to engage with patients to explore opportunities to reduce pill burden
Conflict of Interest None Sources of Funding None
P2 An audit of Acute Kidney Injury (AKI) on an acute stroke ward before and after plannedinterventions to review and maintain hydration
Clare Harris1 Simon Hart2 Fiona Duthie3 1 University of Edinburgh Medical School 2 Stroke Unit Royal Infirmary of Edinburgh 3 Renal Unit Royal Infirmary of Edinburgh
Background Dehydration is an important factor in the development of acute kidney injury which is associated with increased morbidity and mortality particularly in the elderly population Poor fluid intake is common post stroke (1) and dehydration is associated with poorer outcomes 3 months post stroke (2) In late 2014 there was no system of identifying patients with poor oral intake on the stroke ward at the Royal Infirmary of Edinburgh a hydration protocol and education programme were implemented aiming to improve fluid balance This included the use of prescribed water either orally or by nasogastric tube An audit pre and post intervention demonstrated that hydration as measured by ureacreatinine ratio significantly improved after the protocol introduction (3) We aimed to determine whether the incidence of AKI by KDIGO criteria was also reduced as this could have implications for reducing patient morbidity and mortality in this elderly comorbid patient cohort
Method 150 inpatients to the acute stroke ward during JulAug 2014 and JulAug 2015 were selected (n= 80 2014 n=70 2015) Patient data and creatinine values were collected from the electronic patient record and medical notes and retrospectively analysed Baseline creatinine values were calculated and cases of AKI were identified and staged using KDIGO criteria (4) Chi-Squared tests were performed to determine P values Individual patient notes were reviewed for both quantitative and qualitative data of patient management
Results Incidence of AKI (of any stage) was 263 pre-protocol and 200 post-protocol (P=03646) Incidence of AKI stages 23 was 100 pre-protocol and 715 post-protocol (P=05374) In hospital post stroke mortality was 338 pre-protocol and 1286 post protocol (P=00028) AKI was also associated with increased length of stay
Conclusions Despite a trend in benefit there was no significant difference in incidence of AKI pre and post hydration protocol nor in incidence of severe AKI (stage 23) AKI is influenced by many factors one of which is hydration status Further studies are needed to determine whether the trend of benefit exhibited in this sample is significant in a greater sample size if this were the case such a protocol could have great benefit to patient care on stroke units and elsewhere There was a significant difference in inpatient post stroke mortality following introduction of the hydration protocol Further investigations are needed to explain underlying reasons for this factors other than hydration may play an important role
References 1 Whelan K Inadequate fluid intakes in dysphagic acute stroke Clinical Nutrition (2001) 20(5)
423-428 2 Bhalla A Sankaralingam S Dundas R Swaminathan R Wolfe CDA Rudd AG The influence of
raised plasma osmolality on clinical outcome after acute stroke Stroke (2000) 312043ndash2048 3 Hart SR Craig R Berry E Lane N Gad A Farrugia M Burton L Paquay A What Happens to
Acute Stroke Patientsrsquo Fluid Balance Renal Status and Dehydration in the First Two Weeks How Can They Be Markedly Improved doi 101111ijs12634_13
4 KDIGO Clinical Practice Guideline for Acute Kidney InjuryKidney international supplements (2012) 2(1) 1-138
No funding or conflict of interest to declare
P3NHS Highland-Improving the management of hyperkalaemia using a kit Initial resultsCantley N1 Abedin T2 Lambie S3
1FY2 NHS Highland 2ST4 Renal Medicine NHS Grampian 3Renal Consultant Renal unitRaigmore Hospital Inverness
Introduction The incidence of hyperkalaemia in hospitalised in patients is between 1 and 10 Guidelines in Northern Ireland promote the use of a Hyperkalaemia Kit to improve management of hyperkalaemia We assessed the management of hyperkalaemia in Raigmore Hospital including post-treatment monitoring of serum potassium and blood glucose at baseline and after the introduction of a lsquoHyperkalaemia Kitrsquo which contains a pro forma for the management of hyperkalaemia and all the relevant equipment and drugs for treatment
Method Between July and September 2016 an automated algorithm identified 34 patients with a potassium result 65 mmoll or above on laboratory results 12 received no specific treatment of these 6 results were spurious 4 patients died before treatment could be started and 2 patients were chronic haemodialysis patients We introduced the Hyperkalaemia Kit to the Acute Medical Admissions Unit in Raigmore Hospital Since then 15 patients have been identified with serum potassium measurements above 65 and the pro forma and kit was used with eight of these patients One of these patients proceeded straight to acute renal replacement therapy
Results Prior to our intervention all 22 patients that were actively treated received at least one prescription of appropriate doses of Insulin with Dextrose However only 16 patients received intravenous calcium and only 7 received nebulised Salbutamol Potassium was measured at 4 hours in 5 cases and by 12 hours in 17 cases Monitoring of any capillary blood glucose was only documented in 8 cases Of the 22 treated 2 needed acute renal replacement therapy 3 required further doses of insulin and dextrose 2 were treated with Calcium Resonium
Eight cases of hyperkalaemia have been managed with the use of the kit and pro-forma so far An initial ECG was performed in all eight and four patients had continuous cardiac monitoring Intravenous calcium was given in seven and nebulised Salbutamol was given in five out of the eight cases Six out of eight patients had at least three blood sugar measurements One had two measurements documented and one patient was stopped from further monitoring following senior review and decision to palliate Seven patients had appropriate monitoring of their serum potassium by 4h and 12h again one patient was not monitored due to palliation
Conclusion Baseline results showed very low rates of prescription of nebulised Salbutamol low rates of Calcium Gluconate use and very low monitoring of blood sugars and potassium post treatment This has the potential for serious adverse outcomes particularly the potential for iatrogenic hypoglycaemia Our initial data shows the use of a Hyperkalaemia pro forma and kit improves the rate of prescription of intravenous calcium and nebulised Salbutamol and the post-treatment monitoring of serum potassium and blood sugar levels
P4Rituximab as maintenance therapy in ANCA associated vasculitisndash a single centre experience Rathnamalala NK Mcmenamin J Robertson S Almond A Kelly M Muniraju T M Renal Unit Dumfries and Galloway Royal Infirmary NHS Dumfries and Galloway Background The introduction of Cyclophosphamide and high dose steroids transformed ANCA associate vasculitis (AAV) from a disease of high mortality to a relapsing remitting disease Maintenance of remission however still remains a major challenge A two randomised clinical trials have looked at the use of Rituximab in remission induction in AAV and reported similar remission rates between Cyclophosphamide and Rituximab 12 Both these trials used Azathioprine as maintenance therapy and in the follow up showed similar remission rates with either agent for induction The role of Rituximab for maintenance therapy after cyclophosphamide induction was studied in the MAINRITSAN trial 3 Rituximab was compared with azathioprine and found that the relapse rate was significantly lower in the Rituximab group There have been several other retrospective studies that have suggested regular Rituximab infusions are successful in maintaining remission however has not been thoroughly evaluated 4 5678910 Here we share our centrersquos experience using Rituximab for maintenance of remission of AAV Materials and methods We conducted a retrospective review of electronic medical records of all patients who had received Rituximab as maintenance therapy for 12 months or longer between January 2014 to July 2016 Disease activity was assessed using Birmingham Vasculitis Activity Score ( BVAS) Version 3 and complete remission was defined as a score of 0 and partial remission as a score of lt50 of the value at diagnosis Due to uncertainties associated with sub classification we did not assign specific diagnosis but broadly classified as ANCA associated vasculitis Results 6 patients received Rituximab as maintenance therapy during the study period 3 (50) of them had eye ear nose and upper airway manifestations consistent with Granulomatosis with Polyangitis (GPA) All patients were PR3 ANCA positive except for one at initial diagnosis The mean BVAS score at the time of initiation of Rituximab was 4 All patients were initiated on Rituximab for relapses while on maintenance therapy with Azathioprine 4 patients received 6 monthly doses of Rituximab while two received annual doses All of them were also maintained on 5-10 mg of Prednisolone The mean BVAS score by 6 months was 0 and remained 0 at 12 months The mean PR3 titre was 562 at the initiation of treatment while at 12 months it had come down to 68 All patients remained in complete clinical remission at the end of 12 months after initiation of therapy Rituximab was well tolerated by all patients except one who developed pyrexia during an administration
Conclusions All patients had sustained remission at 6 months and 12 months after initiating Rituximab Rituximab has a potential role as maintenance therapy in AAV
P5 Chronic Myelo-Monocytic Leukaemia (CMML) as a contraindication to renal biopsy Alastair Rankin Emily McQuarrie Jennifer Lees Bruce MacKinnon Glasgow Renal and Transplant Unit On behalf of the Scottish Renal Biopsy Registry
Abstract Chronic Myelo-Monocytic Leukaemia (CMML) is a relatively rare mixed myelodysplastic myeloproliferative disorder that predominately affects patients over the age of 65 years Renal impairment in patients with CMML is well described with several different mechanisms reported including tumour infiltration lysozyme-induced injury amyloid deposition and tubulointerstitial nephritis From anecdotal evidence within our centre we are concerned that patients with CMML have an excessive risk of clinically significant bleeding following native renal biopsy This risk appears disproportionate to the degree of any co-existing thrombocytopenia or coagulopathy
We review the cases of 4 patients with an existing diagnosis of CMML who were referred to the renal clinic with proteinuria and excretory renal dysfunction Two of these patients underwent renal biopsy with subsequent major haemorrhage post-procedure despite normal bleeding parameters pre-procedure Patient 1 presented with flank pain 8 days post-biopsy A CT confirmed peri-nephric haematoma with retroperitoneal extension A total of 6 units of packed red cells (PRCs) were transfused prior to successful CT-guided emoblisation Histology from the biopsy revealed chronic tubulointerstitial nephritis Patient 2 experienced haemodynamic instability and haematuria one hour post-biopsy A total of 11 units of PRCs 7 units of fresh frozen plasma 2 pools of platelets intravenous tranexamic acid and 2 attempts at CT-guided embolization were required until haemostasis was achieved Histology later showed evidence of tumour infiltration with associated vasculitis Patient 3 presented with renal impairment and proteinuria on the background of known CMML Following discussion with haematology the risk of bleeding following renal biopsy was considered unjustifiable despite their platelets and coagulation screen being within normal range The patient was treated for presumed renal tumour infiltration with hydroxycarbamide Patient 4 was referred to the renal clinic with acute onset nephrotic syndrome Urinary proteincreatinine ratio was elevated over 800 mgmmol with serum albumin of 23 gL but normal excretory renal function The patient attends the haematology clinic with suspected CMML and chronic thrombocytopenia but previously declined bone marrow biopsy Following discussion with the patient there are no plans to proceed with renal biopsy given potential risks These cases highlight that while CMML is rare these patients are being referred to renal clinics with features that would commonly justify renal biopsy in other settings but in whom there may be an increased risk of bleeding post-procedure Our in-centre risk of major bleeding is 2 therefore to have such extreme amounts of bleeding in 2 patients with this underlying diagnosis is remarkable This creates a dilemma for the clinician as there is a wide range of potential renal pathology associated with CMML some of which will have disease specific but relatively toxic treatments available
Source of funding none Conflicts of interest none
P6 NHS Highland-Prograf to Adoport switch McCulloch K1 Peel R2 Lambie S3
1Renal Pharmacist Renal unit Raigmore Hospital Inverness 23Renal Consultant Renal unit Raigmore Hospital Inverness
Introduction NHS Highland (NHSH) is the first health board in Scotland to implement a switch from Prograf to Adoport for renal transplant patients This will provide considerable cost savings Adoport meets the bioequivalence criteria for drugs with a narrow therapeutic index set by the European Medicines agency and studies indicate therapeutic equivalence1 with the proviso that brands are non- interchangeable unless the switch is overseen by a Renal Consultant and post-conversion therapeutic drug monitoring is conducted23 The switch has been undertaken by a majority of transplant centres in England the main difference being that they have undergone repatriation NHSH Patients receive their transplant primarily at Royal Infirmary of Edinburgh and occasionally at Queen Elizabeth University Hospital Glasgow Care is transferred to NHS Highland on discharge NHS Highland cares for approximately 170 renal transplant patients 110 being prescribed Prograf These patients may live as far as 110 miles from Raigmore Hospital Given that prescribing is carried out by primary care clear communication with patients GPs and community pharmacy is essential to avoid inadvertent switching between brands
Method Clinically it was agreed a switch could be safely undertaken A business case was submitted and funding secured for pharmacist time laboratory costs and primary care time GPs have been informed via GP subgroup and local prescribing bulletin lsquoThe Pink Onersquo Community pharmacies are being informed by phone A protocol has been agreed Eligible patients selected by Renal Consultant and Renal Pharmacist Patients sent letter signed by Renal Consultant and Renal pharmacist Patients phoned prior to clinic to agree Adoport start date and address concerns Patient seen by Renal Consultant and pharmacist + given 1 month of Adoport Tacrolimus level and UampEs checked 5-7 days after commencing Adoport and patient
contacted by phone to check if tolerated If stable letter sent to GP and community pharmacy to continue supply
Results and Evaluation Letters have been sent to all eligible patients Seven patients have been reviewed One has received a one month supply of Adoport and 5 others are due to switch One patient was deemed non-eligible at present as they have a 6 month surplus of Prograf A database will be maintained and analysed at the end and primary care savings will be monitored Extra pharmacist input will give us the opportunity to review how immunosuppression is managed and to evaluate the benefit of having a renal transplant pharmacist Conclusion The switch is at an early stage Ultimately we hope to show that the switch from Prograf to Adoport can be managed safely with extra pharmacist input to a remote and rural population with prescribing being conducted by primary care
Fundingconflicts of interest none 1 McDevitt-Potter LM Sadaka B Tichy EM Rogers CC Gabardi S Transplantation 2011 A multicenter experience with
generic tacrolimus conversion 2 Medicines and Health Products Regulatory Agency Drug Safety Update 2012 Accessed online via
wwwmhragovukSafetyinformationDrugSafetyUpdateCON1557563 ESPRIT Guidance on management of repatriation and immunosuppressant switches in transplant patients 2015
Accessed online via httpwwwespritorgukwp-contentuploads201508Switch-guidance-document-final-Aug-31-2015pdf
P7 NHS Highland-Tacrolimus baseline dataMcCulloch K1 Peel R2 Lambie S3
1Renal Pharmacist Renal unit Raigmore Hospital Inverness 2Renal Consultant Renal unitRaigmore Hospital Inverness 3Renal Consultant Renal unit Raigmore Hospital Inverness
BackgroundAs part of planning a switch from using tacrolimus Prograf to Adoport we assessed baseline data for our transplant patients currently using Prograf After converting patients to Adoport we will compare their tacrolimus levels to their individual target range We assessed our use of appropriate target ranges and our current performance in achieving tacrolimus levels within target range on Prograf therapy
Method 107 renal transplant patients taking Prograf were identified a sample of 19 of these were analysed using electronic patient records and results Time from transplant ranged from 1 month to 18 years All tacrolimus levels for the preceding year were analysed and compared to the target range specified at the time of the level being done The assay used has a Coefficient of Variation of lt5 at the lower limit of the assay
Results All 19 patients had a target range for tacrolimus clearly identified and recorded in clinic letterswhich are routinely copied to the patients themselves A variety of target ranges were specifiedThe commonest used was 5-8 microgramsl in 7 patients followed by 5-7 in a further 4 patientswith another 6 different target ranges being used for the remaining 8 patients The ranges usedhad a breadth of 3 microgramsl in 2 cases the rest had a breadth of 2 microgramslPatients had a median of 12 (range 3-72) tacrolimus levels over the preceding year Results werewithin specified target ranges for 54 +- 22 (Medan +- SD) of results checked
Conclusion We currently use a large number of different target ranges The majority of the ranges used had a breadth of just 2 microgramsl These factors help to account for the low proportion of test results which were within the specified target ranges This is important to bear in mind when interpreting whether tacrolimus levels are within target ranges after switching to Adoport We should consider aligning our target ranges and widening them
P8 Eculizumab use in Scottish paediatric dense deposit disease Stewart D1 David Hughes1 Lynne Riach2 Craig Oxley2 Athavale D1
1Royal Hospital for Children Glasgow 2Royal Aberdeen Childrenrsquos Hospital Aberdeen
Introduction The revised MPGN classification and increasing recognition of Dense Deposit Disease (DDD) a C3 glomerulopathy as an alternative complement pathway disorder suggests Eculizumab an anti-C5 monoclonal antibody may be beneficial in treatment However the experience of Eculizumab as an off-label and expensive treatment in children with DDD is limited with variable clinical response reported in the literature
Method We present the outcomes of the only 2 paediatric patients in Scotland who have received Eculizumab for the management of DDD
Results Case 1 A 10 year old male presented with proteinuria and haematuria resistant to steroid treatment with preserved renal function Initial biopsy confirmed DDD Conservative management with an angiotensin converting enzyme inhibitor and diuretics for symptom control continued until 14 years Due to worsening symptoms (oedema lethargy poor growth) and renal function deterioration along with elevated terminal complement complex (TCC) Eculizumab was commenced A repeat biopsy whilst suggestive of chronic irreversible damage showed 25 glomerular architecture preservation Symptom improvement was noted There was a reduction in proteinuria and renal function stabilisation fall in TCC and discontinuation of diuretics Eculizumab was discontinued after 24 months Progression of renal function decline was seen in the final months of Eculizumab therapy With recurrence of symptoms and increasing proteinuria following discontinuation Eculizumab was recommenced after 6 months Symptomatic improvement has since been noted
Case 2 A 5 year old girl presented with painless frank haematuria and proteinuria Initial biopsy confirmed DDD Proteinuria was unresponsive to steroid therapy and 5 months following diagnosis she rapidly progressed towards end stage renal disease despite the introduction of Mycophenolate Mofetil and plasmapheresis Haemodialysis was subsequently commenced TCC level was elevated and Eculizumab treatment was started 7 months after diagnosis Renal biopsy prior to treatment demonstrated continued severe pathological changes in all visible glomeruli However due to lack of clinical response Eculizumab was discontinued after 2 months and the patient remained dialysis dependent
Conclusions Our experience with Eculizumab in Scotland has demonstrated variable results in our 2 patients with one patient showing a positive response whilst the other experienced no improvement Eculizumab was administered to both patients at varying points in their clinical journey with differing progressive features on biopsy To date the outcomes of 9 paediatric patients with DDD treated with Eculizumab have been described in the literature with 8 experiencing some positive response to treatment including 2 patients who were able to stop renal replacement therapy within 12 weeks of treatment A role for Eculizumab in DDD may be guided by clinical and pathological features Well designed clinical trials will be necessary to define the role of complement inhibition therapy in DDD
No conflict of interest and no funding requested
P9 Examining markers of safety in the use of non-tunnelled central venous catheters
James WT Millar (Speciality Registrar) Scott W Oliver (Speciality Registrar) Peter C Thomson (Consultant Nephrologist) Glasgow Renal and Transplant Unit Queen Elizabeth University Hospital Glasgow
Background Non-tunnelled central venous catheters (NTCVC) remain an essential means of vascular access for incident haemodialysis Associated morbidity is well recognised for example in the form of Staphylococcus aureus bloodstream infections (SAB)[1]
Previous quality improvement initiatives in our unit have sought to both improve traditional markers of quality (such as SAB) and to identify additional areas of clinical risk In 2014 Oliver et al [2] suggested several additional quality measures including peri-procedure haemoglobin drop the need for a further NTCVC during the same clinical episode and the NTCVC insertion site This study further evaluated NTCVC related clinical practice within our unit
Methods The potential markers of clinical quality identified in a previous project were examined using prospectively collected data stored in the electronic patient record Identified cases of SAB significant peri-procedure haemoglobin drop and multiple NTCVC insertion were investigated by case note review
Results Between March 2016 and March 2017 a total of 222 patients received 346 NTCVC 54 patients (243) had more than one NTCVC inserted in a 21-day period (range 2-5) When considering NTCVC insertion site there were 159 (459) femoral vein catheters and 183 (541) internal jugular vein catheters No pneumothoraces were reported
15 SABrsquos were reported during this period equating to 43 of all NTCVC 5 arose in patients with femoral NTCVC (333) and 10 from internal jugular catheters (667) Mean time from line insertion to positive blood culture was 86 days 15 (67) patients had a drop in haemoglobin of greater than 20mgdl with no other source of blood loss identified on review of clinical notes
Discussion These data demonstrate that NTCVC-associated SAB rates remain low and significantly below Scottish government audit standards [3] Of interest is the continued trend towards the use of femoral catheters at 45 of lines compared with 38 in 2014 [2] Although traditionally thought of as having a higher incidence of infectious complications our data has shown fewer bacteraemia events associated with femoral catheters compared with internal jugular Our data also demonstrates a significant rate of peri-procedure haemorrhage arising in up to 1 in 20 cases Together these findings present opportunities to development practice and improve patient safety
References
[1] Murray E Deighan C Geddes CC Thomson PC Reducing haemodialysis bacteraemia rates Scottish Renal Association Glasgow November 2013 [2] Oliver SW Thomson PC Jardine AG defining safe effective and patient-centred dialysis catheter placement Scottish Renal Association Edinburgh September 2014 [3] The Staphylococcus aureus bacteraemia quarterly report of cumulative data from all NHS Boards in Scotland Health Protection Scotland January 2015
Sources of funding none Conflicts of interest none
P10 Prescribing of tolvaptan-The NHS Highland experience Lambie S1 McCulloch K2 Garrod J3
1Renal Consultant Renal unit Raigmore Hospital Inverness 2Renal Pharmacist Renal unit Raigmore Hospital Inverness 3Renal Pharmacist Renal unit Raigmore Hospital Inverness
Introduction Tolvaptan is a vasopressin antagonist It was accepted for use in Scotland by SMC in Jan 2016 to slow the progression of cyst development and renal insufficiency of autosomal dominant polycystic kidney disease in adults with chronic kidney disease (CKD) stage 1 to 3 at initiation of treatment with evidence of rapidly progressing disease1 Adverse effects related to aquaresis may affect patientsrsquo ability to achieve the optimum therapeutic dose and the risk of hepatic toxicity necessitates regular LFT monitoring The geography of NHS Highland required the implementation of novel methods of managing these patients and as a result a MDT approach with an emphasis on pharmacist input was adopted Consultant role Patient selection on the basis of evidence of rapidly progressing kidney disease declining
eGFR large volume kidneys on ultrasound and evidence of complications of PKD Side effects and potential benefits discussed Potential medication interactions reviewed Jinarc risk management prescriber training
Pharmacist role Undertook Jinarc risk management pharmacist training Prepares accurate drug history and reviews for potential drug interactions Carries out patient counselling and supplies patient education material sick day rules card
and lsquogot to gorsquo card Supplies GP education leaflet Provides advice on selection of new drug therapies eg for gout Manages stock and coordinates supply to patients
Results Prescribing commenced May 2016 patients currently prescribed tolvaptan 11 7 Female 4 male Number on target dose 73 n = 811 2 patients are still being titrated One patient did
not tolerate target dose due to aquaresis side effects and is being trialled on the middle dose
Withdrawals One patient has withdrawn due to agoraphobia and an inability to attend for monitoring and another is on hold due to having major surgery
Conclusion The MDT approach between the Renal Consultant and Pharmacist at Raigmore Hospital has enabled tolvaptan prescribing to be efficiently and safely implemented to patients living within a challenging geographical location
1 Scottish Medicines Consortium Detailed Advice Document tolvaptan 15mg 30mg 45mg 60mg and 90mg tablets (Jinarcreg) SMC No 111415 January 2016
NA1 Authors SCN Jacqueline Ross NHS Grampian
SCN Alan Somerville NHS Lanarkshire SCN Jane Humphrey NHS Lanarkshire
e- mail contact jacquelinerossnhsnet Alansommervillelanarkshirescotnhsuk
Janehumphreylanarkshirescotnhsuk
Phone contact 01224 552927 01236 712644
Title Sharing of Adverse Events in Renal Units across Scotland
Introduction Background The Scottish Renal Nurses Strategy Group (SRNSG) are a group of senior nurses from Renal
Units across Scotland who meet 3-4 times per year to discuss and implement best practice At the last meeting it was agreed that it would be good practice for each Health Board to share
their adverse events reported on the Datix System and deliver a presentation with an action plan to prevent incidents and improve patient safety across Scotland NHS Grampian and NHS Lanarkshire will be the first to deliver this presentation discussing adverse events from both Health Boards with an action plan
Top 5 adverse events over the past 12 months Renal Unit NHS Grampian 1 Violence and Aggression 2 Accidents including needlesticks slips trips and falls 3 Medication Errors 4 Infrastructure Staffing and Estates 5 Machines and Equipment
Top 5 adverse events over past 12 months Renal Unit NHS Lanarkshire
1 Slips Trips or Falls 2 Medicine errors 3 Treatment problems 4 Transfer problems 5 Breach of policy
The presentation will also focus on any serious adverse events which may not be in the top 5 categories
Aim Objective Each Health Board to share their adverse events with the aim to prevent them from occurring in other units to improve staff and patient safety and wellbeing across Scotland
Method Power Point Presentation
Outcome Results Sharing of adverse events resulting in the development of a national Action Plan to prevent these incidents improving safety and well being of staff and patients in Renal Units across Scotland
NA2
SRA Oct 2017 Abstract
BBV Never Event - The whats whys and hows
Staff Nurse Gillian Wilson Aberdeen Royal Infirmary
This presentation shares our experience of a never event that occurred and was not picked up for
a period of 18 months
Hepatitis C (HCV) positive antibodies were found in a previously negative patient
These results were a low positive with no biochemistry changes to suggest any liver damage
however steps were put immediately in place to isolate and investigate
Was it contamination from a dialysis machine was it related to a blood transfusion given prior to
first positive result was it faulty diagnostic tests in the laboratory
In Aberdeen we go over and above national guidelines and isolate all our BBV patients whether
they have positive blood results or are PCR negative
Further bloods tested at an external laboratory confirmed negative results
It highlighted that communication errors were to blame for the lack of speed in detecting this issue
Investigations concluded no real answers as to why this happened
NA3
Living Donation Scotland Changing attitudes towards living donor kidney transplantation
Jen Lumsdaine Julie Glen On behalf of the Living Donation Scotland Project Board
Background and aims
The rate of living donor transplantation has remained fairly static in Scotland over the past 10 years
Recent data has shown inequity of access to living donor transplantation throughout the UK so
there is potential to significantly increase this optimum form of treatment for patients with end-stage
renal failure in Scotland The Living Donation Project Board was formed in 2016 aiming to double
the number of living donor transplants by 2020
Method
The two key areas
1 Do recipients receive adequate and appropriate information at the right time about living
kidney donation
2 Informing the general public about altruistic donation
All patients active on the transplant list in Scotland were invited to an information event A follow-up
questionnaire was performed in the East of Scotland examining outcome or reasons for not
attending A scoping exercise looked at information provided by each unit was performed and link
nephrologists and low clearance nurses attended meeting to discuss strategies for early education
Outcome
An information pack containing both recipient and donor written information and short films on DVD
has been produced with the support of the Scottish Government for all recipients and potential
donors in Scotland A new website with comprehensive information both written and visual and
postcode finder to improve ease of access to local unit contact details has been developed
Two national media campaigns have been launched with a significant rise in the number of enquiries
from potential donors and actual increase in altruistic donor numbers
Nursing abstract ndash no conflict of interest
NA4Authors Susan Easson Charge Nurse Ward 4C QEUH Glasgow
e- mail contact SusanEassonggcscotnhsuk
Phone contact 0141 452 3300
Title A Conversational approach to find out ldquoWhat matters to yourdquo in a Renal Transplant ward
Introduction Background Finding out ldquo What Mattersrdquo to people using health and careservices is crucial to delivering safe effective and person centred care It is a simple yet profoundconcept and tries to get to the essence of person centred care by creating deeply personalengagements with patients and their families through a conversational approach However careexperience feedback all too often provides innumerable examples of where what really matters topatients and their family members is poorly understood or not addressed Using care experienceas the driver for change the nursing staff in Ward 4C used improvement approaches to explorehow to hold more meaningful ldquoWhat Matters to yourdquo conversations on a daily basis
Aim Objective To improve the patient experience by utilising a person centred approach
Method Using Care experience feedback What Matters to Me boards and the conversationalapproach
Outcome Results Improvements in patient experience will be shared using examples ofpractice and care experience feedback
There was no additional funding required for this project We worked in collaboration with theperson centred team whorsquos aim is to improve patient experience
NA5
The implementation of a renal education programme and its impact on clinical practice
The purpose was to implement a Renal Education Programme and to evaluate its impact on
clinical practise
It was identified that there was a need for an educational programme to be set up within Forth
Valley Royal Hospital There is no inpatient renal unit in FVRH on site for our renal patients they
attend Queen Elizabeth University Hospital We are an outpatient haemodialysis unit with
outpatient clinics on site Therefore it was identified that there was a need for nursing staff within
FVRH to be educated on all renal complexities for the benefit of our patients
This was done through a work-based learning approach which brought tangible benefits for our
patients However it did not come without pitfalls as educational programmes are often seen as
making very little difference to clinical practise
T
his study describes what methods were used and examines the advantages and disadvantages in
setting up an educational programme and evaluating its impact on clinical practise
NA6
Nursing Abstract ndash SRA Meeting ndash 26 October 2017
Chris McGee Tonya Broe Ken Weir
Renal Unit Forth Valley Royal Hospital
Use of the Therapy Monitor Haemodialysis Patient Record System Can we aim for a paper-
free dialysis unit
We are trialling a new haemodialysis patient monitoring system to work in conjunction with SERPR
and which is intended to supersede the Finesse system used previously
We are in the early stages of this process but with continuing staff education and regular tech
support we are hoping to gather sufficient evidence to evaluate whether the use of paper case
notes needs to continue
Is it a realistic goal to aim for a completely paper-free unit
NA7
THE CLINICAL USES OF APHERESIS WITHIN NHS TAYSIDE
Laura Thomson CN
Ninewells Hospital Dundee
NHS Tayside took over the apheresis service from BTS in 2012 The service has since expanded
with the benefits of carrying out this treatment has been widely recognised within NHS Tayside
and is now more commonly being offered to treat a wider range of conditions with the number of
treatments carried out each year rising
This presentation will highlight the progression of the apheresis service within NHS Tayside We
will identify the various conditions it is currently being used to treat and also identify the decision
making process involved in carrying out these treatments ie which replacement fluid will be used
anticoagulation medication administered
We will highlight the benefits and challenges we face in providing this expanding service within the
Renal Service
NA8Authors Linda McDougall Renal Physiotherapist NHS Highland
e- mail contact lindamcdougall1nhsnet
Phone contact 01463 706022
Title lsquoExercise on Haemodialysis- Keeping the Wheels in Motionrsquo
Introduction Background The impact of CKD on physical fitness functional ability independence amp ultimately quality of life cannot be underestimated Current national guidelines recommend that all individuals with CKD are encouraged to participate in regular exercise programmes between or during dialysis sessions if on HD Following a successful pilot study funding was approved to establish an lsquoExercise on Dialysisrsquo (EOD) programme across NHS Highland through the appointment of a dedicated renal physiotherapist in 2008 A successful programme was soon established but for several years post-vacancies and increasing in-patient demands limited the physiotherapy servicersquos ability to deliver the programme The need to improve the long-term sustainability of the service was recognised and in late 2016 funding was approved to develop a Band 4 PT HCSW role for this purpose
Aim ObjectiveTo optimise the sustainability and continuity of the lsquoExercise on Dialysisrsquo service across NHSHighland through development of a Band 4 PT HCSW role
Method The potential parameters of the role and limits of autonomy were scoped out using current NES resources and guidelines Service and task analysis was then carried out to establish which components of the EOD protocol could be undertaken by a Band 4 A series of competencies were developed in line with the clinical protocol and one-to-one training and supervision provided to the post-holder to ensure competency achieved in delivering the programme
Outcome Results A 10 WTE Band 4 PT HCSW was appointed in Jan 2017 with a dual role between the renal unit and acute medical wards Although training is not yet complete the post-holder is already running the day-to-day delivery and monthly audit of the EOD service with senior physiotherapist input only required for individual patient safety queries and general discussion around patientsrsquo progress and goals The benefit to the unit has been considerable as the band 4 is available to support patients and staff with EOD provision 5 days a week This allows for one-to-one supervision of patients who need more support to participate in EOD regular feedback on performance and reviews of outcome measures and goals to maintain motivation levels Feedback on the post has been very positive and its scope will only continue to expand as we look to further develop renal rehabilitation services across NHS Highland
NA9Authors Nadine Lyall and Kerry Guthrie
e- mail contact nadinelyallbordersscotnhsuk kerryguthriebordersscotnhsuk
Phone contact 01896 826637
Title The Developing Role of the NMP in a Satellite Dialysis Unit
Introduction Background
We have been practising as NMPrsquos for nearly 3 years working in the dialysis unit at the BGH The unit is a satellite unit of the ERI and we have expanded over the last 6 years The unit provides haemodialysis for 12 patients at any one time 3 sessions a day 6 days a week We are nurse-led and have 2 renal consultants who are based at the ERI
We saw an opportunity to use our knowledge and experience to develop our role By becoming NMPrsquos we have enhanced our professional development and we feel we meet the changing needs of the dialysis patient in a more holistic manner
Aim Objective
Our aim is to deliver effective care as we are better placed to deal with issues that often arise byacting swiftly this in turn is cost effective and convenient For example good anaemia and bonemanagement is important for their health wellbeing and lifespanTo help understand our role we will use a power point presentation highlighting issues we dealwith and the drugs we prescribe under the following headings Cardiovascular infection painanticoagulant disequilibrium diet renal bone disease and renal anaemia
Method Power point
Outcome Results
In the future we hope to further develop and have greater autonomy in our role We have great support from our renal consultants and have already built up a great relationship with our patients We hope to undertake the Clinical Decision Making course and this in turn will allow us to deal effectively with acute illness giving the dialysis patient better care We are keen to get feedback from other renal nurses in Scotland to enable us to develop our role further and in turn raise awareness of the NMP role in a dialysis unit We record all our prescribing decisions and keep the consultants up to date regularly Currently we are working on auditing our prescribing practice so that we can improve the service we can provide
NA10 Title Komunikacja w szkoleniu dializy ortzewnowej
Author Senior Charge Nurse Rhoda Bell
Address Raigmore Hospital Old Perth Road Inverness IV2 3UJ
Email rhodabellnhsnet Telephone 01463706023
Introduction Background Case study on lady with Polish as her first language she has some English but requires an interpreter to carry out Peritoneal Dialysis training and attend clinic She had some gynaecological issues that we were not aware of which impacted on the functionality of PD and therefore the success of treatment There were areas of concern in low clearance clinic with signs the patient had a reluctance to engage in decision making
AimObjective
Methods Discussion through the case study highlighted issues with communication between different PD staff and patients Areas of concern include different staffing techniques environment factors on training success Also language and communication issues the patient had were not fully apparent so training could not be individualised
Results We plan to trial training at home and have more individualised training schedule for patients The training step by step guides have been reviewed and practise standardised In collaboration with low clearance nurse we have developed a check list which will highlight concerns before the transition to PD ie language issues and need for training aids in another language gynaecological conditions
Conclusions Everyone learns differently and training methodsaids must be individualised for all It may not be apparent until training has commenced that there are concerns Having one to one training with the same nurse will consolidate training and build confidence in the patient Having a close working relationship with members of the MDT will help make a supportive PD journey
Would we do things differently if we knew about prolapse or lack of English both spoken and written
Key words - Peritoneal dialysis patient training communication
N11
Telehealth amp PDAudrey Jones
Advantages
Information on a daily basis about treatment weight and blood pressure
Change programme remotely via computer or mobile
Earlier intervention for machineprogramme issues
Reduction in home visits ie patient trained but still requires volume increases
No need to download cards to see what problems have been
Can have more detailed information available at clinics
Disadvantages
Relying on patient input data correctly
Machine is noisy especially first wave of machine
Still the same bag connection system and patient connection system (difficult for manual
dexterity problems)
Relying on patient having good signal
Modem problems
NA12Autosomal Dominant Polycystic Kidney Disease A cruel inheritance but new hopeAlistair Lawrie Renal Unit Victoria Hospital KirkcaldySadaf Arshad Corry Dunnigan Paul Phelan Neil Turner Renal Unit Royal Infirmary of Edinburgh
Background Autosomal Dominant Polycystic Kidney Disease (ADPKD) is the most prevalent single gene human genetic disorder and the most common of the inherited cystic and interstitial kidney diseases It is estimated to affect 1 in every 1000 individuals worldwide with over 50 of sufferers eventually developing end stage kidney disease and requiring dialysis or transplantation Symptoms include spasmodic severe pain hypertension haematuria infection and kidney failure There is currently no cure for ADPKD Management of the condition has traditionally involved lifestyle modification BP control and analgesia however a recent study (Torres et al 2012) demonstrated that treatment with V2-receptor antagonist drugs slowed increase in total kidney volume reduced the rate of functional decline and showed a reduced incidence of kidney pain
Aim Provision of a tolvaptan prescribing and monitoring service
Methods Experiential finding report of initial twelve months period of multidisciplinary ADPKDtolvaptan clinic
Results Early results are comparable with TEMPO study outcomes
Conclusion Due to the long term nature of this treatment results available at this time are showing only the earliest benefits of the intervention More quantifiable results such as increased time before the necessity for RRT will only be evident in coming years Torres VE et al (2012) Tolvaptan in Patients with Autosomal Dominant Polycystic Kidney Disease New England Journal of Medicine 367 pp 2407-2418 DOI 101056NEJMoa1205311
No funding requirement No conflict of interest
A3 Glucose dynamics and mortality in RRT patients an initial report
Matthew A Rutherford12 Gregory C Jones3 Alan G Jardine14 Patrick B Mark14 Peter C Thomson12 Christopher AR Sainsbury3
1 Glasgow Renal and Transplant Unit Queen Elizabeth University Hospital Glasgow UK 2 School of Medicine Dentistry and Nursing University of Glasgow UK 3 Diabetes Centre Gartnavel General Hospital Glasgow UK 4 Institute of Cardiovascular and Medical Sciences University of Glasgow UK
Background Glucose variability is increasingly being recognised for an association with adverse outcomes in populations with normal renal function For individuals with abnormal renal function this is less clear particularly for those with end stage renal failure undergoing renal replacement therapy (RRT) In RRT patients sustained extremes of glycaemia appear to be associated with worse survival however the effect of underlying glucose dynamics remains poorly understood Specifically there are few published studies which examine the influence of hypoglycaemic episodes on outcomes in RRT patients We sought to determine the relationship between inpatient hypoglycaemia and long-term mortality in a broad cohort of RRT patients
Methods Data for all incident and prevalent RRT patients within our catchment from July 2008 to December 2016 were extracted from the electronic patient record These were merged with a dataset of hospital capillary blood glucose (CBG) measurements Hospital contact episodes were identified from CBG timestamp data (a technique previously validated in other populations) Contacts with gt1 CBG measured within a 48 hour period were taken as admissions Those with at least one CBG lt4mmolL during the first recorded admission were compared with those without Age length of admission and number of measured CBGs were compared between groups A survival analysis was carried out over 85 years comparing groups A Cox proportional hazard model was used to compare time to death including age as a covariable
Results 367544 CBGs from 2215 individuals and 63559 hospital contact episodes were identified 31340 episodes from 831 individuals had gt1 CBG performed and were analysed as admissions 219 individuals had 1 or more CBGs lt4mmoll recorded This group experienced longer admission (36 vs 19 days plt0001) and had a higher number of recorded CBGs (13 vs 4 p lt 0001) On survival analysis hypoglycaemia was associated with a HR for death of 152 (95 CI 131-173 plt00001)
Discussion Hypoglycaemia is associated with prolonged admission and increased mortality in this broad population Further work investigating the impact of glucose variability RRT modality and presence or absence of diabetes is planned
A4 Vitamin K and Vascular Health A Systematic Review and Meta-Analysis Jennifer Lees12 Fiona Chapman2 Miles Witham3 Alan Jardine12 Patrick Mark12
1 Institute of Cardiovascular and Medical Sciences University of Glasgow 2 Glasgow Renal and Transplant Unit NHS Greater Glasgow and Clyde 3 University of Dundee
Background - Vascular stiffness and calcification occur prematurely in patients with chronic kidney disease (CKD) and are associated with increased mortality Activity of matrix Gla protein - an important regulator of vascular calcification - is dependent on adequate vitamin K intake vitamin K deficiency is prevalent in patients with CKD We conducted a systematic review and meta-analysis of the effect of vitamin K supplementation on vascular health and assessed the evidence that level of (inactive) dephosphorylated undercarboxylated Matrix Gla protein (dp-ucMGP) is associated with incident cardiovascular disease (CVD) or mortality
Methods - Two authors searched Medline and Embase databases Cochrane and ISRCTN registries in May 2017 for i) adult human studies of vitamin K supplementation versus control which measured effects on vascular calcification vascular stiffness or dp-ucMGP and ii) prospective observational studies assessing effect of baseline dp-ucMGP on incident CVD or mortality Random effects meta-analysis was conducted using meta and metafor packages for R statistical software package Egger regression and Trim-and-Fill analyses were used to assess for publication bias
Results ndash Nine intervention studies (n=952) and 13 observational studies (n=7495) met our pre-specified inclusion criteria Vitamin K led to a significant reduction in vascular calcification compared to placebo (-91 [95CI -177 -05] p=004) and a significant decrease in dp-ucMGP (-227pmolL [95CI -281 -173] plt0001) A non-significant improvement in vascular stiffness was evident (-37 [95CI -78 04] p=008) In observational studies with a follow up period of 70 + 40 years stepwise increase in dp-ucMGP was not associated with fatal or non-fatal CVD (log HR 005 [95CI -013 022] p=062) or mortality (log HR 004 [95CI -015 023] p=069) Egger regression and Trim-and-Fill analyses suggest possible publication bias in favour of positive results
Conclusion - Vitamin K supplementation significantly reduces dp-ucMGP level although dp-ucMGP is not associated with incident CVD or mortality Supplementation appears to reduce progression of vascular calcification with a trend towards improvement in vascular stiffness though there are limited data available Clinical trials of the effect of vitamin K supplementation on vascular health are warranted
Funding - JL is supported by a Kidney Research UK Training Fellowship
Conflicts of interest - MW and PM are currently running a BHF-funded trial of vitamin K supplementation in patients with CKD 3b4
A5 Review of management of patients with diabetic nephropathy Wan Shun Wonga Mohammed K Azharuddinb
aRenal and Transplant Unit Queen Elizabeth University Hospital Glasgow bDiabetes Unit Inverclyde Royal Hospital Greenock
Background ndash Diabetic nephropathy is a common and potentially life-threatening complication of both type 1 and type 2 diabetes and is now recognised as the leading cause of end-stage renal disease1 Studies have shown that early interventions can delay the onset and slow the progression of diabetic nephropathy2 The aim of our study was to review the management of patients with diabetic nephropathy at Inverclyde Royal Hospital in accordance to the guideline published by the National Institute for Health and Care Excellence (NICE)
Methods ndash Patients with diabetic nephropathy were identified on SCI-Diabetes Patient data was then extracted from renal electronic patient record SCI-Diabetes and Clinical Portal Clinical notes were also reviewed to determine the reason for cessation of angiotensin-converting-enzyme inhibitor (ACE-I) or angiotensin receptor blocker (ARB) Referral guidelines from the Renal Association were used to assess the eligibility for referral
Results ndash Data was collected from 255 patients with diabetes and urine ACR gt25 (for male) and gt35 (for female) Mean age was 625 years (SD 151) and 584 (n=149) were male 243 of patients (n=62) were classed as type 1 diabetes and 737 (n=188) as type 2 with further 20 (n=5) as others 949 (n=242) patients had an HbA1c recorded within the last year The mean HbA1c was 712 (SD 2052) 8 patients were on RRT (7 on HD and 1 on PD) Serum creatinine and urine ACRPCR were checked in 933 (n=238) and 612 (n=156) of patients in the last year respectively Blood pressure was measured within the past 12 months for 847 (n=216) of patients with 601 (n=146) having blood pressure higher than the target of 13080mmHg Mean systolic and diastolic blood pressures were 1339 mmHg (SD 1735) and 745 mmHg (SD 111) respectively 627 of patients were on ACE-IARB Of the 95 patients who were not on ACE-IARB 421 (n=40) were stopped due to side effects 116 (n=11) patients had their ACE-IARB discontinued but no reason could be found 379 (n=36) patients had never been on an ACE-IARB 157 (n=40) of patients met the criteria for referral to Renal Services and 7 patients had not been referred and all 7 of them recently developed CKD4
Conclusion ndash Our findings were consistent with the national data3 Urine PCR measurement has the lowest completion rate among all the recommended annual care processes Optimal blood pressure control remains a challenging issue for many of the patients with diabetes Further studies could be carried out to look at the reasons behind the low completion rate of urine PCR measurement as well as to devise ways to remind clinicians about starting patients on ACE-IARB and making referral to Renal Services when indicated
References 1 K Bennett B S Aditya An overview of diabetic nephropathy Epidemiology pathophysiology and treatment Journal of Diabetes Nursing 18 61-7 2 Molitch ME DeFronzo RA Franz MJ et al American Diabetes Association Nephropathy in diabetes Diabetes Care 200427(Suppl 1)S79-83 3 Scottish Diabetes Survey 2016 Scottish Diabetes Survey Monitoring Group NHS Scotland
Funding ndash None Conflict of Interest ndash None
A6 Analgesic Use in Dialysis Patients in a District General Hospital Setting
A McCallum L Dickson S Robertson A Almond N Rathnamalala M KellyT Muniraju
Renal Unit Dumfries and Galloway Royal Infirmary
Evidence shows around 50 of haemodialysis patients report pain with 83 describing this as moderate to severei Distinct variability also exists in levels of opiate prescribing between centres with studies showing incidence ranging from 5-50iiiii Consequently we sought to investigate the prevalence of both pain and opioid prescriptions in our local dialysis population as well as investigating whether there are any associations between co-morbidities and the use of opiates This information could then be used to identify new dialysis patients at high risk of pain as well as informing prescribing decisions
In order to achieve this a questionnaire was produced that incorporated validated pain and quality of life scores (the Brief Pain Index and Renal Palliative Care Outcome Scale) with a consent form to access electronic healthcare records Questionnaires were distributed to all our haemodialysis and peritoneal dialysis patients Results were transcribed into Microsoft Excel where they were analysed
Data was collected on 56 patients (46 haemodialysis patients 10 peritoneal dialysis patients) Results showed 46 described ldquopain other than everyday kindsrdquo on the day of survey completion The most common site of pain was in the legs and back On average patients were on 12 different medications of which 15 was for pain (range 0-5) 784 of these pain prescriptions were longstanding (gt3 month use) Amongst haemodialysis patients 45 were on a strong opioid ndash in 73 of cases this was a fentanyl patch Whilst scope exists to increase the use of simple analgesia and neuropathic agents in such patients analysis using the pain management index scale revealed use of opioid analgesia in such cases to be justified As in previous work no link was found between any one co-morbidity and the development of pain
Overall we have shown high rates of pain amongst our dialysis patients We also demonstrate high levels of chronic analgesia use and the overall tablet burden on our patient group is high This work adds to previously published literature and is being used locally to proactively minimise the burden of prescribed tablets and also increase awareness of the value of paracetamol and neuropathic agents in those with uncontrolled pain
Source of funding conflict of interest Nil
References i Davison SN Pain in hemodialysis patients prevalence cause severity and management Am J Kidney Dis 2003421239-1247 ii Butler AM Kshirsagar AV Brookhart MA Opioid Use in the US Hemodialysis Population Am J Kidney Dis 2014 63(1) 164-173 iii Wyne A Rai R Cuerden M Clark WF Suri RS Opioid and Benzodiazepine Use in End-Stage Renal Disease A Systematic Review Clin J Am Soc Nephrol 2011 6 326ndash333
A7 The Role of the Renal Supportive Care Service in Advanced Care Planning JM Sloan CA Douglas S Cathcart L Frame L Stage M Witham ME Lafferty
Renal Service Ninewells Hospital Dundee
Background In 2007 we established a Renal Supportive Care Service for patients with advanced chronic kidney disease who choose not to receive dialysis The service which includes a fortnightly Renal Supportive Care clinic is provided by a Consultant Nephrologist a Consultant Palliative Care Physician and a Renal Supportive Care Specialist nurse The focus of the service is on ongoing management of chronic kidney disease symptom control and improving quality of life while planning for end of life care
Methods We have undertaken a retrospective audit of our Renal Supportive Care Service on all patients known to the Renal Service for whom a conservative care management decision had been made We collected data over a 31-month period from April 2012 until October 2014 We collected data on demographics co-morbidities clinic attendance renal supportive care input anticipatory care planning performance status and mortality data
Results Of the 98 patients for conservative management 62 (6198) were female with a mean age of 837 years During the 31-month period there were 507 documented supportive care consultations with 36 (3598) of patients receiving domiciliary visits from the Renal Supportive care nurse Anticipatory Care Plans (ACP) were in place for 62 (61) of patients with a preferred place of death known for 56 (5598) 65 patients had a documented discussion about their DNACPR status which was communicated in writing to primary care For a further 13 it was not clear whether the discussion had taken place During the study period 61(62) patients died Of those patients with an ACP 29 (1138) died in an acute hospital versus 43 (1023) of those without (p=025) Similarly 24 (834) of patients with a documented preferred place of death died in an acute hospital versus 48 (1327) of those without (p=004)
Conclusions The role of the Renal Supportive Care team is invaluable in providing care and support to patients who have chosen conservative management By discussing and planning for end of life care the Renal Supportive Care team play a role in reducing the number of patients dying within an acute setting
Conflicts None
Funding The Renal Supportive Care Nurse post and one Palliative Care Consultant Programmed activity received 3 years of funding by British Kidney Patients Association
A8 Predictors of transplant failure in patients undergoing indication renal biopsy
Kate Stevens 1 Bruce Mackinnon1 David Kipgen1 Shana Coley1 Marc Clancy1 Colin Geddes1
1Renal and Transplant Unit QEUH NHS GGampC Glasgow United Kingdom
Introduction This study considers indication renal biopsies and factors which may be important
predictors of transplant loss and patient death
Objectives To identify the time line of histological diagnosis from transplant in our population
and to identify predictors of graft and patient survival in those undergoing indication renal biopsy
Methods All indication renal biopsies undertaken between 012011 and 122015 were identified
Demographic data including immunological and outcome data was recorded Statistical analysis
was undertaken in SPSS (v22)
Results 354 patients underwent 549 biopsies Mean patient and transplant age at time of biopsy
was 432 plusmn153 and 42plusmn58 years respectively 449 (n=247) of biopsies showed evidence of
Cell mediated rejection (CMR)ABMR or both 93 (n=51) demonstrated features of chronic
transplant glomerulopathy (CTG) DSA was present at the time of biopsy in 231 (n=127) In
transplants aged le 6 months old histological diagnosis was CMR in 325 (n=69) with ABMR seen
in 28 (n=6) In transplants aged ge10 years CTG was seen in 325 (n=26) with ABMR
accounting for 63 (n=5) 229 (n= 81) of transplants failed at a median of 182 days from most
recent biopsy On cox regression analysis peritubular capillary (PTC) C4d and CTG were
independent predictors of transplant failure Probability of transplant failure was 45 and 50 at
one year if mixed rejection or CTG were present 93 (n=33) patients died at a median of 227
days from most recent biopsy Independent predictors of death included deceased donor
transplant patient age and presence of ABMR on biopsy (plt005)
Conclusion Acute ABMR is a risk factor for patient loss whilst chronic ABMR is a risk factor for
transplant loss This association is independent of DSA but dependent upon PTC C4d staining
indicative of donor humoral activity ndash HLA or otherwise Histological diagnosis in an indication
biopsy is an important factor in predicting outcome This study is limited by the inherent bias in
patient selection with indication biopsy
Disclosure of Interest None Declared
A9 Renal Evaluation of Paediatric Patients with Tuberous Sclerosis Complex (TSC) in aNational TSC Multidisciplinary ClinicDr Jenny Patterson 1 Dr Shelagh Joss 1 Dr Ihab Shaheen 2
1 Clinical Genetics Queen Elizabeth University Hospital Glasgow 2 Paediatric Nephrology Royal Hospital for Sick Children Glasgow
Introduction Tuberous sclerosis complex (TSC) is a dominantly inherited multisystem disorder characterised by development of hamartomas (benign lesions) in multiple organs Previous studies have shown that renal manifestations are common in TSC and also the most frequent cause of TSC-related death in affected individuals With the recent discovery of targeted therapy with mTOR inhibitors early recognition of renal involvement allowing early surveillance and prompt therapy is now more important than ever
AimMethod To review a population of paediatric patients attending a large specialist TSC service in the UK both in terms of key clinical characteristics and current practice for renal radiological surveillance data were collected from electronic medical records pertaining to molecular diagnosis renal surveillance and presence or otherwise of sequelae affecting the renal or other systems Practice was compared to published surveillance recommendations of the International Tuberous Sclerosis Complex Consensus Group (2013)
Results Data were obtained for 41 children (18 males 23 females) Current age range 25 years to 14 years (mean 98 years) Twenty nine patients (707) were diagnosed lt1 year of age Genetic data were available for 29 patients Fifteen patients had a confirmed TSC1 mutation and 14 patients a confirmed TSC2 mutation including one contiguous PKD1 mutation Renal imaging (all US) within a year of diagnosis was documented in 2541(61) performed at a mean age of 3 years Renal symptoms at diagnosis were documented in 741(171) and 941(22) had renal abnormalities on baseline imaging There was wide variability in scanning interval and modality with 1041(243) having previous abdominal MRI with variable documented indication Seventeen (414) of the cohort mean age 102 years had documented renal lesions 917 angiomyolipomas 517 cysts and 317 both These lesions were diagnosed at a mean age of 6 years (range 02 years-142 years) Six patients (353) had normal baseline scans with a mean interval to lesion diagnosis of 1 year One patient had a lesion on MRI not detected on US that required subsequent biopsy Frequency of subsequent scanning ranged from intervals of 2 months to 1 year with a combination of MRIUS in an unclear pattern All patients except one with a contraindication were undergoing current brain surveillance by MRI
Conclusions Our results highlight the significant incidence of renal sequelae within our TSC cohort with renal manifestations ranging both in severity and age of onset International guidelines recommend MRI scanning for renal surveillance at diagnosis and throughout life Benefits of MRI include enhanced accuracy of sizing and characterisation of renal lesions The majority of our cohorts are already undergoing brain MRI surveillance It is our aim to combine and standardise MRI renal surveillance for this cohort to facilitate early and regular monitoring with a view to early intervention is possible
A10 Effect of blood temperature monitoring on intradialytic hypotension in patients with end stage renal disease requiring haemodialysis Heather Walker1 Susan McGeorge1 Drew Henderson2
1 Renal Unit Ninewells Hospital Dundee2 Regional Renal Centre Waikato Hospital Hamilton New Zealand
Background KDIGO define intradialytic hypotension (IDH) as a reduction in systolic bloodpressure (SBP) ge20mmHg or mean arterial pressure (MAP) ge 10mmHg with associatedsymptoms IDH is a common complication of haemodialysis (HD) and is associated with increasedmortality and morbidityStandard dialysis with a set temperature leads to thermal gain during the dialysis session Tocounteract this thermal gain vasodilation occurs and is postulated as one of the causes of IDHActive cooling of dialysis has been shown to reduce IDH but is not routinely applied across wholedialysis populations Isothermic dialysis can be achieved by controlling blood temperature on HDWe report here our experience of doing this using the Blood Temperature Monitoring (BTM)function on Fresenius 5008 dialysis machines
Methods An observational study was performed to assess the rates of IDH in patients with End Stage Kindey Disease (ESKD) undergoing regular satellite HD at NHS Tayside in July 2017 Rates of IDH were assessed (KDIGO definition) for two weeks prior to BTM settings being activated and for a two week study period after introduction SBP and MAP data was collected SBP data was grouped to either SBP decrease lt20mmHg or SBP decrease ge20mmHg compared with Pre HD BP Changes in MAP were also analysed at the same time points Patient reported symptoms related to initiation of BTM were also collected for the same time period
Results 402 dialysis sessions were evaluated in the pre intervention time period and 399 sessions post intervention
IDH 1072 vs 778 (Pre BTM vs Post BTM) p=015 gt20mmg SBP drop Pre vs Post BTM
Mean MAP Change (mmHg) Pre BTM vs Post BTM
1st BP 254 vs 204 (p=005) -522 vs +312 (plt001) 2nd BP 474 vs 435 (p=023) -1589 vs -886 (plt001) 3rd BP 515 vs 435 (p=003) -1862 vs -958 (plt001) Post HD 408 vs 338 (p=003) -1164 vs -077 (plt001)
Following the introduction of blood temperature monitoring only 08 of HD sessions reported experiencing cold or shivering symptoms
Conclusion The use of blood temperature monitoring was not associated with a statistically significant decrease in rates of IDH There was a significant reduction in the number of sessions where SBP decrease by gt20mmHg at the first and third HD BP and a reduction in MAP change across the study group Further evaluation of BTM is required assess its clinical utility in our HD population
Funding No funding was sought for this study
Conflicts of interest None
A11 Evaluating patient satisfaction and clinical outcomes of a new nurse-led dermatology clinic for patients attending the renal transplant clinic Campbell G Naismith K Neil A Rankin A Spalding E (joint first authors) Renal Unit University Hospital Crosshouse Kilmarnock UK
BACKGROUND National Guidelines advise that renal transplant recipients should receive annual skin surveillance to screen for skin cancer In August 2015 a specialist nurse-led dermatology clinic was set-up alongside the renal transplant clinic at University Hospital Crosshouse We aimed to evaluate the success of this joint clinic in terms of clinical outcomes and patient satisfaction
METHODS Clinical records were reviewed to determine the number of patients under dermatology follow-up before and after initiation of the joint clinic and to review cases that were referred for treatment of pathological skin lesions A questionnaire was also distributed to patients attending the new joint renal-dermatology transplant clinic The questionnaire consisted of 5 questions 2 for patient demographics 1 for current understanding of skin care advice and 2 to assess their satisfaction of the new joint clinic
RESULTS A total of 138 and 146 renal transplant recipients were registered on renal transplant clinic lists in 2015 and 2016 respectively Prior to initiation of the new joint-clinic 41 patients had attended dermatology (37 in NHS Ayrshire and Arran and 4 in NHS Greater Glasgow and Clyde) consisting of 30 of the transplant population In September 2016 13 months after initiation of the new clinic 60 patients had attended the new clinic increasing the proportion of patients meeting the national recommendation for skin surveillance to 41 Implementation of the new clinic resulted in patients being 65 more likely to have received the recommended skin checks (odds ratio 165 95 CI 101-270 p=004)
32 patients completed the questionnaire The median age of transplant was 90 years (IQR 38-153) 100 of patients knew to avoid sun exposure and 31 (96) knew to use sunscreen 29 (91) patients were aware of the advice to undergo annual skin surveillance by dermatology with 28 (88) having had a skin check in the last year 29 (91) patients reported that they found the new joint clinic useful although only 18 (56) had attended the clinic so far
CONCLUSIONS Implementation of a new nurse-led dermatology clinic running in parallel with the renal transplant clinic resulted in a considerable increase in the proportion of patients meeting national recommendations for annual skin surveillance The vast majority of patients also found the combined clinic to be useful There is still considerable room for improvement in order to achieve the target of 100 compliance with skin surveillance and ongoing clinical audit is required to assess progress We believe this model would be easily implementable at other units with similar benefits expected
A12 Pneumocystis pneumonia prophylaxis post-renal transplant increased duration of co-trimoxazole is safe and effective FA Chapman JE Dickerson M Clancy C Daly C Geddes Renal amp Transplant Unit Queen Elizabeth University Hospital Glasgow
Introduction All renal transplant recipients receive Pneumocystis jirovecii prophylaxis usually with co-trimoxazole Guidelines suggest this should be continued for 3 to 6 months Our unit previously prescribed 3 months however following an outbreak of Pneumocystis pneumonia (PCP) infection this was increased to 6 months Given its constituents of sulfamethoxazole and trimethoprim co-trimoxazole prophylaxis may influence the frequency of urinary tract infection (UTI) We aimed to compare the frequency of UTI between patients on 3 months vs 6 months prophylaxis and assess rates of multi-drug resistant organisms We also sought to establish if the increased duration of co-trimoxazole was adversely affecting renal function potassium concentration white cell and platelet count and dosing of mycophenolate mofetil
Methods A retrospective search of the West of Scotland Electronic Renal Patient Record was conducted for all renal transplant recipients between 1st January 2012 and 31st May 2016 Patients were grouped according to the intended duration of co-trimoxazole Data were extracted for baseline characteristics co-trimoxazole prescription mycophenolate mofetil (MMF) prescription laboratory results (creatinine potassium white cell count platelets) at 3 6 9 and 12 months post-transplant and microbiology results for 6 months post-transplant Results were analysed on an intention to treat (ITT) basis with a second analysis according to actual duration of co-trimoxazole treatment (AT) Subjects with transplant failure had laboratory results censored from the time of transplant failure and all of their microbiology results were excluded
Results 609 renal transplants were performed over the study period On ITT analysis there were 418 patients in group 1 (ITT1 3 months co-trimoxazole) with 15 transplant failures and 191 patients in group 2 (ITT2 6 months co-trimoxazole) with 12 transplant failures There was a significant difference in the number of patients with at least one UTI with fewer in ITT2 (ITT1 133403 vs ITT2 42179 p = 001) However this was not present when comparing actual treatment duration (AT1 111345 vs AT2 36149 p=007) Overall there was a similar spectrum of organisms cultured There were significantly fewer cultures of multi-resistant organisms in both ITT and AT analyses with 6 months of co-trimoxazole (ITT1 28376 vs ITT2 0106 p= 0004 AT1 22313 vs AT2 198 p = 002) There was no difference in estimated Glomerular Filtration Rate serum potassium concentration platelet count or MMF dose On AT analysis there was a significant difference in the total white cell count (WCC) and lymphocyte count at 6 months post-transplant (WCC 78 x10^5L vs 71 x10^5L p =004 lymphocytes 13 x10^5L vs 12 x10^5L p=002) There were 18 cases of PCP with 7 deaths attributable All cases occurred after cessation of co-trimoxazole prophylaxis (81 ndash 913 days after stopping co-trimoxazole)
Conclusion Although there is a significant difference in UTI frequency on ITT analysis this is not present on AT analysis suggesting no real co-trimoxazole effect There was no increase in frequency of multi-drug resistant organisms with a longer course of co-trimoxazole Renal function and serum potassium were unaffected Our findings support continuing co-trimoxazole prophylaxis for at least 6 months
A13 Kidney transplantation in the over 60rsquos in Scotland 1996-2015 TJW Rennie1 P Phelan1 J Campbell2 JP Traynor2 L Henderson1 W Metcalfe2 On behalf of the Scottish Renal Registry 1Renal transplant unit Royal Infirmary Edinburgh 2NHS National Services Scotland Introduction The proportion of older kidney transplant recipients has increased in the UK but
long term outcome data are scarce We aimed to evaluate patient and graft survival in patients
ge60 years of age receiving a first kidney only transplant in the last 20 years in Scotland
Methods Retrospective analysis of Scottish Renal Registry data of incident Renal Replacement
Therapy (RRT) patients and those in receipt of a kidney only transplant performed 1996-2015
(follow up until 311216) Patients were stratified by age 60-69 ge70 (group 1 and 2 respectively)
and decade of transplantation 1996-2005 2006-2015 (decades 1 and 2 respectively)
Results 6743 patients aged ge60 started RRT from 1996-2016 Of those 108 were ever
transplant-listed 54 had received a transplant by 311216 26 listed and 11 transplanted
were aged ge70
535 patients aged ge60 received a kidney only transplant in 1996-2015 90 patients (168) were
aged ge70 no patients were aged ge80 Mean time from wait listing until transplantation was 33plusmn24
years (plusmnSD) and from starting RRT until transplantation was 38plusmn26 years (plusmnSD) One and five
year graft survival was 97 and 87 in decade 1 95 and 89 in decade 2 (p=NS) there was
no difference in graft survival between age groups 1 and 2 One and five year patient survival was
94 and 78 in age group 1 85 and 56 in group 2 (plt0001) there was no difference in one
and five year patient survival between the two decades
Conclusion One and five year graft and patient survival in renal transplant recipients aged ge60
have not changed significantly in the last 20 years Recipient age ge70 is not associated with
reduced graft survival but patient survival from time of transplant is lower in this age group
compared to recipients aged 60-69
No conflict of interest to be declared No funding received
A14 High Mortality In Older Patients With Primary Nephrotic Syndrome Sarah Beverstock Wendy Metcalfe amp Robert W Hunter Department of Renal Medicine Royal Infirmary of Edinburgh
Introduction
Nephrotic syndrome can develop at any age and may be due to a primary glomerular lesion or secondary to systemic disease The natural history of glomerular disease can be different in older patients For instance minimal change disease (MCD) in children almost always remits promptly with steroid therapy in adulthood it typically remits only after many weeks of steroids or with adjunctive immunosuppression However there are remarkably few published data on the mortality of primary nephrotic syndrome in adults We aimed to study this in our centre
Methods
We enrolled all adult patients who had a kidney biopsy in order to investigate nephrotic syndrome over 38 consecutive months (01 Jan 2014 ndash 28 Feb 2017) We defined nephrotic syndrome as heavy proteinuria (urinary proteincreatinine ratio UPCR gt350 mgmmol or albumincreatinine ratio gt220 mgmmol) and hypoalbuminaemia (serum albumin lt35 gL) In our analysis we included all patients in whom nephrotic syndrome was attributed to a primary glomerular disease We excluded kidney transplant recipients and patients in whom biopsies were performed to follow up a known glomerular disease We collected laboratory data at baseline (time of biopsy) and at 6 and 12 months We assessed patient survival by Kaplan-Meier analysis
Results
Of the 117 patients biopsied for nephrotic syndrome 71 patients (61 ) met the inclusion criteria and were followed up for a median of 469 days We compared outcomes in patients aged under 60 years old (n = 35) with those aged over 60 (n = 36) Mortality was higher in the older group (37 vs 4 mortality at one year p lt005 by logrank test) There were no significant differences between the two groups in serum creatinine or UPCR at any time Serum albumin was similar in both groups at baseline and at 12 months but was lower in the older group at 6 months (27 vs 32 gL p lt 005) Baseline haemoglobin was lower in the older group (114 vs 130 gL p lt005 by unpaired t-test) Primary diagnoses were MCD (n = 10 in younger group amp n = 5 in older group) membranous nephropathy (5 amp 10) IgA nephropathy (9 amp 8) FSGS (5 amp 5) membranoproliferative glomerulonephritis or C3GN (4 amp 7) and other (2 amp 1) Therefore unsurprisingly there were relatively fewer cases of MCD and more cases of membranous nephropathy in the older group otherwise the causative glomerular lesions were similar in both groups In those patients with MCD mortality was significantly higher in the older group none of the 10 patients with MCD diagnosed under 60 yrs old died during the follow-up period whereas 4 of the 5 older patients died 3 patients in the younger group and 1 in the older group were on renal replacement therapy (dialysis or transplant) by the end of follow-up
Conclusions
Primary nephrotic syndrome is associated with high mortality in the over 60s (37 at one year) Mortality was high even for MCD a disease that follows a benign course in childhood and early adulthood The higher mortality in older patients was not associated with greater severity of renal disease at presentation (as assessed by basic blood and urine parameters) This work was not funded we declare no conflicts of interest
A15 Renal biopsies in patients with diabetes mellitus in Scotland
Udana Ratnapala 1 Nicola Joss 2 Colin Geddes 3 Dana Kidder 1
1 Renal Unit Aberdeen Royal Infirmary Aberdeen 2 Renal Unit Raigmore Hospital Inverness 3 Glasgow Renal and Transplant Unit Glasgow
Introduction Diabetes mellitus is the leading cause of end-stage kidney disease (ESKD) requiring renal replacement therapy The utility of renal biopsy in patients with diabetes mellitus is controversial Broadly renal biopsy findings in patients with DM can be divided into diabetic nephropathy (DN) alone DN with non-diabetic renal disease (NDRD) or NDRD alone Timely identification of patients with NDRD is important to provide appropriate therapeutic measures Previously published guidelines on clinical predictors of NDRD have limited specificity and sensitivity The frequency of NDRD in renal biopsies of patients with DM is unclear in ScotlandThis study aimed at identifying the frequency and the pathology spectrum of NDRD in diabetic patients underwent kidney biopsy in 3 renal units
Methods A retrospective observational study was performed on clinical-pathologic findings in all patients with diabetes mellitus who underwent renal biopsy between 01012010 and 31122016 in 3 renal units (Aberdeen Inverness and Greater Glasgow) Data were gathered from electronic patient record systems Scottish Index of Multiple Deprivation (SIMD) 2012 was used to analyse correlation with patient outcomes
Results 247 patients were included 150 men (607) 217 type 2 DM (879) mean age 621 years and mean serum creatinine at the time of renal biopsy of 261 micromolL (+-190 std) On biopsy 92 patients (372) had DN while 127 (514) had NDRD and 28(114) had NDRD superimposed on DN The commonest NDRD aetiologies were IgA nephropathy (187) tubulointerstitial nephritis (168) and idiopathic membranous nephropathy (103) Predictors of NDRD were age (OR 1027 95 CI 1002-1052 p=003) duration of DM (OR 094 95 CI 0900-0987 p=001) and absence of AKI as indication for biopsy (OR 022 95 CI 0059-0826 p=0025) There was no significance difference in renal or patient survival in DN and NDRD Finally no significant correlation was depicted between SIMD quintiles and renal or patient survival in both groups
Conclusions The majority of renal biopsies carried out in patients with DM revealed a NDRD In this study age at the time of biopsy duration of DM and AKI were the main pointers towards NDRD Renal and patient survival were not significantly different between DN and NDRD groups
A16 The Impact of Withdrawal of Maintenance Immunosuppression and Graft Nephrectomy on HLA Sensitisation Ailish Nimmo1 Sophie McIntyre1 Lorna Henderson1 Richard Battle2
(1 Department of Renal Medicine Royal Infirmary of Edinburgh 2 Histocompatibility and Immunogenetics Royal Infirmary of Edinburgh)
Background The development of HLA antibodies towards a failing renal allograft is a barrier to re-transplantation We previously demonstrated an increase in HLA antibodies and calculated reaction frequency (cRF) following nephrectomy but results were confounded by immunosuppression changes occurring in close time proximity We examined the formation of HLA donor specific antibodies (DSA) in patients with failed grafts that remained in situ and compared results with patients undergoing graft nephrectomy to further assess the relative impact of nephrectomy and immunosuppression weaning on sensitisation and chance of transplant
Methods We carried out a single centre retrospective study of all patients with failed grafts in Lothian from 2005 to 2015 Samples were tested for DSA pre-immunosuppression (IS) wean post-IS wean and post-IS cessation Nephrectomy patients also had samples tested for DSA before and after nephrectomy Data on other sensitising events including blood transfusion and rejection were collected cRF was determined at each time point and entered into the ODT chance of transplant calculator with other demographics based on the average patient from the Edinburgh centre
Results 62 grafts failed over this time period Blood samples were available 41 patients (24 with nephrectomy 17 with failed graft left in situ) Patient demographics were similar between groups There was a higher rate of antibody mediated rejection in the nephrectomy group (46 vs 18) 76 of patients with nephrectomy group had received a blood transfusion The pattern of immunosuppression weaning was similar but median time from start of IS wean to cessation was longer in the nephrectomy group (350 vs 298 days) The changes in cRF and chance of transplant (COT) with immunosuppression weaning are shown in Table 1
Pre-IS Wean Post-IS Wean
Failed graft in situ (n=17)
Mean CRF COT at 5
years 15 62 38 59
Nephrectomy (n=24)
Mean cRF COT at 5
years 54 54 69 46
Post-IS Stop 55 53 89 42 Table 1 Mean cRF and Chance of Transplant (COT) at 5 years with IS alterations
Discussion A stepwise increase in cRF with reduced chance of transplant was observed in both groups as immunosuppression was withdrawn with a similar pattern of change irrespective of graft nephrectomy cRF was higher in the nephrectomy group despite a more gradual wean which may reflect a higher rate of antibody mediated rejection and increased number of patients receiving a blood transfusion The risks and benefits of stopping immunosuppression need to be carefully considered on an individual basis to maximise chance of future transplant
The authors have no conflicts of interest No funding was required for this study
A17 Obesity is not associated with progression to end stage renal disease in patients withbiopsy-proven glomerular diseases
Benjamin Elyan Jennifer S Lees Bruce Mackinnon Jonathan G Fox Colin C Geddes Emily PMcQuarrie
Glasgow Renal and Transplant Unit Queen Elizabeth University Hospital Glasgow
Introduction - Addressing risk factors for renal progression is a key aspect of managing chronic kidney disease (CKD) Body mass index (BMI) has been shown to impact on renal progression in unspecified CKD The aim of this study was to evaluate if there was an association between BMI and progression to renal endpoints in patients with biopsy-proven primary glomerular disease (GN)
Methods - We included all adult patients diagnosed with biopsy-proven primary GN (excluding minimal change nephropathy) in Greater Glasgow amp Clyde and Forth Valley between 01012000 and 31122015 Biochemical and anthropometric data were extracted from the electronic patient record at time of biopsy with follow-up data until 20062017 BMI was calculated from height and weight at time of biopsy and categorised into groups BMI le25 kgm2 (G1) gt25 to le30 kgm2 (G2) and gt30 kgm2 (G3 - obese) We assessed factors associated with reaching a combined renal endpoint of CKD5 or renal replacement therapy (RRT) with competing risk of death using the Fine and Gray subdistribution hazard model Analyses were conducted using cmprsk package for R statistical software package and SPSS version 24
Results - 560 patients with primary GN and available BMI data were included The average age was 532 years and 339 were female There were 132 patients in G1 210 in G2 and 207 patients in G3 Those in G2 and G3 were older (p=002) with slightly higher diastolic blood pressure (p=002) than those in G1 There was a greater proportion of focal segmental glomerulosclerosis in G3 but similar proportions of other GN diagnoses across groups There was no significant difference in baseline serum creatinine (sCr) (p=034) or log uPCR (p=045) between BMI groups On multivariate analysis age systolic blood pressure BMI or GN diagnosis were not predictive of renal outcome Higher baseline sCr (SHR 1003 per 1 umoll increase in sCr 1001-1004 plt0001) and log uPCR (SHR 130 per unit increase in log uPCR 95 CI 105-160 p=002) were associated with progression to the combined renal endpoint accounting for competing risk of death BMI was not associated with reaching combined renal endpoint on univariate analysis whether considered as a continuous variable (SHR=100 95 CI 098-102 p=096) or categorised by BMI group
Conclusion - Contrary to our expectations there was no association between BMI and progression to a combined renal endpoint of CKD5 or RRT in this cohort of patients with primary GN Efforts should be directed to managing other known risk factors for CKD progression
Sources of FundingConflicts of Interest - None
A18 Factors influencing long term renal function after living kidney donation
Matthew A Rutherford Norman J Galbraith Marc Clancy Colin C Geddes
Glasgow Renal and Transplant Unit Queen Elizabeth University Hospital Glasgow UK
Background Following live donor nephrectomy the remaining kidney undergoes an increase in filtration capacity known as compensatory hypertrophy Few cohorts with follow up of renal function beyond 5 years have been reported The impact on long term renal function of variability in donor factors such as age sex pre-donation blood pressure and glomerular filtration rate (GFR) is unknown Increasingly kidney donors have potential risk factors for future poor renal function such as hypertension older age and obesity The aim of this study was to analyse factors influencing long-term renal function in living kidney donors from our centre
Method Data were obtained from the electronic patient record Patients with a recorded procedure of lsquolive donor nephrectomyrsquo between 2005 and 2017 were identified GFR after donation (calcGFR) was calculated using the formula lsquocalcGFR = Pre-donation Isotope GFR x (Pre-donation Serum creatinine Serum Creatinine)rsquo which is accurate assuming muscle mass does not change Pre and post donation serum creatinines (two days two weeks three months and one to ten year) were recorded We analysed the influence of age sex pre-donation GFR and blood pressure on post donation GFR compensation
Results 355 live donor nephrectomies were performed between January 2005 and December 2016 The mean age was 469 (plusmn 116) years and 504 (n=179) were female Mean pre-donation isotope GFR was 937 plusmn 156 mlmin173m2 Median follow up was 2 years (IQR 1 to 6 years with range 2 weeks to 10 years) The calculated percentage of pre-donation GFR at 2 days 2 weeks 3 months 1 year 5 years and 10 years were 698 691 712 730 801 and 950 respectively (p lt 0001) Patients aged lt50 y had not only a higher calcGFR (858 plusmn 29 mlmin173m2 compared with 671 plusmn 28 mlmin173m2 p lt 0001) at 5 years following donation but achieved a higher degree of compensation than donors gt 50 y (836 plusmn 16 compared with 756 plusmn 19 (p = 0002) Patients with pre-donation hypertension achieved 774 plusmn 53 of pre-donation GFR compared with 804 plusmn 32 in normotensive patients (p = 0998) Females had equivalent degree of renal compensation achieving 819 plusmn 19 compared with 780 plusmn 16 in males (p = 0131) at 5 years following donation Patients with pre-donation GFR gt 100 mlmin173m2 achieved 844 plusmn 23 of pre-donation function by 5 years compared with 777 plusmn 14 in those with pre-donation GFR lt 100 mlmin173m2 (p = 001)
Conclusion Following live donor nephrectomy renal function has a nadir of 691 at 2 weeks Compensation in GFR occurs rapidly and appears to be maintained regardless of sex and pre-donation blood pressure Younger age and higher pre-donation GFR were associated with a greater degree of compensation
A19 The utility of high-sensitivity cardiac troponin to stratify cardiovascular risk in patients with renal impairment
Eve Miller-Hodges Atul Anand Anoop S V Shah Nicholas L Mills Neeraj Dhaun
Background Cardiovascular disease is the most common outcome of chronic kidney disease1
Declining glomerular filtration rate (GFR) and proteinuria predict increased cardiovascular risk over the long term2 However there are currently no methods to stratify cardiovascular risk in the short or medium term in patients with renal impairment We have already shown that high-sensitivity cardiac troponin I concentrations (hs-cTnI) lt5ngL in patients presenting with symptoms of acute coronary syndrome identifies those at low risk of cardiac events within 30 days and over the next year3 However uncertainty remains over the role of hs-cTnI testing in patients with renal impairment This study investigated whether hs-cTnI could also stratify future cardiovascular risk in patients with renal impairment
Methods In a prospective study of consecutive patients presenting with suspected acute coronary syndrome we evaluated the performance of hs-cTnI in patients with and without renal impairment (estimated glomerular filtration rate lt60mLmin173m2) using an early risk stratification threshold of 5ngL to ldquorule outrdquo acute myocardial infarction at presentation and within 30 days and sex-specific 99th centile diagnostic thresholds for index type 1 myocardial infarction Subsequent type 1 myocardial infarction and cardiac death were reported at one year
Results Of 4726 patients identified 904 (19) had renal impairment Index diagnosis of type 1 and type 2 myocardial infarction was almost twice as likely in patients with renal impairment (30 vs 15) Performance of the early risk stratification threshold of 5ngL to identify patients at low risk of major cardiac events was similar in patients with (NPV 984 95CI 960-997 sensitivity 989 95CI 975-999) and without renal impairment (NPV 997 95CI 994-999 sensitivity 984 95CI 972-994) These patients continued to remain at low risk over the next year The PPV and specificity at the 99th centile for diagnosis of myocardial infarction were lower in patients with renal impairment at 500 (95CI 452-548) and 709 (95CI 675-742) respectively compared to 624 (95CI 588-659) and 921 (95CI 912-930) At one year 24 of patients with renal impairment and troponin gt99th centile regardless of index diagnosis had experienced further myocardial infarction or cardiac death compared with 10 of patients without
Conclusion In suspected acute coronary syndrome hs-cTnI can stratify risk in patients with renal impairment Irrespective of diagnosis patients with renal impairment and elevated cardiac troponin concentrations had two-fold greater risk of a major cardiac event compared to those with normal renal function and should be considered for further investigation and treatment
Funders Wellcome Trust British Heart Foundation and Chest Heart amp Stroke Scotland
1 Gansevoort RT Lancet 2013
2 Chronic Kidney Disease Prognosis Consortium Lancet 2010
3 Shah AS Lancet 2015
A20 lsquoDOES IT DIALYSE OUTrsquo - THE EFFECT OF RENAL REPLACEMENT THERAPY ON THE BRAIN Mark Findlay Jesse Dawson David Dickie Deborah McGlynn Patrick Mark Institute of Cardiovascular and Medical Science University of Glasgow amp Queen Elizabeth University Hospital Glasgow
Introduction Cerebrovascular disease is common in end-stage renal disease (ESRD) on renal replacement therapy (RRT) We investigated the effect of RRT on cerebral structure and cognitive function over 12 months Methods Observational cohort study in ESRD patients receiving HD Prior cognitive impairment or cerebrovascular disease were exclusion criteria Multi-domain cognitive testing was performed at baseline and at follow-up Transcranial Doppler was used to assess intra-dialysis related alterations in mean flow velocity (MFV) ndash a marker of cerebral blood flow MR imaging was performed at 0 and 12 months We performed T1 T2 FLAIR and DWI sequences and used volumetric software to calculate white matter hyperintensity (WMH) burden markers of atrophy mean diffusivity and fractional anisotropy (FA) to describe structural changes at 1 year Results 97 patients median age 59 years 412 female At follow-up 15 patients were transplanted 6 died 4 withdrew and the remainder continued HD Those who were transplanted were younger (median age 51 vs 60 years p=0019) and had been on dialysis for a shorter period (median 06 vs 21 years p=0003) MFV declined during HD median 475cms to 405cms plt0001 and correlated with lower scores of executive and frontal lobe function during HD (Rho 045 p lt0001 and Rho -0313 p lt001 respectively) In all patients MR imaging demonstrated a significant decline in frontal parietal and temporal lobe volume at follow-up Median WMH volume increased in those who remained on HD but not in transplanted patients (median change 023 vs -012ml p=0018) WMH burden correlated with worsening scores of frontal lobe tests Rho 0585 p0005 and worse mood Rho -0485 p0026 FA improved following renal transplant (028 to 029 p=0016) and correlated with improved executive function testing at follow-up Rho 089 p0019 Conclusion Cerebral blood flow is reduced during haemodialysis and correlates with a reduction in intradialytic executive function There is an improvement in FA following transplantation WMH volume increases in those who remain on dialysis and the degree of increase correlates with executive and frontal lobe function This suggests that haemodialysis is associated with clinically significant changes in the brain and that these may be ameliorated by transplantation
Source of fundingconflicts MF is funded by a KRUK fellowship
A21 Pathological classification of IgA nephropathy to predict renal outcomes ndash is there a better way to score tubulointerstitial inflammation
Alastair Rankin David Kipgen Bruce Mackinnon Jonathan Fox Colin Geddes Emily McQuarrie Glasgow Renal and Transplant Unit On behalf of the Scottish Renal Biopsy Registry
Background The Oxford pathological classification of IgA nephropathy (IgAN MEST-C score) is limited by the fact that individual features of the score are not all predictive and its utility in assisting clinical decision-making is questioned The addition of tubulointerstitial inflammation to the existing scoring system is appealing but is not currently included due to reportedly wide inter-observer variability We report a novel method to score percentage of cortex containing tubulo-interstitial inflammation in non-atrophic renal cortex (ATIN) in patients with IgAN similar to that used in transplant biopsy reporting and assess its utility to predict clinical outcomes
Methods All adult patients with a native renal biopsy diagnosis of IgAN between 2010 and 2015 in a unit serving 15 million people were identified Baseline characteristics biopsy reports and outcome data were collected ATIN was calculated by subtracting the percentage of atrophic cortex from the percentage of total cortex with tubulo-interstitial inflammation withge10 representing significant tubulo-interstitial inflammation in non-atrophic cortex The primary outcome was a composite of requiring renal replacement therapy (RRT) or doubling of serum creatinine (sCr)
Results 153 new cases of IgAN were identified 33 were excluded (24 had lt8 glomeruli on biopsy 6 inadequate biopsy for MEST scoring and 3 on RRT at time of biopsy) In addition patients with a tubular atrophy (T) score of 2 were also excluded (n=9) Of the remaining 111 patients 76 (68) were male Mean age at biopsy was 52 years (+- 167) and 18 (16) had a co-existing clinical diagnosis of henoch-schonlein purpura (HSP) Median sCr was 156 micromoll (IQR 101-212) and 54 (49) had ATIN on biopsy During a median follow-up of 23 years 34 (31) reached the primary outcome 20 (18) received immunosuppression and 16 (14) died On univariate Cox regression survival analysis ATIN was associated with a four-fold increase in the primary outcome (HR 49 (21-113)) On multivariate analysis mesangial hypercellularity (M) T and ATIN independently predicted renal outcome while endocapillary proliferation (E) and segmental sclerosis (S) did not (plt002 for ATIN) Excluding patients with HSP or those who received immunosuppression did not change the result
Conclusion Within our centre ATIN predicts renal outcome for IgAN independently of established histological features Assessment of inter-observer reproducibility and validation in other cohorts is still required but these results suggest ATIN could be a worthwhile addition to current pathological scoring systems for IgAN
Source of funding none Conflicts of interest none
P1 Polypharmacy in Renal Replacement Therapy Patients
Jason McMinn Colin Geddes Glasgow Renal and Transplant Unit Queen Elizabeth University Hospital
Introduction
Prescribing is often led by evidence from studies containing participants with single health conditions and without multimorbidity Polypharmacy is becoming increasingly recognised in patients with multiple chronic health conditions Additional medications are more likely to result in diminishing returns in benefit with an increased risk of harm Patients with established renal failure (ERF) are likely to be susceptible to medication-related harm A high pill burden is also likely to contribute adversely to an already restricted quality of life and has been associated with poor medication adherence The aim of this study was to analyse polypharmacy in all patients with ERF attending our service
Methods
We extracted medication records for all prevalent ERF patients attending the Glasgow Renal and Transplant Unit from the West of Scotland Electronic Renal Patient Record (SERPR) as of 01012017 The records were analysed to calculate the number of regular medications and total pill burden of each patient These medications were categorised as being lsquopreventativersquo or lsquosymptomaticrsquo We also analysed the prescription of specific drug classes to examine the prevalence of these medications
Results
We identified 1091 transplant follow-up 529 hospital haemodialysis and 46 peritoneal dialysis patients who were on a mean of 94 13 and 129 different medications respectively Overall pill burden was 139 tablets a day in transplant follow-up patients 141 in haemodialysis patients and 162 in peritoneal dialysis patients There were similar rates of prescribing between the different dialysis units and clinics within our service
The proportions of medications deemed as preventative rather than symptomatic were 76 in transplant 69 in haemodialysis and 60 in peritoneal dialysis
In transplant patients decreasing renal function was associated with a higher pill burden but even patients with a transplant eGFR gt 60 were on a mean of 126 tablets per day including a mean of 14 antihypertensives
Rates of antidepressant prescribing were 15 in transplant patients and 20 in hospital haemodialysis patients 53 of haemodialysis patients were on a statin 39 on aspirin 61 on a proton pump inhibitor and 7 were on warfarin
Conclusion
Patients undergoing all forms of renal replacement therapy are likely to be on a considerable number of medications Whilst these drugs are inevitably prescribed for valid reasons this data demonstrates the need for clinicians to engage with patients to explore opportunities to reduce pill burden
Conflict of Interest None Sources of Funding None
P2 An audit of Acute Kidney Injury (AKI) on an acute stroke ward before and after plannedinterventions to review and maintain hydration
Clare Harris1 Simon Hart2 Fiona Duthie3 1 University of Edinburgh Medical School 2 Stroke Unit Royal Infirmary of Edinburgh 3 Renal Unit Royal Infirmary of Edinburgh
Background Dehydration is an important factor in the development of acute kidney injury which is associated with increased morbidity and mortality particularly in the elderly population Poor fluid intake is common post stroke (1) and dehydration is associated with poorer outcomes 3 months post stroke (2) In late 2014 there was no system of identifying patients with poor oral intake on the stroke ward at the Royal Infirmary of Edinburgh a hydration protocol and education programme were implemented aiming to improve fluid balance This included the use of prescribed water either orally or by nasogastric tube An audit pre and post intervention demonstrated that hydration as measured by ureacreatinine ratio significantly improved after the protocol introduction (3) We aimed to determine whether the incidence of AKI by KDIGO criteria was also reduced as this could have implications for reducing patient morbidity and mortality in this elderly comorbid patient cohort
Method 150 inpatients to the acute stroke ward during JulAug 2014 and JulAug 2015 were selected (n= 80 2014 n=70 2015) Patient data and creatinine values were collected from the electronic patient record and medical notes and retrospectively analysed Baseline creatinine values were calculated and cases of AKI were identified and staged using KDIGO criteria (4) Chi-Squared tests were performed to determine P values Individual patient notes were reviewed for both quantitative and qualitative data of patient management
Results Incidence of AKI (of any stage) was 263 pre-protocol and 200 post-protocol (P=03646) Incidence of AKI stages 23 was 100 pre-protocol and 715 post-protocol (P=05374) In hospital post stroke mortality was 338 pre-protocol and 1286 post protocol (P=00028) AKI was also associated with increased length of stay
Conclusions Despite a trend in benefit there was no significant difference in incidence of AKI pre and post hydration protocol nor in incidence of severe AKI (stage 23) AKI is influenced by many factors one of which is hydration status Further studies are needed to determine whether the trend of benefit exhibited in this sample is significant in a greater sample size if this were the case such a protocol could have great benefit to patient care on stroke units and elsewhere There was a significant difference in inpatient post stroke mortality following introduction of the hydration protocol Further investigations are needed to explain underlying reasons for this factors other than hydration may play an important role
References 1 Whelan K Inadequate fluid intakes in dysphagic acute stroke Clinical Nutrition (2001) 20(5)
423-428 2 Bhalla A Sankaralingam S Dundas R Swaminathan R Wolfe CDA Rudd AG The influence of
raised plasma osmolality on clinical outcome after acute stroke Stroke (2000) 312043ndash2048 3 Hart SR Craig R Berry E Lane N Gad A Farrugia M Burton L Paquay A What Happens to
Acute Stroke Patientsrsquo Fluid Balance Renal Status and Dehydration in the First Two Weeks How Can They Be Markedly Improved doi 101111ijs12634_13
4 KDIGO Clinical Practice Guideline for Acute Kidney InjuryKidney international supplements (2012) 2(1) 1-138
No funding or conflict of interest to declare
P3NHS Highland-Improving the management of hyperkalaemia using a kit Initial resultsCantley N1 Abedin T2 Lambie S3
1FY2 NHS Highland 2ST4 Renal Medicine NHS Grampian 3Renal Consultant Renal unitRaigmore Hospital Inverness
Introduction The incidence of hyperkalaemia in hospitalised in patients is between 1 and 10 Guidelines in Northern Ireland promote the use of a Hyperkalaemia Kit to improve management of hyperkalaemia We assessed the management of hyperkalaemia in Raigmore Hospital including post-treatment monitoring of serum potassium and blood glucose at baseline and after the introduction of a lsquoHyperkalaemia Kitrsquo which contains a pro forma for the management of hyperkalaemia and all the relevant equipment and drugs for treatment
Method Between July and September 2016 an automated algorithm identified 34 patients with a potassium result 65 mmoll or above on laboratory results 12 received no specific treatment of these 6 results were spurious 4 patients died before treatment could be started and 2 patients were chronic haemodialysis patients We introduced the Hyperkalaemia Kit to the Acute Medical Admissions Unit in Raigmore Hospital Since then 15 patients have been identified with serum potassium measurements above 65 and the pro forma and kit was used with eight of these patients One of these patients proceeded straight to acute renal replacement therapy
Results Prior to our intervention all 22 patients that were actively treated received at least one prescription of appropriate doses of Insulin with Dextrose However only 16 patients received intravenous calcium and only 7 received nebulised Salbutamol Potassium was measured at 4 hours in 5 cases and by 12 hours in 17 cases Monitoring of any capillary blood glucose was only documented in 8 cases Of the 22 treated 2 needed acute renal replacement therapy 3 required further doses of insulin and dextrose 2 were treated with Calcium Resonium
Eight cases of hyperkalaemia have been managed with the use of the kit and pro-forma so far An initial ECG was performed in all eight and four patients had continuous cardiac monitoring Intravenous calcium was given in seven and nebulised Salbutamol was given in five out of the eight cases Six out of eight patients had at least three blood sugar measurements One had two measurements documented and one patient was stopped from further monitoring following senior review and decision to palliate Seven patients had appropriate monitoring of their serum potassium by 4h and 12h again one patient was not monitored due to palliation
Conclusion Baseline results showed very low rates of prescription of nebulised Salbutamol low rates of Calcium Gluconate use and very low monitoring of blood sugars and potassium post treatment This has the potential for serious adverse outcomes particularly the potential for iatrogenic hypoglycaemia Our initial data shows the use of a Hyperkalaemia pro forma and kit improves the rate of prescription of intravenous calcium and nebulised Salbutamol and the post-treatment monitoring of serum potassium and blood sugar levels
P4Rituximab as maintenance therapy in ANCA associated vasculitisndash a single centre experience Rathnamalala NK Mcmenamin J Robertson S Almond A Kelly M Muniraju T M Renal Unit Dumfries and Galloway Royal Infirmary NHS Dumfries and Galloway Background The introduction of Cyclophosphamide and high dose steroids transformed ANCA associate vasculitis (AAV) from a disease of high mortality to a relapsing remitting disease Maintenance of remission however still remains a major challenge A two randomised clinical trials have looked at the use of Rituximab in remission induction in AAV and reported similar remission rates between Cyclophosphamide and Rituximab 12 Both these trials used Azathioprine as maintenance therapy and in the follow up showed similar remission rates with either agent for induction The role of Rituximab for maintenance therapy after cyclophosphamide induction was studied in the MAINRITSAN trial 3 Rituximab was compared with azathioprine and found that the relapse rate was significantly lower in the Rituximab group There have been several other retrospective studies that have suggested regular Rituximab infusions are successful in maintaining remission however has not been thoroughly evaluated 4 5678910 Here we share our centrersquos experience using Rituximab for maintenance of remission of AAV Materials and methods We conducted a retrospective review of electronic medical records of all patients who had received Rituximab as maintenance therapy for 12 months or longer between January 2014 to July 2016 Disease activity was assessed using Birmingham Vasculitis Activity Score ( BVAS) Version 3 and complete remission was defined as a score of 0 and partial remission as a score of lt50 of the value at diagnosis Due to uncertainties associated with sub classification we did not assign specific diagnosis but broadly classified as ANCA associated vasculitis Results 6 patients received Rituximab as maintenance therapy during the study period 3 (50) of them had eye ear nose and upper airway manifestations consistent with Granulomatosis with Polyangitis (GPA) All patients were PR3 ANCA positive except for one at initial diagnosis The mean BVAS score at the time of initiation of Rituximab was 4 All patients were initiated on Rituximab for relapses while on maintenance therapy with Azathioprine 4 patients received 6 monthly doses of Rituximab while two received annual doses All of them were also maintained on 5-10 mg of Prednisolone The mean BVAS score by 6 months was 0 and remained 0 at 12 months The mean PR3 titre was 562 at the initiation of treatment while at 12 months it had come down to 68 All patients remained in complete clinical remission at the end of 12 months after initiation of therapy Rituximab was well tolerated by all patients except one who developed pyrexia during an administration
Conclusions All patients had sustained remission at 6 months and 12 months after initiating Rituximab Rituximab has a potential role as maintenance therapy in AAV
P5 Chronic Myelo-Monocytic Leukaemia (CMML) as a contraindication to renal biopsy Alastair Rankin Emily McQuarrie Jennifer Lees Bruce MacKinnon Glasgow Renal and Transplant Unit On behalf of the Scottish Renal Biopsy Registry
Abstract Chronic Myelo-Monocytic Leukaemia (CMML) is a relatively rare mixed myelodysplastic myeloproliferative disorder that predominately affects patients over the age of 65 years Renal impairment in patients with CMML is well described with several different mechanisms reported including tumour infiltration lysozyme-induced injury amyloid deposition and tubulointerstitial nephritis From anecdotal evidence within our centre we are concerned that patients with CMML have an excessive risk of clinically significant bleeding following native renal biopsy This risk appears disproportionate to the degree of any co-existing thrombocytopenia or coagulopathy
We review the cases of 4 patients with an existing diagnosis of CMML who were referred to the renal clinic with proteinuria and excretory renal dysfunction Two of these patients underwent renal biopsy with subsequent major haemorrhage post-procedure despite normal bleeding parameters pre-procedure Patient 1 presented with flank pain 8 days post-biopsy A CT confirmed peri-nephric haematoma with retroperitoneal extension A total of 6 units of packed red cells (PRCs) were transfused prior to successful CT-guided emoblisation Histology from the biopsy revealed chronic tubulointerstitial nephritis Patient 2 experienced haemodynamic instability and haematuria one hour post-biopsy A total of 11 units of PRCs 7 units of fresh frozen plasma 2 pools of platelets intravenous tranexamic acid and 2 attempts at CT-guided embolization were required until haemostasis was achieved Histology later showed evidence of tumour infiltration with associated vasculitis Patient 3 presented with renal impairment and proteinuria on the background of known CMML Following discussion with haematology the risk of bleeding following renal biopsy was considered unjustifiable despite their platelets and coagulation screen being within normal range The patient was treated for presumed renal tumour infiltration with hydroxycarbamide Patient 4 was referred to the renal clinic with acute onset nephrotic syndrome Urinary proteincreatinine ratio was elevated over 800 mgmmol with serum albumin of 23 gL but normal excretory renal function The patient attends the haematology clinic with suspected CMML and chronic thrombocytopenia but previously declined bone marrow biopsy Following discussion with the patient there are no plans to proceed with renal biopsy given potential risks These cases highlight that while CMML is rare these patients are being referred to renal clinics with features that would commonly justify renal biopsy in other settings but in whom there may be an increased risk of bleeding post-procedure Our in-centre risk of major bleeding is 2 therefore to have such extreme amounts of bleeding in 2 patients with this underlying diagnosis is remarkable This creates a dilemma for the clinician as there is a wide range of potential renal pathology associated with CMML some of which will have disease specific but relatively toxic treatments available
Source of funding none Conflicts of interest none
P6 NHS Highland-Prograf to Adoport switch McCulloch K1 Peel R2 Lambie S3
1Renal Pharmacist Renal unit Raigmore Hospital Inverness 23Renal Consultant Renal unit Raigmore Hospital Inverness
Introduction NHS Highland (NHSH) is the first health board in Scotland to implement a switch from Prograf to Adoport for renal transplant patients This will provide considerable cost savings Adoport meets the bioequivalence criteria for drugs with a narrow therapeutic index set by the European Medicines agency and studies indicate therapeutic equivalence1 with the proviso that brands are non- interchangeable unless the switch is overseen by a Renal Consultant and post-conversion therapeutic drug monitoring is conducted23 The switch has been undertaken by a majority of transplant centres in England the main difference being that they have undergone repatriation NHSH Patients receive their transplant primarily at Royal Infirmary of Edinburgh and occasionally at Queen Elizabeth University Hospital Glasgow Care is transferred to NHS Highland on discharge NHS Highland cares for approximately 170 renal transplant patients 110 being prescribed Prograf These patients may live as far as 110 miles from Raigmore Hospital Given that prescribing is carried out by primary care clear communication with patients GPs and community pharmacy is essential to avoid inadvertent switching between brands
Method Clinically it was agreed a switch could be safely undertaken A business case was submitted and funding secured for pharmacist time laboratory costs and primary care time GPs have been informed via GP subgroup and local prescribing bulletin lsquoThe Pink Onersquo Community pharmacies are being informed by phone A protocol has been agreed Eligible patients selected by Renal Consultant and Renal Pharmacist Patients sent letter signed by Renal Consultant and Renal pharmacist Patients phoned prior to clinic to agree Adoport start date and address concerns Patient seen by Renal Consultant and pharmacist + given 1 month of Adoport Tacrolimus level and UampEs checked 5-7 days after commencing Adoport and patient
contacted by phone to check if tolerated If stable letter sent to GP and community pharmacy to continue supply
Results and Evaluation Letters have been sent to all eligible patients Seven patients have been reviewed One has received a one month supply of Adoport and 5 others are due to switch One patient was deemed non-eligible at present as they have a 6 month surplus of Prograf A database will be maintained and analysed at the end and primary care savings will be monitored Extra pharmacist input will give us the opportunity to review how immunosuppression is managed and to evaluate the benefit of having a renal transplant pharmacist Conclusion The switch is at an early stage Ultimately we hope to show that the switch from Prograf to Adoport can be managed safely with extra pharmacist input to a remote and rural population with prescribing being conducted by primary care
Fundingconflicts of interest none 1 McDevitt-Potter LM Sadaka B Tichy EM Rogers CC Gabardi S Transplantation 2011 A multicenter experience with
generic tacrolimus conversion 2 Medicines and Health Products Regulatory Agency Drug Safety Update 2012 Accessed online via
wwwmhragovukSafetyinformationDrugSafetyUpdateCON1557563 ESPRIT Guidance on management of repatriation and immunosuppressant switches in transplant patients 2015
Accessed online via httpwwwespritorgukwp-contentuploads201508Switch-guidance-document-final-Aug-31-2015pdf
P7 NHS Highland-Tacrolimus baseline dataMcCulloch K1 Peel R2 Lambie S3
1Renal Pharmacist Renal unit Raigmore Hospital Inverness 2Renal Consultant Renal unitRaigmore Hospital Inverness 3Renal Consultant Renal unit Raigmore Hospital Inverness
BackgroundAs part of planning a switch from using tacrolimus Prograf to Adoport we assessed baseline data for our transplant patients currently using Prograf After converting patients to Adoport we will compare their tacrolimus levels to their individual target range We assessed our use of appropriate target ranges and our current performance in achieving tacrolimus levels within target range on Prograf therapy
Method 107 renal transplant patients taking Prograf were identified a sample of 19 of these were analysed using electronic patient records and results Time from transplant ranged from 1 month to 18 years All tacrolimus levels for the preceding year were analysed and compared to the target range specified at the time of the level being done The assay used has a Coefficient of Variation of lt5 at the lower limit of the assay
Results All 19 patients had a target range for tacrolimus clearly identified and recorded in clinic letterswhich are routinely copied to the patients themselves A variety of target ranges were specifiedThe commonest used was 5-8 microgramsl in 7 patients followed by 5-7 in a further 4 patientswith another 6 different target ranges being used for the remaining 8 patients The ranges usedhad a breadth of 3 microgramsl in 2 cases the rest had a breadth of 2 microgramslPatients had a median of 12 (range 3-72) tacrolimus levels over the preceding year Results werewithin specified target ranges for 54 +- 22 (Medan +- SD) of results checked
Conclusion We currently use a large number of different target ranges The majority of the ranges used had a breadth of just 2 microgramsl These factors help to account for the low proportion of test results which were within the specified target ranges This is important to bear in mind when interpreting whether tacrolimus levels are within target ranges after switching to Adoport We should consider aligning our target ranges and widening them
P8 Eculizumab use in Scottish paediatric dense deposit disease Stewart D1 David Hughes1 Lynne Riach2 Craig Oxley2 Athavale D1
1Royal Hospital for Children Glasgow 2Royal Aberdeen Childrenrsquos Hospital Aberdeen
Introduction The revised MPGN classification and increasing recognition of Dense Deposit Disease (DDD) a C3 glomerulopathy as an alternative complement pathway disorder suggests Eculizumab an anti-C5 monoclonal antibody may be beneficial in treatment However the experience of Eculizumab as an off-label and expensive treatment in children with DDD is limited with variable clinical response reported in the literature
Method We present the outcomes of the only 2 paediatric patients in Scotland who have received Eculizumab for the management of DDD
Results Case 1 A 10 year old male presented with proteinuria and haematuria resistant to steroid treatment with preserved renal function Initial biopsy confirmed DDD Conservative management with an angiotensin converting enzyme inhibitor and diuretics for symptom control continued until 14 years Due to worsening symptoms (oedema lethargy poor growth) and renal function deterioration along with elevated terminal complement complex (TCC) Eculizumab was commenced A repeat biopsy whilst suggestive of chronic irreversible damage showed 25 glomerular architecture preservation Symptom improvement was noted There was a reduction in proteinuria and renal function stabilisation fall in TCC and discontinuation of diuretics Eculizumab was discontinued after 24 months Progression of renal function decline was seen in the final months of Eculizumab therapy With recurrence of symptoms and increasing proteinuria following discontinuation Eculizumab was recommenced after 6 months Symptomatic improvement has since been noted
Case 2 A 5 year old girl presented with painless frank haematuria and proteinuria Initial biopsy confirmed DDD Proteinuria was unresponsive to steroid therapy and 5 months following diagnosis she rapidly progressed towards end stage renal disease despite the introduction of Mycophenolate Mofetil and plasmapheresis Haemodialysis was subsequently commenced TCC level was elevated and Eculizumab treatment was started 7 months after diagnosis Renal biopsy prior to treatment demonstrated continued severe pathological changes in all visible glomeruli However due to lack of clinical response Eculizumab was discontinued after 2 months and the patient remained dialysis dependent
Conclusions Our experience with Eculizumab in Scotland has demonstrated variable results in our 2 patients with one patient showing a positive response whilst the other experienced no improvement Eculizumab was administered to both patients at varying points in their clinical journey with differing progressive features on biopsy To date the outcomes of 9 paediatric patients with DDD treated with Eculizumab have been described in the literature with 8 experiencing some positive response to treatment including 2 patients who were able to stop renal replacement therapy within 12 weeks of treatment A role for Eculizumab in DDD may be guided by clinical and pathological features Well designed clinical trials will be necessary to define the role of complement inhibition therapy in DDD
No conflict of interest and no funding requested
P9 Examining markers of safety in the use of non-tunnelled central venous catheters
James WT Millar (Speciality Registrar) Scott W Oliver (Speciality Registrar) Peter C Thomson (Consultant Nephrologist) Glasgow Renal and Transplant Unit Queen Elizabeth University Hospital Glasgow
Background Non-tunnelled central venous catheters (NTCVC) remain an essential means of vascular access for incident haemodialysis Associated morbidity is well recognised for example in the form of Staphylococcus aureus bloodstream infections (SAB)[1]
Previous quality improvement initiatives in our unit have sought to both improve traditional markers of quality (such as SAB) and to identify additional areas of clinical risk In 2014 Oliver et al [2] suggested several additional quality measures including peri-procedure haemoglobin drop the need for a further NTCVC during the same clinical episode and the NTCVC insertion site This study further evaluated NTCVC related clinical practice within our unit
Methods The potential markers of clinical quality identified in a previous project were examined using prospectively collected data stored in the electronic patient record Identified cases of SAB significant peri-procedure haemoglobin drop and multiple NTCVC insertion were investigated by case note review
Results Between March 2016 and March 2017 a total of 222 patients received 346 NTCVC 54 patients (243) had more than one NTCVC inserted in a 21-day period (range 2-5) When considering NTCVC insertion site there were 159 (459) femoral vein catheters and 183 (541) internal jugular vein catheters No pneumothoraces were reported
15 SABrsquos were reported during this period equating to 43 of all NTCVC 5 arose in patients with femoral NTCVC (333) and 10 from internal jugular catheters (667) Mean time from line insertion to positive blood culture was 86 days 15 (67) patients had a drop in haemoglobin of greater than 20mgdl with no other source of blood loss identified on review of clinical notes
Discussion These data demonstrate that NTCVC-associated SAB rates remain low and significantly below Scottish government audit standards [3] Of interest is the continued trend towards the use of femoral catheters at 45 of lines compared with 38 in 2014 [2] Although traditionally thought of as having a higher incidence of infectious complications our data has shown fewer bacteraemia events associated with femoral catheters compared with internal jugular Our data also demonstrates a significant rate of peri-procedure haemorrhage arising in up to 1 in 20 cases Together these findings present opportunities to development practice and improve patient safety
References
[1] Murray E Deighan C Geddes CC Thomson PC Reducing haemodialysis bacteraemia rates Scottish Renal Association Glasgow November 2013 [2] Oliver SW Thomson PC Jardine AG defining safe effective and patient-centred dialysis catheter placement Scottish Renal Association Edinburgh September 2014 [3] The Staphylococcus aureus bacteraemia quarterly report of cumulative data from all NHS Boards in Scotland Health Protection Scotland January 2015
Sources of funding none Conflicts of interest none
P10 Prescribing of tolvaptan-The NHS Highland experience Lambie S1 McCulloch K2 Garrod J3
1Renal Consultant Renal unit Raigmore Hospital Inverness 2Renal Pharmacist Renal unit Raigmore Hospital Inverness 3Renal Pharmacist Renal unit Raigmore Hospital Inverness
Introduction Tolvaptan is a vasopressin antagonist It was accepted for use in Scotland by SMC in Jan 2016 to slow the progression of cyst development and renal insufficiency of autosomal dominant polycystic kidney disease in adults with chronic kidney disease (CKD) stage 1 to 3 at initiation of treatment with evidence of rapidly progressing disease1 Adverse effects related to aquaresis may affect patientsrsquo ability to achieve the optimum therapeutic dose and the risk of hepatic toxicity necessitates regular LFT monitoring The geography of NHS Highland required the implementation of novel methods of managing these patients and as a result a MDT approach with an emphasis on pharmacist input was adopted Consultant role Patient selection on the basis of evidence of rapidly progressing kidney disease declining
eGFR large volume kidneys on ultrasound and evidence of complications of PKD Side effects and potential benefits discussed Potential medication interactions reviewed Jinarc risk management prescriber training
Pharmacist role Undertook Jinarc risk management pharmacist training Prepares accurate drug history and reviews for potential drug interactions Carries out patient counselling and supplies patient education material sick day rules card
and lsquogot to gorsquo card Supplies GP education leaflet Provides advice on selection of new drug therapies eg for gout Manages stock and coordinates supply to patients
Results Prescribing commenced May 2016 patients currently prescribed tolvaptan 11 7 Female 4 male Number on target dose 73 n = 811 2 patients are still being titrated One patient did
not tolerate target dose due to aquaresis side effects and is being trialled on the middle dose
Withdrawals One patient has withdrawn due to agoraphobia and an inability to attend for monitoring and another is on hold due to having major surgery
Conclusion The MDT approach between the Renal Consultant and Pharmacist at Raigmore Hospital has enabled tolvaptan prescribing to be efficiently and safely implemented to patients living within a challenging geographical location
1 Scottish Medicines Consortium Detailed Advice Document tolvaptan 15mg 30mg 45mg 60mg and 90mg tablets (Jinarcreg) SMC No 111415 January 2016
NA1 Authors SCN Jacqueline Ross NHS Grampian
SCN Alan Somerville NHS Lanarkshire SCN Jane Humphrey NHS Lanarkshire
e- mail contact jacquelinerossnhsnet Alansommervillelanarkshirescotnhsuk
Janehumphreylanarkshirescotnhsuk
Phone contact 01224 552927 01236 712644
Title Sharing of Adverse Events in Renal Units across Scotland
Introduction Background The Scottish Renal Nurses Strategy Group (SRNSG) are a group of senior nurses from Renal
Units across Scotland who meet 3-4 times per year to discuss and implement best practice At the last meeting it was agreed that it would be good practice for each Health Board to share
their adverse events reported on the Datix System and deliver a presentation with an action plan to prevent incidents and improve patient safety across Scotland NHS Grampian and NHS Lanarkshire will be the first to deliver this presentation discussing adverse events from both Health Boards with an action plan
Top 5 adverse events over the past 12 months Renal Unit NHS Grampian 1 Violence and Aggression 2 Accidents including needlesticks slips trips and falls 3 Medication Errors 4 Infrastructure Staffing and Estates 5 Machines and Equipment
Top 5 adverse events over past 12 months Renal Unit NHS Lanarkshire
1 Slips Trips or Falls 2 Medicine errors 3 Treatment problems 4 Transfer problems 5 Breach of policy
The presentation will also focus on any serious adverse events which may not be in the top 5 categories
Aim Objective Each Health Board to share their adverse events with the aim to prevent them from occurring in other units to improve staff and patient safety and wellbeing across Scotland
Method Power Point Presentation
Outcome Results Sharing of adverse events resulting in the development of a national Action Plan to prevent these incidents improving safety and well being of staff and patients in Renal Units across Scotland
NA2
SRA Oct 2017 Abstract
BBV Never Event - The whats whys and hows
Staff Nurse Gillian Wilson Aberdeen Royal Infirmary
This presentation shares our experience of a never event that occurred and was not picked up for
a period of 18 months
Hepatitis C (HCV) positive antibodies were found in a previously negative patient
These results were a low positive with no biochemistry changes to suggest any liver damage
however steps were put immediately in place to isolate and investigate
Was it contamination from a dialysis machine was it related to a blood transfusion given prior to
first positive result was it faulty diagnostic tests in the laboratory
In Aberdeen we go over and above national guidelines and isolate all our BBV patients whether
they have positive blood results or are PCR negative
Further bloods tested at an external laboratory confirmed negative results
It highlighted that communication errors were to blame for the lack of speed in detecting this issue
Investigations concluded no real answers as to why this happened
NA3
Living Donation Scotland Changing attitudes towards living donor kidney transplantation
Jen Lumsdaine Julie Glen On behalf of the Living Donation Scotland Project Board
Background and aims
The rate of living donor transplantation has remained fairly static in Scotland over the past 10 years
Recent data has shown inequity of access to living donor transplantation throughout the UK so
there is potential to significantly increase this optimum form of treatment for patients with end-stage
renal failure in Scotland The Living Donation Project Board was formed in 2016 aiming to double
the number of living donor transplants by 2020
Method
The two key areas
1 Do recipients receive adequate and appropriate information at the right time about living
kidney donation
2 Informing the general public about altruistic donation
All patients active on the transplant list in Scotland were invited to an information event A follow-up
questionnaire was performed in the East of Scotland examining outcome or reasons for not
attending A scoping exercise looked at information provided by each unit was performed and link
nephrologists and low clearance nurses attended meeting to discuss strategies for early education
Outcome
An information pack containing both recipient and donor written information and short films on DVD
has been produced with the support of the Scottish Government for all recipients and potential
donors in Scotland A new website with comprehensive information both written and visual and
postcode finder to improve ease of access to local unit contact details has been developed
Two national media campaigns have been launched with a significant rise in the number of enquiries
from potential donors and actual increase in altruistic donor numbers
Nursing abstract ndash no conflict of interest
NA4Authors Susan Easson Charge Nurse Ward 4C QEUH Glasgow
e- mail contact SusanEassonggcscotnhsuk
Phone contact 0141 452 3300
Title A Conversational approach to find out ldquoWhat matters to yourdquo in a Renal Transplant ward
Introduction Background Finding out ldquo What Mattersrdquo to people using health and careservices is crucial to delivering safe effective and person centred care It is a simple yet profoundconcept and tries to get to the essence of person centred care by creating deeply personalengagements with patients and their families through a conversational approach However careexperience feedback all too often provides innumerable examples of where what really matters topatients and their family members is poorly understood or not addressed Using care experienceas the driver for change the nursing staff in Ward 4C used improvement approaches to explorehow to hold more meaningful ldquoWhat Matters to yourdquo conversations on a daily basis
Aim Objective To improve the patient experience by utilising a person centred approach
Method Using Care experience feedback What Matters to Me boards and the conversationalapproach
Outcome Results Improvements in patient experience will be shared using examples ofpractice and care experience feedback
There was no additional funding required for this project We worked in collaboration with theperson centred team whorsquos aim is to improve patient experience
NA5
The implementation of a renal education programme and its impact on clinical practice
The purpose was to implement a Renal Education Programme and to evaluate its impact on
clinical practise
It was identified that there was a need for an educational programme to be set up within Forth
Valley Royal Hospital There is no inpatient renal unit in FVRH on site for our renal patients they
attend Queen Elizabeth University Hospital We are an outpatient haemodialysis unit with
outpatient clinics on site Therefore it was identified that there was a need for nursing staff within
FVRH to be educated on all renal complexities for the benefit of our patients
This was done through a work-based learning approach which brought tangible benefits for our
patients However it did not come without pitfalls as educational programmes are often seen as
making very little difference to clinical practise
T
his study describes what methods were used and examines the advantages and disadvantages in
setting up an educational programme and evaluating its impact on clinical practise
NA6
Nursing Abstract ndash SRA Meeting ndash 26 October 2017
Chris McGee Tonya Broe Ken Weir
Renal Unit Forth Valley Royal Hospital
Use of the Therapy Monitor Haemodialysis Patient Record System Can we aim for a paper-
free dialysis unit
We are trialling a new haemodialysis patient monitoring system to work in conjunction with SERPR
and which is intended to supersede the Finesse system used previously
We are in the early stages of this process but with continuing staff education and regular tech
support we are hoping to gather sufficient evidence to evaluate whether the use of paper case
notes needs to continue
Is it a realistic goal to aim for a completely paper-free unit
NA7
THE CLINICAL USES OF APHERESIS WITHIN NHS TAYSIDE
Laura Thomson CN
Ninewells Hospital Dundee
NHS Tayside took over the apheresis service from BTS in 2012 The service has since expanded
with the benefits of carrying out this treatment has been widely recognised within NHS Tayside
and is now more commonly being offered to treat a wider range of conditions with the number of
treatments carried out each year rising
This presentation will highlight the progression of the apheresis service within NHS Tayside We
will identify the various conditions it is currently being used to treat and also identify the decision
making process involved in carrying out these treatments ie which replacement fluid will be used
anticoagulation medication administered
We will highlight the benefits and challenges we face in providing this expanding service within the
Renal Service
NA8Authors Linda McDougall Renal Physiotherapist NHS Highland
e- mail contact lindamcdougall1nhsnet
Phone contact 01463 706022
Title lsquoExercise on Haemodialysis- Keeping the Wheels in Motionrsquo
Introduction Background The impact of CKD on physical fitness functional ability independence amp ultimately quality of life cannot be underestimated Current national guidelines recommend that all individuals with CKD are encouraged to participate in regular exercise programmes between or during dialysis sessions if on HD Following a successful pilot study funding was approved to establish an lsquoExercise on Dialysisrsquo (EOD) programme across NHS Highland through the appointment of a dedicated renal physiotherapist in 2008 A successful programme was soon established but for several years post-vacancies and increasing in-patient demands limited the physiotherapy servicersquos ability to deliver the programme The need to improve the long-term sustainability of the service was recognised and in late 2016 funding was approved to develop a Band 4 PT HCSW role for this purpose
Aim ObjectiveTo optimise the sustainability and continuity of the lsquoExercise on Dialysisrsquo service across NHSHighland through development of a Band 4 PT HCSW role
Method The potential parameters of the role and limits of autonomy were scoped out using current NES resources and guidelines Service and task analysis was then carried out to establish which components of the EOD protocol could be undertaken by a Band 4 A series of competencies were developed in line with the clinical protocol and one-to-one training and supervision provided to the post-holder to ensure competency achieved in delivering the programme
Outcome Results A 10 WTE Band 4 PT HCSW was appointed in Jan 2017 with a dual role between the renal unit and acute medical wards Although training is not yet complete the post-holder is already running the day-to-day delivery and monthly audit of the EOD service with senior physiotherapist input only required for individual patient safety queries and general discussion around patientsrsquo progress and goals The benefit to the unit has been considerable as the band 4 is available to support patients and staff with EOD provision 5 days a week This allows for one-to-one supervision of patients who need more support to participate in EOD regular feedback on performance and reviews of outcome measures and goals to maintain motivation levels Feedback on the post has been very positive and its scope will only continue to expand as we look to further develop renal rehabilitation services across NHS Highland
NA9Authors Nadine Lyall and Kerry Guthrie
e- mail contact nadinelyallbordersscotnhsuk kerryguthriebordersscotnhsuk
Phone contact 01896 826637
Title The Developing Role of the NMP in a Satellite Dialysis Unit
Introduction Background
We have been practising as NMPrsquos for nearly 3 years working in the dialysis unit at the BGH The unit is a satellite unit of the ERI and we have expanded over the last 6 years The unit provides haemodialysis for 12 patients at any one time 3 sessions a day 6 days a week We are nurse-led and have 2 renal consultants who are based at the ERI
We saw an opportunity to use our knowledge and experience to develop our role By becoming NMPrsquos we have enhanced our professional development and we feel we meet the changing needs of the dialysis patient in a more holistic manner
Aim Objective
Our aim is to deliver effective care as we are better placed to deal with issues that often arise byacting swiftly this in turn is cost effective and convenient For example good anaemia and bonemanagement is important for their health wellbeing and lifespanTo help understand our role we will use a power point presentation highlighting issues we dealwith and the drugs we prescribe under the following headings Cardiovascular infection painanticoagulant disequilibrium diet renal bone disease and renal anaemia
Method Power point
Outcome Results
In the future we hope to further develop and have greater autonomy in our role We have great support from our renal consultants and have already built up a great relationship with our patients We hope to undertake the Clinical Decision Making course and this in turn will allow us to deal effectively with acute illness giving the dialysis patient better care We are keen to get feedback from other renal nurses in Scotland to enable us to develop our role further and in turn raise awareness of the NMP role in a dialysis unit We record all our prescribing decisions and keep the consultants up to date regularly Currently we are working on auditing our prescribing practice so that we can improve the service we can provide
NA10 Title Komunikacja w szkoleniu dializy ortzewnowej
Author Senior Charge Nurse Rhoda Bell
Address Raigmore Hospital Old Perth Road Inverness IV2 3UJ
Email rhodabellnhsnet Telephone 01463706023
Introduction Background Case study on lady with Polish as her first language she has some English but requires an interpreter to carry out Peritoneal Dialysis training and attend clinic She had some gynaecological issues that we were not aware of which impacted on the functionality of PD and therefore the success of treatment There were areas of concern in low clearance clinic with signs the patient had a reluctance to engage in decision making
AimObjective
Methods Discussion through the case study highlighted issues with communication between different PD staff and patients Areas of concern include different staffing techniques environment factors on training success Also language and communication issues the patient had were not fully apparent so training could not be individualised
Results We plan to trial training at home and have more individualised training schedule for patients The training step by step guides have been reviewed and practise standardised In collaboration with low clearance nurse we have developed a check list which will highlight concerns before the transition to PD ie language issues and need for training aids in another language gynaecological conditions
Conclusions Everyone learns differently and training methodsaids must be individualised for all It may not be apparent until training has commenced that there are concerns Having one to one training with the same nurse will consolidate training and build confidence in the patient Having a close working relationship with members of the MDT will help make a supportive PD journey
Would we do things differently if we knew about prolapse or lack of English both spoken and written
Key words - Peritoneal dialysis patient training communication
N11
Telehealth amp PDAudrey Jones
Advantages
Information on a daily basis about treatment weight and blood pressure
Change programme remotely via computer or mobile
Earlier intervention for machineprogramme issues
Reduction in home visits ie patient trained but still requires volume increases
No need to download cards to see what problems have been
Can have more detailed information available at clinics
Disadvantages
Relying on patient input data correctly
Machine is noisy especially first wave of machine
Still the same bag connection system and patient connection system (difficult for manual
dexterity problems)
Relying on patient having good signal
Modem problems
NA12Autosomal Dominant Polycystic Kidney Disease A cruel inheritance but new hopeAlistair Lawrie Renal Unit Victoria Hospital KirkcaldySadaf Arshad Corry Dunnigan Paul Phelan Neil Turner Renal Unit Royal Infirmary of Edinburgh
Background Autosomal Dominant Polycystic Kidney Disease (ADPKD) is the most prevalent single gene human genetic disorder and the most common of the inherited cystic and interstitial kidney diseases It is estimated to affect 1 in every 1000 individuals worldwide with over 50 of sufferers eventually developing end stage kidney disease and requiring dialysis or transplantation Symptoms include spasmodic severe pain hypertension haematuria infection and kidney failure There is currently no cure for ADPKD Management of the condition has traditionally involved lifestyle modification BP control and analgesia however a recent study (Torres et al 2012) demonstrated that treatment with V2-receptor antagonist drugs slowed increase in total kidney volume reduced the rate of functional decline and showed a reduced incidence of kidney pain
Aim Provision of a tolvaptan prescribing and monitoring service
Methods Experiential finding report of initial twelve months period of multidisciplinary ADPKDtolvaptan clinic
Results Early results are comparable with TEMPO study outcomes
Conclusion Due to the long term nature of this treatment results available at this time are showing only the earliest benefits of the intervention More quantifiable results such as increased time before the necessity for RRT will only be evident in coming years Torres VE et al (2012) Tolvaptan in Patients with Autosomal Dominant Polycystic Kidney Disease New England Journal of Medicine 367 pp 2407-2418 DOI 101056NEJMoa1205311
No funding requirement No conflict of interest
A4 Vitamin K and Vascular Health A Systematic Review and Meta-Analysis Jennifer Lees12 Fiona Chapman2 Miles Witham3 Alan Jardine12 Patrick Mark12
1 Institute of Cardiovascular and Medical Sciences University of Glasgow 2 Glasgow Renal and Transplant Unit NHS Greater Glasgow and Clyde 3 University of Dundee
Background - Vascular stiffness and calcification occur prematurely in patients with chronic kidney disease (CKD) and are associated with increased mortality Activity of matrix Gla protein - an important regulator of vascular calcification - is dependent on adequate vitamin K intake vitamin K deficiency is prevalent in patients with CKD We conducted a systematic review and meta-analysis of the effect of vitamin K supplementation on vascular health and assessed the evidence that level of (inactive) dephosphorylated undercarboxylated Matrix Gla protein (dp-ucMGP) is associated with incident cardiovascular disease (CVD) or mortality
Methods - Two authors searched Medline and Embase databases Cochrane and ISRCTN registries in May 2017 for i) adult human studies of vitamin K supplementation versus control which measured effects on vascular calcification vascular stiffness or dp-ucMGP and ii) prospective observational studies assessing effect of baseline dp-ucMGP on incident CVD or mortality Random effects meta-analysis was conducted using meta and metafor packages for R statistical software package Egger regression and Trim-and-Fill analyses were used to assess for publication bias
Results ndash Nine intervention studies (n=952) and 13 observational studies (n=7495) met our pre-specified inclusion criteria Vitamin K led to a significant reduction in vascular calcification compared to placebo (-91 [95CI -177 -05] p=004) and a significant decrease in dp-ucMGP (-227pmolL [95CI -281 -173] plt0001) A non-significant improvement in vascular stiffness was evident (-37 [95CI -78 04] p=008) In observational studies with a follow up period of 70 + 40 years stepwise increase in dp-ucMGP was not associated with fatal or non-fatal CVD (log HR 005 [95CI -013 022] p=062) or mortality (log HR 004 [95CI -015 023] p=069) Egger regression and Trim-and-Fill analyses suggest possible publication bias in favour of positive results
Conclusion - Vitamin K supplementation significantly reduces dp-ucMGP level although dp-ucMGP is not associated with incident CVD or mortality Supplementation appears to reduce progression of vascular calcification with a trend towards improvement in vascular stiffness though there are limited data available Clinical trials of the effect of vitamin K supplementation on vascular health are warranted
Funding - JL is supported by a Kidney Research UK Training Fellowship
Conflicts of interest - MW and PM are currently running a BHF-funded trial of vitamin K supplementation in patients with CKD 3b4
A5 Review of management of patients with diabetic nephropathy Wan Shun Wonga Mohammed K Azharuddinb
aRenal and Transplant Unit Queen Elizabeth University Hospital Glasgow bDiabetes Unit Inverclyde Royal Hospital Greenock
Background ndash Diabetic nephropathy is a common and potentially life-threatening complication of both type 1 and type 2 diabetes and is now recognised as the leading cause of end-stage renal disease1 Studies have shown that early interventions can delay the onset and slow the progression of diabetic nephropathy2 The aim of our study was to review the management of patients with diabetic nephropathy at Inverclyde Royal Hospital in accordance to the guideline published by the National Institute for Health and Care Excellence (NICE)
Methods ndash Patients with diabetic nephropathy were identified on SCI-Diabetes Patient data was then extracted from renal electronic patient record SCI-Diabetes and Clinical Portal Clinical notes were also reviewed to determine the reason for cessation of angiotensin-converting-enzyme inhibitor (ACE-I) or angiotensin receptor blocker (ARB) Referral guidelines from the Renal Association were used to assess the eligibility for referral
Results ndash Data was collected from 255 patients with diabetes and urine ACR gt25 (for male) and gt35 (for female) Mean age was 625 years (SD 151) and 584 (n=149) were male 243 of patients (n=62) were classed as type 1 diabetes and 737 (n=188) as type 2 with further 20 (n=5) as others 949 (n=242) patients had an HbA1c recorded within the last year The mean HbA1c was 712 (SD 2052) 8 patients were on RRT (7 on HD and 1 on PD) Serum creatinine and urine ACRPCR were checked in 933 (n=238) and 612 (n=156) of patients in the last year respectively Blood pressure was measured within the past 12 months for 847 (n=216) of patients with 601 (n=146) having blood pressure higher than the target of 13080mmHg Mean systolic and diastolic blood pressures were 1339 mmHg (SD 1735) and 745 mmHg (SD 111) respectively 627 of patients were on ACE-IARB Of the 95 patients who were not on ACE-IARB 421 (n=40) were stopped due to side effects 116 (n=11) patients had their ACE-IARB discontinued but no reason could be found 379 (n=36) patients had never been on an ACE-IARB 157 (n=40) of patients met the criteria for referral to Renal Services and 7 patients had not been referred and all 7 of them recently developed CKD4
Conclusion ndash Our findings were consistent with the national data3 Urine PCR measurement has the lowest completion rate among all the recommended annual care processes Optimal blood pressure control remains a challenging issue for many of the patients with diabetes Further studies could be carried out to look at the reasons behind the low completion rate of urine PCR measurement as well as to devise ways to remind clinicians about starting patients on ACE-IARB and making referral to Renal Services when indicated
References 1 K Bennett B S Aditya An overview of diabetic nephropathy Epidemiology pathophysiology and treatment Journal of Diabetes Nursing 18 61-7 2 Molitch ME DeFronzo RA Franz MJ et al American Diabetes Association Nephropathy in diabetes Diabetes Care 200427(Suppl 1)S79-83 3 Scottish Diabetes Survey 2016 Scottish Diabetes Survey Monitoring Group NHS Scotland
Funding ndash None Conflict of Interest ndash None
A6 Analgesic Use in Dialysis Patients in a District General Hospital Setting
A McCallum L Dickson S Robertson A Almond N Rathnamalala M KellyT Muniraju
Renal Unit Dumfries and Galloway Royal Infirmary
Evidence shows around 50 of haemodialysis patients report pain with 83 describing this as moderate to severei Distinct variability also exists in levels of opiate prescribing between centres with studies showing incidence ranging from 5-50iiiii Consequently we sought to investigate the prevalence of both pain and opioid prescriptions in our local dialysis population as well as investigating whether there are any associations between co-morbidities and the use of opiates This information could then be used to identify new dialysis patients at high risk of pain as well as informing prescribing decisions
In order to achieve this a questionnaire was produced that incorporated validated pain and quality of life scores (the Brief Pain Index and Renal Palliative Care Outcome Scale) with a consent form to access electronic healthcare records Questionnaires were distributed to all our haemodialysis and peritoneal dialysis patients Results were transcribed into Microsoft Excel where they were analysed
Data was collected on 56 patients (46 haemodialysis patients 10 peritoneal dialysis patients) Results showed 46 described ldquopain other than everyday kindsrdquo on the day of survey completion The most common site of pain was in the legs and back On average patients were on 12 different medications of which 15 was for pain (range 0-5) 784 of these pain prescriptions were longstanding (gt3 month use) Amongst haemodialysis patients 45 were on a strong opioid ndash in 73 of cases this was a fentanyl patch Whilst scope exists to increase the use of simple analgesia and neuropathic agents in such patients analysis using the pain management index scale revealed use of opioid analgesia in such cases to be justified As in previous work no link was found between any one co-morbidity and the development of pain
Overall we have shown high rates of pain amongst our dialysis patients We also demonstrate high levels of chronic analgesia use and the overall tablet burden on our patient group is high This work adds to previously published literature and is being used locally to proactively minimise the burden of prescribed tablets and also increase awareness of the value of paracetamol and neuropathic agents in those with uncontrolled pain
Source of funding conflict of interest Nil
References i Davison SN Pain in hemodialysis patients prevalence cause severity and management Am J Kidney Dis 2003421239-1247 ii Butler AM Kshirsagar AV Brookhart MA Opioid Use in the US Hemodialysis Population Am J Kidney Dis 2014 63(1) 164-173 iii Wyne A Rai R Cuerden M Clark WF Suri RS Opioid and Benzodiazepine Use in End-Stage Renal Disease A Systematic Review Clin J Am Soc Nephrol 2011 6 326ndash333
A7 The Role of the Renal Supportive Care Service in Advanced Care Planning JM Sloan CA Douglas S Cathcart L Frame L Stage M Witham ME Lafferty
Renal Service Ninewells Hospital Dundee
Background In 2007 we established a Renal Supportive Care Service for patients with advanced chronic kidney disease who choose not to receive dialysis The service which includes a fortnightly Renal Supportive Care clinic is provided by a Consultant Nephrologist a Consultant Palliative Care Physician and a Renal Supportive Care Specialist nurse The focus of the service is on ongoing management of chronic kidney disease symptom control and improving quality of life while planning for end of life care
Methods We have undertaken a retrospective audit of our Renal Supportive Care Service on all patients known to the Renal Service for whom a conservative care management decision had been made We collected data over a 31-month period from April 2012 until October 2014 We collected data on demographics co-morbidities clinic attendance renal supportive care input anticipatory care planning performance status and mortality data
Results Of the 98 patients for conservative management 62 (6198) were female with a mean age of 837 years During the 31-month period there were 507 documented supportive care consultations with 36 (3598) of patients receiving domiciliary visits from the Renal Supportive care nurse Anticipatory Care Plans (ACP) were in place for 62 (61) of patients with a preferred place of death known for 56 (5598) 65 patients had a documented discussion about their DNACPR status which was communicated in writing to primary care For a further 13 it was not clear whether the discussion had taken place During the study period 61(62) patients died Of those patients with an ACP 29 (1138) died in an acute hospital versus 43 (1023) of those without (p=025) Similarly 24 (834) of patients with a documented preferred place of death died in an acute hospital versus 48 (1327) of those without (p=004)
Conclusions The role of the Renal Supportive Care team is invaluable in providing care and support to patients who have chosen conservative management By discussing and planning for end of life care the Renal Supportive Care team play a role in reducing the number of patients dying within an acute setting
Conflicts None
Funding The Renal Supportive Care Nurse post and one Palliative Care Consultant Programmed activity received 3 years of funding by British Kidney Patients Association
A8 Predictors of transplant failure in patients undergoing indication renal biopsy
Kate Stevens 1 Bruce Mackinnon1 David Kipgen1 Shana Coley1 Marc Clancy1 Colin Geddes1
1Renal and Transplant Unit QEUH NHS GGampC Glasgow United Kingdom
Introduction This study considers indication renal biopsies and factors which may be important
predictors of transplant loss and patient death
Objectives To identify the time line of histological diagnosis from transplant in our population
and to identify predictors of graft and patient survival in those undergoing indication renal biopsy
Methods All indication renal biopsies undertaken between 012011 and 122015 were identified
Demographic data including immunological and outcome data was recorded Statistical analysis
was undertaken in SPSS (v22)
Results 354 patients underwent 549 biopsies Mean patient and transplant age at time of biopsy
was 432 plusmn153 and 42plusmn58 years respectively 449 (n=247) of biopsies showed evidence of
Cell mediated rejection (CMR)ABMR or both 93 (n=51) demonstrated features of chronic
transplant glomerulopathy (CTG) DSA was present at the time of biopsy in 231 (n=127) In
transplants aged le 6 months old histological diagnosis was CMR in 325 (n=69) with ABMR seen
in 28 (n=6) In transplants aged ge10 years CTG was seen in 325 (n=26) with ABMR
accounting for 63 (n=5) 229 (n= 81) of transplants failed at a median of 182 days from most
recent biopsy On cox regression analysis peritubular capillary (PTC) C4d and CTG were
independent predictors of transplant failure Probability of transplant failure was 45 and 50 at
one year if mixed rejection or CTG were present 93 (n=33) patients died at a median of 227
days from most recent biopsy Independent predictors of death included deceased donor
transplant patient age and presence of ABMR on biopsy (plt005)
Conclusion Acute ABMR is a risk factor for patient loss whilst chronic ABMR is a risk factor for
transplant loss This association is independent of DSA but dependent upon PTC C4d staining
indicative of donor humoral activity ndash HLA or otherwise Histological diagnosis in an indication
biopsy is an important factor in predicting outcome This study is limited by the inherent bias in
patient selection with indication biopsy
Disclosure of Interest None Declared
A9 Renal Evaluation of Paediatric Patients with Tuberous Sclerosis Complex (TSC) in aNational TSC Multidisciplinary ClinicDr Jenny Patterson 1 Dr Shelagh Joss 1 Dr Ihab Shaheen 2
1 Clinical Genetics Queen Elizabeth University Hospital Glasgow 2 Paediatric Nephrology Royal Hospital for Sick Children Glasgow
Introduction Tuberous sclerosis complex (TSC) is a dominantly inherited multisystem disorder characterised by development of hamartomas (benign lesions) in multiple organs Previous studies have shown that renal manifestations are common in TSC and also the most frequent cause of TSC-related death in affected individuals With the recent discovery of targeted therapy with mTOR inhibitors early recognition of renal involvement allowing early surveillance and prompt therapy is now more important than ever
AimMethod To review a population of paediatric patients attending a large specialist TSC service in the UK both in terms of key clinical characteristics and current practice for renal radiological surveillance data were collected from electronic medical records pertaining to molecular diagnosis renal surveillance and presence or otherwise of sequelae affecting the renal or other systems Practice was compared to published surveillance recommendations of the International Tuberous Sclerosis Complex Consensus Group (2013)
Results Data were obtained for 41 children (18 males 23 females) Current age range 25 years to 14 years (mean 98 years) Twenty nine patients (707) were diagnosed lt1 year of age Genetic data were available for 29 patients Fifteen patients had a confirmed TSC1 mutation and 14 patients a confirmed TSC2 mutation including one contiguous PKD1 mutation Renal imaging (all US) within a year of diagnosis was documented in 2541(61) performed at a mean age of 3 years Renal symptoms at diagnosis were documented in 741(171) and 941(22) had renal abnormalities on baseline imaging There was wide variability in scanning interval and modality with 1041(243) having previous abdominal MRI with variable documented indication Seventeen (414) of the cohort mean age 102 years had documented renal lesions 917 angiomyolipomas 517 cysts and 317 both These lesions were diagnosed at a mean age of 6 years (range 02 years-142 years) Six patients (353) had normal baseline scans with a mean interval to lesion diagnosis of 1 year One patient had a lesion on MRI not detected on US that required subsequent biopsy Frequency of subsequent scanning ranged from intervals of 2 months to 1 year with a combination of MRIUS in an unclear pattern All patients except one with a contraindication were undergoing current brain surveillance by MRI
Conclusions Our results highlight the significant incidence of renal sequelae within our TSC cohort with renal manifestations ranging both in severity and age of onset International guidelines recommend MRI scanning for renal surveillance at diagnosis and throughout life Benefits of MRI include enhanced accuracy of sizing and characterisation of renal lesions The majority of our cohorts are already undergoing brain MRI surveillance It is our aim to combine and standardise MRI renal surveillance for this cohort to facilitate early and regular monitoring with a view to early intervention is possible
A10 Effect of blood temperature monitoring on intradialytic hypotension in patients with end stage renal disease requiring haemodialysis Heather Walker1 Susan McGeorge1 Drew Henderson2
1 Renal Unit Ninewells Hospital Dundee2 Regional Renal Centre Waikato Hospital Hamilton New Zealand
Background KDIGO define intradialytic hypotension (IDH) as a reduction in systolic bloodpressure (SBP) ge20mmHg or mean arterial pressure (MAP) ge 10mmHg with associatedsymptoms IDH is a common complication of haemodialysis (HD) and is associated with increasedmortality and morbidityStandard dialysis with a set temperature leads to thermal gain during the dialysis session Tocounteract this thermal gain vasodilation occurs and is postulated as one of the causes of IDHActive cooling of dialysis has been shown to reduce IDH but is not routinely applied across wholedialysis populations Isothermic dialysis can be achieved by controlling blood temperature on HDWe report here our experience of doing this using the Blood Temperature Monitoring (BTM)function on Fresenius 5008 dialysis machines
Methods An observational study was performed to assess the rates of IDH in patients with End Stage Kindey Disease (ESKD) undergoing regular satellite HD at NHS Tayside in July 2017 Rates of IDH were assessed (KDIGO definition) for two weeks prior to BTM settings being activated and for a two week study period after introduction SBP and MAP data was collected SBP data was grouped to either SBP decrease lt20mmHg or SBP decrease ge20mmHg compared with Pre HD BP Changes in MAP were also analysed at the same time points Patient reported symptoms related to initiation of BTM were also collected for the same time period
Results 402 dialysis sessions were evaluated in the pre intervention time period and 399 sessions post intervention
IDH 1072 vs 778 (Pre BTM vs Post BTM) p=015 gt20mmg SBP drop Pre vs Post BTM
Mean MAP Change (mmHg) Pre BTM vs Post BTM
1st BP 254 vs 204 (p=005) -522 vs +312 (plt001) 2nd BP 474 vs 435 (p=023) -1589 vs -886 (plt001) 3rd BP 515 vs 435 (p=003) -1862 vs -958 (plt001) Post HD 408 vs 338 (p=003) -1164 vs -077 (plt001)
Following the introduction of blood temperature monitoring only 08 of HD sessions reported experiencing cold or shivering symptoms
Conclusion The use of blood temperature monitoring was not associated with a statistically significant decrease in rates of IDH There was a significant reduction in the number of sessions where SBP decrease by gt20mmHg at the first and third HD BP and a reduction in MAP change across the study group Further evaluation of BTM is required assess its clinical utility in our HD population
Funding No funding was sought for this study
Conflicts of interest None
A11 Evaluating patient satisfaction and clinical outcomes of a new nurse-led dermatology clinic for patients attending the renal transplant clinic Campbell G Naismith K Neil A Rankin A Spalding E (joint first authors) Renal Unit University Hospital Crosshouse Kilmarnock UK
BACKGROUND National Guidelines advise that renal transplant recipients should receive annual skin surveillance to screen for skin cancer In August 2015 a specialist nurse-led dermatology clinic was set-up alongside the renal transplant clinic at University Hospital Crosshouse We aimed to evaluate the success of this joint clinic in terms of clinical outcomes and patient satisfaction
METHODS Clinical records were reviewed to determine the number of patients under dermatology follow-up before and after initiation of the joint clinic and to review cases that were referred for treatment of pathological skin lesions A questionnaire was also distributed to patients attending the new joint renal-dermatology transplant clinic The questionnaire consisted of 5 questions 2 for patient demographics 1 for current understanding of skin care advice and 2 to assess their satisfaction of the new joint clinic
RESULTS A total of 138 and 146 renal transplant recipients were registered on renal transplant clinic lists in 2015 and 2016 respectively Prior to initiation of the new joint-clinic 41 patients had attended dermatology (37 in NHS Ayrshire and Arran and 4 in NHS Greater Glasgow and Clyde) consisting of 30 of the transplant population In September 2016 13 months after initiation of the new clinic 60 patients had attended the new clinic increasing the proportion of patients meeting the national recommendation for skin surveillance to 41 Implementation of the new clinic resulted in patients being 65 more likely to have received the recommended skin checks (odds ratio 165 95 CI 101-270 p=004)
32 patients completed the questionnaire The median age of transplant was 90 years (IQR 38-153) 100 of patients knew to avoid sun exposure and 31 (96) knew to use sunscreen 29 (91) patients were aware of the advice to undergo annual skin surveillance by dermatology with 28 (88) having had a skin check in the last year 29 (91) patients reported that they found the new joint clinic useful although only 18 (56) had attended the clinic so far
CONCLUSIONS Implementation of a new nurse-led dermatology clinic running in parallel with the renal transplant clinic resulted in a considerable increase in the proportion of patients meeting national recommendations for annual skin surveillance The vast majority of patients also found the combined clinic to be useful There is still considerable room for improvement in order to achieve the target of 100 compliance with skin surveillance and ongoing clinical audit is required to assess progress We believe this model would be easily implementable at other units with similar benefits expected
A12 Pneumocystis pneumonia prophylaxis post-renal transplant increased duration of co-trimoxazole is safe and effective FA Chapman JE Dickerson M Clancy C Daly C Geddes Renal amp Transplant Unit Queen Elizabeth University Hospital Glasgow
Introduction All renal transplant recipients receive Pneumocystis jirovecii prophylaxis usually with co-trimoxazole Guidelines suggest this should be continued for 3 to 6 months Our unit previously prescribed 3 months however following an outbreak of Pneumocystis pneumonia (PCP) infection this was increased to 6 months Given its constituents of sulfamethoxazole and trimethoprim co-trimoxazole prophylaxis may influence the frequency of urinary tract infection (UTI) We aimed to compare the frequency of UTI between patients on 3 months vs 6 months prophylaxis and assess rates of multi-drug resistant organisms We also sought to establish if the increased duration of co-trimoxazole was adversely affecting renal function potassium concentration white cell and platelet count and dosing of mycophenolate mofetil
Methods A retrospective search of the West of Scotland Electronic Renal Patient Record was conducted for all renal transplant recipients between 1st January 2012 and 31st May 2016 Patients were grouped according to the intended duration of co-trimoxazole Data were extracted for baseline characteristics co-trimoxazole prescription mycophenolate mofetil (MMF) prescription laboratory results (creatinine potassium white cell count platelets) at 3 6 9 and 12 months post-transplant and microbiology results for 6 months post-transplant Results were analysed on an intention to treat (ITT) basis with a second analysis according to actual duration of co-trimoxazole treatment (AT) Subjects with transplant failure had laboratory results censored from the time of transplant failure and all of their microbiology results were excluded
Results 609 renal transplants were performed over the study period On ITT analysis there were 418 patients in group 1 (ITT1 3 months co-trimoxazole) with 15 transplant failures and 191 patients in group 2 (ITT2 6 months co-trimoxazole) with 12 transplant failures There was a significant difference in the number of patients with at least one UTI with fewer in ITT2 (ITT1 133403 vs ITT2 42179 p = 001) However this was not present when comparing actual treatment duration (AT1 111345 vs AT2 36149 p=007) Overall there was a similar spectrum of organisms cultured There were significantly fewer cultures of multi-resistant organisms in both ITT and AT analyses with 6 months of co-trimoxazole (ITT1 28376 vs ITT2 0106 p= 0004 AT1 22313 vs AT2 198 p = 002) There was no difference in estimated Glomerular Filtration Rate serum potassium concentration platelet count or MMF dose On AT analysis there was a significant difference in the total white cell count (WCC) and lymphocyte count at 6 months post-transplant (WCC 78 x10^5L vs 71 x10^5L p =004 lymphocytes 13 x10^5L vs 12 x10^5L p=002) There were 18 cases of PCP with 7 deaths attributable All cases occurred after cessation of co-trimoxazole prophylaxis (81 ndash 913 days after stopping co-trimoxazole)
Conclusion Although there is a significant difference in UTI frequency on ITT analysis this is not present on AT analysis suggesting no real co-trimoxazole effect There was no increase in frequency of multi-drug resistant organisms with a longer course of co-trimoxazole Renal function and serum potassium were unaffected Our findings support continuing co-trimoxazole prophylaxis for at least 6 months
A13 Kidney transplantation in the over 60rsquos in Scotland 1996-2015 TJW Rennie1 P Phelan1 J Campbell2 JP Traynor2 L Henderson1 W Metcalfe2 On behalf of the Scottish Renal Registry 1Renal transplant unit Royal Infirmary Edinburgh 2NHS National Services Scotland Introduction The proportion of older kidney transplant recipients has increased in the UK but
long term outcome data are scarce We aimed to evaluate patient and graft survival in patients
ge60 years of age receiving a first kidney only transplant in the last 20 years in Scotland
Methods Retrospective analysis of Scottish Renal Registry data of incident Renal Replacement
Therapy (RRT) patients and those in receipt of a kidney only transplant performed 1996-2015
(follow up until 311216) Patients were stratified by age 60-69 ge70 (group 1 and 2 respectively)
and decade of transplantation 1996-2005 2006-2015 (decades 1 and 2 respectively)
Results 6743 patients aged ge60 started RRT from 1996-2016 Of those 108 were ever
transplant-listed 54 had received a transplant by 311216 26 listed and 11 transplanted
were aged ge70
535 patients aged ge60 received a kidney only transplant in 1996-2015 90 patients (168) were
aged ge70 no patients were aged ge80 Mean time from wait listing until transplantation was 33plusmn24
years (plusmnSD) and from starting RRT until transplantation was 38plusmn26 years (plusmnSD) One and five
year graft survival was 97 and 87 in decade 1 95 and 89 in decade 2 (p=NS) there was
no difference in graft survival between age groups 1 and 2 One and five year patient survival was
94 and 78 in age group 1 85 and 56 in group 2 (plt0001) there was no difference in one
and five year patient survival between the two decades
Conclusion One and five year graft and patient survival in renal transplant recipients aged ge60
have not changed significantly in the last 20 years Recipient age ge70 is not associated with
reduced graft survival but patient survival from time of transplant is lower in this age group
compared to recipients aged 60-69
No conflict of interest to be declared No funding received
A14 High Mortality In Older Patients With Primary Nephrotic Syndrome Sarah Beverstock Wendy Metcalfe amp Robert W Hunter Department of Renal Medicine Royal Infirmary of Edinburgh
Introduction
Nephrotic syndrome can develop at any age and may be due to a primary glomerular lesion or secondary to systemic disease The natural history of glomerular disease can be different in older patients For instance minimal change disease (MCD) in children almost always remits promptly with steroid therapy in adulthood it typically remits only after many weeks of steroids or with adjunctive immunosuppression However there are remarkably few published data on the mortality of primary nephrotic syndrome in adults We aimed to study this in our centre
Methods
We enrolled all adult patients who had a kidney biopsy in order to investigate nephrotic syndrome over 38 consecutive months (01 Jan 2014 ndash 28 Feb 2017) We defined nephrotic syndrome as heavy proteinuria (urinary proteincreatinine ratio UPCR gt350 mgmmol or albumincreatinine ratio gt220 mgmmol) and hypoalbuminaemia (serum albumin lt35 gL) In our analysis we included all patients in whom nephrotic syndrome was attributed to a primary glomerular disease We excluded kidney transplant recipients and patients in whom biopsies were performed to follow up a known glomerular disease We collected laboratory data at baseline (time of biopsy) and at 6 and 12 months We assessed patient survival by Kaplan-Meier analysis
Results
Of the 117 patients biopsied for nephrotic syndrome 71 patients (61 ) met the inclusion criteria and were followed up for a median of 469 days We compared outcomes in patients aged under 60 years old (n = 35) with those aged over 60 (n = 36) Mortality was higher in the older group (37 vs 4 mortality at one year p lt005 by logrank test) There were no significant differences between the two groups in serum creatinine or UPCR at any time Serum albumin was similar in both groups at baseline and at 12 months but was lower in the older group at 6 months (27 vs 32 gL p lt 005) Baseline haemoglobin was lower in the older group (114 vs 130 gL p lt005 by unpaired t-test) Primary diagnoses were MCD (n = 10 in younger group amp n = 5 in older group) membranous nephropathy (5 amp 10) IgA nephropathy (9 amp 8) FSGS (5 amp 5) membranoproliferative glomerulonephritis or C3GN (4 amp 7) and other (2 amp 1) Therefore unsurprisingly there were relatively fewer cases of MCD and more cases of membranous nephropathy in the older group otherwise the causative glomerular lesions were similar in both groups In those patients with MCD mortality was significantly higher in the older group none of the 10 patients with MCD diagnosed under 60 yrs old died during the follow-up period whereas 4 of the 5 older patients died 3 patients in the younger group and 1 in the older group were on renal replacement therapy (dialysis or transplant) by the end of follow-up
Conclusions
Primary nephrotic syndrome is associated with high mortality in the over 60s (37 at one year) Mortality was high even for MCD a disease that follows a benign course in childhood and early adulthood The higher mortality in older patients was not associated with greater severity of renal disease at presentation (as assessed by basic blood and urine parameters) This work was not funded we declare no conflicts of interest
A15 Renal biopsies in patients with diabetes mellitus in Scotland
Udana Ratnapala 1 Nicola Joss 2 Colin Geddes 3 Dana Kidder 1
1 Renal Unit Aberdeen Royal Infirmary Aberdeen 2 Renal Unit Raigmore Hospital Inverness 3 Glasgow Renal and Transplant Unit Glasgow
Introduction Diabetes mellitus is the leading cause of end-stage kidney disease (ESKD) requiring renal replacement therapy The utility of renal biopsy in patients with diabetes mellitus is controversial Broadly renal biopsy findings in patients with DM can be divided into diabetic nephropathy (DN) alone DN with non-diabetic renal disease (NDRD) or NDRD alone Timely identification of patients with NDRD is important to provide appropriate therapeutic measures Previously published guidelines on clinical predictors of NDRD have limited specificity and sensitivity The frequency of NDRD in renal biopsies of patients with DM is unclear in ScotlandThis study aimed at identifying the frequency and the pathology spectrum of NDRD in diabetic patients underwent kidney biopsy in 3 renal units
Methods A retrospective observational study was performed on clinical-pathologic findings in all patients with diabetes mellitus who underwent renal biopsy between 01012010 and 31122016 in 3 renal units (Aberdeen Inverness and Greater Glasgow) Data were gathered from electronic patient record systems Scottish Index of Multiple Deprivation (SIMD) 2012 was used to analyse correlation with patient outcomes
Results 247 patients were included 150 men (607) 217 type 2 DM (879) mean age 621 years and mean serum creatinine at the time of renal biopsy of 261 micromolL (+-190 std) On biopsy 92 patients (372) had DN while 127 (514) had NDRD and 28(114) had NDRD superimposed on DN The commonest NDRD aetiologies were IgA nephropathy (187) tubulointerstitial nephritis (168) and idiopathic membranous nephropathy (103) Predictors of NDRD were age (OR 1027 95 CI 1002-1052 p=003) duration of DM (OR 094 95 CI 0900-0987 p=001) and absence of AKI as indication for biopsy (OR 022 95 CI 0059-0826 p=0025) There was no significance difference in renal or patient survival in DN and NDRD Finally no significant correlation was depicted between SIMD quintiles and renal or patient survival in both groups
Conclusions The majority of renal biopsies carried out in patients with DM revealed a NDRD In this study age at the time of biopsy duration of DM and AKI were the main pointers towards NDRD Renal and patient survival were not significantly different between DN and NDRD groups
A16 The Impact of Withdrawal of Maintenance Immunosuppression and Graft Nephrectomy on HLA Sensitisation Ailish Nimmo1 Sophie McIntyre1 Lorna Henderson1 Richard Battle2
(1 Department of Renal Medicine Royal Infirmary of Edinburgh 2 Histocompatibility and Immunogenetics Royal Infirmary of Edinburgh)
Background The development of HLA antibodies towards a failing renal allograft is a barrier to re-transplantation We previously demonstrated an increase in HLA antibodies and calculated reaction frequency (cRF) following nephrectomy but results were confounded by immunosuppression changes occurring in close time proximity We examined the formation of HLA donor specific antibodies (DSA) in patients with failed grafts that remained in situ and compared results with patients undergoing graft nephrectomy to further assess the relative impact of nephrectomy and immunosuppression weaning on sensitisation and chance of transplant
Methods We carried out a single centre retrospective study of all patients with failed grafts in Lothian from 2005 to 2015 Samples were tested for DSA pre-immunosuppression (IS) wean post-IS wean and post-IS cessation Nephrectomy patients also had samples tested for DSA before and after nephrectomy Data on other sensitising events including blood transfusion and rejection were collected cRF was determined at each time point and entered into the ODT chance of transplant calculator with other demographics based on the average patient from the Edinburgh centre
Results 62 grafts failed over this time period Blood samples were available 41 patients (24 with nephrectomy 17 with failed graft left in situ) Patient demographics were similar between groups There was a higher rate of antibody mediated rejection in the nephrectomy group (46 vs 18) 76 of patients with nephrectomy group had received a blood transfusion The pattern of immunosuppression weaning was similar but median time from start of IS wean to cessation was longer in the nephrectomy group (350 vs 298 days) The changes in cRF and chance of transplant (COT) with immunosuppression weaning are shown in Table 1
Pre-IS Wean Post-IS Wean
Failed graft in situ (n=17)
Mean CRF COT at 5
years 15 62 38 59
Nephrectomy (n=24)
Mean cRF COT at 5
years 54 54 69 46
Post-IS Stop 55 53 89 42 Table 1 Mean cRF and Chance of Transplant (COT) at 5 years with IS alterations
Discussion A stepwise increase in cRF with reduced chance of transplant was observed in both groups as immunosuppression was withdrawn with a similar pattern of change irrespective of graft nephrectomy cRF was higher in the nephrectomy group despite a more gradual wean which may reflect a higher rate of antibody mediated rejection and increased number of patients receiving a blood transfusion The risks and benefits of stopping immunosuppression need to be carefully considered on an individual basis to maximise chance of future transplant
The authors have no conflicts of interest No funding was required for this study
A17 Obesity is not associated with progression to end stage renal disease in patients withbiopsy-proven glomerular diseases
Benjamin Elyan Jennifer S Lees Bruce Mackinnon Jonathan G Fox Colin C Geddes Emily PMcQuarrie
Glasgow Renal and Transplant Unit Queen Elizabeth University Hospital Glasgow
Introduction - Addressing risk factors for renal progression is a key aspect of managing chronic kidney disease (CKD) Body mass index (BMI) has been shown to impact on renal progression in unspecified CKD The aim of this study was to evaluate if there was an association between BMI and progression to renal endpoints in patients with biopsy-proven primary glomerular disease (GN)
Methods - We included all adult patients diagnosed with biopsy-proven primary GN (excluding minimal change nephropathy) in Greater Glasgow amp Clyde and Forth Valley between 01012000 and 31122015 Biochemical and anthropometric data were extracted from the electronic patient record at time of biopsy with follow-up data until 20062017 BMI was calculated from height and weight at time of biopsy and categorised into groups BMI le25 kgm2 (G1) gt25 to le30 kgm2 (G2) and gt30 kgm2 (G3 - obese) We assessed factors associated with reaching a combined renal endpoint of CKD5 or renal replacement therapy (RRT) with competing risk of death using the Fine and Gray subdistribution hazard model Analyses were conducted using cmprsk package for R statistical software package and SPSS version 24
Results - 560 patients with primary GN and available BMI data were included The average age was 532 years and 339 were female There were 132 patients in G1 210 in G2 and 207 patients in G3 Those in G2 and G3 were older (p=002) with slightly higher diastolic blood pressure (p=002) than those in G1 There was a greater proportion of focal segmental glomerulosclerosis in G3 but similar proportions of other GN diagnoses across groups There was no significant difference in baseline serum creatinine (sCr) (p=034) or log uPCR (p=045) between BMI groups On multivariate analysis age systolic blood pressure BMI or GN diagnosis were not predictive of renal outcome Higher baseline sCr (SHR 1003 per 1 umoll increase in sCr 1001-1004 plt0001) and log uPCR (SHR 130 per unit increase in log uPCR 95 CI 105-160 p=002) were associated with progression to the combined renal endpoint accounting for competing risk of death BMI was not associated with reaching combined renal endpoint on univariate analysis whether considered as a continuous variable (SHR=100 95 CI 098-102 p=096) or categorised by BMI group
Conclusion - Contrary to our expectations there was no association between BMI and progression to a combined renal endpoint of CKD5 or RRT in this cohort of patients with primary GN Efforts should be directed to managing other known risk factors for CKD progression
Sources of FundingConflicts of Interest - None
A18 Factors influencing long term renal function after living kidney donation
Matthew A Rutherford Norman J Galbraith Marc Clancy Colin C Geddes
Glasgow Renal and Transplant Unit Queen Elizabeth University Hospital Glasgow UK
Background Following live donor nephrectomy the remaining kidney undergoes an increase in filtration capacity known as compensatory hypertrophy Few cohorts with follow up of renal function beyond 5 years have been reported The impact on long term renal function of variability in donor factors such as age sex pre-donation blood pressure and glomerular filtration rate (GFR) is unknown Increasingly kidney donors have potential risk factors for future poor renal function such as hypertension older age and obesity The aim of this study was to analyse factors influencing long-term renal function in living kidney donors from our centre
Method Data were obtained from the electronic patient record Patients with a recorded procedure of lsquolive donor nephrectomyrsquo between 2005 and 2017 were identified GFR after donation (calcGFR) was calculated using the formula lsquocalcGFR = Pre-donation Isotope GFR x (Pre-donation Serum creatinine Serum Creatinine)rsquo which is accurate assuming muscle mass does not change Pre and post donation serum creatinines (two days two weeks three months and one to ten year) were recorded We analysed the influence of age sex pre-donation GFR and blood pressure on post donation GFR compensation
Results 355 live donor nephrectomies were performed between January 2005 and December 2016 The mean age was 469 (plusmn 116) years and 504 (n=179) were female Mean pre-donation isotope GFR was 937 plusmn 156 mlmin173m2 Median follow up was 2 years (IQR 1 to 6 years with range 2 weeks to 10 years) The calculated percentage of pre-donation GFR at 2 days 2 weeks 3 months 1 year 5 years and 10 years were 698 691 712 730 801 and 950 respectively (p lt 0001) Patients aged lt50 y had not only a higher calcGFR (858 plusmn 29 mlmin173m2 compared with 671 plusmn 28 mlmin173m2 p lt 0001) at 5 years following donation but achieved a higher degree of compensation than donors gt 50 y (836 plusmn 16 compared with 756 plusmn 19 (p = 0002) Patients with pre-donation hypertension achieved 774 plusmn 53 of pre-donation GFR compared with 804 plusmn 32 in normotensive patients (p = 0998) Females had equivalent degree of renal compensation achieving 819 plusmn 19 compared with 780 plusmn 16 in males (p = 0131) at 5 years following donation Patients with pre-donation GFR gt 100 mlmin173m2 achieved 844 plusmn 23 of pre-donation function by 5 years compared with 777 plusmn 14 in those with pre-donation GFR lt 100 mlmin173m2 (p = 001)
Conclusion Following live donor nephrectomy renal function has a nadir of 691 at 2 weeks Compensation in GFR occurs rapidly and appears to be maintained regardless of sex and pre-donation blood pressure Younger age and higher pre-donation GFR were associated with a greater degree of compensation
A19 The utility of high-sensitivity cardiac troponin to stratify cardiovascular risk in patients with renal impairment
Eve Miller-Hodges Atul Anand Anoop S V Shah Nicholas L Mills Neeraj Dhaun
Background Cardiovascular disease is the most common outcome of chronic kidney disease1
Declining glomerular filtration rate (GFR) and proteinuria predict increased cardiovascular risk over the long term2 However there are currently no methods to stratify cardiovascular risk in the short or medium term in patients with renal impairment We have already shown that high-sensitivity cardiac troponin I concentrations (hs-cTnI) lt5ngL in patients presenting with symptoms of acute coronary syndrome identifies those at low risk of cardiac events within 30 days and over the next year3 However uncertainty remains over the role of hs-cTnI testing in patients with renal impairment This study investigated whether hs-cTnI could also stratify future cardiovascular risk in patients with renal impairment
Methods In a prospective study of consecutive patients presenting with suspected acute coronary syndrome we evaluated the performance of hs-cTnI in patients with and without renal impairment (estimated glomerular filtration rate lt60mLmin173m2) using an early risk stratification threshold of 5ngL to ldquorule outrdquo acute myocardial infarction at presentation and within 30 days and sex-specific 99th centile diagnostic thresholds for index type 1 myocardial infarction Subsequent type 1 myocardial infarction and cardiac death were reported at one year
Results Of 4726 patients identified 904 (19) had renal impairment Index diagnosis of type 1 and type 2 myocardial infarction was almost twice as likely in patients with renal impairment (30 vs 15) Performance of the early risk stratification threshold of 5ngL to identify patients at low risk of major cardiac events was similar in patients with (NPV 984 95CI 960-997 sensitivity 989 95CI 975-999) and without renal impairment (NPV 997 95CI 994-999 sensitivity 984 95CI 972-994) These patients continued to remain at low risk over the next year The PPV and specificity at the 99th centile for diagnosis of myocardial infarction were lower in patients with renal impairment at 500 (95CI 452-548) and 709 (95CI 675-742) respectively compared to 624 (95CI 588-659) and 921 (95CI 912-930) At one year 24 of patients with renal impairment and troponin gt99th centile regardless of index diagnosis had experienced further myocardial infarction or cardiac death compared with 10 of patients without
Conclusion In suspected acute coronary syndrome hs-cTnI can stratify risk in patients with renal impairment Irrespective of diagnosis patients with renal impairment and elevated cardiac troponin concentrations had two-fold greater risk of a major cardiac event compared to those with normal renal function and should be considered for further investigation and treatment
Funders Wellcome Trust British Heart Foundation and Chest Heart amp Stroke Scotland
1 Gansevoort RT Lancet 2013
2 Chronic Kidney Disease Prognosis Consortium Lancet 2010
3 Shah AS Lancet 2015
A20 lsquoDOES IT DIALYSE OUTrsquo - THE EFFECT OF RENAL REPLACEMENT THERAPY ON THE BRAIN Mark Findlay Jesse Dawson David Dickie Deborah McGlynn Patrick Mark Institute of Cardiovascular and Medical Science University of Glasgow amp Queen Elizabeth University Hospital Glasgow
Introduction Cerebrovascular disease is common in end-stage renal disease (ESRD) on renal replacement therapy (RRT) We investigated the effect of RRT on cerebral structure and cognitive function over 12 months Methods Observational cohort study in ESRD patients receiving HD Prior cognitive impairment or cerebrovascular disease were exclusion criteria Multi-domain cognitive testing was performed at baseline and at follow-up Transcranial Doppler was used to assess intra-dialysis related alterations in mean flow velocity (MFV) ndash a marker of cerebral blood flow MR imaging was performed at 0 and 12 months We performed T1 T2 FLAIR and DWI sequences and used volumetric software to calculate white matter hyperintensity (WMH) burden markers of atrophy mean diffusivity and fractional anisotropy (FA) to describe structural changes at 1 year Results 97 patients median age 59 years 412 female At follow-up 15 patients were transplanted 6 died 4 withdrew and the remainder continued HD Those who were transplanted were younger (median age 51 vs 60 years p=0019) and had been on dialysis for a shorter period (median 06 vs 21 years p=0003) MFV declined during HD median 475cms to 405cms plt0001 and correlated with lower scores of executive and frontal lobe function during HD (Rho 045 p lt0001 and Rho -0313 p lt001 respectively) In all patients MR imaging demonstrated a significant decline in frontal parietal and temporal lobe volume at follow-up Median WMH volume increased in those who remained on HD but not in transplanted patients (median change 023 vs -012ml p=0018) WMH burden correlated with worsening scores of frontal lobe tests Rho 0585 p0005 and worse mood Rho -0485 p0026 FA improved following renal transplant (028 to 029 p=0016) and correlated with improved executive function testing at follow-up Rho 089 p0019 Conclusion Cerebral blood flow is reduced during haemodialysis and correlates with a reduction in intradialytic executive function There is an improvement in FA following transplantation WMH volume increases in those who remain on dialysis and the degree of increase correlates with executive and frontal lobe function This suggests that haemodialysis is associated with clinically significant changes in the brain and that these may be ameliorated by transplantation
Source of fundingconflicts MF is funded by a KRUK fellowship
A21 Pathological classification of IgA nephropathy to predict renal outcomes ndash is there a better way to score tubulointerstitial inflammation
Alastair Rankin David Kipgen Bruce Mackinnon Jonathan Fox Colin Geddes Emily McQuarrie Glasgow Renal and Transplant Unit On behalf of the Scottish Renal Biopsy Registry
Background The Oxford pathological classification of IgA nephropathy (IgAN MEST-C score) is limited by the fact that individual features of the score are not all predictive and its utility in assisting clinical decision-making is questioned The addition of tubulointerstitial inflammation to the existing scoring system is appealing but is not currently included due to reportedly wide inter-observer variability We report a novel method to score percentage of cortex containing tubulo-interstitial inflammation in non-atrophic renal cortex (ATIN) in patients with IgAN similar to that used in transplant biopsy reporting and assess its utility to predict clinical outcomes
Methods All adult patients with a native renal biopsy diagnosis of IgAN between 2010 and 2015 in a unit serving 15 million people were identified Baseline characteristics biopsy reports and outcome data were collected ATIN was calculated by subtracting the percentage of atrophic cortex from the percentage of total cortex with tubulo-interstitial inflammation withge10 representing significant tubulo-interstitial inflammation in non-atrophic cortex The primary outcome was a composite of requiring renal replacement therapy (RRT) or doubling of serum creatinine (sCr)
Results 153 new cases of IgAN were identified 33 were excluded (24 had lt8 glomeruli on biopsy 6 inadequate biopsy for MEST scoring and 3 on RRT at time of biopsy) In addition patients with a tubular atrophy (T) score of 2 were also excluded (n=9) Of the remaining 111 patients 76 (68) were male Mean age at biopsy was 52 years (+- 167) and 18 (16) had a co-existing clinical diagnosis of henoch-schonlein purpura (HSP) Median sCr was 156 micromoll (IQR 101-212) and 54 (49) had ATIN on biopsy During a median follow-up of 23 years 34 (31) reached the primary outcome 20 (18) received immunosuppression and 16 (14) died On univariate Cox regression survival analysis ATIN was associated with a four-fold increase in the primary outcome (HR 49 (21-113)) On multivariate analysis mesangial hypercellularity (M) T and ATIN independently predicted renal outcome while endocapillary proliferation (E) and segmental sclerosis (S) did not (plt002 for ATIN) Excluding patients with HSP or those who received immunosuppression did not change the result
Conclusion Within our centre ATIN predicts renal outcome for IgAN independently of established histological features Assessment of inter-observer reproducibility and validation in other cohorts is still required but these results suggest ATIN could be a worthwhile addition to current pathological scoring systems for IgAN
Source of funding none Conflicts of interest none
P1 Polypharmacy in Renal Replacement Therapy Patients
Jason McMinn Colin Geddes Glasgow Renal and Transplant Unit Queen Elizabeth University Hospital
Introduction
Prescribing is often led by evidence from studies containing participants with single health conditions and without multimorbidity Polypharmacy is becoming increasingly recognised in patients with multiple chronic health conditions Additional medications are more likely to result in diminishing returns in benefit with an increased risk of harm Patients with established renal failure (ERF) are likely to be susceptible to medication-related harm A high pill burden is also likely to contribute adversely to an already restricted quality of life and has been associated with poor medication adherence The aim of this study was to analyse polypharmacy in all patients with ERF attending our service
Methods
We extracted medication records for all prevalent ERF patients attending the Glasgow Renal and Transplant Unit from the West of Scotland Electronic Renal Patient Record (SERPR) as of 01012017 The records were analysed to calculate the number of regular medications and total pill burden of each patient These medications were categorised as being lsquopreventativersquo or lsquosymptomaticrsquo We also analysed the prescription of specific drug classes to examine the prevalence of these medications
Results
We identified 1091 transplant follow-up 529 hospital haemodialysis and 46 peritoneal dialysis patients who were on a mean of 94 13 and 129 different medications respectively Overall pill burden was 139 tablets a day in transplant follow-up patients 141 in haemodialysis patients and 162 in peritoneal dialysis patients There were similar rates of prescribing between the different dialysis units and clinics within our service
The proportions of medications deemed as preventative rather than symptomatic were 76 in transplant 69 in haemodialysis and 60 in peritoneal dialysis
In transplant patients decreasing renal function was associated with a higher pill burden but even patients with a transplant eGFR gt 60 were on a mean of 126 tablets per day including a mean of 14 antihypertensives
Rates of antidepressant prescribing were 15 in transplant patients and 20 in hospital haemodialysis patients 53 of haemodialysis patients were on a statin 39 on aspirin 61 on a proton pump inhibitor and 7 were on warfarin
Conclusion
Patients undergoing all forms of renal replacement therapy are likely to be on a considerable number of medications Whilst these drugs are inevitably prescribed for valid reasons this data demonstrates the need for clinicians to engage with patients to explore opportunities to reduce pill burden
Conflict of Interest None Sources of Funding None
P2 An audit of Acute Kidney Injury (AKI) on an acute stroke ward before and after plannedinterventions to review and maintain hydration
Clare Harris1 Simon Hart2 Fiona Duthie3 1 University of Edinburgh Medical School 2 Stroke Unit Royal Infirmary of Edinburgh 3 Renal Unit Royal Infirmary of Edinburgh
Background Dehydration is an important factor in the development of acute kidney injury which is associated with increased morbidity and mortality particularly in the elderly population Poor fluid intake is common post stroke (1) and dehydration is associated with poorer outcomes 3 months post stroke (2) In late 2014 there was no system of identifying patients with poor oral intake on the stroke ward at the Royal Infirmary of Edinburgh a hydration protocol and education programme were implemented aiming to improve fluid balance This included the use of prescribed water either orally or by nasogastric tube An audit pre and post intervention demonstrated that hydration as measured by ureacreatinine ratio significantly improved after the protocol introduction (3) We aimed to determine whether the incidence of AKI by KDIGO criteria was also reduced as this could have implications for reducing patient morbidity and mortality in this elderly comorbid patient cohort
Method 150 inpatients to the acute stroke ward during JulAug 2014 and JulAug 2015 were selected (n= 80 2014 n=70 2015) Patient data and creatinine values were collected from the electronic patient record and medical notes and retrospectively analysed Baseline creatinine values were calculated and cases of AKI were identified and staged using KDIGO criteria (4) Chi-Squared tests were performed to determine P values Individual patient notes were reviewed for both quantitative and qualitative data of patient management
Results Incidence of AKI (of any stage) was 263 pre-protocol and 200 post-protocol (P=03646) Incidence of AKI stages 23 was 100 pre-protocol and 715 post-protocol (P=05374) In hospital post stroke mortality was 338 pre-protocol and 1286 post protocol (P=00028) AKI was also associated with increased length of stay
Conclusions Despite a trend in benefit there was no significant difference in incidence of AKI pre and post hydration protocol nor in incidence of severe AKI (stage 23) AKI is influenced by many factors one of which is hydration status Further studies are needed to determine whether the trend of benefit exhibited in this sample is significant in a greater sample size if this were the case such a protocol could have great benefit to patient care on stroke units and elsewhere There was a significant difference in inpatient post stroke mortality following introduction of the hydration protocol Further investigations are needed to explain underlying reasons for this factors other than hydration may play an important role
References 1 Whelan K Inadequate fluid intakes in dysphagic acute stroke Clinical Nutrition (2001) 20(5)
423-428 2 Bhalla A Sankaralingam S Dundas R Swaminathan R Wolfe CDA Rudd AG The influence of
raised plasma osmolality on clinical outcome after acute stroke Stroke (2000) 312043ndash2048 3 Hart SR Craig R Berry E Lane N Gad A Farrugia M Burton L Paquay A What Happens to
Acute Stroke Patientsrsquo Fluid Balance Renal Status and Dehydration in the First Two Weeks How Can They Be Markedly Improved doi 101111ijs12634_13
4 KDIGO Clinical Practice Guideline for Acute Kidney InjuryKidney international supplements (2012) 2(1) 1-138
No funding or conflict of interest to declare
P3NHS Highland-Improving the management of hyperkalaemia using a kit Initial resultsCantley N1 Abedin T2 Lambie S3
1FY2 NHS Highland 2ST4 Renal Medicine NHS Grampian 3Renal Consultant Renal unitRaigmore Hospital Inverness
Introduction The incidence of hyperkalaemia in hospitalised in patients is between 1 and 10 Guidelines in Northern Ireland promote the use of a Hyperkalaemia Kit to improve management of hyperkalaemia We assessed the management of hyperkalaemia in Raigmore Hospital including post-treatment monitoring of serum potassium and blood glucose at baseline and after the introduction of a lsquoHyperkalaemia Kitrsquo which contains a pro forma for the management of hyperkalaemia and all the relevant equipment and drugs for treatment
Method Between July and September 2016 an automated algorithm identified 34 patients with a potassium result 65 mmoll or above on laboratory results 12 received no specific treatment of these 6 results were spurious 4 patients died before treatment could be started and 2 patients were chronic haemodialysis patients We introduced the Hyperkalaemia Kit to the Acute Medical Admissions Unit in Raigmore Hospital Since then 15 patients have been identified with serum potassium measurements above 65 and the pro forma and kit was used with eight of these patients One of these patients proceeded straight to acute renal replacement therapy
Results Prior to our intervention all 22 patients that were actively treated received at least one prescription of appropriate doses of Insulin with Dextrose However only 16 patients received intravenous calcium and only 7 received nebulised Salbutamol Potassium was measured at 4 hours in 5 cases and by 12 hours in 17 cases Monitoring of any capillary blood glucose was only documented in 8 cases Of the 22 treated 2 needed acute renal replacement therapy 3 required further doses of insulin and dextrose 2 were treated with Calcium Resonium
Eight cases of hyperkalaemia have been managed with the use of the kit and pro-forma so far An initial ECG was performed in all eight and four patients had continuous cardiac monitoring Intravenous calcium was given in seven and nebulised Salbutamol was given in five out of the eight cases Six out of eight patients had at least three blood sugar measurements One had two measurements documented and one patient was stopped from further monitoring following senior review and decision to palliate Seven patients had appropriate monitoring of their serum potassium by 4h and 12h again one patient was not monitored due to palliation
Conclusion Baseline results showed very low rates of prescription of nebulised Salbutamol low rates of Calcium Gluconate use and very low monitoring of blood sugars and potassium post treatment This has the potential for serious adverse outcomes particularly the potential for iatrogenic hypoglycaemia Our initial data shows the use of a Hyperkalaemia pro forma and kit improves the rate of prescription of intravenous calcium and nebulised Salbutamol and the post-treatment monitoring of serum potassium and blood sugar levels
P4Rituximab as maintenance therapy in ANCA associated vasculitisndash a single centre experience Rathnamalala NK Mcmenamin J Robertson S Almond A Kelly M Muniraju T M Renal Unit Dumfries and Galloway Royal Infirmary NHS Dumfries and Galloway Background The introduction of Cyclophosphamide and high dose steroids transformed ANCA associate vasculitis (AAV) from a disease of high mortality to a relapsing remitting disease Maintenance of remission however still remains a major challenge A two randomised clinical trials have looked at the use of Rituximab in remission induction in AAV and reported similar remission rates between Cyclophosphamide and Rituximab 12 Both these trials used Azathioprine as maintenance therapy and in the follow up showed similar remission rates with either agent for induction The role of Rituximab for maintenance therapy after cyclophosphamide induction was studied in the MAINRITSAN trial 3 Rituximab was compared with azathioprine and found that the relapse rate was significantly lower in the Rituximab group There have been several other retrospective studies that have suggested regular Rituximab infusions are successful in maintaining remission however has not been thoroughly evaluated 4 5678910 Here we share our centrersquos experience using Rituximab for maintenance of remission of AAV Materials and methods We conducted a retrospective review of electronic medical records of all patients who had received Rituximab as maintenance therapy for 12 months or longer between January 2014 to July 2016 Disease activity was assessed using Birmingham Vasculitis Activity Score ( BVAS) Version 3 and complete remission was defined as a score of 0 and partial remission as a score of lt50 of the value at diagnosis Due to uncertainties associated with sub classification we did not assign specific diagnosis but broadly classified as ANCA associated vasculitis Results 6 patients received Rituximab as maintenance therapy during the study period 3 (50) of them had eye ear nose and upper airway manifestations consistent with Granulomatosis with Polyangitis (GPA) All patients were PR3 ANCA positive except for one at initial diagnosis The mean BVAS score at the time of initiation of Rituximab was 4 All patients were initiated on Rituximab for relapses while on maintenance therapy with Azathioprine 4 patients received 6 monthly doses of Rituximab while two received annual doses All of them were also maintained on 5-10 mg of Prednisolone The mean BVAS score by 6 months was 0 and remained 0 at 12 months The mean PR3 titre was 562 at the initiation of treatment while at 12 months it had come down to 68 All patients remained in complete clinical remission at the end of 12 months after initiation of therapy Rituximab was well tolerated by all patients except one who developed pyrexia during an administration
Conclusions All patients had sustained remission at 6 months and 12 months after initiating Rituximab Rituximab has a potential role as maintenance therapy in AAV
P5 Chronic Myelo-Monocytic Leukaemia (CMML) as a contraindication to renal biopsy Alastair Rankin Emily McQuarrie Jennifer Lees Bruce MacKinnon Glasgow Renal and Transplant Unit On behalf of the Scottish Renal Biopsy Registry
Abstract Chronic Myelo-Monocytic Leukaemia (CMML) is a relatively rare mixed myelodysplastic myeloproliferative disorder that predominately affects patients over the age of 65 years Renal impairment in patients with CMML is well described with several different mechanisms reported including tumour infiltration lysozyme-induced injury amyloid deposition and tubulointerstitial nephritis From anecdotal evidence within our centre we are concerned that patients with CMML have an excessive risk of clinically significant bleeding following native renal biopsy This risk appears disproportionate to the degree of any co-existing thrombocytopenia or coagulopathy
We review the cases of 4 patients with an existing diagnosis of CMML who were referred to the renal clinic with proteinuria and excretory renal dysfunction Two of these patients underwent renal biopsy with subsequent major haemorrhage post-procedure despite normal bleeding parameters pre-procedure Patient 1 presented with flank pain 8 days post-biopsy A CT confirmed peri-nephric haematoma with retroperitoneal extension A total of 6 units of packed red cells (PRCs) were transfused prior to successful CT-guided emoblisation Histology from the biopsy revealed chronic tubulointerstitial nephritis Patient 2 experienced haemodynamic instability and haematuria one hour post-biopsy A total of 11 units of PRCs 7 units of fresh frozen plasma 2 pools of platelets intravenous tranexamic acid and 2 attempts at CT-guided embolization were required until haemostasis was achieved Histology later showed evidence of tumour infiltration with associated vasculitis Patient 3 presented with renal impairment and proteinuria on the background of known CMML Following discussion with haematology the risk of bleeding following renal biopsy was considered unjustifiable despite their platelets and coagulation screen being within normal range The patient was treated for presumed renal tumour infiltration with hydroxycarbamide Patient 4 was referred to the renal clinic with acute onset nephrotic syndrome Urinary proteincreatinine ratio was elevated over 800 mgmmol with serum albumin of 23 gL but normal excretory renal function The patient attends the haematology clinic with suspected CMML and chronic thrombocytopenia but previously declined bone marrow biopsy Following discussion with the patient there are no plans to proceed with renal biopsy given potential risks These cases highlight that while CMML is rare these patients are being referred to renal clinics with features that would commonly justify renal biopsy in other settings but in whom there may be an increased risk of bleeding post-procedure Our in-centre risk of major bleeding is 2 therefore to have such extreme amounts of bleeding in 2 patients with this underlying diagnosis is remarkable This creates a dilemma for the clinician as there is a wide range of potential renal pathology associated with CMML some of which will have disease specific but relatively toxic treatments available
Source of funding none Conflicts of interest none
P6 NHS Highland-Prograf to Adoport switch McCulloch K1 Peel R2 Lambie S3
1Renal Pharmacist Renal unit Raigmore Hospital Inverness 23Renal Consultant Renal unit Raigmore Hospital Inverness
Introduction NHS Highland (NHSH) is the first health board in Scotland to implement a switch from Prograf to Adoport for renal transplant patients This will provide considerable cost savings Adoport meets the bioequivalence criteria for drugs with a narrow therapeutic index set by the European Medicines agency and studies indicate therapeutic equivalence1 with the proviso that brands are non- interchangeable unless the switch is overseen by a Renal Consultant and post-conversion therapeutic drug monitoring is conducted23 The switch has been undertaken by a majority of transplant centres in England the main difference being that they have undergone repatriation NHSH Patients receive their transplant primarily at Royal Infirmary of Edinburgh and occasionally at Queen Elizabeth University Hospital Glasgow Care is transferred to NHS Highland on discharge NHS Highland cares for approximately 170 renal transplant patients 110 being prescribed Prograf These patients may live as far as 110 miles from Raigmore Hospital Given that prescribing is carried out by primary care clear communication with patients GPs and community pharmacy is essential to avoid inadvertent switching between brands
Method Clinically it was agreed a switch could be safely undertaken A business case was submitted and funding secured for pharmacist time laboratory costs and primary care time GPs have been informed via GP subgroup and local prescribing bulletin lsquoThe Pink Onersquo Community pharmacies are being informed by phone A protocol has been agreed Eligible patients selected by Renal Consultant and Renal Pharmacist Patients sent letter signed by Renal Consultant and Renal pharmacist Patients phoned prior to clinic to agree Adoport start date and address concerns Patient seen by Renal Consultant and pharmacist + given 1 month of Adoport Tacrolimus level and UampEs checked 5-7 days after commencing Adoport and patient
contacted by phone to check if tolerated If stable letter sent to GP and community pharmacy to continue supply
Results and Evaluation Letters have been sent to all eligible patients Seven patients have been reviewed One has received a one month supply of Adoport and 5 others are due to switch One patient was deemed non-eligible at present as they have a 6 month surplus of Prograf A database will be maintained and analysed at the end and primary care savings will be monitored Extra pharmacist input will give us the opportunity to review how immunosuppression is managed and to evaluate the benefit of having a renal transplant pharmacist Conclusion The switch is at an early stage Ultimately we hope to show that the switch from Prograf to Adoport can be managed safely with extra pharmacist input to a remote and rural population with prescribing being conducted by primary care
Fundingconflicts of interest none 1 McDevitt-Potter LM Sadaka B Tichy EM Rogers CC Gabardi S Transplantation 2011 A multicenter experience with
generic tacrolimus conversion 2 Medicines and Health Products Regulatory Agency Drug Safety Update 2012 Accessed online via
wwwmhragovukSafetyinformationDrugSafetyUpdateCON1557563 ESPRIT Guidance on management of repatriation and immunosuppressant switches in transplant patients 2015
Accessed online via httpwwwespritorgukwp-contentuploads201508Switch-guidance-document-final-Aug-31-2015pdf
P7 NHS Highland-Tacrolimus baseline dataMcCulloch K1 Peel R2 Lambie S3
1Renal Pharmacist Renal unit Raigmore Hospital Inverness 2Renal Consultant Renal unitRaigmore Hospital Inverness 3Renal Consultant Renal unit Raigmore Hospital Inverness
BackgroundAs part of planning a switch from using tacrolimus Prograf to Adoport we assessed baseline data for our transplant patients currently using Prograf After converting patients to Adoport we will compare their tacrolimus levels to their individual target range We assessed our use of appropriate target ranges and our current performance in achieving tacrolimus levels within target range on Prograf therapy
Method 107 renal transplant patients taking Prograf were identified a sample of 19 of these were analysed using electronic patient records and results Time from transplant ranged from 1 month to 18 years All tacrolimus levels for the preceding year were analysed and compared to the target range specified at the time of the level being done The assay used has a Coefficient of Variation of lt5 at the lower limit of the assay
Results All 19 patients had a target range for tacrolimus clearly identified and recorded in clinic letterswhich are routinely copied to the patients themselves A variety of target ranges were specifiedThe commonest used was 5-8 microgramsl in 7 patients followed by 5-7 in a further 4 patientswith another 6 different target ranges being used for the remaining 8 patients The ranges usedhad a breadth of 3 microgramsl in 2 cases the rest had a breadth of 2 microgramslPatients had a median of 12 (range 3-72) tacrolimus levels over the preceding year Results werewithin specified target ranges for 54 +- 22 (Medan +- SD) of results checked
Conclusion We currently use a large number of different target ranges The majority of the ranges used had a breadth of just 2 microgramsl These factors help to account for the low proportion of test results which were within the specified target ranges This is important to bear in mind when interpreting whether tacrolimus levels are within target ranges after switching to Adoport We should consider aligning our target ranges and widening them
P8 Eculizumab use in Scottish paediatric dense deposit disease Stewart D1 David Hughes1 Lynne Riach2 Craig Oxley2 Athavale D1
1Royal Hospital for Children Glasgow 2Royal Aberdeen Childrenrsquos Hospital Aberdeen
Introduction The revised MPGN classification and increasing recognition of Dense Deposit Disease (DDD) a C3 glomerulopathy as an alternative complement pathway disorder suggests Eculizumab an anti-C5 monoclonal antibody may be beneficial in treatment However the experience of Eculizumab as an off-label and expensive treatment in children with DDD is limited with variable clinical response reported in the literature
Method We present the outcomes of the only 2 paediatric patients in Scotland who have received Eculizumab for the management of DDD
Results Case 1 A 10 year old male presented with proteinuria and haematuria resistant to steroid treatment with preserved renal function Initial biopsy confirmed DDD Conservative management with an angiotensin converting enzyme inhibitor and diuretics for symptom control continued until 14 years Due to worsening symptoms (oedema lethargy poor growth) and renal function deterioration along with elevated terminal complement complex (TCC) Eculizumab was commenced A repeat biopsy whilst suggestive of chronic irreversible damage showed 25 glomerular architecture preservation Symptom improvement was noted There was a reduction in proteinuria and renal function stabilisation fall in TCC and discontinuation of diuretics Eculizumab was discontinued after 24 months Progression of renal function decline was seen in the final months of Eculizumab therapy With recurrence of symptoms and increasing proteinuria following discontinuation Eculizumab was recommenced after 6 months Symptomatic improvement has since been noted
Case 2 A 5 year old girl presented with painless frank haematuria and proteinuria Initial biopsy confirmed DDD Proteinuria was unresponsive to steroid therapy and 5 months following diagnosis she rapidly progressed towards end stage renal disease despite the introduction of Mycophenolate Mofetil and plasmapheresis Haemodialysis was subsequently commenced TCC level was elevated and Eculizumab treatment was started 7 months after diagnosis Renal biopsy prior to treatment demonstrated continued severe pathological changes in all visible glomeruli However due to lack of clinical response Eculizumab was discontinued after 2 months and the patient remained dialysis dependent
Conclusions Our experience with Eculizumab in Scotland has demonstrated variable results in our 2 patients with one patient showing a positive response whilst the other experienced no improvement Eculizumab was administered to both patients at varying points in their clinical journey with differing progressive features on biopsy To date the outcomes of 9 paediatric patients with DDD treated with Eculizumab have been described in the literature with 8 experiencing some positive response to treatment including 2 patients who were able to stop renal replacement therapy within 12 weeks of treatment A role for Eculizumab in DDD may be guided by clinical and pathological features Well designed clinical trials will be necessary to define the role of complement inhibition therapy in DDD
No conflict of interest and no funding requested
P9 Examining markers of safety in the use of non-tunnelled central venous catheters
James WT Millar (Speciality Registrar) Scott W Oliver (Speciality Registrar) Peter C Thomson (Consultant Nephrologist) Glasgow Renal and Transplant Unit Queen Elizabeth University Hospital Glasgow
Background Non-tunnelled central venous catheters (NTCVC) remain an essential means of vascular access for incident haemodialysis Associated morbidity is well recognised for example in the form of Staphylococcus aureus bloodstream infections (SAB)[1]
Previous quality improvement initiatives in our unit have sought to both improve traditional markers of quality (such as SAB) and to identify additional areas of clinical risk In 2014 Oliver et al [2] suggested several additional quality measures including peri-procedure haemoglobin drop the need for a further NTCVC during the same clinical episode and the NTCVC insertion site This study further evaluated NTCVC related clinical practice within our unit
Methods The potential markers of clinical quality identified in a previous project were examined using prospectively collected data stored in the electronic patient record Identified cases of SAB significant peri-procedure haemoglobin drop and multiple NTCVC insertion were investigated by case note review
Results Between March 2016 and March 2017 a total of 222 patients received 346 NTCVC 54 patients (243) had more than one NTCVC inserted in a 21-day period (range 2-5) When considering NTCVC insertion site there were 159 (459) femoral vein catheters and 183 (541) internal jugular vein catheters No pneumothoraces were reported
15 SABrsquos were reported during this period equating to 43 of all NTCVC 5 arose in patients with femoral NTCVC (333) and 10 from internal jugular catheters (667) Mean time from line insertion to positive blood culture was 86 days 15 (67) patients had a drop in haemoglobin of greater than 20mgdl with no other source of blood loss identified on review of clinical notes
Discussion These data demonstrate that NTCVC-associated SAB rates remain low and significantly below Scottish government audit standards [3] Of interest is the continued trend towards the use of femoral catheters at 45 of lines compared with 38 in 2014 [2] Although traditionally thought of as having a higher incidence of infectious complications our data has shown fewer bacteraemia events associated with femoral catheters compared with internal jugular Our data also demonstrates a significant rate of peri-procedure haemorrhage arising in up to 1 in 20 cases Together these findings present opportunities to development practice and improve patient safety
References
[1] Murray E Deighan C Geddes CC Thomson PC Reducing haemodialysis bacteraemia rates Scottish Renal Association Glasgow November 2013 [2] Oliver SW Thomson PC Jardine AG defining safe effective and patient-centred dialysis catheter placement Scottish Renal Association Edinburgh September 2014 [3] The Staphylococcus aureus bacteraemia quarterly report of cumulative data from all NHS Boards in Scotland Health Protection Scotland January 2015
Sources of funding none Conflicts of interest none
P10 Prescribing of tolvaptan-The NHS Highland experience Lambie S1 McCulloch K2 Garrod J3
1Renal Consultant Renal unit Raigmore Hospital Inverness 2Renal Pharmacist Renal unit Raigmore Hospital Inverness 3Renal Pharmacist Renal unit Raigmore Hospital Inverness
Introduction Tolvaptan is a vasopressin antagonist It was accepted for use in Scotland by SMC in Jan 2016 to slow the progression of cyst development and renal insufficiency of autosomal dominant polycystic kidney disease in adults with chronic kidney disease (CKD) stage 1 to 3 at initiation of treatment with evidence of rapidly progressing disease1 Adverse effects related to aquaresis may affect patientsrsquo ability to achieve the optimum therapeutic dose and the risk of hepatic toxicity necessitates regular LFT monitoring The geography of NHS Highland required the implementation of novel methods of managing these patients and as a result a MDT approach with an emphasis on pharmacist input was adopted Consultant role Patient selection on the basis of evidence of rapidly progressing kidney disease declining
eGFR large volume kidneys on ultrasound and evidence of complications of PKD Side effects and potential benefits discussed Potential medication interactions reviewed Jinarc risk management prescriber training
Pharmacist role Undertook Jinarc risk management pharmacist training Prepares accurate drug history and reviews for potential drug interactions Carries out patient counselling and supplies patient education material sick day rules card
and lsquogot to gorsquo card Supplies GP education leaflet Provides advice on selection of new drug therapies eg for gout Manages stock and coordinates supply to patients
Results Prescribing commenced May 2016 patients currently prescribed tolvaptan 11 7 Female 4 male Number on target dose 73 n = 811 2 patients are still being titrated One patient did
not tolerate target dose due to aquaresis side effects and is being trialled on the middle dose
Withdrawals One patient has withdrawn due to agoraphobia and an inability to attend for monitoring and another is on hold due to having major surgery
Conclusion The MDT approach between the Renal Consultant and Pharmacist at Raigmore Hospital has enabled tolvaptan prescribing to be efficiently and safely implemented to patients living within a challenging geographical location
1 Scottish Medicines Consortium Detailed Advice Document tolvaptan 15mg 30mg 45mg 60mg and 90mg tablets (Jinarcreg) SMC No 111415 January 2016
NA1 Authors SCN Jacqueline Ross NHS Grampian
SCN Alan Somerville NHS Lanarkshire SCN Jane Humphrey NHS Lanarkshire
e- mail contact jacquelinerossnhsnet Alansommervillelanarkshirescotnhsuk
Janehumphreylanarkshirescotnhsuk
Phone contact 01224 552927 01236 712644
Title Sharing of Adverse Events in Renal Units across Scotland
Introduction Background The Scottish Renal Nurses Strategy Group (SRNSG) are a group of senior nurses from Renal
Units across Scotland who meet 3-4 times per year to discuss and implement best practice At the last meeting it was agreed that it would be good practice for each Health Board to share
their adverse events reported on the Datix System and deliver a presentation with an action plan to prevent incidents and improve patient safety across Scotland NHS Grampian and NHS Lanarkshire will be the first to deliver this presentation discussing adverse events from both Health Boards with an action plan
Top 5 adverse events over the past 12 months Renal Unit NHS Grampian 1 Violence and Aggression 2 Accidents including needlesticks slips trips and falls 3 Medication Errors 4 Infrastructure Staffing and Estates 5 Machines and Equipment
Top 5 adverse events over past 12 months Renal Unit NHS Lanarkshire
1 Slips Trips or Falls 2 Medicine errors 3 Treatment problems 4 Transfer problems 5 Breach of policy
The presentation will also focus on any serious adverse events which may not be in the top 5 categories
Aim Objective Each Health Board to share their adverse events with the aim to prevent them from occurring in other units to improve staff and patient safety and wellbeing across Scotland
Method Power Point Presentation
Outcome Results Sharing of adverse events resulting in the development of a national Action Plan to prevent these incidents improving safety and well being of staff and patients in Renal Units across Scotland
NA2
SRA Oct 2017 Abstract
BBV Never Event - The whats whys and hows
Staff Nurse Gillian Wilson Aberdeen Royal Infirmary
This presentation shares our experience of a never event that occurred and was not picked up for
a period of 18 months
Hepatitis C (HCV) positive antibodies were found in a previously negative patient
These results were a low positive with no biochemistry changes to suggest any liver damage
however steps were put immediately in place to isolate and investigate
Was it contamination from a dialysis machine was it related to a blood transfusion given prior to
first positive result was it faulty diagnostic tests in the laboratory
In Aberdeen we go over and above national guidelines and isolate all our BBV patients whether
they have positive blood results or are PCR negative
Further bloods tested at an external laboratory confirmed negative results
It highlighted that communication errors were to blame for the lack of speed in detecting this issue
Investigations concluded no real answers as to why this happened
NA3
Living Donation Scotland Changing attitudes towards living donor kidney transplantation
Jen Lumsdaine Julie Glen On behalf of the Living Donation Scotland Project Board
Background and aims
The rate of living donor transplantation has remained fairly static in Scotland over the past 10 years
Recent data has shown inequity of access to living donor transplantation throughout the UK so
there is potential to significantly increase this optimum form of treatment for patients with end-stage
renal failure in Scotland The Living Donation Project Board was formed in 2016 aiming to double
the number of living donor transplants by 2020
Method
The two key areas
1 Do recipients receive adequate and appropriate information at the right time about living
kidney donation
2 Informing the general public about altruistic donation
All patients active on the transplant list in Scotland were invited to an information event A follow-up
questionnaire was performed in the East of Scotland examining outcome or reasons for not
attending A scoping exercise looked at information provided by each unit was performed and link
nephrologists and low clearance nurses attended meeting to discuss strategies for early education
Outcome
An information pack containing both recipient and donor written information and short films on DVD
has been produced with the support of the Scottish Government for all recipients and potential
donors in Scotland A new website with comprehensive information both written and visual and
postcode finder to improve ease of access to local unit contact details has been developed
Two national media campaigns have been launched with a significant rise in the number of enquiries
from potential donors and actual increase in altruistic donor numbers
Nursing abstract ndash no conflict of interest
NA4Authors Susan Easson Charge Nurse Ward 4C QEUH Glasgow
e- mail contact SusanEassonggcscotnhsuk
Phone contact 0141 452 3300
Title A Conversational approach to find out ldquoWhat matters to yourdquo in a Renal Transplant ward
Introduction Background Finding out ldquo What Mattersrdquo to people using health and careservices is crucial to delivering safe effective and person centred care It is a simple yet profoundconcept and tries to get to the essence of person centred care by creating deeply personalengagements with patients and their families through a conversational approach However careexperience feedback all too often provides innumerable examples of where what really matters topatients and their family members is poorly understood or not addressed Using care experienceas the driver for change the nursing staff in Ward 4C used improvement approaches to explorehow to hold more meaningful ldquoWhat Matters to yourdquo conversations on a daily basis
Aim Objective To improve the patient experience by utilising a person centred approach
Method Using Care experience feedback What Matters to Me boards and the conversationalapproach
Outcome Results Improvements in patient experience will be shared using examples ofpractice and care experience feedback
There was no additional funding required for this project We worked in collaboration with theperson centred team whorsquos aim is to improve patient experience
NA5
The implementation of a renal education programme and its impact on clinical practice
The purpose was to implement a Renal Education Programme and to evaluate its impact on
clinical practise
It was identified that there was a need for an educational programme to be set up within Forth
Valley Royal Hospital There is no inpatient renal unit in FVRH on site for our renal patients they
attend Queen Elizabeth University Hospital We are an outpatient haemodialysis unit with
outpatient clinics on site Therefore it was identified that there was a need for nursing staff within
FVRH to be educated on all renal complexities for the benefit of our patients
This was done through a work-based learning approach which brought tangible benefits for our
patients However it did not come without pitfalls as educational programmes are often seen as
making very little difference to clinical practise
T
his study describes what methods were used and examines the advantages and disadvantages in
setting up an educational programme and evaluating its impact on clinical practise
NA6
Nursing Abstract ndash SRA Meeting ndash 26 October 2017
Chris McGee Tonya Broe Ken Weir
Renal Unit Forth Valley Royal Hospital
Use of the Therapy Monitor Haemodialysis Patient Record System Can we aim for a paper-
free dialysis unit
We are trialling a new haemodialysis patient monitoring system to work in conjunction with SERPR
and which is intended to supersede the Finesse system used previously
We are in the early stages of this process but with continuing staff education and regular tech
support we are hoping to gather sufficient evidence to evaluate whether the use of paper case
notes needs to continue
Is it a realistic goal to aim for a completely paper-free unit
NA7
THE CLINICAL USES OF APHERESIS WITHIN NHS TAYSIDE
Laura Thomson CN
Ninewells Hospital Dundee
NHS Tayside took over the apheresis service from BTS in 2012 The service has since expanded
with the benefits of carrying out this treatment has been widely recognised within NHS Tayside
and is now more commonly being offered to treat a wider range of conditions with the number of
treatments carried out each year rising
This presentation will highlight the progression of the apheresis service within NHS Tayside We
will identify the various conditions it is currently being used to treat and also identify the decision
making process involved in carrying out these treatments ie which replacement fluid will be used
anticoagulation medication administered
We will highlight the benefits and challenges we face in providing this expanding service within the
Renal Service
NA8Authors Linda McDougall Renal Physiotherapist NHS Highland
e- mail contact lindamcdougall1nhsnet
Phone contact 01463 706022
Title lsquoExercise on Haemodialysis- Keeping the Wheels in Motionrsquo
Introduction Background The impact of CKD on physical fitness functional ability independence amp ultimately quality of life cannot be underestimated Current national guidelines recommend that all individuals with CKD are encouraged to participate in regular exercise programmes between or during dialysis sessions if on HD Following a successful pilot study funding was approved to establish an lsquoExercise on Dialysisrsquo (EOD) programme across NHS Highland through the appointment of a dedicated renal physiotherapist in 2008 A successful programme was soon established but for several years post-vacancies and increasing in-patient demands limited the physiotherapy servicersquos ability to deliver the programme The need to improve the long-term sustainability of the service was recognised and in late 2016 funding was approved to develop a Band 4 PT HCSW role for this purpose
Aim ObjectiveTo optimise the sustainability and continuity of the lsquoExercise on Dialysisrsquo service across NHSHighland through development of a Band 4 PT HCSW role
Method The potential parameters of the role and limits of autonomy were scoped out using current NES resources and guidelines Service and task analysis was then carried out to establish which components of the EOD protocol could be undertaken by a Band 4 A series of competencies were developed in line with the clinical protocol and one-to-one training and supervision provided to the post-holder to ensure competency achieved in delivering the programme
Outcome Results A 10 WTE Band 4 PT HCSW was appointed in Jan 2017 with a dual role between the renal unit and acute medical wards Although training is not yet complete the post-holder is already running the day-to-day delivery and monthly audit of the EOD service with senior physiotherapist input only required for individual patient safety queries and general discussion around patientsrsquo progress and goals The benefit to the unit has been considerable as the band 4 is available to support patients and staff with EOD provision 5 days a week This allows for one-to-one supervision of patients who need more support to participate in EOD regular feedback on performance and reviews of outcome measures and goals to maintain motivation levels Feedback on the post has been very positive and its scope will only continue to expand as we look to further develop renal rehabilitation services across NHS Highland
NA9Authors Nadine Lyall and Kerry Guthrie
e- mail contact nadinelyallbordersscotnhsuk kerryguthriebordersscotnhsuk
Phone contact 01896 826637
Title The Developing Role of the NMP in a Satellite Dialysis Unit
Introduction Background
We have been practising as NMPrsquos for nearly 3 years working in the dialysis unit at the BGH The unit is a satellite unit of the ERI and we have expanded over the last 6 years The unit provides haemodialysis for 12 patients at any one time 3 sessions a day 6 days a week We are nurse-led and have 2 renal consultants who are based at the ERI
We saw an opportunity to use our knowledge and experience to develop our role By becoming NMPrsquos we have enhanced our professional development and we feel we meet the changing needs of the dialysis patient in a more holistic manner
Aim Objective
Our aim is to deliver effective care as we are better placed to deal with issues that often arise byacting swiftly this in turn is cost effective and convenient For example good anaemia and bonemanagement is important for their health wellbeing and lifespanTo help understand our role we will use a power point presentation highlighting issues we dealwith and the drugs we prescribe under the following headings Cardiovascular infection painanticoagulant disequilibrium diet renal bone disease and renal anaemia
Method Power point
Outcome Results
In the future we hope to further develop and have greater autonomy in our role We have great support from our renal consultants and have already built up a great relationship with our patients We hope to undertake the Clinical Decision Making course and this in turn will allow us to deal effectively with acute illness giving the dialysis patient better care We are keen to get feedback from other renal nurses in Scotland to enable us to develop our role further and in turn raise awareness of the NMP role in a dialysis unit We record all our prescribing decisions and keep the consultants up to date regularly Currently we are working on auditing our prescribing practice so that we can improve the service we can provide
NA10 Title Komunikacja w szkoleniu dializy ortzewnowej
Author Senior Charge Nurse Rhoda Bell
Address Raigmore Hospital Old Perth Road Inverness IV2 3UJ
Email rhodabellnhsnet Telephone 01463706023
Introduction Background Case study on lady with Polish as her first language she has some English but requires an interpreter to carry out Peritoneal Dialysis training and attend clinic She had some gynaecological issues that we were not aware of which impacted on the functionality of PD and therefore the success of treatment There were areas of concern in low clearance clinic with signs the patient had a reluctance to engage in decision making
AimObjective
Methods Discussion through the case study highlighted issues with communication between different PD staff and patients Areas of concern include different staffing techniques environment factors on training success Also language and communication issues the patient had were not fully apparent so training could not be individualised
Results We plan to trial training at home and have more individualised training schedule for patients The training step by step guides have been reviewed and practise standardised In collaboration with low clearance nurse we have developed a check list which will highlight concerns before the transition to PD ie language issues and need for training aids in another language gynaecological conditions
Conclusions Everyone learns differently and training methodsaids must be individualised for all It may not be apparent until training has commenced that there are concerns Having one to one training with the same nurse will consolidate training and build confidence in the patient Having a close working relationship with members of the MDT will help make a supportive PD journey
Would we do things differently if we knew about prolapse or lack of English both spoken and written
Key words - Peritoneal dialysis patient training communication
N11
Telehealth amp PDAudrey Jones
Advantages
Information on a daily basis about treatment weight and blood pressure
Change programme remotely via computer or mobile
Earlier intervention for machineprogramme issues
Reduction in home visits ie patient trained but still requires volume increases
No need to download cards to see what problems have been
Can have more detailed information available at clinics
Disadvantages
Relying on patient input data correctly
Machine is noisy especially first wave of machine
Still the same bag connection system and patient connection system (difficult for manual
dexterity problems)
Relying on patient having good signal
Modem problems
NA12Autosomal Dominant Polycystic Kidney Disease A cruel inheritance but new hopeAlistair Lawrie Renal Unit Victoria Hospital KirkcaldySadaf Arshad Corry Dunnigan Paul Phelan Neil Turner Renal Unit Royal Infirmary of Edinburgh
Background Autosomal Dominant Polycystic Kidney Disease (ADPKD) is the most prevalent single gene human genetic disorder and the most common of the inherited cystic and interstitial kidney diseases It is estimated to affect 1 in every 1000 individuals worldwide with over 50 of sufferers eventually developing end stage kidney disease and requiring dialysis or transplantation Symptoms include spasmodic severe pain hypertension haematuria infection and kidney failure There is currently no cure for ADPKD Management of the condition has traditionally involved lifestyle modification BP control and analgesia however a recent study (Torres et al 2012) demonstrated that treatment with V2-receptor antagonist drugs slowed increase in total kidney volume reduced the rate of functional decline and showed a reduced incidence of kidney pain
Aim Provision of a tolvaptan prescribing and monitoring service
Methods Experiential finding report of initial twelve months period of multidisciplinary ADPKDtolvaptan clinic
Results Early results are comparable with TEMPO study outcomes
Conclusion Due to the long term nature of this treatment results available at this time are showing only the earliest benefits of the intervention More quantifiable results such as increased time before the necessity for RRT will only be evident in coming years Torres VE et al (2012) Tolvaptan in Patients with Autosomal Dominant Polycystic Kidney Disease New England Journal of Medicine 367 pp 2407-2418 DOI 101056NEJMoa1205311
No funding requirement No conflict of interest
A5 Review of management of patients with diabetic nephropathy Wan Shun Wonga Mohammed K Azharuddinb
aRenal and Transplant Unit Queen Elizabeth University Hospital Glasgow bDiabetes Unit Inverclyde Royal Hospital Greenock
Background ndash Diabetic nephropathy is a common and potentially life-threatening complication of both type 1 and type 2 diabetes and is now recognised as the leading cause of end-stage renal disease1 Studies have shown that early interventions can delay the onset and slow the progression of diabetic nephropathy2 The aim of our study was to review the management of patients with diabetic nephropathy at Inverclyde Royal Hospital in accordance to the guideline published by the National Institute for Health and Care Excellence (NICE)
Methods ndash Patients with diabetic nephropathy were identified on SCI-Diabetes Patient data was then extracted from renal electronic patient record SCI-Diabetes and Clinical Portal Clinical notes were also reviewed to determine the reason for cessation of angiotensin-converting-enzyme inhibitor (ACE-I) or angiotensin receptor blocker (ARB) Referral guidelines from the Renal Association were used to assess the eligibility for referral
Results ndash Data was collected from 255 patients with diabetes and urine ACR gt25 (for male) and gt35 (for female) Mean age was 625 years (SD 151) and 584 (n=149) were male 243 of patients (n=62) were classed as type 1 diabetes and 737 (n=188) as type 2 with further 20 (n=5) as others 949 (n=242) patients had an HbA1c recorded within the last year The mean HbA1c was 712 (SD 2052) 8 patients were on RRT (7 on HD and 1 on PD) Serum creatinine and urine ACRPCR were checked in 933 (n=238) and 612 (n=156) of patients in the last year respectively Blood pressure was measured within the past 12 months for 847 (n=216) of patients with 601 (n=146) having blood pressure higher than the target of 13080mmHg Mean systolic and diastolic blood pressures were 1339 mmHg (SD 1735) and 745 mmHg (SD 111) respectively 627 of patients were on ACE-IARB Of the 95 patients who were not on ACE-IARB 421 (n=40) were stopped due to side effects 116 (n=11) patients had their ACE-IARB discontinued but no reason could be found 379 (n=36) patients had never been on an ACE-IARB 157 (n=40) of patients met the criteria for referral to Renal Services and 7 patients had not been referred and all 7 of them recently developed CKD4
Conclusion ndash Our findings were consistent with the national data3 Urine PCR measurement has the lowest completion rate among all the recommended annual care processes Optimal blood pressure control remains a challenging issue for many of the patients with diabetes Further studies could be carried out to look at the reasons behind the low completion rate of urine PCR measurement as well as to devise ways to remind clinicians about starting patients on ACE-IARB and making referral to Renal Services when indicated
References 1 K Bennett B S Aditya An overview of diabetic nephropathy Epidemiology pathophysiology and treatment Journal of Diabetes Nursing 18 61-7 2 Molitch ME DeFronzo RA Franz MJ et al American Diabetes Association Nephropathy in diabetes Diabetes Care 200427(Suppl 1)S79-83 3 Scottish Diabetes Survey 2016 Scottish Diabetes Survey Monitoring Group NHS Scotland
Funding ndash None Conflict of Interest ndash None
A6 Analgesic Use in Dialysis Patients in a District General Hospital Setting
A McCallum L Dickson S Robertson A Almond N Rathnamalala M KellyT Muniraju
Renal Unit Dumfries and Galloway Royal Infirmary
Evidence shows around 50 of haemodialysis patients report pain with 83 describing this as moderate to severei Distinct variability also exists in levels of opiate prescribing between centres with studies showing incidence ranging from 5-50iiiii Consequently we sought to investigate the prevalence of both pain and opioid prescriptions in our local dialysis population as well as investigating whether there are any associations between co-morbidities and the use of opiates This information could then be used to identify new dialysis patients at high risk of pain as well as informing prescribing decisions
In order to achieve this a questionnaire was produced that incorporated validated pain and quality of life scores (the Brief Pain Index and Renal Palliative Care Outcome Scale) with a consent form to access electronic healthcare records Questionnaires were distributed to all our haemodialysis and peritoneal dialysis patients Results were transcribed into Microsoft Excel where they were analysed
Data was collected on 56 patients (46 haemodialysis patients 10 peritoneal dialysis patients) Results showed 46 described ldquopain other than everyday kindsrdquo on the day of survey completion The most common site of pain was in the legs and back On average patients were on 12 different medications of which 15 was for pain (range 0-5) 784 of these pain prescriptions were longstanding (gt3 month use) Amongst haemodialysis patients 45 were on a strong opioid ndash in 73 of cases this was a fentanyl patch Whilst scope exists to increase the use of simple analgesia and neuropathic agents in such patients analysis using the pain management index scale revealed use of opioid analgesia in such cases to be justified As in previous work no link was found between any one co-morbidity and the development of pain
Overall we have shown high rates of pain amongst our dialysis patients We also demonstrate high levels of chronic analgesia use and the overall tablet burden on our patient group is high This work adds to previously published literature and is being used locally to proactively minimise the burden of prescribed tablets and also increase awareness of the value of paracetamol and neuropathic agents in those with uncontrolled pain
Source of funding conflict of interest Nil
References i Davison SN Pain in hemodialysis patients prevalence cause severity and management Am J Kidney Dis 2003421239-1247 ii Butler AM Kshirsagar AV Brookhart MA Opioid Use in the US Hemodialysis Population Am J Kidney Dis 2014 63(1) 164-173 iii Wyne A Rai R Cuerden M Clark WF Suri RS Opioid and Benzodiazepine Use in End-Stage Renal Disease A Systematic Review Clin J Am Soc Nephrol 2011 6 326ndash333
A7 The Role of the Renal Supportive Care Service in Advanced Care Planning JM Sloan CA Douglas S Cathcart L Frame L Stage M Witham ME Lafferty
Renal Service Ninewells Hospital Dundee
Background In 2007 we established a Renal Supportive Care Service for patients with advanced chronic kidney disease who choose not to receive dialysis The service which includes a fortnightly Renal Supportive Care clinic is provided by a Consultant Nephrologist a Consultant Palliative Care Physician and a Renal Supportive Care Specialist nurse The focus of the service is on ongoing management of chronic kidney disease symptom control and improving quality of life while planning for end of life care
Methods We have undertaken a retrospective audit of our Renal Supportive Care Service on all patients known to the Renal Service for whom a conservative care management decision had been made We collected data over a 31-month period from April 2012 until October 2014 We collected data on demographics co-morbidities clinic attendance renal supportive care input anticipatory care planning performance status and mortality data
Results Of the 98 patients for conservative management 62 (6198) were female with a mean age of 837 years During the 31-month period there were 507 documented supportive care consultations with 36 (3598) of patients receiving domiciliary visits from the Renal Supportive care nurse Anticipatory Care Plans (ACP) were in place for 62 (61) of patients with a preferred place of death known for 56 (5598) 65 patients had a documented discussion about their DNACPR status which was communicated in writing to primary care For a further 13 it was not clear whether the discussion had taken place During the study period 61(62) patients died Of those patients with an ACP 29 (1138) died in an acute hospital versus 43 (1023) of those without (p=025) Similarly 24 (834) of patients with a documented preferred place of death died in an acute hospital versus 48 (1327) of those without (p=004)
Conclusions The role of the Renal Supportive Care team is invaluable in providing care and support to patients who have chosen conservative management By discussing and planning for end of life care the Renal Supportive Care team play a role in reducing the number of patients dying within an acute setting
Conflicts None
Funding The Renal Supportive Care Nurse post and one Palliative Care Consultant Programmed activity received 3 years of funding by British Kidney Patients Association
A8 Predictors of transplant failure in patients undergoing indication renal biopsy
Kate Stevens 1 Bruce Mackinnon1 David Kipgen1 Shana Coley1 Marc Clancy1 Colin Geddes1
1Renal and Transplant Unit QEUH NHS GGampC Glasgow United Kingdom
Introduction This study considers indication renal biopsies and factors which may be important
predictors of transplant loss and patient death
Objectives To identify the time line of histological diagnosis from transplant in our population
and to identify predictors of graft and patient survival in those undergoing indication renal biopsy
Methods All indication renal biopsies undertaken between 012011 and 122015 were identified
Demographic data including immunological and outcome data was recorded Statistical analysis
was undertaken in SPSS (v22)
Results 354 patients underwent 549 biopsies Mean patient and transplant age at time of biopsy
was 432 plusmn153 and 42plusmn58 years respectively 449 (n=247) of biopsies showed evidence of
Cell mediated rejection (CMR)ABMR or both 93 (n=51) demonstrated features of chronic
transplant glomerulopathy (CTG) DSA was present at the time of biopsy in 231 (n=127) In
transplants aged le 6 months old histological diagnosis was CMR in 325 (n=69) with ABMR seen
in 28 (n=6) In transplants aged ge10 years CTG was seen in 325 (n=26) with ABMR
accounting for 63 (n=5) 229 (n= 81) of transplants failed at a median of 182 days from most
recent biopsy On cox regression analysis peritubular capillary (PTC) C4d and CTG were
independent predictors of transplant failure Probability of transplant failure was 45 and 50 at
one year if mixed rejection or CTG were present 93 (n=33) patients died at a median of 227
days from most recent biopsy Independent predictors of death included deceased donor
transplant patient age and presence of ABMR on biopsy (plt005)
Conclusion Acute ABMR is a risk factor for patient loss whilst chronic ABMR is a risk factor for
transplant loss This association is independent of DSA but dependent upon PTC C4d staining
indicative of donor humoral activity ndash HLA or otherwise Histological diagnosis in an indication
biopsy is an important factor in predicting outcome This study is limited by the inherent bias in
patient selection with indication biopsy
Disclosure of Interest None Declared
A9 Renal Evaluation of Paediatric Patients with Tuberous Sclerosis Complex (TSC) in aNational TSC Multidisciplinary ClinicDr Jenny Patterson 1 Dr Shelagh Joss 1 Dr Ihab Shaheen 2
1 Clinical Genetics Queen Elizabeth University Hospital Glasgow 2 Paediatric Nephrology Royal Hospital for Sick Children Glasgow
Introduction Tuberous sclerosis complex (TSC) is a dominantly inherited multisystem disorder characterised by development of hamartomas (benign lesions) in multiple organs Previous studies have shown that renal manifestations are common in TSC and also the most frequent cause of TSC-related death in affected individuals With the recent discovery of targeted therapy with mTOR inhibitors early recognition of renal involvement allowing early surveillance and prompt therapy is now more important than ever
AimMethod To review a population of paediatric patients attending a large specialist TSC service in the UK both in terms of key clinical characteristics and current practice for renal radiological surveillance data were collected from electronic medical records pertaining to molecular diagnosis renal surveillance and presence or otherwise of sequelae affecting the renal or other systems Practice was compared to published surveillance recommendations of the International Tuberous Sclerosis Complex Consensus Group (2013)
Results Data were obtained for 41 children (18 males 23 females) Current age range 25 years to 14 years (mean 98 years) Twenty nine patients (707) were diagnosed lt1 year of age Genetic data were available for 29 patients Fifteen patients had a confirmed TSC1 mutation and 14 patients a confirmed TSC2 mutation including one contiguous PKD1 mutation Renal imaging (all US) within a year of diagnosis was documented in 2541(61) performed at a mean age of 3 years Renal symptoms at diagnosis were documented in 741(171) and 941(22) had renal abnormalities on baseline imaging There was wide variability in scanning interval and modality with 1041(243) having previous abdominal MRI with variable documented indication Seventeen (414) of the cohort mean age 102 years had documented renal lesions 917 angiomyolipomas 517 cysts and 317 both These lesions were diagnosed at a mean age of 6 years (range 02 years-142 years) Six patients (353) had normal baseline scans with a mean interval to lesion diagnosis of 1 year One patient had a lesion on MRI not detected on US that required subsequent biopsy Frequency of subsequent scanning ranged from intervals of 2 months to 1 year with a combination of MRIUS in an unclear pattern All patients except one with a contraindication were undergoing current brain surveillance by MRI
Conclusions Our results highlight the significant incidence of renal sequelae within our TSC cohort with renal manifestations ranging both in severity and age of onset International guidelines recommend MRI scanning for renal surveillance at diagnosis and throughout life Benefits of MRI include enhanced accuracy of sizing and characterisation of renal lesions The majority of our cohorts are already undergoing brain MRI surveillance It is our aim to combine and standardise MRI renal surveillance for this cohort to facilitate early and regular monitoring with a view to early intervention is possible
A10 Effect of blood temperature monitoring on intradialytic hypotension in patients with end stage renal disease requiring haemodialysis Heather Walker1 Susan McGeorge1 Drew Henderson2
1 Renal Unit Ninewells Hospital Dundee2 Regional Renal Centre Waikato Hospital Hamilton New Zealand
Background KDIGO define intradialytic hypotension (IDH) as a reduction in systolic bloodpressure (SBP) ge20mmHg or mean arterial pressure (MAP) ge 10mmHg with associatedsymptoms IDH is a common complication of haemodialysis (HD) and is associated with increasedmortality and morbidityStandard dialysis with a set temperature leads to thermal gain during the dialysis session Tocounteract this thermal gain vasodilation occurs and is postulated as one of the causes of IDHActive cooling of dialysis has been shown to reduce IDH but is not routinely applied across wholedialysis populations Isothermic dialysis can be achieved by controlling blood temperature on HDWe report here our experience of doing this using the Blood Temperature Monitoring (BTM)function on Fresenius 5008 dialysis machines
Methods An observational study was performed to assess the rates of IDH in patients with End Stage Kindey Disease (ESKD) undergoing regular satellite HD at NHS Tayside in July 2017 Rates of IDH were assessed (KDIGO definition) for two weeks prior to BTM settings being activated and for a two week study period after introduction SBP and MAP data was collected SBP data was grouped to either SBP decrease lt20mmHg or SBP decrease ge20mmHg compared with Pre HD BP Changes in MAP were also analysed at the same time points Patient reported symptoms related to initiation of BTM were also collected for the same time period
Results 402 dialysis sessions were evaluated in the pre intervention time period and 399 sessions post intervention
IDH 1072 vs 778 (Pre BTM vs Post BTM) p=015 gt20mmg SBP drop Pre vs Post BTM
Mean MAP Change (mmHg) Pre BTM vs Post BTM
1st BP 254 vs 204 (p=005) -522 vs +312 (plt001) 2nd BP 474 vs 435 (p=023) -1589 vs -886 (plt001) 3rd BP 515 vs 435 (p=003) -1862 vs -958 (plt001) Post HD 408 vs 338 (p=003) -1164 vs -077 (plt001)
Following the introduction of blood temperature monitoring only 08 of HD sessions reported experiencing cold or shivering symptoms
Conclusion The use of blood temperature monitoring was not associated with a statistically significant decrease in rates of IDH There was a significant reduction in the number of sessions where SBP decrease by gt20mmHg at the first and third HD BP and a reduction in MAP change across the study group Further evaluation of BTM is required assess its clinical utility in our HD population
Funding No funding was sought for this study
Conflicts of interest None
A11 Evaluating patient satisfaction and clinical outcomes of a new nurse-led dermatology clinic for patients attending the renal transplant clinic Campbell G Naismith K Neil A Rankin A Spalding E (joint first authors) Renal Unit University Hospital Crosshouse Kilmarnock UK
BACKGROUND National Guidelines advise that renal transplant recipients should receive annual skin surveillance to screen for skin cancer In August 2015 a specialist nurse-led dermatology clinic was set-up alongside the renal transplant clinic at University Hospital Crosshouse We aimed to evaluate the success of this joint clinic in terms of clinical outcomes and patient satisfaction
METHODS Clinical records were reviewed to determine the number of patients under dermatology follow-up before and after initiation of the joint clinic and to review cases that were referred for treatment of pathological skin lesions A questionnaire was also distributed to patients attending the new joint renal-dermatology transplant clinic The questionnaire consisted of 5 questions 2 for patient demographics 1 for current understanding of skin care advice and 2 to assess their satisfaction of the new joint clinic
RESULTS A total of 138 and 146 renal transplant recipients were registered on renal transplant clinic lists in 2015 and 2016 respectively Prior to initiation of the new joint-clinic 41 patients had attended dermatology (37 in NHS Ayrshire and Arran and 4 in NHS Greater Glasgow and Clyde) consisting of 30 of the transplant population In September 2016 13 months after initiation of the new clinic 60 patients had attended the new clinic increasing the proportion of patients meeting the national recommendation for skin surveillance to 41 Implementation of the new clinic resulted in patients being 65 more likely to have received the recommended skin checks (odds ratio 165 95 CI 101-270 p=004)
32 patients completed the questionnaire The median age of transplant was 90 years (IQR 38-153) 100 of patients knew to avoid sun exposure and 31 (96) knew to use sunscreen 29 (91) patients were aware of the advice to undergo annual skin surveillance by dermatology with 28 (88) having had a skin check in the last year 29 (91) patients reported that they found the new joint clinic useful although only 18 (56) had attended the clinic so far
CONCLUSIONS Implementation of a new nurse-led dermatology clinic running in parallel with the renal transplant clinic resulted in a considerable increase in the proportion of patients meeting national recommendations for annual skin surveillance The vast majority of patients also found the combined clinic to be useful There is still considerable room for improvement in order to achieve the target of 100 compliance with skin surveillance and ongoing clinical audit is required to assess progress We believe this model would be easily implementable at other units with similar benefits expected
A12 Pneumocystis pneumonia prophylaxis post-renal transplant increased duration of co-trimoxazole is safe and effective FA Chapman JE Dickerson M Clancy C Daly C Geddes Renal amp Transplant Unit Queen Elizabeth University Hospital Glasgow
Introduction All renal transplant recipients receive Pneumocystis jirovecii prophylaxis usually with co-trimoxazole Guidelines suggest this should be continued for 3 to 6 months Our unit previously prescribed 3 months however following an outbreak of Pneumocystis pneumonia (PCP) infection this was increased to 6 months Given its constituents of sulfamethoxazole and trimethoprim co-trimoxazole prophylaxis may influence the frequency of urinary tract infection (UTI) We aimed to compare the frequency of UTI between patients on 3 months vs 6 months prophylaxis and assess rates of multi-drug resistant organisms We also sought to establish if the increased duration of co-trimoxazole was adversely affecting renal function potassium concentration white cell and platelet count and dosing of mycophenolate mofetil
Methods A retrospective search of the West of Scotland Electronic Renal Patient Record was conducted for all renal transplant recipients between 1st January 2012 and 31st May 2016 Patients were grouped according to the intended duration of co-trimoxazole Data were extracted for baseline characteristics co-trimoxazole prescription mycophenolate mofetil (MMF) prescription laboratory results (creatinine potassium white cell count platelets) at 3 6 9 and 12 months post-transplant and microbiology results for 6 months post-transplant Results were analysed on an intention to treat (ITT) basis with a second analysis according to actual duration of co-trimoxazole treatment (AT) Subjects with transplant failure had laboratory results censored from the time of transplant failure and all of their microbiology results were excluded
Results 609 renal transplants were performed over the study period On ITT analysis there were 418 patients in group 1 (ITT1 3 months co-trimoxazole) with 15 transplant failures and 191 patients in group 2 (ITT2 6 months co-trimoxazole) with 12 transplant failures There was a significant difference in the number of patients with at least one UTI with fewer in ITT2 (ITT1 133403 vs ITT2 42179 p = 001) However this was not present when comparing actual treatment duration (AT1 111345 vs AT2 36149 p=007) Overall there was a similar spectrum of organisms cultured There were significantly fewer cultures of multi-resistant organisms in both ITT and AT analyses with 6 months of co-trimoxazole (ITT1 28376 vs ITT2 0106 p= 0004 AT1 22313 vs AT2 198 p = 002) There was no difference in estimated Glomerular Filtration Rate serum potassium concentration platelet count or MMF dose On AT analysis there was a significant difference in the total white cell count (WCC) and lymphocyte count at 6 months post-transplant (WCC 78 x10^5L vs 71 x10^5L p =004 lymphocytes 13 x10^5L vs 12 x10^5L p=002) There were 18 cases of PCP with 7 deaths attributable All cases occurred after cessation of co-trimoxazole prophylaxis (81 ndash 913 days after stopping co-trimoxazole)
Conclusion Although there is a significant difference in UTI frequency on ITT analysis this is not present on AT analysis suggesting no real co-trimoxazole effect There was no increase in frequency of multi-drug resistant organisms with a longer course of co-trimoxazole Renal function and serum potassium were unaffected Our findings support continuing co-trimoxazole prophylaxis for at least 6 months
A13 Kidney transplantation in the over 60rsquos in Scotland 1996-2015 TJW Rennie1 P Phelan1 J Campbell2 JP Traynor2 L Henderson1 W Metcalfe2 On behalf of the Scottish Renal Registry 1Renal transplant unit Royal Infirmary Edinburgh 2NHS National Services Scotland Introduction The proportion of older kidney transplant recipients has increased in the UK but
long term outcome data are scarce We aimed to evaluate patient and graft survival in patients
ge60 years of age receiving a first kidney only transplant in the last 20 years in Scotland
Methods Retrospective analysis of Scottish Renal Registry data of incident Renal Replacement
Therapy (RRT) patients and those in receipt of a kidney only transplant performed 1996-2015
(follow up until 311216) Patients were stratified by age 60-69 ge70 (group 1 and 2 respectively)
and decade of transplantation 1996-2005 2006-2015 (decades 1 and 2 respectively)
Results 6743 patients aged ge60 started RRT from 1996-2016 Of those 108 were ever
transplant-listed 54 had received a transplant by 311216 26 listed and 11 transplanted
were aged ge70
535 patients aged ge60 received a kidney only transplant in 1996-2015 90 patients (168) were
aged ge70 no patients were aged ge80 Mean time from wait listing until transplantation was 33plusmn24
years (plusmnSD) and from starting RRT until transplantation was 38plusmn26 years (plusmnSD) One and five
year graft survival was 97 and 87 in decade 1 95 and 89 in decade 2 (p=NS) there was
no difference in graft survival between age groups 1 and 2 One and five year patient survival was
94 and 78 in age group 1 85 and 56 in group 2 (plt0001) there was no difference in one
and five year patient survival between the two decades
Conclusion One and five year graft and patient survival in renal transplant recipients aged ge60
have not changed significantly in the last 20 years Recipient age ge70 is not associated with
reduced graft survival but patient survival from time of transplant is lower in this age group
compared to recipients aged 60-69
No conflict of interest to be declared No funding received
A14 High Mortality In Older Patients With Primary Nephrotic Syndrome Sarah Beverstock Wendy Metcalfe amp Robert W Hunter Department of Renal Medicine Royal Infirmary of Edinburgh
Introduction
Nephrotic syndrome can develop at any age and may be due to a primary glomerular lesion or secondary to systemic disease The natural history of glomerular disease can be different in older patients For instance minimal change disease (MCD) in children almost always remits promptly with steroid therapy in adulthood it typically remits only after many weeks of steroids or with adjunctive immunosuppression However there are remarkably few published data on the mortality of primary nephrotic syndrome in adults We aimed to study this in our centre
Methods
We enrolled all adult patients who had a kidney biopsy in order to investigate nephrotic syndrome over 38 consecutive months (01 Jan 2014 ndash 28 Feb 2017) We defined nephrotic syndrome as heavy proteinuria (urinary proteincreatinine ratio UPCR gt350 mgmmol or albumincreatinine ratio gt220 mgmmol) and hypoalbuminaemia (serum albumin lt35 gL) In our analysis we included all patients in whom nephrotic syndrome was attributed to a primary glomerular disease We excluded kidney transplant recipients and patients in whom biopsies were performed to follow up a known glomerular disease We collected laboratory data at baseline (time of biopsy) and at 6 and 12 months We assessed patient survival by Kaplan-Meier analysis
Results
Of the 117 patients biopsied for nephrotic syndrome 71 patients (61 ) met the inclusion criteria and were followed up for a median of 469 days We compared outcomes in patients aged under 60 years old (n = 35) with those aged over 60 (n = 36) Mortality was higher in the older group (37 vs 4 mortality at one year p lt005 by logrank test) There were no significant differences between the two groups in serum creatinine or UPCR at any time Serum albumin was similar in both groups at baseline and at 12 months but was lower in the older group at 6 months (27 vs 32 gL p lt 005) Baseline haemoglobin was lower in the older group (114 vs 130 gL p lt005 by unpaired t-test) Primary diagnoses were MCD (n = 10 in younger group amp n = 5 in older group) membranous nephropathy (5 amp 10) IgA nephropathy (9 amp 8) FSGS (5 amp 5) membranoproliferative glomerulonephritis or C3GN (4 amp 7) and other (2 amp 1) Therefore unsurprisingly there were relatively fewer cases of MCD and more cases of membranous nephropathy in the older group otherwise the causative glomerular lesions were similar in both groups In those patients with MCD mortality was significantly higher in the older group none of the 10 patients with MCD diagnosed under 60 yrs old died during the follow-up period whereas 4 of the 5 older patients died 3 patients in the younger group and 1 in the older group were on renal replacement therapy (dialysis or transplant) by the end of follow-up
Conclusions
Primary nephrotic syndrome is associated with high mortality in the over 60s (37 at one year) Mortality was high even for MCD a disease that follows a benign course in childhood and early adulthood The higher mortality in older patients was not associated with greater severity of renal disease at presentation (as assessed by basic blood and urine parameters) This work was not funded we declare no conflicts of interest
A15 Renal biopsies in patients with diabetes mellitus in Scotland
Udana Ratnapala 1 Nicola Joss 2 Colin Geddes 3 Dana Kidder 1
1 Renal Unit Aberdeen Royal Infirmary Aberdeen 2 Renal Unit Raigmore Hospital Inverness 3 Glasgow Renal and Transplant Unit Glasgow
Introduction Diabetes mellitus is the leading cause of end-stage kidney disease (ESKD) requiring renal replacement therapy The utility of renal biopsy in patients with diabetes mellitus is controversial Broadly renal biopsy findings in patients with DM can be divided into diabetic nephropathy (DN) alone DN with non-diabetic renal disease (NDRD) or NDRD alone Timely identification of patients with NDRD is important to provide appropriate therapeutic measures Previously published guidelines on clinical predictors of NDRD have limited specificity and sensitivity The frequency of NDRD in renal biopsies of patients with DM is unclear in ScotlandThis study aimed at identifying the frequency and the pathology spectrum of NDRD in diabetic patients underwent kidney biopsy in 3 renal units
Methods A retrospective observational study was performed on clinical-pathologic findings in all patients with diabetes mellitus who underwent renal biopsy between 01012010 and 31122016 in 3 renal units (Aberdeen Inverness and Greater Glasgow) Data were gathered from electronic patient record systems Scottish Index of Multiple Deprivation (SIMD) 2012 was used to analyse correlation with patient outcomes
Results 247 patients were included 150 men (607) 217 type 2 DM (879) mean age 621 years and mean serum creatinine at the time of renal biopsy of 261 micromolL (+-190 std) On biopsy 92 patients (372) had DN while 127 (514) had NDRD and 28(114) had NDRD superimposed on DN The commonest NDRD aetiologies were IgA nephropathy (187) tubulointerstitial nephritis (168) and idiopathic membranous nephropathy (103) Predictors of NDRD were age (OR 1027 95 CI 1002-1052 p=003) duration of DM (OR 094 95 CI 0900-0987 p=001) and absence of AKI as indication for biopsy (OR 022 95 CI 0059-0826 p=0025) There was no significance difference in renal or patient survival in DN and NDRD Finally no significant correlation was depicted between SIMD quintiles and renal or patient survival in both groups
Conclusions The majority of renal biopsies carried out in patients with DM revealed a NDRD In this study age at the time of biopsy duration of DM and AKI were the main pointers towards NDRD Renal and patient survival were not significantly different between DN and NDRD groups
A16 The Impact of Withdrawal of Maintenance Immunosuppression and Graft Nephrectomy on HLA Sensitisation Ailish Nimmo1 Sophie McIntyre1 Lorna Henderson1 Richard Battle2
(1 Department of Renal Medicine Royal Infirmary of Edinburgh 2 Histocompatibility and Immunogenetics Royal Infirmary of Edinburgh)
Background The development of HLA antibodies towards a failing renal allograft is a barrier to re-transplantation We previously demonstrated an increase in HLA antibodies and calculated reaction frequency (cRF) following nephrectomy but results were confounded by immunosuppression changes occurring in close time proximity We examined the formation of HLA donor specific antibodies (DSA) in patients with failed grafts that remained in situ and compared results with patients undergoing graft nephrectomy to further assess the relative impact of nephrectomy and immunosuppression weaning on sensitisation and chance of transplant
Methods We carried out a single centre retrospective study of all patients with failed grafts in Lothian from 2005 to 2015 Samples were tested for DSA pre-immunosuppression (IS) wean post-IS wean and post-IS cessation Nephrectomy patients also had samples tested for DSA before and after nephrectomy Data on other sensitising events including blood transfusion and rejection were collected cRF was determined at each time point and entered into the ODT chance of transplant calculator with other demographics based on the average patient from the Edinburgh centre
Results 62 grafts failed over this time period Blood samples were available 41 patients (24 with nephrectomy 17 with failed graft left in situ) Patient demographics were similar between groups There was a higher rate of antibody mediated rejection in the nephrectomy group (46 vs 18) 76 of patients with nephrectomy group had received a blood transfusion The pattern of immunosuppression weaning was similar but median time from start of IS wean to cessation was longer in the nephrectomy group (350 vs 298 days) The changes in cRF and chance of transplant (COT) with immunosuppression weaning are shown in Table 1
Pre-IS Wean Post-IS Wean
Failed graft in situ (n=17)
Mean CRF COT at 5
years 15 62 38 59
Nephrectomy (n=24)
Mean cRF COT at 5
years 54 54 69 46
Post-IS Stop 55 53 89 42 Table 1 Mean cRF and Chance of Transplant (COT) at 5 years with IS alterations
Discussion A stepwise increase in cRF with reduced chance of transplant was observed in both groups as immunosuppression was withdrawn with a similar pattern of change irrespective of graft nephrectomy cRF was higher in the nephrectomy group despite a more gradual wean which may reflect a higher rate of antibody mediated rejection and increased number of patients receiving a blood transfusion The risks and benefits of stopping immunosuppression need to be carefully considered on an individual basis to maximise chance of future transplant
The authors have no conflicts of interest No funding was required for this study
A17 Obesity is not associated with progression to end stage renal disease in patients withbiopsy-proven glomerular diseases
Benjamin Elyan Jennifer S Lees Bruce Mackinnon Jonathan G Fox Colin C Geddes Emily PMcQuarrie
Glasgow Renal and Transplant Unit Queen Elizabeth University Hospital Glasgow
Introduction - Addressing risk factors for renal progression is a key aspect of managing chronic kidney disease (CKD) Body mass index (BMI) has been shown to impact on renal progression in unspecified CKD The aim of this study was to evaluate if there was an association between BMI and progression to renal endpoints in patients with biopsy-proven primary glomerular disease (GN)
Methods - We included all adult patients diagnosed with biopsy-proven primary GN (excluding minimal change nephropathy) in Greater Glasgow amp Clyde and Forth Valley between 01012000 and 31122015 Biochemical and anthropometric data were extracted from the electronic patient record at time of biopsy with follow-up data until 20062017 BMI was calculated from height and weight at time of biopsy and categorised into groups BMI le25 kgm2 (G1) gt25 to le30 kgm2 (G2) and gt30 kgm2 (G3 - obese) We assessed factors associated with reaching a combined renal endpoint of CKD5 or renal replacement therapy (RRT) with competing risk of death using the Fine and Gray subdistribution hazard model Analyses were conducted using cmprsk package for R statistical software package and SPSS version 24
Results - 560 patients with primary GN and available BMI data were included The average age was 532 years and 339 were female There were 132 patients in G1 210 in G2 and 207 patients in G3 Those in G2 and G3 were older (p=002) with slightly higher diastolic blood pressure (p=002) than those in G1 There was a greater proportion of focal segmental glomerulosclerosis in G3 but similar proportions of other GN diagnoses across groups There was no significant difference in baseline serum creatinine (sCr) (p=034) or log uPCR (p=045) between BMI groups On multivariate analysis age systolic blood pressure BMI or GN diagnosis were not predictive of renal outcome Higher baseline sCr (SHR 1003 per 1 umoll increase in sCr 1001-1004 plt0001) and log uPCR (SHR 130 per unit increase in log uPCR 95 CI 105-160 p=002) were associated with progression to the combined renal endpoint accounting for competing risk of death BMI was not associated with reaching combined renal endpoint on univariate analysis whether considered as a continuous variable (SHR=100 95 CI 098-102 p=096) or categorised by BMI group
Conclusion - Contrary to our expectations there was no association between BMI and progression to a combined renal endpoint of CKD5 or RRT in this cohort of patients with primary GN Efforts should be directed to managing other known risk factors for CKD progression
Sources of FundingConflicts of Interest - None
A18 Factors influencing long term renal function after living kidney donation
Matthew A Rutherford Norman J Galbraith Marc Clancy Colin C Geddes
Glasgow Renal and Transplant Unit Queen Elizabeth University Hospital Glasgow UK
Background Following live donor nephrectomy the remaining kidney undergoes an increase in filtration capacity known as compensatory hypertrophy Few cohorts with follow up of renal function beyond 5 years have been reported The impact on long term renal function of variability in donor factors such as age sex pre-donation blood pressure and glomerular filtration rate (GFR) is unknown Increasingly kidney donors have potential risk factors for future poor renal function such as hypertension older age and obesity The aim of this study was to analyse factors influencing long-term renal function in living kidney donors from our centre
Method Data were obtained from the electronic patient record Patients with a recorded procedure of lsquolive donor nephrectomyrsquo between 2005 and 2017 were identified GFR after donation (calcGFR) was calculated using the formula lsquocalcGFR = Pre-donation Isotope GFR x (Pre-donation Serum creatinine Serum Creatinine)rsquo which is accurate assuming muscle mass does not change Pre and post donation serum creatinines (two days two weeks three months and one to ten year) were recorded We analysed the influence of age sex pre-donation GFR and blood pressure on post donation GFR compensation
Results 355 live donor nephrectomies were performed between January 2005 and December 2016 The mean age was 469 (plusmn 116) years and 504 (n=179) were female Mean pre-donation isotope GFR was 937 plusmn 156 mlmin173m2 Median follow up was 2 years (IQR 1 to 6 years with range 2 weeks to 10 years) The calculated percentage of pre-donation GFR at 2 days 2 weeks 3 months 1 year 5 years and 10 years were 698 691 712 730 801 and 950 respectively (p lt 0001) Patients aged lt50 y had not only a higher calcGFR (858 plusmn 29 mlmin173m2 compared with 671 plusmn 28 mlmin173m2 p lt 0001) at 5 years following donation but achieved a higher degree of compensation than donors gt 50 y (836 plusmn 16 compared with 756 plusmn 19 (p = 0002) Patients with pre-donation hypertension achieved 774 plusmn 53 of pre-donation GFR compared with 804 plusmn 32 in normotensive patients (p = 0998) Females had equivalent degree of renal compensation achieving 819 plusmn 19 compared with 780 plusmn 16 in males (p = 0131) at 5 years following donation Patients with pre-donation GFR gt 100 mlmin173m2 achieved 844 plusmn 23 of pre-donation function by 5 years compared with 777 plusmn 14 in those with pre-donation GFR lt 100 mlmin173m2 (p = 001)
Conclusion Following live donor nephrectomy renal function has a nadir of 691 at 2 weeks Compensation in GFR occurs rapidly and appears to be maintained regardless of sex and pre-donation blood pressure Younger age and higher pre-donation GFR were associated with a greater degree of compensation
A19 The utility of high-sensitivity cardiac troponin to stratify cardiovascular risk in patients with renal impairment
Eve Miller-Hodges Atul Anand Anoop S V Shah Nicholas L Mills Neeraj Dhaun
Background Cardiovascular disease is the most common outcome of chronic kidney disease1
Declining glomerular filtration rate (GFR) and proteinuria predict increased cardiovascular risk over the long term2 However there are currently no methods to stratify cardiovascular risk in the short or medium term in patients with renal impairment We have already shown that high-sensitivity cardiac troponin I concentrations (hs-cTnI) lt5ngL in patients presenting with symptoms of acute coronary syndrome identifies those at low risk of cardiac events within 30 days and over the next year3 However uncertainty remains over the role of hs-cTnI testing in patients with renal impairment This study investigated whether hs-cTnI could also stratify future cardiovascular risk in patients with renal impairment
Methods In a prospective study of consecutive patients presenting with suspected acute coronary syndrome we evaluated the performance of hs-cTnI in patients with and without renal impairment (estimated glomerular filtration rate lt60mLmin173m2) using an early risk stratification threshold of 5ngL to ldquorule outrdquo acute myocardial infarction at presentation and within 30 days and sex-specific 99th centile diagnostic thresholds for index type 1 myocardial infarction Subsequent type 1 myocardial infarction and cardiac death were reported at one year
Results Of 4726 patients identified 904 (19) had renal impairment Index diagnosis of type 1 and type 2 myocardial infarction was almost twice as likely in patients with renal impairment (30 vs 15) Performance of the early risk stratification threshold of 5ngL to identify patients at low risk of major cardiac events was similar in patients with (NPV 984 95CI 960-997 sensitivity 989 95CI 975-999) and without renal impairment (NPV 997 95CI 994-999 sensitivity 984 95CI 972-994) These patients continued to remain at low risk over the next year The PPV and specificity at the 99th centile for diagnosis of myocardial infarction were lower in patients with renal impairment at 500 (95CI 452-548) and 709 (95CI 675-742) respectively compared to 624 (95CI 588-659) and 921 (95CI 912-930) At one year 24 of patients with renal impairment and troponin gt99th centile regardless of index diagnosis had experienced further myocardial infarction or cardiac death compared with 10 of patients without
Conclusion In suspected acute coronary syndrome hs-cTnI can stratify risk in patients with renal impairment Irrespective of diagnosis patients with renal impairment and elevated cardiac troponin concentrations had two-fold greater risk of a major cardiac event compared to those with normal renal function and should be considered for further investigation and treatment
Funders Wellcome Trust British Heart Foundation and Chest Heart amp Stroke Scotland
1 Gansevoort RT Lancet 2013
2 Chronic Kidney Disease Prognosis Consortium Lancet 2010
3 Shah AS Lancet 2015
A20 lsquoDOES IT DIALYSE OUTrsquo - THE EFFECT OF RENAL REPLACEMENT THERAPY ON THE BRAIN Mark Findlay Jesse Dawson David Dickie Deborah McGlynn Patrick Mark Institute of Cardiovascular and Medical Science University of Glasgow amp Queen Elizabeth University Hospital Glasgow
Introduction Cerebrovascular disease is common in end-stage renal disease (ESRD) on renal replacement therapy (RRT) We investigated the effect of RRT on cerebral structure and cognitive function over 12 months Methods Observational cohort study in ESRD patients receiving HD Prior cognitive impairment or cerebrovascular disease were exclusion criteria Multi-domain cognitive testing was performed at baseline and at follow-up Transcranial Doppler was used to assess intra-dialysis related alterations in mean flow velocity (MFV) ndash a marker of cerebral blood flow MR imaging was performed at 0 and 12 months We performed T1 T2 FLAIR and DWI sequences and used volumetric software to calculate white matter hyperintensity (WMH) burden markers of atrophy mean diffusivity and fractional anisotropy (FA) to describe structural changes at 1 year Results 97 patients median age 59 years 412 female At follow-up 15 patients were transplanted 6 died 4 withdrew and the remainder continued HD Those who were transplanted were younger (median age 51 vs 60 years p=0019) and had been on dialysis for a shorter period (median 06 vs 21 years p=0003) MFV declined during HD median 475cms to 405cms plt0001 and correlated with lower scores of executive and frontal lobe function during HD (Rho 045 p lt0001 and Rho -0313 p lt001 respectively) In all patients MR imaging demonstrated a significant decline in frontal parietal and temporal lobe volume at follow-up Median WMH volume increased in those who remained on HD but not in transplanted patients (median change 023 vs -012ml p=0018) WMH burden correlated with worsening scores of frontal lobe tests Rho 0585 p0005 and worse mood Rho -0485 p0026 FA improved following renal transplant (028 to 029 p=0016) and correlated with improved executive function testing at follow-up Rho 089 p0019 Conclusion Cerebral blood flow is reduced during haemodialysis and correlates with a reduction in intradialytic executive function There is an improvement in FA following transplantation WMH volume increases in those who remain on dialysis and the degree of increase correlates with executive and frontal lobe function This suggests that haemodialysis is associated with clinically significant changes in the brain and that these may be ameliorated by transplantation
Source of fundingconflicts MF is funded by a KRUK fellowship
A21 Pathological classification of IgA nephropathy to predict renal outcomes ndash is there a better way to score tubulointerstitial inflammation
Alastair Rankin David Kipgen Bruce Mackinnon Jonathan Fox Colin Geddes Emily McQuarrie Glasgow Renal and Transplant Unit On behalf of the Scottish Renal Biopsy Registry
Background The Oxford pathological classification of IgA nephropathy (IgAN MEST-C score) is limited by the fact that individual features of the score are not all predictive and its utility in assisting clinical decision-making is questioned The addition of tubulointerstitial inflammation to the existing scoring system is appealing but is not currently included due to reportedly wide inter-observer variability We report a novel method to score percentage of cortex containing tubulo-interstitial inflammation in non-atrophic renal cortex (ATIN) in patients with IgAN similar to that used in transplant biopsy reporting and assess its utility to predict clinical outcomes
Methods All adult patients with a native renal biopsy diagnosis of IgAN between 2010 and 2015 in a unit serving 15 million people were identified Baseline characteristics biopsy reports and outcome data were collected ATIN was calculated by subtracting the percentage of atrophic cortex from the percentage of total cortex with tubulo-interstitial inflammation withge10 representing significant tubulo-interstitial inflammation in non-atrophic cortex The primary outcome was a composite of requiring renal replacement therapy (RRT) or doubling of serum creatinine (sCr)
Results 153 new cases of IgAN were identified 33 were excluded (24 had lt8 glomeruli on biopsy 6 inadequate biopsy for MEST scoring and 3 on RRT at time of biopsy) In addition patients with a tubular atrophy (T) score of 2 were also excluded (n=9) Of the remaining 111 patients 76 (68) were male Mean age at biopsy was 52 years (+- 167) and 18 (16) had a co-existing clinical diagnosis of henoch-schonlein purpura (HSP) Median sCr was 156 micromoll (IQR 101-212) and 54 (49) had ATIN on biopsy During a median follow-up of 23 years 34 (31) reached the primary outcome 20 (18) received immunosuppression and 16 (14) died On univariate Cox regression survival analysis ATIN was associated with a four-fold increase in the primary outcome (HR 49 (21-113)) On multivariate analysis mesangial hypercellularity (M) T and ATIN independently predicted renal outcome while endocapillary proliferation (E) and segmental sclerosis (S) did not (plt002 for ATIN) Excluding patients with HSP or those who received immunosuppression did not change the result
Conclusion Within our centre ATIN predicts renal outcome for IgAN independently of established histological features Assessment of inter-observer reproducibility and validation in other cohorts is still required but these results suggest ATIN could be a worthwhile addition to current pathological scoring systems for IgAN
Source of funding none Conflicts of interest none
P1 Polypharmacy in Renal Replacement Therapy Patients
Jason McMinn Colin Geddes Glasgow Renal and Transplant Unit Queen Elizabeth University Hospital
Introduction
Prescribing is often led by evidence from studies containing participants with single health conditions and without multimorbidity Polypharmacy is becoming increasingly recognised in patients with multiple chronic health conditions Additional medications are more likely to result in diminishing returns in benefit with an increased risk of harm Patients with established renal failure (ERF) are likely to be susceptible to medication-related harm A high pill burden is also likely to contribute adversely to an already restricted quality of life and has been associated with poor medication adherence The aim of this study was to analyse polypharmacy in all patients with ERF attending our service
Methods
We extracted medication records for all prevalent ERF patients attending the Glasgow Renal and Transplant Unit from the West of Scotland Electronic Renal Patient Record (SERPR) as of 01012017 The records were analysed to calculate the number of regular medications and total pill burden of each patient These medications were categorised as being lsquopreventativersquo or lsquosymptomaticrsquo We also analysed the prescription of specific drug classes to examine the prevalence of these medications
Results
We identified 1091 transplant follow-up 529 hospital haemodialysis and 46 peritoneal dialysis patients who were on a mean of 94 13 and 129 different medications respectively Overall pill burden was 139 tablets a day in transplant follow-up patients 141 in haemodialysis patients and 162 in peritoneal dialysis patients There were similar rates of prescribing between the different dialysis units and clinics within our service
The proportions of medications deemed as preventative rather than symptomatic were 76 in transplant 69 in haemodialysis and 60 in peritoneal dialysis
In transplant patients decreasing renal function was associated with a higher pill burden but even patients with a transplant eGFR gt 60 were on a mean of 126 tablets per day including a mean of 14 antihypertensives
Rates of antidepressant prescribing were 15 in transplant patients and 20 in hospital haemodialysis patients 53 of haemodialysis patients were on a statin 39 on aspirin 61 on a proton pump inhibitor and 7 were on warfarin
Conclusion
Patients undergoing all forms of renal replacement therapy are likely to be on a considerable number of medications Whilst these drugs are inevitably prescribed for valid reasons this data demonstrates the need for clinicians to engage with patients to explore opportunities to reduce pill burden
Conflict of Interest None Sources of Funding None
P2 An audit of Acute Kidney Injury (AKI) on an acute stroke ward before and after plannedinterventions to review and maintain hydration
Clare Harris1 Simon Hart2 Fiona Duthie3 1 University of Edinburgh Medical School 2 Stroke Unit Royal Infirmary of Edinburgh 3 Renal Unit Royal Infirmary of Edinburgh
Background Dehydration is an important factor in the development of acute kidney injury which is associated with increased morbidity and mortality particularly in the elderly population Poor fluid intake is common post stroke (1) and dehydration is associated with poorer outcomes 3 months post stroke (2) In late 2014 there was no system of identifying patients with poor oral intake on the stroke ward at the Royal Infirmary of Edinburgh a hydration protocol and education programme were implemented aiming to improve fluid balance This included the use of prescribed water either orally or by nasogastric tube An audit pre and post intervention demonstrated that hydration as measured by ureacreatinine ratio significantly improved after the protocol introduction (3) We aimed to determine whether the incidence of AKI by KDIGO criteria was also reduced as this could have implications for reducing patient morbidity and mortality in this elderly comorbid patient cohort
Method 150 inpatients to the acute stroke ward during JulAug 2014 and JulAug 2015 were selected (n= 80 2014 n=70 2015) Patient data and creatinine values were collected from the electronic patient record and medical notes and retrospectively analysed Baseline creatinine values were calculated and cases of AKI were identified and staged using KDIGO criteria (4) Chi-Squared tests were performed to determine P values Individual patient notes were reviewed for both quantitative and qualitative data of patient management
Results Incidence of AKI (of any stage) was 263 pre-protocol and 200 post-protocol (P=03646) Incidence of AKI stages 23 was 100 pre-protocol and 715 post-protocol (P=05374) In hospital post stroke mortality was 338 pre-protocol and 1286 post protocol (P=00028) AKI was also associated with increased length of stay
Conclusions Despite a trend in benefit there was no significant difference in incidence of AKI pre and post hydration protocol nor in incidence of severe AKI (stage 23) AKI is influenced by many factors one of which is hydration status Further studies are needed to determine whether the trend of benefit exhibited in this sample is significant in a greater sample size if this were the case such a protocol could have great benefit to patient care on stroke units and elsewhere There was a significant difference in inpatient post stroke mortality following introduction of the hydration protocol Further investigations are needed to explain underlying reasons for this factors other than hydration may play an important role
References 1 Whelan K Inadequate fluid intakes in dysphagic acute stroke Clinical Nutrition (2001) 20(5)
423-428 2 Bhalla A Sankaralingam S Dundas R Swaminathan R Wolfe CDA Rudd AG The influence of
raised plasma osmolality on clinical outcome after acute stroke Stroke (2000) 312043ndash2048 3 Hart SR Craig R Berry E Lane N Gad A Farrugia M Burton L Paquay A What Happens to
Acute Stroke Patientsrsquo Fluid Balance Renal Status and Dehydration in the First Two Weeks How Can They Be Markedly Improved doi 101111ijs12634_13
4 KDIGO Clinical Practice Guideline for Acute Kidney InjuryKidney international supplements (2012) 2(1) 1-138
No funding or conflict of interest to declare
P3NHS Highland-Improving the management of hyperkalaemia using a kit Initial resultsCantley N1 Abedin T2 Lambie S3
1FY2 NHS Highland 2ST4 Renal Medicine NHS Grampian 3Renal Consultant Renal unitRaigmore Hospital Inverness
Introduction The incidence of hyperkalaemia in hospitalised in patients is between 1 and 10 Guidelines in Northern Ireland promote the use of a Hyperkalaemia Kit to improve management of hyperkalaemia We assessed the management of hyperkalaemia in Raigmore Hospital including post-treatment monitoring of serum potassium and blood glucose at baseline and after the introduction of a lsquoHyperkalaemia Kitrsquo which contains a pro forma for the management of hyperkalaemia and all the relevant equipment and drugs for treatment
Method Between July and September 2016 an automated algorithm identified 34 patients with a potassium result 65 mmoll or above on laboratory results 12 received no specific treatment of these 6 results were spurious 4 patients died before treatment could be started and 2 patients were chronic haemodialysis patients We introduced the Hyperkalaemia Kit to the Acute Medical Admissions Unit in Raigmore Hospital Since then 15 patients have been identified with serum potassium measurements above 65 and the pro forma and kit was used with eight of these patients One of these patients proceeded straight to acute renal replacement therapy
Results Prior to our intervention all 22 patients that were actively treated received at least one prescription of appropriate doses of Insulin with Dextrose However only 16 patients received intravenous calcium and only 7 received nebulised Salbutamol Potassium was measured at 4 hours in 5 cases and by 12 hours in 17 cases Monitoring of any capillary blood glucose was only documented in 8 cases Of the 22 treated 2 needed acute renal replacement therapy 3 required further doses of insulin and dextrose 2 were treated with Calcium Resonium
Eight cases of hyperkalaemia have been managed with the use of the kit and pro-forma so far An initial ECG was performed in all eight and four patients had continuous cardiac monitoring Intravenous calcium was given in seven and nebulised Salbutamol was given in five out of the eight cases Six out of eight patients had at least three blood sugar measurements One had two measurements documented and one patient was stopped from further monitoring following senior review and decision to palliate Seven patients had appropriate monitoring of their serum potassium by 4h and 12h again one patient was not monitored due to palliation
Conclusion Baseline results showed very low rates of prescription of nebulised Salbutamol low rates of Calcium Gluconate use and very low monitoring of blood sugars and potassium post treatment This has the potential for serious adverse outcomes particularly the potential for iatrogenic hypoglycaemia Our initial data shows the use of a Hyperkalaemia pro forma and kit improves the rate of prescription of intravenous calcium and nebulised Salbutamol and the post-treatment monitoring of serum potassium and blood sugar levels
P4Rituximab as maintenance therapy in ANCA associated vasculitisndash a single centre experience Rathnamalala NK Mcmenamin J Robertson S Almond A Kelly M Muniraju T M Renal Unit Dumfries and Galloway Royal Infirmary NHS Dumfries and Galloway Background The introduction of Cyclophosphamide and high dose steroids transformed ANCA associate vasculitis (AAV) from a disease of high mortality to a relapsing remitting disease Maintenance of remission however still remains a major challenge A two randomised clinical trials have looked at the use of Rituximab in remission induction in AAV and reported similar remission rates between Cyclophosphamide and Rituximab 12 Both these trials used Azathioprine as maintenance therapy and in the follow up showed similar remission rates with either agent for induction The role of Rituximab for maintenance therapy after cyclophosphamide induction was studied in the MAINRITSAN trial 3 Rituximab was compared with azathioprine and found that the relapse rate was significantly lower in the Rituximab group There have been several other retrospective studies that have suggested regular Rituximab infusions are successful in maintaining remission however has not been thoroughly evaluated 4 5678910 Here we share our centrersquos experience using Rituximab for maintenance of remission of AAV Materials and methods We conducted a retrospective review of electronic medical records of all patients who had received Rituximab as maintenance therapy for 12 months or longer between January 2014 to July 2016 Disease activity was assessed using Birmingham Vasculitis Activity Score ( BVAS) Version 3 and complete remission was defined as a score of 0 and partial remission as a score of lt50 of the value at diagnosis Due to uncertainties associated with sub classification we did not assign specific diagnosis but broadly classified as ANCA associated vasculitis Results 6 patients received Rituximab as maintenance therapy during the study period 3 (50) of them had eye ear nose and upper airway manifestations consistent with Granulomatosis with Polyangitis (GPA) All patients were PR3 ANCA positive except for one at initial diagnosis The mean BVAS score at the time of initiation of Rituximab was 4 All patients were initiated on Rituximab for relapses while on maintenance therapy with Azathioprine 4 patients received 6 monthly doses of Rituximab while two received annual doses All of them were also maintained on 5-10 mg of Prednisolone The mean BVAS score by 6 months was 0 and remained 0 at 12 months The mean PR3 titre was 562 at the initiation of treatment while at 12 months it had come down to 68 All patients remained in complete clinical remission at the end of 12 months after initiation of therapy Rituximab was well tolerated by all patients except one who developed pyrexia during an administration
Conclusions All patients had sustained remission at 6 months and 12 months after initiating Rituximab Rituximab has a potential role as maintenance therapy in AAV
P5 Chronic Myelo-Monocytic Leukaemia (CMML) as a contraindication to renal biopsy Alastair Rankin Emily McQuarrie Jennifer Lees Bruce MacKinnon Glasgow Renal and Transplant Unit On behalf of the Scottish Renal Biopsy Registry
Abstract Chronic Myelo-Monocytic Leukaemia (CMML) is a relatively rare mixed myelodysplastic myeloproliferative disorder that predominately affects patients over the age of 65 years Renal impairment in patients with CMML is well described with several different mechanisms reported including tumour infiltration lysozyme-induced injury amyloid deposition and tubulointerstitial nephritis From anecdotal evidence within our centre we are concerned that patients with CMML have an excessive risk of clinically significant bleeding following native renal biopsy This risk appears disproportionate to the degree of any co-existing thrombocytopenia or coagulopathy
We review the cases of 4 patients with an existing diagnosis of CMML who were referred to the renal clinic with proteinuria and excretory renal dysfunction Two of these patients underwent renal biopsy with subsequent major haemorrhage post-procedure despite normal bleeding parameters pre-procedure Patient 1 presented with flank pain 8 days post-biopsy A CT confirmed peri-nephric haematoma with retroperitoneal extension A total of 6 units of packed red cells (PRCs) were transfused prior to successful CT-guided emoblisation Histology from the biopsy revealed chronic tubulointerstitial nephritis Patient 2 experienced haemodynamic instability and haematuria one hour post-biopsy A total of 11 units of PRCs 7 units of fresh frozen plasma 2 pools of platelets intravenous tranexamic acid and 2 attempts at CT-guided embolization were required until haemostasis was achieved Histology later showed evidence of tumour infiltration with associated vasculitis Patient 3 presented with renal impairment and proteinuria on the background of known CMML Following discussion with haematology the risk of bleeding following renal biopsy was considered unjustifiable despite their platelets and coagulation screen being within normal range The patient was treated for presumed renal tumour infiltration with hydroxycarbamide Patient 4 was referred to the renal clinic with acute onset nephrotic syndrome Urinary proteincreatinine ratio was elevated over 800 mgmmol with serum albumin of 23 gL but normal excretory renal function The patient attends the haematology clinic with suspected CMML and chronic thrombocytopenia but previously declined bone marrow biopsy Following discussion with the patient there are no plans to proceed with renal biopsy given potential risks These cases highlight that while CMML is rare these patients are being referred to renal clinics with features that would commonly justify renal biopsy in other settings but in whom there may be an increased risk of bleeding post-procedure Our in-centre risk of major bleeding is 2 therefore to have such extreme amounts of bleeding in 2 patients with this underlying diagnosis is remarkable This creates a dilemma for the clinician as there is a wide range of potential renal pathology associated with CMML some of which will have disease specific but relatively toxic treatments available
Source of funding none Conflicts of interest none
P6 NHS Highland-Prograf to Adoport switch McCulloch K1 Peel R2 Lambie S3
1Renal Pharmacist Renal unit Raigmore Hospital Inverness 23Renal Consultant Renal unit Raigmore Hospital Inverness
Introduction NHS Highland (NHSH) is the first health board in Scotland to implement a switch from Prograf to Adoport for renal transplant patients This will provide considerable cost savings Adoport meets the bioequivalence criteria for drugs with a narrow therapeutic index set by the European Medicines agency and studies indicate therapeutic equivalence1 with the proviso that brands are non- interchangeable unless the switch is overseen by a Renal Consultant and post-conversion therapeutic drug monitoring is conducted23 The switch has been undertaken by a majority of transplant centres in England the main difference being that they have undergone repatriation NHSH Patients receive their transplant primarily at Royal Infirmary of Edinburgh and occasionally at Queen Elizabeth University Hospital Glasgow Care is transferred to NHS Highland on discharge NHS Highland cares for approximately 170 renal transplant patients 110 being prescribed Prograf These patients may live as far as 110 miles from Raigmore Hospital Given that prescribing is carried out by primary care clear communication with patients GPs and community pharmacy is essential to avoid inadvertent switching between brands
Method Clinically it was agreed a switch could be safely undertaken A business case was submitted and funding secured for pharmacist time laboratory costs and primary care time GPs have been informed via GP subgroup and local prescribing bulletin lsquoThe Pink Onersquo Community pharmacies are being informed by phone A protocol has been agreed Eligible patients selected by Renal Consultant and Renal Pharmacist Patients sent letter signed by Renal Consultant and Renal pharmacist Patients phoned prior to clinic to agree Adoport start date and address concerns Patient seen by Renal Consultant and pharmacist + given 1 month of Adoport Tacrolimus level and UampEs checked 5-7 days after commencing Adoport and patient
contacted by phone to check if tolerated If stable letter sent to GP and community pharmacy to continue supply
Results and Evaluation Letters have been sent to all eligible patients Seven patients have been reviewed One has received a one month supply of Adoport and 5 others are due to switch One patient was deemed non-eligible at present as they have a 6 month surplus of Prograf A database will be maintained and analysed at the end and primary care savings will be monitored Extra pharmacist input will give us the opportunity to review how immunosuppression is managed and to evaluate the benefit of having a renal transplant pharmacist Conclusion The switch is at an early stage Ultimately we hope to show that the switch from Prograf to Adoport can be managed safely with extra pharmacist input to a remote and rural population with prescribing being conducted by primary care
Fundingconflicts of interest none 1 McDevitt-Potter LM Sadaka B Tichy EM Rogers CC Gabardi S Transplantation 2011 A multicenter experience with
generic tacrolimus conversion 2 Medicines and Health Products Regulatory Agency Drug Safety Update 2012 Accessed online via
wwwmhragovukSafetyinformationDrugSafetyUpdateCON1557563 ESPRIT Guidance on management of repatriation and immunosuppressant switches in transplant patients 2015
Accessed online via httpwwwespritorgukwp-contentuploads201508Switch-guidance-document-final-Aug-31-2015pdf
P7 NHS Highland-Tacrolimus baseline dataMcCulloch K1 Peel R2 Lambie S3
1Renal Pharmacist Renal unit Raigmore Hospital Inverness 2Renal Consultant Renal unitRaigmore Hospital Inverness 3Renal Consultant Renal unit Raigmore Hospital Inverness
BackgroundAs part of planning a switch from using tacrolimus Prograf to Adoport we assessed baseline data for our transplant patients currently using Prograf After converting patients to Adoport we will compare their tacrolimus levels to their individual target range We assessed our use of appropriate target ranges and our current performance in achieving tacrolimus levels within target range on Prograf therapy
Method 107 renal transplant patients taking Prograf were identified a sample of 19 of these were analysed using electronic patient records and results Time from transplant ranged from 1 month to 18 years All tacrolimus levels for the preceding year were analysed and compared to the target range specified at the time of the level being done The assay used has a Coefficient of Variation of lt5 at the lower limit of the assay
Results All 19 patients had a target range for tacrolimus clearly identified and recorded in clinic letterswhich are routinely copied to the patients themselves A variety of target ranges were specifiedThe commonest used was 5-8 microgramsl in 7 patients followed by 5-7 in a further 4 patientswith another 6 different target ranges being used for the remaining 8 patients The ranges usedhad a breadth of 3 microgramsl in 2 cases the rest had a breadth of 2 microgramslPatients had a median of 12 (range 3-72) tacrolimus levels over the preceding year Results werewithin specified target ranges for 54 +- 22 (Medan +- SD) of results checked
Conclusion We currently use a large number of different target ranges The majority of the ranges used had a breadth of just 2 microgramsl These factors help to account for the low proportion of test results which were within the specified target ranges This is important to bear in mind when interpreting whether tacrolimus levels are within target ranges after switching to Adoport We should consider aligning our target ranges and widening them
P8 Eculizumab use in Scottish paediatric dense deposit disease Stewart D1 David Hughes1 Lynne Riach2 Craig Oxley2 Athavale D1
1Royal Hospital for Children Glasgow 2Royal Aberdeen Childrenrsquos Hospital Aberdeen
Introduction The revised MPGN classification and increasing recognition of Dense Deposit Disease (DDD) a C3 glomerulopathy as an alternative complement pathway disorder suggests Eculizumab an anti-C5 monoclonal antibody may be beneficial in treatment However the experience of Eculizumab as an off-label and expensive treatment in children with DDD is limited with variable clinical response reported in the literature
Method We present the outcomes of the only 2 paediatric patients in Scotland who have received Eculizumab for the management of DDD
Results Case 1 A 10 year old male presented with proteinuria and haematuria resistant to steroid treatment with preserved renal function Initial biopsy confirmed DDD Conservative management with an angiotensin converting enzyme inhibitor and diuretics for symptom control continued until 14 years Due to worsening symptoms (oedema lethargy poor growth) and renal function deterioration along with elevated terminal complement complex (TCC) Eculizumab was commenced A repeat biopsy whilst suggestive of chronic irreversible damage showed 25 glomerular architecture preservation Symptom improvement was noted There was a reduction in proteinuria and renal function stabilisation fall in TCC and discontinuation of diuretics Eculizumab was discontinued after 24 months Progression of renal function decline was seen in the final months of Eculizumab therapy With recurrence of symptoms and increasing proteinuria following discontinuation Eculizumab was recommenced after 6 months Symptomatic improvement has since been noted
Case 2 A 5 year old girl presented with painless frank haematuria and proteinuria Initial biopsy confirmed DDD Proteinuria was unresponsive to steroid therapy and 5 months following diagnosis she rapidly progressed towards end stage renal disease despite the introduction of Mycophenolate Mofetil and plasmapheresis Haemodialysis was subsequently commenced TCC level was elevated and Eculizumab treatment was started 7 months after diagnosis Renal biopsy prior to treatment demonstrated continued severe pathological changes in all visible glomeruli However due to lack of clinical response Eculizumab was discontinued after 2 months and the patient remained dialysis dependent
Conclusions Our experience with Eculizumab in Scotland has demonstrated variable results in our 2 patients with one patient showing a positive response whilst the other experienced no improvement Eculizumab was administered to both patients at varying points in their clinical journey with differing progressive features on biopsy To date the outcomes of 9 paediatric patients with DDD treated with Eculizumab have been described in the literature with 8 experiencing some positive response to treatment including 2 patients who were able to stop renal replacement therapy within 12 weeks of treatment A role for Eculizumab in DDD may be guided by clinical and pathological features Well designed clinical trials will be necessary to define the role of complement inhibition therapy in DDD
No conflict of interest and no funding requested
P9 Examining markers of safety in the use of non-tunnelled central venous catheters
James WT Millar (Speciality Registrar) Scott W Oliver (Speciality Registrar) Peter C Thomson (Consultant Nephrologist) Glasgow Renal and Transplant Unit Queen Elizabeth University Hospital Glasgow
Background Non-tunnelled central venous catheters (NTCVC) remain an essential means of vascular access for incident haemodialysis Associated morbidity is well recognised for example in the form of Staphylococcus aureus bloodstream infections (SAB)[1]
Previous quality improvement initiatives in our unit have sought to both improve traditional markers of quality (such as SAB) and to identify additional areas of clinical risk In 2014 Oliver et al [2] suggested several additional quality measures including peri-procedure haemoglobin drop the need for a further NTCVC during the same clinical episode and the NTCVC insertion site This study further evaluated NTCVC related clinical practice within our unit
Methods The potential markers of clinical quality identified in a previous project were examined using prospectively collected data stored in the electronic patient record Identified cases of SAB significant peri-procedure haemoglobin drop and multiple NTCVC insertion were investigated by case note review
Results Between March 2016 and March 2017 a total of 222 patients received 346 NTCVC 54 patients (243) had more than one NTCVC inserted in a 21-day period (range 2-5) When considering NTCVC insertion site there were 159 (459) femoral vein catheters and 183 (541) internal jugular vein catheters No pneumothoraces were reported
15 SABrsquos were reported during this period equating to 43 of all NTCVC 5 arose in patients with femoral NTCVC (333) and 10 from internal jugular catheters (667) Mean time from line insertion to positive blood culture was 86 days 15 (67) patients had a drop in haemoglobin of greater than 20mgdl with no other source of blood loss identified on review of clinical notes
Discussion These data demonstrate that NTCVC-associated SAB rates remain low and significantly below Scottish government audit standards [3] Of interest is the continued trend towards the use of femoral catheters at 45 of lines compared with 38 in 2014 [2] Although traditionally thought of as having a higher incidence of infectious complications our data has shown fewer bacteraemia events associated with femoral catheters compared with internal jugular Our data also demonstrates a significant rate of peri-procedure haemorrhage arising in up to 1 in 20 cases Together these findings present opportunities to development practice and improve patient safety
References
[1] Murray E Deighan C Geddes CC Thomson PC Reducing haemodialysis bacteraemia rates Scottish Renal Association Glasgow November 2013 [2] Oliver SW Thomson PC Jardine AG defining safe effective and patient-centred dialysis catheter placement Scottish Renal Association Edinburgh September 2014 [3] The Staphylococcus aureus bacteraemia quarterly report of cumulative data from all NHS Boards in Scotland Health Protection Scotland January 2015
Sources of funding none Conflicts of interest none
P10 Prescribing of tolvaptan-The NHS Highland experience Lambie S1 McCulloch K2 Garrod J3
1Renal Consultant Renal unit Raigmore Hospital Inverness 2Renal Pharmacist Renal unit Raigmore Hospital Inverness 3Renal Pharmacist Renal unit Raigmore Hospital Inverness
Introduction Tolvaptan is a vasopressin antagonist It was accepted for use in Scotland by SMC in Jan 2016 to slow the progression of cyst development and renal insufficiency of autosomal dominant polycystic kidney disease in adults with chronic kidney disease (CKD) stage 1 to 3 at initiation of treatment with evidence of rapidly progressing disease1 Adverse effects related to aquaresis may affect patientsrsquo ability to achieve the optimum therapeutic dose and the risk of hepatic toxicity necessitates regular LFT monitoring The geography of NHS Highland required the implementation of novel methods of managing these patients and as a result a MDT approach with an emphasis on pharmacist input was adopted Consultant role Patient selection on the basis of evidence of rapidly progressing kidney disease declining
eGFR large volume kidneys on ultrasound and evidence of complications of PKD Side effects and potential benefits discussed Potential medication interactions reviewed Jinarc risk management prescriber training
Pharmacist role Undertook Jinarc risk management pharmacist training Prepares accurate drug history and reviews for potential drug interactions Carries out patient counselling and supplies patient education material sick day rules card
and lsquogot to gorsquo card Supplies GP education leaflet Provides advice on selection of new drug therapies eg for gout Manages stock and coordinates supply to patients
Results Prescribing commenced May 2016 patients currently prescribed tolvaptan 11 7 Female 4 male Number on target dose 73 n = 811 2 patients are still being titrated One patient did
not tolerate target dose due to aquaresis side effects and is being trialled on the middle dose
Withdrawals One patient has withdrawn due to agoraphobia and an inability to attend for monitoring and another is on hold due to having major surgery
Conclusion The MDT approach between the Renal Consultant and Pharmacist at Raigmore Hospital has enabled tolvaptan prescribing to be efficiently and safely implemented to patients living within a challenging geographical location
1 Scottish Medicines Consortium Detailed Advice Document tolvaptan 15mg 30mg 45mg 60mg and 90mg tablets (Jinarcreg) SMC No 111415 January 2016
NA1 Authors SCN Jacqueline Ross NHS Grampian
SCN Alan Somerville NHS Lanarkshire SCN Jane Humphrey NHS Lanarkshire
e- mail contact jacquelinerossnhsnet Alansommervillelanarkshirescotnhsuk
Janehumphreylanarkshirescotnhsuk
Phone contact 01224 552927 01236 712644
Title Sharing of Adverse Events in Renal Units across Scotland
Introduction Background The Scottish Renal Nurses Strategy Group (SRNSG) are a group of senior nurses from Renal
Units across Scotland who meet 3-4 times per year to discuss and implement best practice At the last meeting it was agreed that it would be good practice for each Health Board to share
their adverse events reported on the Datix System and deliver a presentation with an action plan to prevent incidents and improve patient safety across Scotland NHS Grampian and NHS Lanarkshire will be the first to deliver this presentation discussing adverse events from both Health Boards with an action plan
Top 5 adverse events over the past 12 months Renal Unit NHS Grampian 1 Violence and Aggression 2 Accidents including needlesticks slips trips and falls 3 Medication Errors 4 Infrastructure Staffing and Estates 5 Machines and Equipment
Top 5 adverse events over past 12 months Renal Unit NHS Lanarkshire
1 Slips Trips or Falls 2 Medicine errors 3 Treatment problems 4 Transfer problems 5 Breach of policy
The presentation will also focus on any serious adverse events which may not be in the top 5 categories
Aim Objective Each Health Board to share their adverse events with the aim to prevent them from occurring in other units to improve staff and patient safety and wellbeing across Scotland
Method Power Point Presentation
Outcome Results Sharing of adverse events resulting in the development of a national Action Plan to prevent these incidents improving safety and well being of staff and patients in Renal Units across Scotland
NA2
SRA Oct 2017 Abstract
BBV Never Event - The whats whys and hows
Staff Nurse Gillian Wilson Aberdeen Royal Infirmary
This presentation shares our experience of a never event that occurred and was not picked up for
a period of 18 months
Hepatitis C (HCV) positive antibodies were found in a previously negative patient
These results were a low positive with no biochemistry changes to suggest any liver damage
however steps were put immediately in place to isolate and investigate
Was it contamination from a dialysis machine was it related to a blood transfusion given prior to
first positive result was it faulty diagnostic tests in the laboratory
In Aberdeen we go over and above national guidelines and isolate all our BBV patients whether
they have positive blood results or are PCR negative
Further bloods tested at an external laboratory confirmed negative results
It highlighted that communication errors were to blame for the lack of speed in detecting this issue
Investigations concluded no real answers as to why this happened
NA3
Living Donation Scotland Changing attitudes towards living donor kidney transplantation
Jen Lumsdaine Julie Glen On behalf of the Living Donation Scotland Project Board
Background and aims
The rate of living donor transplantation has remained fairly static in Scotland over the past 10 years
Recent data has shown inequity of access to living donor transplantation throughout the UK so
there is potential to significantly increase this optimum form of treatment for patients with end-stage
renal failure in Scotland The Living Donation Project Board was formed in 2016 aiming to double
the number of living donor transplants by 2020
Method
The two key areas
1 Do recipients receive adequate and appropriate information at the right time about living
kidney donation
2 Informing the general public about altruistic donation
All patients active on the transplant list in Scotland were invited to an information event A follow-up
questionnaire was performed in the East of Scotland examining outcome or reasons for not
attending A scoping exercise looked at information provided by each unit was performed and link
nephrologists and low clearance nurses attended meeting to discuss strategies for early education
Outcome
An information pack containing both recipient and donor written information and short films on DVD
has been produced with the support of the Scottish Government for all recipients and potential
donors in Scotland A new website with comprehensive information both written and visual and
postcode finder to improve ease of access to local unit contact details has been developed
Two national media campaigns have been launched with a significant rise in the number of enquiries
from potential donors and actual increase in altruistic donor numbers
Nursing abstract ndash no conflict of interest
NA4Authors Susan Easson Charge Nurse Ward 4C QEUH Glasgow
e- mail contact SusanEassonggcscotnhsuk
Phone contact 0141 452 3300
Title A Conversational approach to find out ldquoWhat matters to yourdquo in a Renal Transplant ward
Introduction Background Finding out ldquo What Mattersrdquo to people using health and careservices is crucial to delivering safe effective and person centred care It is a simple yet profoundconcept and tries to get to the essence of person centred care by creating deeply personalengagements with patients and their families through a conversational approach However careexperience feedback all too often provides innumerable examples of where what really matters topatients and their family members is poorly understood or not addressed Using care experienceas the driver for change the nursing staff in Ward 4C used improvement approaches to explorehow to hold more meaningful ldquoWhat Matters to yourdquo conversations on a daily basis
Aim Objective To improve the patient experience by utilising a person centred approach
Method Using Care experience feedback What Matters to Me boards and the conversationalapproach
Outcome Results Improvements in patient experience will be shared using examples ofpractice and care experience feedback
There was no additional funding required for this project We worked in collaboration with theperson centred team whorsquos aim is to improve patient experience
NA5
The implementation of a renal education programme and its impact on clinical practice
The purpose was to implement a Renal Education Programme and to evaluate its impact on
clinical practise
It was identified that there was a need for an educational programme to be set up within Forth
Valley Royal Hospital There is no inpatient renal unit in FVRH on site for our renal patients they
attend Queen Elizabeth University Hospital We are an outpatient haemodialysis unit with
outpatient clinics on site Therefore it was identified that there was a need for nursing staff within
FVRH to be educated on all renal complexities for the benefit of our patients
This was done through a work-based learning approach which brought tangible benefits for our
patients However it did not come without pitfalls as educational programmes are often seen as
making very little difference to clinical practise
T
his study describes what methods were used and examines the advantages and disadvantages in
setting up an educational programme and evaluating its impact on clinical practise
NA6
Nursing Abstract ndash SRA Meeting ndash 26 October 2017
Chris McGee Tonya Broe Ken Weir
Renal Unit Forth Valley Royal Hospital
Use of the Therapy Monitor Haemodialysis Patient Record System Can we aim for a paper-
free dialysis unit
We are trialling a new haemodialysis patient monitoring system to work in conjunction with SERPR
and which is intended to supersede the Finesse system used previously
We are in the early stages of this process but with continuing staff education and regular tech
support we are hoping to gather sufficient evidence to evaluate whether the use of paper case
notes needs to continue
Is it a realistic goal to aim for a completely paper-free unit
NA7
THE CLINICAL USES OF APHERESIS WITHIN NHS TAYSIDE
Laura Thomson CN
Ninewells Hospital Dundee
NHS Tayside took over the apheresis service from BTS in 2012 The service has since expanded
with the benefits of carrying out this treatment has been widely recognised within NHS Tayside
and is now more commonly being offered to treat a wider range of conditions with the number of
treatments carried out each year rising
This presentation will highlight the progression of the apheresis service within NHS Tayside We
will identify the various conditions it is currently being used to treat and also identify the decision
making process involved in carrying out these treatments ie which replacement fluid will be used
anticoagulation medication administered
We will highlight the benefits and challenges we face in providing this expanding service within the
Renal Service
NA8Authors Linda McDougall Renal Physiotherapist NHS Highland
e- mail contact lindamcdougall1nhsnet
Phone contact 01463 706022
Title lsquoExercise on Haemodialysis- Keeping the Wheels in Motionrsquo
Introduction Background The impact of CKD on physical fitness functional ability independence amp ultimately quality of life cannot be underestimated Current national guidelines recommend that all individuals with CKD are encouraged to participate in regular exercise programmes between or during dialysis sessions if on HD Following a successful pilot study funding was approved to establish an lsquoExercise on Dialysisrsquo (EOD) programme across NHS Highland through the appointment of a dedicated renal physiotherapist in 2008 A successful programme was soon established but for several years post-vacancies and increasing in-patient demands limited the physiotherapy servicersquos ability to deliver the programme The need to improve the long-term sustainability of the service was recognised and in late 2016 funding was approved to develop a Band 4 PT HCSW role for this purpose
Aim ObjectiveTo optimise the sustainability and continuity of the lsquoExercise on Dialysisrsquo service across NHSHighland through development of a Band 4 PT HCSW role
Method The potential parameters of the role and limits of autonomy were scoped out using current NES resources and guidelines Service and task analysis was then carried out to establish which components of the EOD protocol could be undertaken by a Band 4 A series of competencies were developed in line with the clinical protocol and one-to-one training and supervision provided to the post-holder to ensure competency achieved in delivering the programme
Outcome Results A 10 WTE Band 4 PT HCSW was appointed in Jan 2017 with a dual role between the renal unit and acute medical wards Although training is not yet complete the post-holder is already running the day-to-day delivery and monthly audit of the EOD service with senior physiotherapist input only required for individual patient safety queries and general discussion around patientsrsquo progress and goals The benefit to the unit has been considerable as the band 4 is available to support patients and staff with EOD provision 5 days a week This allows for one-to-one supervision of patients who need more support to participate in EOD regular feedback on performance and reviews of outcome measures and goals to maintain motivation levels Feedback on the post has been very positive and its scope will only continue to expand as we look to further develop renal rehabilitation services across NHS Highland
NA9Authors Nadine Lyall and Kerry Guthrie
e- mail contact nadinelyallbordersscotnhsuk kerryguthriebordersscotnhsuk
Phone contact 01896 826637
Title The Developing Role of the NMP in a Satellite Dialysis Unit
Introduction Background
We have been practising as NMPrsquos for nearly 3 years working in the dialysis unit at the BGH The unit is a satellite unit of the ERI and we have expanded over the last 6 years The unit provides haemodialysis for 12 patients at any one time 3 sessions a day 6 days a week We are nurse-led and have 2 renal consultants who are based at the ERI
We saw an opportunity to use our knowledge and experience to develop our role By becoming NMPrsquos we have enhanced our professional development and we feel we meet the changing needs of the dialysis patient in a more holistic manner
Aim Objective
Our aim is to deliver effective care as we are better placed to deal with issues that often arise byacting swiftly this in turn is cost effective and convenient For example good anaemia and bonemanagement is important for their health wellbeing and lifespanTo help understand our role we will use a power point presentation highlighting issues we dealwith and the drugs we prescribe under the following headings Cardiovascular infection painanticoagulant disequilibrium diet renal bone disease and renal anaemia
Method Power point
Outcome Results
In the future we hope to further develop and have greater autonomy in our role We have great support from our renal consultants and have already built up a great relationship with our patients We hope to undertake the Clinical Decision Making course and this in turn will allow us to deal effectively with acute illness giving the dialysis patient better care We are keen to get feedback from other renal nurses in Scotland to enable us to develop our role further and in turn raise awareness of the NMP role in a dialysis unit We record all our prescribing decisions and keep the consultants up to date regularly Currently we are working on auditing our prescribing practice so that we can improve the service we can provide
NA10 Title Komunikacja w szkoleniu dializy ortzewnowej
Author Senior Charge Nurse Rhoda Bell
Address Raigmore Hospital Old Perth Road Inverness IV2 3UJ
Email rhodabellnhsnet Telephone 01463706023
Introduction Background Case study on lady with Polish as her first language she has some English but requires an interpreter to carry out Peritoneal Dialysis training and attend clinic She had some gynaecological issues that we were not aware of which impacted on the functionality of PD and therefore the success of treatment There were areas of concern in low clearance clinic with signs the patient had a reluctance to engage in decision making
AimObjective
Methods Discussion through the case study highlighted issues with communication between different PD staff and patients Areas of concern include different staffing techniques environment factors on training success Also language and communication issues the patient had were not fully apparent so training could not be individualised
Results We plan to trial training at home and have more individualised training schedule for patients The training step by step guides have been reviewed and practise standardised In collaboration with low clearance nurse we have developed a check list which will highlight concerns before the transition to PD ie language issues and need for training aids in another language gynaecological conditions
Conclusions Everyone learns differently and training methodsaids must be individualised for all It may not be apparent until training has commenced that there are concerns Having one to one training with the same nurse will consolidate training and build confidence in the patient Having a close working relationship with members of the MDT will help make a supportive PD journey
Would we do things differently if we knew about prolapse or lack of English both spoken and written
Key words - Peritoneal dialysis patient training communication
N11
Telehealth amp PDAudrey Jones
Advantages
Information on a daily basis about treatment weight and blood pressure
Change programme remotely via computer or mobile
Earlier intervention for machineprogramme issues
Reduction in home visits ie patient trained but still requires volume increases
No need to download cards to see what problems have been
Can have more detailed information available at clinics
Disadvantages
Relying on patient input data correctly
Machine is noisy especially first wave of machine
Still the same bag connection system and patient connection system (difficult for manual
dexterity problems)
Relying on patient having good signal
Modem problems
NA12Autosomal Dominant Polycystic Kidney Disease A cruel inheritance but new hopeAlistair Lawrie Renal Unit Victoria Hospital KirkcaldySadaf Arshad Corry Dunnigan Paul Phelan Neil Turner Renal Unit Royal Infirmary of Edinburgh
Background Autosomal Dominant Polycystic Kidney Disease (ADPKD) is the most prevalent single gene human genetic disorder and the most common of the inherited cystic and interstitial kidney diseases It is estimated to affect 1 in every 1000 individuals worldwide with over 50 of sufferers eventually developing end stage kidney disease and requiring dialysis or transplantation Symptoms include spasmodic severe pain hypertension haematuria infection and kidney failure There is currently no cure for ADPKD Management of the condition has traditionally involved lifestyle modification BP control and analgesia however a recent study (Torres et al 2012) demonstrated that treatment with V2-receptor antagonist drugs slowed increase in total kidney volume reduced the rate of functional decline and showed a reduced incidence of kidney pain
Aim Provision of a tolvaptan prescribing and monitoring service
Methods Experiential finding report of initial twelve months period of multidisciplinary ADPKDtolvaptan clinic
Results Early results are comparable with TEMPO study outcomes
Conclusion Due to the long term nature of this treatment results available at this time are showing only the earliest benefits of the intervention More quantifiable results such as increased time before the necessity for RRT will only be evident in coming years Torres VE et al (2012) Tolvaptan in Patients with Autosomal Dominant Polycystic Kidney Disease New England Journal of Medicine 367 pp 2407-2418 DOI 101056NEJMoa1205311
No funding requirement No conflict of interest
A6 Analgesic Use in Dialysis Patients in a District General Hospital Setting
A McCallum L Dickson S Robertson A Almond N Rathnamalala M KellyT Muniraju
Renal Unit Dumfries and Galloway Royal Infirmary
Evidence shows around 50 of haemodialysis patients report pain with 83 describing this as moderate to severei Distinct variability also exists in levels of opiate prescribing between centres with studies showing incidence ranging from 5-50iiiii Consequently we sought to investigate the prevalence of both pain and opioid prescriptions in our local dialysis population as well as investigating whether there are any associations between co-morbidities and the use of opiates This information could then be used to identify new dialysis patients at high risk of pain as well as informing prescribing decisions
In order to achieve this a questionnaire was produced that incorporated validated pain and quality of life scores (the Brief Pain Index and Renal Palliative Care Outcome Scale) with a consent form to access electronic healthcare records Questionnaires were distributed to all our haemodialysis and peritoneal dialysis patients Results were transcribed into Microsoft Excel where they were analysed
Data was collected on 56 patients (46 haemodialysis patients 10 peritoneal dialysis patients) Results showed 46 described ldquopain other than everyday kindsrdquo on the day of survey completion The most common site of pain was in the legs and back On average patients were on 12 different medications of which 15 was for pain (range 0-5) 784 of these pain prescriptions were longstanding (gt3 month use) Amongst haemodialysis patients 45 were on a strong opioid ndash in 73 of cases this was a fentanyl patch Whilst scope exists to increase the use of simple analgesia and neuropathic agents in such patients analysis using the pain management index scale revealed use of opioid analgesia in such cases to be justified As in previous work no link was found between any one co-morbidity and the development of pain
Overall we have shown high rates of pain amongst our dialysis patients We also demonstrate high levels of chronic analgesia use and the overall tablet burden on our patient group is high This work adds to previously published literature and is being used locally to proactively minimise the burden of prescribed tablets and also increase awareness of the value of paracetamol and neuropathic agents in those with uncontrolled pain
Source of funding conflict of interest Nil
References i Davison SN Pain in hemodialysis patients prevalence cause severity and management Am J Kidney Dis 2003421239-1247 ii Butler AM Kshirsagar AV Brookhart MA Opioid Use in the US Hemodialysis Population Am J Kidney Dis 2014 63(1) 164-173 iii Wyne A Rai R Cuerden M Clark WF Suri RS Opioid and Benzodiazepine Use in End-Stage Renal Disease A Systematic Review Clin J Am Soc Nephrol 2011 6 326ndash333
A7 The Role of the Renal Supportive Care Service in Advanced Care Planning JM Sloan CA Douglas S Cathcart L Frame L Stage M Witham ME Lafferty
Renal Service Ninewells Hospital Dundee
Background In 2007 we established a Renal Supportive Care Service for patients with advanced chronic kidney disease who choose not to receive dialysis The service which includes a fortnightly Renal Supportive Care clinic is provided by a Consultant Nephrologist a Consultant Palliative Care Physician and a Renal Supportive Care Specialist nurse The focus of the service is on ongoing management of chronic kidney disease symptom control and improving quality of life while planning for end of life care
Methods We have undertaken a retrospective audit of our Renal Supportive Care Service on all patients known to the Renal Service for whom a conservative care management decision had been made We collected data over a 31-month period from April 2012 until October 2014 We collected data on demographics co-morbidities clinic attendance renal supportive care input anticipatory care planning performance status and mortality data
Results Of the 98 patients for conservative management 62 (6198) were female with a mean age of 837 years During the 31-month period there were 507 documented supportive care consultations with 36 (3598) of patients receiving domiciliary visits from the Renal Supportive care nurse Anticipatory Care Plans (ACP) were in place for 62 (61) of patients with a preferred place of death known for 56 (5598) 65 patients had a documented discussion about their DNACPR status which was communicated in writing to primary care For a further 13 it was not clear whether the discussion had taken place During the study period 61(62) patients died Of those patients with an ACP 29 (1138) died in an acute hospital versus 43 (1023) of those without (p=025) Similarly 24 (834) of patients with a documented preferred place of death died in an acute hospital versus 48 (1327) of those without (p=004)
Conclusions The role of the Renal Supportive Care team is invaluable in providing care and support to patients who have chosen conservative management By discussing and planning for end of life care the Renal Supportive Care team play a role in reducing the number of patients dying within an acute setting
Conflicts None
Funding The Renal Supportive Care Nurse post and one Palliative Care Consultant Programmed activity received 3 years of funding by British Kidney Patients Association
A8 Predictors of transplant failure in patients undergoing indication renal biopsy
Kate Stevens 1 Bruce Mackinnon1 David Kipgen1 Shana Coley1 Marc Clancy1 Colin Geddes1
1Renal and Transplant Unit QEUH NHS GGampC Glasgow United Kingdom
Introduction This study considers indication renal biopsies and factors which may be important
predictors of transplant loss and patient death
Objectives To identify the time line of histological diagnosis from transplant in our population
and to identify predictors of graft and patient survival in those undergoing indication renal biopsy
Methods All indication renal biopsies undertaken between 012011 and 122015 were identified
Demographic data including immunological and outcome data was recorded Statistical analysis
was undertaken in SPSS (v22)
Results 354 patients underwent 549 biopsies Mean patient and transplant age at time of biopsy
was 432 plusmn153 and 42plusmn58 years respectively 449 (n=247) of biopsies showed evidence of
Cell mediated rejection (CMR)ABMR or both 93 (n=51) demonstrated features of chronic
transplant glomerulopathy (CTG) DSA was present at the time of biopsy in 231 (n=127) In
transplants aged le 6 months old histological diagnosis was CMR in 325 (n=69) with ABMR seen
in 28 (n=6) In transplants aged ge10 years CTG was seen in 325 (n=26) with ABMR
accounting for 63 (n=5) 229 (n= 81) of transplants failed at a median of 182 days from most
recent biopsy On cox regression analysis peritubular capillary (PTC) C4d and CTG were
independent predictors of transplant failure Probability of transplant failure was 45 and 50 at
one year if mixed rejection or CTG were present 93 (n=33) patients died at a median of 227
days from most recent biopsy Independent predictors of death included deceased donor
transplant patient age and presence of ABMR on biopsy (plt005)
Conclusion Acute ABMR is a risk factor for patient loss whilst chronic ABMR is a risk factor for
transplant loss This association is independent of DSA but dependent upon PTC C4d staining
indicative of donor humoral activity ndash HLA or otherwise Histological diagnosis in an indication
biopsy is an important factor in predicting outcome This study is limited by the inherent bias in
patient selection with indication biopsy
Disclosure of Interest None Declared
A9 Renal Evaluation of Paediatric Patients with Tuberous Sclerosis Complex (TSC) in aNational TSC Multidisciplinary ClinicDr Jenny Patterson 1 Dr Shelagh Joss 1 Dr Ihab Shaheen 2
1 Clinical Genetics Queen Elizabeth University Hospital Glasgow 2 Paediatric Nephrology Royal Hospital for Sick Children Glasgow
Introduction Tuberous sclerosis complex (TSC) is a dominantly inherited multisystem disorder characterised by development of hamartomas (benign lesions) in multiple organs Previous studies have shown that renal manifestations are common in TSC and also the most frequent cause of TSC-related death in affected individuals With the recent discovery of targeted therapy with mTOR inhibitors early recognition of renal involvement allowing early surveillance and prompt therapy is now more important than ever
AimMethod To review a population of paediatric patients attending a large specialist TSC service in the UK both in terms of key clinical characteristics and current practice for renal radiological surveillance data were collected from electronic medical records pertaining to molecular diagnosis renal surveillance and presence or otherwise of sequelae affecting the renal or other systems Practice was compared to published surveillance recommendations of the International Tuberous Sclerosis Complex Consensus Group (2013)
Results Data were obtained for 41 children (18 males 23 females) Current age range 25 years to 14 years (mean 98 years) Twenty nine patients (707) were diagnosed lt1 year of age Genetic data were available for 29 patients Fifteen patients had a confirmed TSC1 mutation and 14 patients a confirmed TSC2 mutation including one contiguous PKD1 mutation Renal imaging (all US) within a year of diagnosis was documented in 2541(61) performed at a mean age of 3 years Renal symptoms at diagnosis were documented in 741(171) and 941(22) had renal abnormalities on baseline imaging There was wide variability in scanning interval and modality with 1041(243) having previous abdominal MRI with variable documented indication Seventeen (414) of the cohort mean age 102 years had documented renal lesions 917 angiomyolipomas 517 cysts and 317 both These lesions were diagnosed at a mean age of 6 years (range 02 years-142 years) Six patients (353) had normal baseline scans with a mean interval to lesion diagnosis of 1 year One patient had a lesion on MRI not detected on US that required subsequent biopsy Frequency of subsequent scanning ranged from intervals of 2 months to 1 year with a combination of MRIUS in an unclear pattern All patients except one with a contraindication were undergoing current brain surveillance by MRI
Conclusions Our results highlight the significant incidence of renal sequelae within our TSC cohort with renal manifestations ranging both in severity and age of onset International guidelines recommend MRI scanning for renal surveillance at diagnosis and throughout life Benefits of MRI include enhanced accuracy of sizing and characterisation of renal lesions The majority of our cohorts are already undergoing brain MRI surveillance It is our aim to combine and standardise MRI renal surveillance for this cohort to facilitate early and regular monitoring with a view to early intervention is possible
A10 Effect of blood temperature monitoring on intradialytic hypotension in patients with end stage renal disease requiring haemodialysis Heather Walker1 Susan McGeorge1 Drew Henderson2
1 Renal Unit Ninewells Hospital Dundee2 Regional Renal Centre Waikato Hospital Hamilton New Zealand
Background KDIGO define intradialytic hypotension (IDH) as a reduction in systolic bloodpressure (SBP) ge20mmHg or mean arterial pressure (MAP) ge 10mmHg with associatedsymptoms IDH is a common complication of haemodialysis (HD) and is associated with increasedmortality and morbidityStandard dialysis with a set temperature leads to thermal gain during the dialysis session Tocounteract this thermal gain vasodilation occurs and is postulated as one of the causes of IDHActive cooling of dialysis has been shown to reduce IDH but is not routinely applied across wholedialysis populations Isothermic dialysis can be achieved by controlling blood temperature on HDWe report here our experience of doing this using the Blood Temperature Monitoring (BTM)function on Fresenius 5008 dialysis machines
Methods An observational study was performed to assess the rates of IDH in patients with End Stage Kindey Disease (ESKD) undergoing regular satellite HD at NHS Tayside in July 2017 Rates of IDH were assessed (KDIGO definition) for two weeks prior to BTM settings being activated and for a two week study period after introduction SBP and MAP data was collected SBP data was grouped to either SBP decrease lt20mmHg or SBP decrease ge20mmHg compared with Pre HD BP Changes in MAP were also analysed at the same time points Patient reported symptoms related to initiation of BTM were also collected for the same time period
Results 402 dialysis sessions were evaluated in the pre intervention time period and 399 sessions post intervention
IDH 1072 vs 778 (Pre BTM vs Post BTM) p=015 gt20mmg SBP drop Pre vs Post BTM
Mean MAP Change (mmHg) Pre BTM vs Post BTM
1st BP 254 vs 204 (p=005) -522 vs +312 (plt001) 2nd BP 474 vs 435 (p=023) -1589 vs -886 (plt001) 3rd BP 515 vs 435 (p=003) -1862 vs -958 (plt001) Post HD 408 vs 338 (p=003) -1164 vs -077 (plt001)
Following the introduction of blood temperature monitoring only 08 of HD sessions reported experiencing cold or shivering symptoms
Conclusion The use of blood temperature monitoring was not associated with a statistically significant decrease in rates of IDH There was a significant reduction in the number of sessions where SBP decrease by gt20mmHg at the first and third HD BP and a reduction in MAP change across the study group Further evaluation of BTM is required assess its clinical utility in our HD population
Funding No funding was sought for this study
Conflicts of interest None
A11 Evaluating patient satisfaction and clinical outcomes of a new nurse-led dermatology clinic for patients attending the renal transplant clinic Campbell G Naismith K Neil A Rankin A Spalding E (joint first authors) Renal Unit University Hospital Crosshouse Kilmarnock UK
BACKGROUND National Guidelines advise that renal transplant recipients should receive annual skin surveillance to screen for skin cancer In August 2015 a specialist nurse-led dermatology clinic was set-up alongside the renal transplant clinic at University Hospital Crosshouse We aimed to evaluate the success of this joint clinic in terms of clinical outcomes and patient satisfaction
METHODS Clinical records were reviewed to determine the number of patients under dermatology follow-up before and after initiation of the joint clinic and to review cases that were referred for treatment of pathological skin lesions A questionnaire was also distributed to patients attending the new joint renal-dermatology transplant clinic The questionnaire consisted of 5 questions 2 for patient demographics 1 for current understanding of skin care advice and 2 to assess their satisfaction of the new joint clinic
RESULTS A total of 138 and 146 renal transplant recipients were registered on renal transplant clinic lists in 2015 and 2016 respectively Prior to initiation of the new joint-clinic 41 patients had attended dermatology (37 in NHS Ayrshire and Arran and 4 in NHS Greater Glasgow and Clyde) consisting of 30 of the transplant population In September 2016 13 months after initiation of the new clinic 60 patients had attended the new clinic increasing the proportion of patients meeting the national recommendation for skin surveillance to 41 Implementation of the new clinic resulted in patients being 65 more likely to have received the recommended skin checks (odds ratio 165 95 CI 101-270 p=004)
32 patients completed the questionnaire The median age of transplant was 90 years (IQR 38-153) 100 of patients knew to avoid sun exposure and 31 (96) knew to use sunscreen 29 (91) patients were aware of the advice to undergo annual skin surveillance by dermatology with 28 (88) having had a skin check in the last year 29 (91) patients reported that they found the new joint clinic useful although only 18 (56) had attended the clinic so far
CONCLUSIONS Implementation of a new nurse-led dermatology clinic running in parallel with the renal transplant clinic resulted in a considerable increase in the proportion of patients meeting national recommendations for annual skin surveillance The vast majority of patients also found the combined clinic to be useful There is still considerable room for improvement in order to achieve the target of 100 compliance with skin surveillance and ongoing clinical audit is required to assess progress We believe this model would be easily implementable at other units with similar benefits expected
A12 Pneumocystis pneumonia prophylaxis post-renal transplant increased duration of co-trimoxazole is safe and effective FA Chapman JE Dickerson M Clancy C Daly C Geddes Renal amp Transplant Unit Queen Elizabeth University Hospital Glasgow
Introduction All renal transplant recipients receive Pneumocystis jirovecii prophylaxis usually with co-trimoxazole Guidelines suggest this should be continued for 3 to 6 months Our unit previously prescribed 3 months however following an outbreak of Pneumocystis pneumonia (PCP) infection this was increased to 6 months Given its constituents of sulfamethoxazole and trimethoprim co-trimoxazole prophylaxis may influence the frequency of urinary tract infection (UTI) We aimed to compare the frequency of UTI between patients on 3 months vs 6 months prophylaxis and assess rates of multi-drug resistant organisms We also sought to establish if the increased duration of co-trimoxazole was adversely affecting renal function potassium concentration white cell and platelet count and dosing of mycophenolate mofetil
Methods A retrospective search of the West of Scotland Electronic Renal Patient Record was conducted for all renal transplant recipients between 1st January 2012 and 31st May 2016 Patients were grouped according to the intended duration of co-trimoxazole Data were extracted for baseline characteristics co-trimoxazole prescription mycophenolate mofetil (MMF) prescription laboratory results (creatinine potassium white cell count platelets) at 3 6 9 and 12 months post-transplant and microbiology results for 6 months post-transplant Results were analysed on an intention to treat (ITT) basis with a second analysis according to actual duration of co-trimoxazole treatment (AT) Subjects with transplant failure had laboratory results censored from the time of transplant failure and all of their microbiology results were excluded
Results 609 renal transplants were performed over the study period On ITT analysis there were 418 patients in group 1 (ITT1 3 months co-trimoxazole) with 15 transplant failures and 191 patients in group 2 (ITT2 6 months co-trimoxazole) with 12 transplant failures There was a significant difference in the number of patients with at least one UTI with fewer in ITT2 (ITT1 133403 vs ITT2 42179 p = 001) However this was not present when comparing actual treatment duration (AT1 111345 vs AT2 36149 p=007) Overall there was a similar spectrum of organisms cultured There were significantly fewer cultures of multi-resistant organisms in both ITT and AT analyses with 6 months of co-trimoxazole (ITT1 28376 vs ITT2 0106 p= 0004 AT1 22313 vs AT2 198 p = 002) There was no difference in estimated Glomerular Filtration Rate serum potassium concentration platelet count or MMF dose On AT analysis there was a significant difference in the total white cell count (WCC) and lymphocyte count at 6 months post-transplant (WCC 78 x10^5L vs 71 x10^5L p =004 lymphocytes 13 x10^5L vs 12 x10^5L p=002) There were 18 cases of PCP with 7 deaths attributable All cases occurred after cessation of co-trimoxazole prophylaxis (81 ndash 913 days after stopping co-trimoxazole)
Conclusion Although there is a significant difference in UTI frequency on ITT analysis this is not present on AT analysis suggesting no real co-trimoxazole effect There was no increase in frequency of multi-drug resistant organisms with a longer course of co-trimoxazole Renal function and serum potassium were unaffected Our findings support continuing co-trimoxazole prophylaxis for at least 6 months
A13 Kidney transplantation in the over 60rsquos in Scotland 1996-2015 TJW Rennie1 P Phelan1 J Campbell2 JP Traynor2 L Henderson1 W Metcalfe2 On behalf of the Scottish Renal Registry 1Renal transplant unit Royal Infirmary Edinburgh 2NHS National Services Scotland Introduction The proportion of older kidney transplant recipients has increased in the UK but
long term outcome data are scarce We aimed to evaluate patient and graft survival in patients
ge60 years of age receiving a first kidney only transplant in the last 20 years in Scotland
Methods Retrospective analysis of Scottish Renal Registry data of incident Renal Replacement
Therapy (RRT) patients and those in receipt of a kidney only transplant performed 1996-2015
(follow up until 311216) Patients were stratified by age 60-69 ge70 (group 1 and 2 respectively)
and decade of transplantation 1996-2005 2006-2015 (decades 1 and 2 respectively)
Results 6743 patients aged ge60 started RRT from 1996-2016 Of those 108 were ever
transplant-listed 54 had received a transplant by 311216 26 listed and 11 transplanted
were aged ge70
535 patients aged ge60 received a kidney only transplant in 1996-2015 90 patients (168) were
aged ge70 no patients were aged ge80 Mean time from wait listing until transplantation was 33plusmn24
years (plusmnSD) and from starting RRT until transplantation was 38plusmn26 years (plusmnSD) One and five
year graft survival was 97 and 87 in decade 1 95 and 89 in decade 2 (p=NS) there was
no difference in graft survival between age groups 1 and 2 One and five year patient survival was
94 and 78 in age group 1 85 and 56 in group 2 (plt0001) there was no difference in one
and five year patient survival between the two decades
Conclusion One and five year graft and patient survival in renal transplant recipients aged ge60
have not changed significantly in the last 20 years Recipient age ge70 is not associated with
reduced graft survival but patient survival from time of transplant is lower in this age group
compared to recipients aged 60-69
No conflict of interest to be declared No funding received
A14 High Mortality In Older Patients With Primary Nephrotic Syndrome Sarah Beverstock Wendy Metcalfe amp Robert W Hunter Department of Renal Medicine Royal Infirmary of Edinburgh
Introduction
Nephrotic syndrome can develop at any age and may be due to a primary glomerular lesion or secondary to systemic disease The natural history of glomerular disease can be different in older patients For instance minimal change disease (MCD) in children almost always remits promptly with steroid therapy in adulthood it typically remits only after many weeks of steroids or with adjunctive immunosuppression However there are remarkably few published data on the mortality of primary nephrotic syndrome in adults We aimed to study this in our centre
Methods
We enrolled all adult patients who had a kidney biopsy in order to investigate nephrotic syndrome over 38 consecutive months (01 Jan 2014 ndash 28 Feb 2017) We defined nephrotic syndrome as heavy proteinuria (urinary proteincreatinine ratio UPCR gt350 mgmmol or albumincreatinine ratio gt220 mgmmol) and hypoalbuminaemia (serum albumin lt35 gL) In our analysis we included all patients in whom nephrotic syndrome was attributed to a primary glomerular disease We excluded kidney transplant recipients and patients in whom biopsies were performed to follow up a known glomerular disease We collected laboratory data at baseline (time of biopsy) and at 6 and 12 months We assessed patient survival by Kaplan-Meier analysis
Results
Of the 117 patients biopsied for nephrotic syndrome 71 patients (61 ) met the inclusion criteria and were followed up for a median of 469 days We compared outcomes in patients aged under 60 years old (n = 35) with those aged over 60 (n = 36) Mortality was higher in the older group (37 vs 4 mortality at one year p lt005 by logrank test) There were no significant differences between the two groups in serum creatinine or UPCR at any time Serum albumin was similar in both groups at baseline and at 12 months but was lower in the older group at 6 months (27 vs 32 gL p lt 005) Baseline haemoglobin was lower in the older group (114 vs 130 gL p lt005 by unpaired t-test) Primary diagnoses were MCD (n = 10 in younger group amp n = 5 in older group) membranous nephropathy (5 amp 10) IgA nephropathy (9 amp 8) FSGS (5 amp 5) membranoproliferative glomerulonephritis or C3GN (4 amp 7) and other (2 amp 1) Therefore unsurprisingly there were relatively fewer cases of MCD and more cases of membranous nephropathy in the older group otherwise the causative glomerular lesions were similar in both groups In those patients with MCD mortality was significantly higher in the older group none of the 10 patients with MCD diagnosed under 60 yrs old died during the follow-up period whereas 4 of the 5 older patients died 3 patients in the younger group and 1 in the older group were on renal replacement therapy (dialysis or transplant) by the end of follow-up
Conclusions
Primary nephrotic syndrome is associated with high mortality in the over 60s (37 at one year) Mortality was high even for MCD a disease that follows a benign course in childhood and early adulthood The higher mortality in older patients was not associated with greater severity of renal disease at presentation (as assessed by basic blood and urine parameters) This work was not funded we declare no conflicts of interest
A15 Renal biopsies in patients with diabetes mellitus in Scotland
Udana Ratnapala 1 Nicola Joss 2 Colin Geddes 3 Dana Kidder 1
1 Renal Unit Aberdeen Royal Infirmary Aberdeen 2 Renal Unit Raigmore Hospital Inverness 3 Glasgow Renal and Transplant Unit Glasgow
Introduction Diabetes mellitus is the leading cause of end-stage kidney disease (ESKD) requiring renal replacement therapy The utility of renal biopsy in patients with diabetes mellitus is controversial Broadly renal biopsy findings in patients with DM can be divided into diabetic nephropathy (DN) alone DN with non-diabetic renal disease (NDRD) or NDRD alone Timely identification of patients with NDRD is important to provide appropriate therapeutic measures Previously published guidelines on clinical predictors of NDRD have limited specificity and sensitivity The frequency of NDRD in renal biopsies of patients with DM is unclear in ScotlandThis study aimed at identifying the frequency and the pathology spectrum of NDRD in diabetic patients underwent kidney biopsy in 3 renal units
Methods A retrospective observational study was performed on clinical-pathologic findings in all patients with diabetes mellitus who underwent renal biopsy between 01012010 and 31122016 in 3 renal units (Aberdeen Inverness and Greater Glasgow) Data were gathered from electronic patient record systems Scottish Index of Multiple Deprivation (SIMD) 2012 was used to analyse correlation with patient outcomes
Results 247 patients were included 150 men (607) 217 type 2 DM (879) mean age 621 years and mean serum creatinine at the time of renal biopsy of 261 micromolL (+-190 std) On biopsy 92 patients (372) had DN while 127 (514) had NDRD and 28(114) had NDRD superimposed on DN The commonest NDRD aetiologies were IgA nephropathy (187) tubulointerstitial nephritis (168) and idiopathic membranous nephropathy (103) Predictors of NDRD were age (OR 1027 95 CI 1002-1052 p=003) duration of DM (OR 094 95 CI 0900-0987 p=001) and absence of AKI as indication for biopsy (OR 022 95 CI 0059-0826 p=0025) There was no significance difference in renal or patient survival in DN and NDRD Finally no significant correlation was depicted between SIMD quintiles and renal or patient survival in both groups
Conclusions The majority of renal biopsies carried out in patients with DM revealed a NDRD In this study age at the time of biopsy duration of DM and AKI were the main pointers towards NDRD Renal and patient survival were not significantly different between DN and NDRD groups
A16 The Impact of Withdrawal of Maintenance Immunosuppression and Graft Nephrectomy on HLA Sensitisation Ailish Nimmo1 Sophie McIntyre1 Lorna Henderson1 Richard Battle2
(1 Department of Renal Medicine Royal Infirmary of Edinburgh 2 Histocompatibility and Immunogenetics Royal Infirmary of Edinburgh)
Background The development of HLA antibodies towards a failing renal allograft is a barrier to re-transplantation We previously demonstrated an increase in HLA antibodies and calculated reaction frequency (cRF) following nephrectomy but results were confounded by immunosuppression changes occurring in close time proximity We examined the formation of HLA donor specific antibodies (DSA) in patients with failed grafts that remained in situ and compared results with patients undergoing graft nephrectomy to further assess the relative impact of nephrectomy and immunosuppression weaning on sensitisation and chance of transplant
Methods We carried out a single centre retrospective study of all patients with failed grafts in Lothian from 2005 to 2015 Samples were tested for DSA pre-immunosuppression (IS) wean post-IS wean and post-IS cessation Nephrectomy patients also had samples tested for DSA before and after nephrectomy Data on other sensitising events including blood transfusion and rejection were collected cRF was determined at each time point and entered into the ODT chance of transplant calculator with other demographics based on the average patient from the Edinburgh centre
Results 62 grafts failed over this time period Blood samples were available 41 patients (24 with nephrectomy 17 with failed graft left in situ) Patient demographics were similar between groups There was a higher rate of antibody mediated rejection in the nephrectomy group (46 vs 18) 76 of patients with nephrectomy group had received a blood transfusion The pattern of immunosuppression weaning was similar but median time from start of IS wean to cessation was longer in the nephrectomy group (350 vs 298 days) The changes in cRF and chance of transplant (COT) with immunosuppression weaning are shown in Table 1
Pre-IS Wean Post-IS Wean
Failed graft in situ (n=17)
Mean CRF COT at 5
years 15 62 38 59
Nephrectomy (n=24)
Mean cRF COT at 5
years 54 54 69 46
Post-IS Stop 55 53 89 42 Table 1 Mean cRF and Chance of Transplant (COT) at 5 years with IS alterations
Discussion A stepwise increase in cRF with reduced chance of transplant was observed in both groups as immunosuppression was withdrawn with a similar pattern of change irrespective of graft nephrectomy cRF was higher in the nephrectomy group despite a more gradual wean which may reflect a higher rate of antibody mediated rejection and increased number of patients receiving a blood transfusion The risks and benefits of stopping immunosuppression need to be carefully considered on an individual basis to maximise chance of future transplant
The authors have no conflicts of interest No funding was required for this study
A17 Obesity is not associated with progression to end stage renal disease in patients withbiopsy-proven glomerular diseases
Benjamin Elyan Jennifer S Lees Bruce Mackinnon Jonathan G Fox Colin C Geddes Emily PMcQuarrie
Glasgow Renal and Transplant Unit Queen Elizabeth University Hospital Glasgow
Introduction - Addressing risk factors for renal progression is a key aspect of managing chronic kidney disease (CKD) Body mass index (BMI) has been shown to impact on renal progression in unspecified CKD The aim of this study was to evaluate if there was an association between BMI and progression to renal endpoints in patients with biopsy-proven primary glomerular disease (GN)
Methods - We included all adult patients diagnosed with biopsy-proven primary GN (excluding minimal change nephropathy) in Greater Glasgow amp Clyde and Forth Valley between 01012000 and 31122015 Biochemical and anthropometric data were extracted from the electronic patient record at time of biopsy with follow-up data until 20062017 BMI was calculated from height and weight at time of biopsy and categorised into groups BMI le25 kgm2 (G1) gt25 to le30 kgm2 (G2) and gt30 kgm2 (G3 - obese) We assessed factors associated with reaching a combined renal endpoint of CKD5 or renal replacement therapy (RRT) with competing risk of death using the Fine and Gray subdistribution hazard model Analyses were conducted using cmprsk package for R statistical software package and SPSS version 24
Results - 560 patients with primary GN and available BMI data were included The average age was 532 years and 339 were female There were 132 patients in G1 210 in G2 and 207 patients in G3 Those in G2 and G3 were older (p=002) with slightly higher diastolic blood pressure (p=002) than those in G1 There was a greater proportion of focal segmental glomerulosclerosis in G3 but similar proportions of other GN diagnoses across groups There was no significant difference in baseline serum creatinine (sCr) (p=034) or log uPCR (p=045) between BMI groups On multivariate analysis age systolic blood pressure BMI or GN diagnosis were not predictive of renal outcome Higher baseline sCr (SHR 1003 per 1 umoll increase in sCr 1001-1004 plt0001) and log uPCR (SHR 130 per unit increase in log uPCR 95 CI 105-160 p=002) were associated with progression to the combined renal endpoint accounting for competing risk of death BMI was not associated with reaching combined renal endpoint on univariate analysis whether considered as a continuous variable (SHR=100 95 CI 098-102 p=096) or categorised by BMI group
Conclusion - Contrary to our expectations there was no association between BMI and progression to a combined renal endpoint of CKD5 or RRT in this cohort of patients with primary GN Efforts should be directed to managing other known risk factors for CKD progression
Sources of FundingConflicts of Interest - None
A18 Factors influencing long term renal function after living kidney donation
Matthew A Rutherford Norman J Galbraith Marc Clancy Colin C Geddes
Glasgow Renal and Transplant Unit Queen Elizabeth University Hospital Glasgow UK
Background Following live donor nephrectomy the remaining kidney undergoes an increase in filtration capacity known as compensatory hypertrophy Few cohorts with follow up of renal function beyond 5 years have been reported The impact on long term renal function of variability in donor factors such as age sex pre-donation blood pressure and glomerular filtration rate (GFR) is unknown Increasingly kidney donors have potential risk factors for future poor renal function such as hypertension older age and obesity The aim of this study was to analyse factors influencing long-term renal function in living kidney donors from our centre
Method Data were obtained from the electronic patient record Patients with a recorded procedure of lsquolive donor nephrectomyrsquo between 2005 and 2017 were identified GFR after donation (calcGFR) was calculated using the formula lsquocalcGFR = Pre-donation Isotope GFR x (Pre-donation Serum creatinine Serum Creatinine)rsquo which is accurate assuming muscle mass does not change Pre and post donation serum creatinines (two days two weeks three months and one to ten year) were recorded We analysed the influence of age sex pre-donation GFR and blood pressure on post donation GFR compensation
Results 355 live donor nephrectomies were performed between January 2005 and December 2016 The mean age was 469 (plusmn 116) years and 504 (n=179) were female Mean pre-donation isotope GFR was 937 plusmn 156 mlmin173m2 Median follow up was 2 years (IQR 1 to 6 years with range 2 weeks to 10 years) The calculated percentage of pre-donation GFR at 2 days 2 weeks 3 months 1 year 5 years and 10 years were 698 691 712 730 801 and 950 respectively (p lt 0001) Patients aged lt50 y had not only a higher calcGFR (858 plusmn 29 mlmin173m2 compared with 671 plusmn 28 mlmin173m2 p lt 0001) at 5 years following donation but achieved a higher degree of compensation than donors gt 50 y (836 plusmn 16 compared with 756 plusmn 19 (p = 0002) Patients with pre-donation hypertension achieved 774 plusmn 53 of pre-donation GFR compared with 804 plusmn 32 in normotensive patients (p = 0998) Females had equivalent degree of renal compensation achieving 819 plusmn 19 compared with 780 plusmn 16 in males (p = 0131) at 5 years following donation Patients with pre-donation GFR gt 100 mlmin173m2 achieved 844 plusmn 23 of pre-donation function by 5 years compared with 777 plusmn 14 in those with pre-donation GFR lt 100 mlmin173m2 (p = 001)
Conclusion Following live donor nephrectomy renal function has a nadir of 691 at 2 weeks Compensation in GFR occurs rapidly and appears to be maintained regardless of sex and pre-donation blood pressure Younger age and higher pre-donation GFR were associated with a greater degree of compensation
A19 The utility of high-sensitivity cardiac troponin to stratify cardiovascular risk in patients with renal impairment
Eve Miller-Hodges Atul Anand Anoop S V Shah Nicholas L Mills Neeraj Dhaun
Background Cardiovascular disease is the most common outcome of chronic kidney disease1
Declining glomerular filtration rate (GFR) and proteinuria predict increased cardiovascular risk over the long term2 However there are currently no methods to stratify cardiovascular risk in the short or medium term in patients with renal impairment We have already shown that high-sensitivity cardiac troponin I concentrations (hs-cTnI) lt5ngL in patients presenting with symptoms of acute coronary syndrome identifies those at low risk of cardiac events within 30 days and over the next year3 However uncertainty remains over the role of hs-cTnI testing in patients with renal impairment This study investigated whether hs-cTnI could also stratify future cardiovascular risk in patients with renal impairment
Methods In a prospective study of consecutive patients presenting with suspected acute coronary syndrome we evaluated the performance of hs-cTnI in patients with and without renal impairment (estimated glomerular filtration rate lt60mLmin173m2) using an early risk stratification threshold of 5ngL to ldquorule outrdquo acute myocardial infarction at presentation and within 30 days and sex-specific 99th centile diagnostic thresholds for index type 1 myocardial infarction Subsequent type 1 myocardial infarction and cardiac death were reported at one year
Results Of 4726 patients identified 904 (19) had renal impairment Index diagnosis of type 1 and type 2 myocardial infarction was almost twice as likely in patients with renal impairment (30 vs 15) Performance of the early risk stratification threshold of 5ngL to identify patients at low risk of major cardiac events was similar in patients with (NPV 984 95CI 960-997 sensitivity 989 95CI 975-999) and without renal impairment (NPV 997 95CI 994-999 sensitivity 984 95CI 972-994) These patients continued to remain at low risk over the next year The PPV and specificity at the 99th centile for diagnosis of myocardial infarction were lower in patients with renal impairment at 500 (95CI 452-548) and 709 (95CI 675-742) respectively compared to 624 (95CI 588-659) and 921 (95CI 912-930) At one year 24 of patients with renal impairment and troponin gt99th centile regardless of index diagnosis had experienced further myocardial infarction or cardiac death compared with 10 of patients without
Conclusion In suspected acute coronary syndrome hs-cTnI can stratify risk in patients with renal impairment Irrespective of diagnosis patients with renal impairment and elevated cardiac troponin concentrations had two-fold greater risk of a major cardiac event compared to those with normal renal function and should be considered for further investigation and treatment
Funders Wellcome Trust British Heart Foundation and Chest Heart amp Stroke Scotland
1 Gansevoort RT Lancet 2013
2 Chronic Kidney Disease Prognosis Consortium Lancet 2010
3 Shah AS Lancet 2015
A20 lsquoDOES IT DIALYSE OUTrsquo - THE EFFECT OF RENAL REPLACEMENT THERAPY ON THE BRAIN Mark Findlay Jesse Dawson David Dickie Deborah McGlynn Patrick Mark Institute of Cardiovascular and Medical Science University of Glasgow amp Queen Elizabeth University Hospital Glasgow
Introduction Cerebrovascular disease is common in end-stage renal disease (ESRD) on renal replacement therapy (RRT) We investigated the effect of RRT on cerebral structure and cognitive function over 12 months Methods Observational cohort study in ESRD patients receiving HD Prior cognitive impairment or cerebrovascular disease were exclusion criteria Multi-domain cognitive testing was performed at baseline and at follow-up Transcranial Doppler was used to assess intra-dialysis related alterations in mean flow velocity (MFV) ndash a marker of cerebral blood flow MR imaging was performed at 0 and 12 months We performed T1 T2 FLAIR and DWI sequences and used volumetric software to calculate white matter hyperintensity (WMH) burden markers of atrophy mean diffusivity and fractional anisotropy (FA) to describe structural changes at 1 year Results 97 patients median age 59 years 412 female At follow-up 15 patients were transplanted 6 died 4 withdrew and the remainder continued HD Those who were transplanted were younger (median age 51 vs 60 years p=0019) and had been on dialysis for a shorter period (median 06 vs 21 years p=0003) MFV declined during HD median 475cms to 405cms plt0001 and correlated with lower scores of executive and frontal lobe function during HD (Rho 045 p lt0001 and Rho -0313 p lt001 respectively) In all patients MR imaging demonstrated a significant decline in frontal parietal and temporal lobe volume at follow-up Median WMH volume increased in those who remained on HD but not in transplanted patients (median change 023 vs -012ml p=0018) WMH burden correlated with worsening scores of frontal lobe tests Rho 0585 p0005 and worse mood Rho -0485 p0026 FA improved following renal transplant (028 to 029 p=0016) and correlated with improved executive function testing at follow-up Rho 089 p0019 Conclusion Cerebral blood flow is reduced during haemodialysis and correlates with a reduction in intradialytic executive function There is an improvement in FA following transplantation WMH volume increases in those who remain on dialysis and the degree of increase correlates with executive and frontal lobe function This suggests that haemodialysis is associated with clinically significant changes in the brain and that these may be ameliorated by transplantation
Source of fundingconflicts MF is funded by a KRUK fellowship
A21 Pathological classification of IgA nephropathy to predict renal outcomes ndash is there a better way to score tubulointerstitial inflammation
Alastair Rankin David Kipgen Bruce Mackinnon Jonathan Fox Colin Geddes Emily McQuarrie Glasgow Renal and Transplant Unit On behalf of the Scottish Renal Biopsy Registry
Background The Oxford pathological classification of IgA nephropathy (IgAN MEST-C score) is limited by the fact that individual features of the score are not all predictive and its utility in assisting clinical decision-making is questioned The addition of tubulointerstitial inflammation to the existing scoring system is appealing but is not currently included due to reportedly wide inter-observer variability We report a novel method to score percentage of cortex containing tubulo-interstitial inflammation in non-atrophic renal cortex (ATIN) in patients with IgAN similar to that used in transplant biopsy reporting and assess its utility to predict clinical outcomes
Methods All adult patients with a native renal biopsy diagnosis of IgAN between 2010 and 2015 in a unit serving 15 million people were identified Baseline characteristics biopsy reports and outcome data were collected ATIN was calculated by subtracting the percentage of atrophic cortex from the percentage of total cortex with tubulo-interstitial inflammation withge10 representing significant tubulo-interstitial inflammation in non-atrophic cortex The primary outcome was a composite of requiring renal replacement therapy (RRT) or doubling of serum creatinine (sCr)
Results 153 new cases of IgAN were identified 33 were excluded (24 had lt8 glomeruli on biopsy 6 inadequate biopsy for MEST scoring and 3 on RRT at time of biopsy) In addition patients with a tubular atrophy (T) score of 2 were also excluded (n=9) Of the remaining 111 patients 76 (68) were male Mean age at biopsy was 52 years (+- 167) and 18 (16) had a co-existing clinical diagnosis of henoch-schonlein purpura (HSP) Median sCr was 156 micromoll (IQR 101-212) and 54 (49) had ATIN on biopsy During a median follow-up of 23 years 34 (31) reached the primary outcome 20 (18) received immunosuppression and 16 (14) died On univariate Cox regression survival analysis ATIN was associated with a four-fold increase in the primary outcome (HR 49 (21-113)) On multivariate analysis mesangial hypercellularity (M) T and ATIN independently predicted renal outcome while endocapillary proliferation (E) and segmental sclerosis (S) did not (plt002 for ATIN) Excluding patients with HSP or those who received immunosuppression did not change the result
Conclusion Within our centre ATIN predicts renal outcome for IgAN independently of established histological features Assessment of inter-observer reproducibility and validation in other cohorts is still required but these results suggest ATIN could be a worthwhile addition to current pathological scoring systems for IgAN
Source of funding none Conflicts of interest none
P1 Polypharmacy in Renal Replacement Therapy Patients
Jason McMinn Colin Geddes Glasgow Renal and Transplant Unit Queen Elizabeth University Hospital
Introduction
Prescribing is often led by evidence from studies containing participants with single health conditions and without multimorbidity Polypharmacy is becoming increasingly recognised in patients with multiple chronic health conditions Additional medications are more likely to result in diminishing returns in benefit with an increased risk of harm Patients with established renal failure (ERF) are likely to be susceptible to medication-related harm A high pill burden is also likely to contribute adversely to an already restricted quality of life and has been associated with poor medication adherence The aim of this study was to analyse polypharmacy in all patients with ERF attending our service
Methods
We extracted medication records for all prevalent ERF patients attending the Glasgow Renal and Transplant Unit from the West of Scotland Electronic Renal Patient Record (SERPR) as of 01012017 The records were analysed to calculate the number of regular medications and total pill burden of each patient These medications were categorised as being lsquopreventativersquo or lsquosymptomaticrsquo We also analysed the prescription of specific drug classes to examine the prevalence of these medications
Results
We identified 1091 transplant follow-up 529 hospital haemodialysis and 46 peritoneal dialysis patients who were on a mean of 94 13 and 129 different medications respectively Overall pill burden was 139 tablets a day in transplant follow-up patients 141 in haemodialysis patients and 162 in peritoneal dialysis patients There were similar rates of prescribing between the different dialysis units and clinics within our service
The proportions of medications deemed as preventative rather than symptomatic were 76 in transplant 69 in haemodialysis and 60 in peritoneal dialysis
In transplant patients decreasing renal function was associated with a higher pill burden but even patients with a transplant eGFR gt 60 were on a mean of 126 tablets per day including a mean of 14 antihypertensives
Rates of antidepressant prescribing were 15 in transplant patients and 20 in hospital haemodialysis patients 53 of haemodialysis patients were on a statin 39 on aspirin 61 on a proton pump inhibitor and 7 were on warfarin
Conclusion
Patients undergoing all forms of renal replacement therapy are likely to be on a considerable number of medications Whilst these drugs are inevitably prescribed for valid reasons this data demonstrates the need for clinicians to engage with patients to explore opportunities to reduce pill burden
Conflict of Interest None Sources of Funding None
P2 An audit of Acute Kidney Injury (AKI) on an acute stroke ward before and after plannedinterventions to review and maintain hydration
Clare Harris1 Simon Hart2 Fiona Duthie3 1 University of Edinburgh Medical School 2 Stroke Unit Royal Infirmary of Edinburgh 3 Renal Unit Royal Infirmary of Edinburgh
Background Dehydration is an important factor in the development of acute kidney injury which is associated with increased morbidity and mortality particularly in the elderly population Poor fluid intake is common post stroke (1) and dehydration is associated with poorer outcomes 3 months post stroke (2) In late 2014 there was no system of identifying patients with poor oral intake on the stroke ward at the Royal Infirmary of Edinburgh a hydration protocol and education programme were implemented aiming to improve fluid balance This included the use of prescribed water either orally or by nasogastric tube An audit pre and post intervention demonstrated that hydration as measured by ureacreatinine ratio significantly improved after the protocol introduction (3) We aimed to determine whether the incidence of AKI by KDIGO criteria was also reduced as this could have implications for reducing patient morbidity and mortality in this elderly comorbid patient cohort
Method 150 inpatients to the acute stroke ward during JulAug 2014 and JulAug 2015 were selected (n= 80 2014 n=70 2015) Patient data and creatinine values were collected from the electronic patient record and medical notes and retrospectively analysed Baseline creatinine values were calculated and cases of AKI were identified and staged using KDIGO criteria (4) Chi-Squared tests were performed to determine P values Individual patient notes were reviewed for both quantitative and qualitative data of patient management
Results Incidence of AKI (of any stage) was 263 pre-protocol and 200 post-protocol (P=03646) Incidence of AKI stages 23 was 100 pre-protocol and 715 post-protocol (P=05374) In hospital post stroke mortality was 338 pre-protocol and 1286 post protocol (P=00028) AKI was also associated with increased length of stay
Conclusions Despite a trend in benefit there was no significant difference in incidence of AKI pre and post hydration protocol nor in incidence of severe AKI (stage 23) AKI is influenced by many factors one of which is hydration status Further studies are needed to determine whether the trend of benefit exhibited in this sample is significant in a greater sample size if this were the case such a protocol could have great benefit to patient care on stroke units and elsewhere There was a significant difference in inpatient post stroke mortality following introduction of the hydration protocol Further investigations are needed to explain underlying reasons for this factors other than hydration may play an important role
References 1 Whelan K Inadequate fluid intakes in dysphagic acute stroke Clinical Nutrition (2001) 20(5)
423-428 2 Bhalla A Sankaralingam S Dundas R Swaminathan R Wolfe CDA Rudd AG The influence of
raised plasma osmolality on clinical outcome after acute stroke Stroke (2000) 312043ndash2048 3 Hart SR Craig R Berry E Lane N Gad A Farrugia M Burton L Paquay A What Happens to
Acute Stroke Patientsrsquo Fluid Balance Renal Status and Dehydration in the First Two Weeks How Can They Be Markedly Improved doi 101111ijs12634_13
4 KDIGO Clinical Practice Guideline for Acute Kidney InjuryKidney international supplements (2012) 2(1) 1-138
No funding or conflict of interest to declare
P3NHS Highland-Improving the management of hyperkalaemia using a kit Initial resultsCantley N1 Abedin T2 Lambie S3
1FY2 NHS Highland 2ST4 Renal Medicine NHS Grampian 3Renal Consultant Renal unitRaigmore Hospital Inverness
Introduction The incidence of hyperkalaemia in hospitalised in patients is between 1 and 10 Guidelines in Northern Ireland promote the use of a Hyperkalaemia Kit to improve management of hyperkalaemia We assessed the management of hyperkalaemia in Raigmore Hospital including post-treatment monitoring of serum potassium and blood glucose at baseline and after the introduction of a lsquoHyperkalaemia Kitrsquo which contains a pro forma for the management of hyperkalaemia and all the relevant equipment and drugs for treatment
Method Between July and September 2016 an automated algorithm identified 34 patients with a potassium result 65 mmoll or above on laboratory results 12 received no specific treatment of these 6 results were spurious 4 patients died before treatment could be started and 2 patients were chronic haemodialysis patients We introduced the Hyperkalaemia Kit to the Acute Medical Admissions Unit in Raigmore Hospital Since then 15 patients have been identified with serum potassium measurements above 65 and the pro forma and kit was used with eight of these patients One of these patients proceeded straight to acute renal replacement therapy
Results Prior to our intervention all 22 patients that were actively treated received at least one prescription of appropriate doses of Insulin with Dextrose However only 16 patients received intravenous calcium and only 7 received nebulised Salbutamol Potassium was measured at 4 hours in 5 cases and by 12 hours in 17 cases Monitoring of any capillary blood glucose was only documented in 8 cases Of the 22 treated 2 needed acute renal replacement therapy 3 required further doses of insulin and dextrose 2 were treated with Calcium Resonium
Eight cases of hyperkalaemia have been managed with the use of the kit and pro-forma so far An initial ECG was performed in all eight and four patients had continuous cardiac monitoring Intravenous calcium was given in seven and nebulised Salbutamol was given in five out of the eight cases Six out of eight patients had at least three blood sugar measurements One had two measurements documented and one patient was stopped from further monitoring following senior review and decision to palliate Seven patients had appropriate monitoring of their serum potassium by 4h and 12h again one patient was not monitored due to palliation
Conclusion Baseline results showed very low rates of prescription of nebulised Salbutamol low rates of Calcium Gluconate use and very low monitoring of blood sugars and potassium post treatment This has the potential for serious adverse outcomes particularly the potential for iatrogenic hypoglycaemia Our initial data shows the use of a Hyperkalaemia pro forma and kit improves the rate of prescription of intravenous calcium and nebulised Salbutamol and the post-treatment monitoring of serum potassium and blood sugar levels
P4Rituximab as maintenance therapy in ANCA associated vasculitisndash a single centre experience Rathnamalala NK Mcmenamin J Robertson S Almond A Kelly M Muniraju T M Renal Unit Dumfries and Galloway Royal Infirmary NHS Dumfries and Galloway Background The introduction of Cyclophosphamide and high dose steroids transformed ANCA associate vasculitis (AAV) from a disease of high mortality to a relapsing remitting disease Maintenance of remission however still remains a major challenge A two randomised clinical trials have looked at the use of Rituximab in remission induction in AAV and reported similar remission rates between Cyclophosphamide and Rituximab 12 Both these trials used Azathioprine as maintenance therapy and in the follow up showed similar remission rates with either agent for induction The role of Rituximab for maintenance therapy after cyclophosphamide induction was studied in the MAINRITSAN trial 3 Rituximab was compared with azathioprine and found that the relapse rate was significantly lower in the Rituximab group There have been several other retrospective studies that have suggested regular Rituximab infusions are successful in maintaining remission however has not been thoroughly evaluated 4 5678910 Here we share our centrersquos experience using Rituximab for maintenance of remission of AAV Materials and methods We conducted a retrospective review of electronic medical records of all patients who had received Rituximab as maintenance therapy for 12 months or longer between January 2014 to July 2016 Disease activity was assessed using Birmingham Vasculitis Activity Score ( BVAS) Version 3 and complete remission was defined as a score of 0 and partial remission as a score of lt50 of the value at diagnosis Due to uncertainties associated with sub classification we did not assign specific diagnosis but broadly classified as ANCA associated vasculitis Results 6 patients received Rituximab as maintenance therapy during the study period 3 (50) of them had eye ear nose and upper airway manifestations consistent with Granulomatosis with Polyangitis (GPA) All patients were PR3 ANCA positive except for one at initial diagnosis The mean BVAS score at the time of initiation of Rituximab was 4 All patients were initiated on Rituximab for relapses while on maintenance therapy with Azathioprine 4 patients received 6 monthly doses of Rituximab while two received annual doses All of them were also maintained on 5-10 mg of Prednisolone The mean BVAS score by 6 months was 0 and remained 0 at 12 months The mean PR3 titre was 562 at the initiation of treatment while at 12 months it had come down to 68 All patients remained in complete clinical remission at the end of 12 months after initiation of therapy Rituximab was well tolerated by all patients except one who developed pyrexia during an administration
Conclusions All patients had sustained remission at 6 months and 12 months after initiating Rituximab Rituximab has a potential role as maintenance therapy in AAV
P5 Chronic Myelo-Monocytic Leukaemia (CMML) as a contraindication to renal biopsy Alastair Rankin Emily McQuarrie Jennifer Lees Bruce MacKinnon Glasgow Renal and Transplant Unit On behalf of the Scottish Renal Biopsy Registry
Abstract Chronic Myelo-Monocytic Leukaemia (CMML) is a relatively rare mixed myelodysplastic myeloproliferative disorder that predominately affects patients over the age of 65 years Renal impairment in patients with CMML is well described with several different mechanisms reported including tumour infiltration lysozyme-induced injury amyloid deposition and tubulointerstitial nephritis From anecdotal evidence within our centre we are concerned that patients with CMML have an excessive risk of clinically significant bleeding following native renal biopsy This risk appears disproportionate to the degree of any co-existing thrombocytopenia or coagulopathy
We review the cases of 4 patients with an existing diagnosis of CMML who were referred to the renal clinic with proteinuria and excretory renal dysfunction Two of these patients underwent renal biopsy with subsequent major haemorrhage post-procedure despite normal bleeding parameters pre-procedure Patient 1 presented with flank pain 8 days post-biopsy A CT confirmed peri-nephric haematoma with retroperitoneal extension A total of 6 units of packed red cells (PRCs) were transfused prior to successful CT-guided emoblisation Histology from the biopsy revealed chronic tubulointerstitial nephritis Patient 2 experienced haemodynamic instability and haematuria one hour post-biopsy A total of 11 units of PRCs 7 units of fresh frozen plasma 2 pools of platelets intravenous tranexamic acid and 2 attempts at CT-guided embolization were required until haemostasis was achieved Histology later showed evidence of tumour infiltration with associated vasculitis Patient 3 presented with renal impairment and proteinuria on the background of known CMML Following discussion with haematology the risk of bleeding following renal biopsy was considered unjustifiable despite their platelets and coagulation screen being within normal range The patient was treated for presumed renal tumour infiltration with hydroxycarbamide Patient 4 was referred to the renal clinic with acute onset nephrotic syndrome Urinary proteincreatinine ratio was elevated over 800 mgmmol with serum albumin of 23 gL but normal excretory renal function The patient attends the haematology clinic with suspected CMML and chronic thrombocytopenia but previously declined bone marrow biopsy Following discussion with the patient there are no plans to proceed with renal biopsy given potential risks These cases highlight that while CMML is rare these patients are being referred to renal clinics with features that would commonly justify renal biopsy in other settings but in whom there may be an increased risk of bleeding post-procedure Our in-centre risk of major bleeding is 2 therefore to have such extreme amounts of bleeding in 2 patients with this underlying diagnosis is remarkable This creates a dilemma for the clinician as there is a wide range of potential renal pathology associated with CMML some of which will have disease specific but relatively toxic treatments available
Source of funding none Conflicts of interest none
P6 NHS Highland-Prograf to Adoport switch McCulloch K1 Peel R2 Lambie S3
1Renal Pharmacist Renal unit Raigmore Hospital Inverness 23Renal Consultant Renal unit Raigmore Hospital Inverness
Introduction NHS Highland (NHSH) is the first health board in Scotland to implement a switch from Prograf to Adoport for renal transplant patients This will provide considerable cost savings Adoport meets the bioequivalence criteria for drugs with a narrow therapeutic index set by the European Medicines agency and studies indicate therapeutic equivalence1 with the proviso that brands are non- interchangeable unless the switch is overseen by a Renal Consultant and post-conversion therapeutic drug monitoring is conducted23 The switch has been undertaken by a majority of transplant centres in England the main difference being that they have undergone repatriation NHSH Patients receive their transplant primarily at Royal Infirmary of Edinburgh and occasionally at Queen Elizabeth University Hospital Glasgow Care is transferred to NHS Highland on discharge NHS Highland cares for approximately 170 renal transplant patients 110 being prescribed Prograf These patients may live as far as 110 miles from Raigmore Hospital Given that prescribing is carried out by primary care clear communication with patients GPs and community pharmacy is essential to avoid inadvertent switching between brands
Method Clinically it was agreed a switch could be safely undertaken A business case was submitted and funding secured for pharmacist time laboratory costs and primary care time GPs have been informed via GP subgroup and local prescribing bulletin lsquoThe Pink Onersquo Community pharmacies are being informed by phone A protocol has been agreed Eligible patients selected by Renal Consultant and Renal Pharmacist Patients sent letter signed by Renal Consultant and Renal pharmacist Patients phoned prior to clinic to agree Adoport start date and address concerns Patient seen by Renal Consultant and pharmacist + given 1 month of Adoport Tacrolimus level and UampEs checked 5-7 days after commencing Adoport and patient
contacted by phone to check if tolerated If stable letter sent to GP and community pharmacy to continue supply
Results and Evaluation Letters have been sent to all eligible patients Seven patients have been reviewed One has received a one month supply of Adoport and 5 others are due to switch One patient was deemed non-eligible at present as they have a 6 month surplus of Prograf A database will be maintained and analysed at the end and primary care savings will be monitored Extra pharmacist input will give us the opportunity to review how immunosuppression is managed and to evaluate the benefit of having a renal transplant pharmacist Conclusion The switch is at an early stage Ultimately we hope to show that the switch from Prograf to Adoport can be managed safely with extra pharmacist input to a remote and rural population with prescribing being conducted by primary care
Fundingconflicts of interest none 1 McDevitt-Potter LM Sadaka B Tichy EM Rogers CC Gabardi S Transplantation 2011 A multicenter experience with
generic tacrolimus conversion 2 Medicines and Health Products Regulatory Agency Drug Safety Update 2012 Accessed online via
wwwmhragovukSafetyinformationDrugSafetyUpdateCON1557563 ESPRIT Guidance on management of repatriation and immunosuppressant switches in transplant patients 2015
Accessed online via httpwwwespritorgukwp-contentuploads201508Switch-guidance-document-final-Aug-31-2015pdf
P7 NHS Highland-Tacrolimus baseline dataMcCulloch K1 Peel R2 Lambie S3
1Renal Pharmacist Renal unit Raigmore Hospital Inverness 2Renal Consultant Renal unitRaigmore Hospital Inverness 3Renal Consultant Renal unit Raigmore Hospital Inverness
BackgroundAs part of planning a switch from using tacrolimus Prograf to Adoport we assessed baseline data for our transplant patients currently using Prograf After converting patients to Adoport we will compare their tacrolimus levels to their individual target range We assessed our use of appropriate target ranges and our current performance in achieving tacrolimus levels within target range on Prograf therapy
Method 107 renal transplant patients taking Prograf were identified a sample of 19 of these were analysed using electronic patient records and results Time from transplant ranged from 1 month to 18 years All tacrolimus levels for the preceding year were analysed and compared to the target range specified at the time of the level being done The assay used has a Coefficient of Variation of lt5 at the lower limit of the assay
Results All 19 patients had a target range for tacrolimus clearly identified and recorded in clinic letterswhich are routinely copied to the patients themselves A variety of target ranges were specifiedThe commonest used was 5-8 microgramsl in 7 patients followed by 5-7 in a further 4 patientswith another 6 different target ranges being used for the remaining 8 patients The ranges usedhad a breadth of 3 microgramsl in 2 cases the rest had a breadth of 2 microgramslPatients had a median of 12 (range 3-72) tacrolimus levels over the preceding year Results werewithin specified target ranges for 54 +- 22 (Medan +- SD) of results checked
Conclusion We currently use a large number of different target ranges The majority of the ranges used had a breadth of just 2 microgramsl These factors help to account for the low proportion of test results which were within the specified target ranges This is important to bear in mind when interpreting whether tacrolimus levels are within target ranges after switching to Adoport We should consider aligning our target ranges and widening them
P8 Eculizumab use in Scottish paediatric dense deposit disease Stewart D1 David Hughes1 Lynne Riach2 Craig Oxley2 Athavale D1
1Royal Hospital for Children Glasgow 2Royal Aberdeen Childrenrsquos Hospital Aberdeen
Introduction The revised MPGN classification and increasing recognition of Dense Deposit Disease (DDD) a C3 glomerulopathy as an alternative complement pathway disorder suggests Eculizumab an anti-C5 monoclonal antibody may be beneficial in treatment However the experience of Eculizumab as an off-label and expensive treatment in children with DDD is limited with variable clinical response reported in the literature
Method We present the outcomes of the only 2 paediatric patients in Scotland who have received Eculizumab for the management of DDD
Results Case 1 A 10 year old male presented with proteinuria and haematuria resistant to steroid treatment with preserved renal function Initial biopsy confirmed DDD Conservative management with an angiotensin converting enzyme inhibitor and diuretics for symptom control continued until 14 years Due to worsening symptoms (oedema lethargy poor growth) and renal function deterioration along with elevated terminal complement complex (TCC) Eculizumab was commenced A repeat biopsy whilst suggestive of chronic irreversible damage showed 25 glomerular architecture preservation Symptom improvement was noted There was a reduction in proteinuria and renal function stabilisation fall in TCC and discontinuation of diuretics Eculizumab was discontinued after 24 months Progression of renal function decline was seen in the final months of Eculizumab therapy With recurrence of symptoms and increasing proteinuria following discontinuation Eculizumab was recommenced after 6 months Symptomatic improvement has since been noted
Case 2 A 5 year old girl presented with painless frank haematuria and proteinuria Initial biopsy confirmed DDD Proteinuria was unresponsive to steroid therapy and 5 months following diagnosis she rapidly progressed towards end stage renal disease despite the introduction of Mycophenolate Mofetil and plasmapheresis Haemodialysis was subsequently commenced TCC level was elevated and Eculizumab treatment was started 7 months after diagnosis Renal biopsy prior to treatment demonstrated continued severe pathological changes in all visible glomeruli However due to lack of clinical response Eculizumab was discontinued after 2 months and the patient remained dialysis dependent
Conclusions Our experience with Eculizumab in Scotland has demonstrated variable results in our 2 patients with one patient showing a positive response whilst the other experienced no improvement Eculizumab was administered to both patients at varying points in their clinical journey with differing progressive features on biopsy To date the outcomes of 9 paediatric patients with DDD treated with Eculizumab have been described in the literature with 8 experiencing some positive response to treatment including 2 patients who were able to stop renal replacement therapy within 12 weeks of treatment A role for Eculizumab in DDD may be guided by clinical and pathological features Well designed clinical trials will be necessary to define the role of complement inhibition therapy in DDD
No conflict of interest and no funding requested
P9 Examining markers of safety in the use of non-tunnelled central venous catheters
James WT Millar (Speciality Registrar) Scott W Oliver (Speciality Registrar) Peter C Thomson (Consultant Nephrologist) Glasgow Renal and Transplant Unit Queen Elizabeth University Hospital Glasgow
Background Non-tunnelled central venous catheters (NTCVC) remain an essential means of vascular access for incident haemodialysis Associated morbidity is well recognised for example in the form of Staphylococcus aureus bloodstream infections (SAB)[1]
Previous quality improvement initiatives in our unit have sought to both improve traditional markers of quality (such as SAB) and to identify additional areas of clinical risk In 2014 Oliver et al [2] suggested several additional quality measures including peri-procedure haemoglobin drop the need for a further NTCVC during the same clinical episode and the NTCVC insertion site This study further evaluated NTCVC related clinical practice within our unit
Methods The potential markers of clinical quality identified in a previous project were examined using prospectively collected data stored in the electronic patient record Identified cases of SAB significant peri-procedure haemoglobin drop and multiple NTCVC insertion were investigated by case note review
Results Between March 2016 and March 2017 a total of 222 patients received 346 NTCVC 54 patients (243) had more than one NTCVC inserted in a 21-day period (range 2-5) When considering NTCVC insertion site there were 159 (459) femoral vein catheters and 183 (541) internal jugular vein catheters No pneumothoraces were reported
15 SABrsquos were reported during this period equating to 43 of all NTCVC 5 arose in patients with femoral NTCVC (333) and 10 from internal jugular catheters (667) Mean time from line insertion to positive blood culture was 86 days 15 (67) patients had a drop in haemoglobin of greater than 20mgdl with no other source of blood loss identified on review of clinical notes
Discussion These data demonstrate that NTCVC-associated SAB rates remain low and significantly below Scottish government audit standards [3] Of interest is the continued trend towards the use of femoral catheters at 45 of lines compared with 38 in 2014 [2] Although traditionally thought of as having a higher incidence of infectious complications our data has shown fewer bacteraemia events associated with femoral catheters compared with internal jugular Our data also demonstrates a significant rate of peri-procedure haemorrhage arising in up to 1 in 20 cases Together these findings present opportunities to development practice and improve patient safety
References
[1] Murray E Deighan C Geddes CC Thomson PC Reducing haemodialysis bacteraemia rates Scottish Renal Association Glasgow November 2013 [2] Oliver SW Thomson PC Jardine AG defining safe effective and patient-centred dialysis catheter placement Scottish Renal Association Edinburgh September 2014 [3] The Staphylococcus aureus bacteraemia quarterly report of cumulative data from all NHS Boards in Scotland Health Protection Scotland January 2015
Sources of funding none Conflicts of interest none
P10 Prescribing of tolvaptan-The NHS Highland experience Lambie S1 McCulloch K2 Garrod J3
1Renal Consultant Renal unit Raigmore Hospital Inverness 2Renal Pharmacist Renal unit Raigmore Hospital Inverness 3Renal Pharmacist Renal unit Raigmore Hospital Inverness
Introduction Tolvaptan is a vasopressin antagonist It was accepted for use in Scotland by SMC in Jan 2016 to slow the progression of cyst development and renal insufficiency of autosomal dominant polycystic kidney disease in adults with chronic kidney disease (CKD) stage 1 to 3 at initiation of treatment with evidence of rapidly progressing disease1 Adverse effects related to aquaresis may affect patientsrsquo ability to achieve the optimum therapeutic dose and the risk of hepatic toxicity necessitates regular LFT monitoring The geography of NHS Highland required the implementation of novel methods of managing these patients and as a result a MDT approach with an emphasis on pharmacist input was adopted Consultant role Patient selection on the basis of evidence of rapidly progressing kidney disease declining
eGFR large volume kidneys on ultrasound and evidence of complications of PKD Side effects and potential benefits discussed Potential medication interactions reviewed Jinarc risk management prescriber training
Pharmacist role Undertook Jinarc risk management pharmacist training Prepares accurate drug history and reviews for potential drug interactions Carries out patient counselling and supplies patient education material sick day rules card
and lsquogot to gorsquo card Supplies GP education leaflet Provides advice on selection of new drug therapies eg for gout Manages stock and coordinates supply to patients
Results Prescribing commenced May 2016 patients currently prescribed tolvaptan 11 7 Female 4 male Number on target dose 73 n = 811 2 patients are still being titrated One patient did
not tolerate target dose due to aquaresis side effects and is being trialled on the middle dose
Withdrawals One patient has withdrawn due to agoraphobia and an inability to attend for monitoring and another is on hold due to having major surgery
Conclusion The MDT approach between the Renal Consultant and Pharmacist at Raigmore Hospital has enabled tolvaptan prescribing to be efficiently and safely implemented to patients living within a challenging geographical location
1 Scottish Medicines Consortium Detailed Advice Document tolvaptan 15mg 30mg 45mg 60mg and 90mg tablets (Jinarcreg) SMC No 111415 January 2016
NA1 Authors SCN Jacqueline Ross NHS Grampian
SCN Alan Somerville NHS Lanarkshire SCN Jane Humphrey NHS Lanarkshire
e- mail contact jacquelinerossnhsnet Alansommervillelanarkshirescotnhsuk
Janehumphreylanarkshirescotnhsuk
Phone contact 01224 552927 01236 712644
Title Sharing of Adverse Events in Renal Units across Scotland
Introduction Background The Scottish Renal Nurses Strategy Group (SRNSG) are a group of senior nurses from Renal
Units across Scotland who meet 3-4 times per year to discuss and implement best practice At the last meeting it was agreed that it would be good practice for each Health Board to share
their adverse events reported on the Datix System and deliver a presentation with an action plan to prevent incidents and improve patient safety across Scotland NHS Grampian and NHS Lanarkshire will be the first to deliver this presentation discussing adverse events from both Health Boards with an action plan
Top 5 adverse events over the past 12 months Renal Unit NHS Grampian 1 Violence and Aggression 2 Accidents including needlesticks slips trips and falls 3 Medication Errors 4 Infrastructure Staffing and Estates 5 Machines and Equipment
Top 5 adverse events over past 12 months Renal Unit NHS Lanarkshire
1 Slips Trips or Falls 2 Medicine errors 3 Treatment problems 4 Transfer problems 5 Breach of policy
The presentation will also focus on any serious adverse events which may not be in the top 5 categories
Aim Objective Each Health Board to share their adverse events with the aim to prevent them from occurring in other units to improve staff and patient safety and wellbeing across Scotland
Method Power Point Presentation
Outcome Results Sharing of adverse events resulting in the development of a national Action Plan to prevent these incidents improving safety and well being of staff and patients in Renal Units across Scotland
NA2
SRA Oct 2017 Abstract
BBV Never Event - The whats whys and hows
Staff Nurse Gillian Wilson Aberdeen Royal Infirmary
This presentation shares our experience of a never event that occurred and was not picked up for
a period of 18 months
Hepatitis C (HCV) positive antibodies were found in a previously negative patient
These results were a low positive with no biochemistry changes to suggest any liver damage
however steps were put immediately in place to isolate and investigate
Was it contamination from a dialysis machine was it related to a blood transfusion given prior to
first positive result was it faulty diagnostic tests in the laboratory
In Aberdeen we go over and above national guidelines and isolate all our BBV patients whether
they have positive blood results or are PCR negative
Further bloods tested at an external laboratory confirmed negative results
It highlighted that communication errors were to blame for the lack of speed in detecting this issue
Investigations concluded no real answers as to why this happened
NA3
Living Donation Scotland Changing attitudes towards living donor kidney transplantation
Jen Lumsdaine Julie Glen On behalf of the Living Donation Scotland Project Board
Background and aims
The rate of living donor transplantation has remained fairly static in Scotland over the past 10 years
Recent data has shown inequity of access to living donor transplantation throughout the UK so
there is potential to significantly increase this optimum form of treatment for patients with end-stage
renal failure in Scotland The Living Donation Project Board was formed in 2016 aiming to double
the number of living donor transplants by 2020
Method
The two key areas
1 Do recipients receive adequate and appropriate information at the right time about living
kidney donation
2 Informing the general public about altruistic donation
All patients active on the transplant list in Scotland were invited to an information event A follow-up
questionnaire was performed in the East of Scotland examining outcome or reasons for not
attending A scoping exercise looked at information provided by each unit was performed and link
nephrologists and low clearance nurses attended meeting to discuss strategies for early education
Outcome
An information pack containing both recipient and donor written information and short films on DVD
has been produced with the support of the Scottish Government for all recipients and potential
donors in Scotland A new website with comprehensive information both written and visual and
postcode finder to improve ease of access to local unit contact details has been developed
Two national media campaigns have been launched with a significant rise in the number of enquiries
from potential donors and actual increase in altruistic donor numbers
Nursing abstract ndash no conflict of interest
NA4Authors Susan Easson Charge Nurse Ward 4C QEUH Glasgow
e- mail contact SusanEassonggcscotnhsuk
Phone contact 0141 452 3300
Title A Conversational approach to find out ldquoWhat matters to yourdquo in a Renal Transplant ward
Introduction Background Finding out ldquo What Mattersrdquo to people using health and careservices is crucial to delivering safe effective and person centred care It is a simple yet profoundconcept and tries to get to the essence of person centred care by creating deeply personalengagements with patients and their families through a conversational approach However careexperience feedback all too often provides innumerable examples of where what really matters topatients and their family members is poorly understood or not addressed Using care experienceas the driver for change the nursing staff in Ward 4C used improvement approaches to explorehow to hold more meaningful ldquoWhat Matters to yourdquo conversations on a daily basis
Aim Objective To improve the patient experience by utilising a person centred approach
Method Using Care experience feedback What Matters to Me boards and the conversationalapproach
Outcome Results Improvements in patient experience will be shared using examples ofpractice and care experience feedback
There was no additional funding required for this project We worked in collaboration with theperson centred team whorsquos aim is to improve patient experience
NA5
The implementation of a renal education programme and its impact on clinical practice
The purpose was to implement a Renal Education Programme and to evaluate its impact on
clinical practise
It was identified that there was a need for an educational programme to be set up within Forth
Valley Royal Hospital There is no inpatient renal unit in FVRH on site for our renal patients they
attend Queen Elizabeth University Hospital We are an outpatient haemodialysis unit with
outpatient clinics on site Therefore it was identified that there was a need for nursing staff within
FVRH to be educated on all renal complexities for the benefit of our patients
This was done through a work-based learning approach which brought tangible benefits for our
patients However it did not come without pitfalls as educational programmes are often seen as
making very little difference to clinical practise
T
his study describes what methods were used and examines the advantages and disadvantages in
setting up an educational programme and evaluating its impact on clinical practise
NA6
Nursing Abstract ndash SRA Meeting ndash 26 October 2017
Chris McGee Tonya Broe Ken Weir
Renal Unit Forth Valley Royal Hospital
Use of the Therapy Monitor Haemodialysis Patient Record System Can we aim for a paper-
free dialysis unit
We are trialling a new haemodialysis patient monitoring system to work in conjunction with SERPR
and which is intended to supersede the Finesse system used previously
We are in the early stages of this process but with continuing staff education and regular tech
support we are hoping to gather sufficient evidence to evaluate whether the use of paper case
notes needs to continue
Is it a realistic goal to aim for a completely paper-free unit
NA7
THE CLINICAL USES OF APHERESIS WITHIN NHS TAYSIDE
Laura Thomson CN
Ninewells Hospital Dundee
NHS Tayside took over the apheresis service from BTS in 2012 The service has since expanded
with the benefits of carrying out this treatment has been widely recognised within NHS Tayside
and is now more commonly being offered to treat a wider range of conditions with the number of
treatments carried out each year rising
This presentation will highlight the progression of the apheresis service within NHS Tayside We
will identify the various conditions it is currently being used to treat and also identify the decision
making process involved in carrying out these treatments ie which replacement fluid will be used
anticoagulation medication administered
We will highlight the benefits and challenges we face in providing this expanding service within the
Renal Service
NA8Authors Linda McDougall Renal Physiotherapist NHS Highland
e- mail contact lindamcdougall1nhsnet
Phone contact 01463 706022
Title lsquoExercise on Haemodialysis- Keeping the Wheels in Motionrsquo
Introduction Background The impact of CKD on physical fitness functional ability independence amp ultimately quality of life cannot be underestimated Current national guidelines recommend that all individuals with CKD are encouraged to participate in regular exercise programmes between or during dialysis sessions if on HD Following a successful pilot study funding was approved to establish an lsquoExercise on Dialysisrsquo (EOD) programme across NHS Highland through the appointment of a dedicated renal physiotherapist in 2008 A successful programme was soon established but for several years post-vacancies and increasing in-patient demands limited the physiotherapy servicersquos ability to deliver the programme The need to improve the long-term sustainability of the service was recognised and in late 2016 funding was approved to develop a Band 4 PT HCSW role for this purpose
Aim ObjectiveTo optimise the sustainability and continuity of the lsquoExercise on Dialysisrsquo service across NHSHighland through development of a Band 4 PT HCSW role
Method The potential parameters of the role and limits of autonomy were scoped out using current NES resources and guidelines Service and task analysis was then carried out to establish which components of the EOD protocol could be undertaken by a Band 4 A series of competencies were developed in line with the clinical protocol and one-to-one training and supervision provided to the post-holder to ensure competency achieved in delivering the programme
Outcome Results A 10 WTE Band 4 PT HCSW was appointed in Jan 2017 with a dual role between the renal unit and acute medical wards Although training is not yet complete the post-holder is already running the day-to-day delivery and monthly audit of the EOD service with senior physiotherapist input only required for individual patient safety queries and general discussion around patientsrsquo progress and goals The benefit to the unit has been considerable as the band 4 is available to support patients and staff with EOD provision 5 days a week This allows for one-to-one supervision of patients who need more support to participate in EOD regular feedback on performance and reviews of outcome measures and goals to maintain motivation levels Feedback on the post has been very positive and its scope will only continue to expand as we look to further develop renal rehabilitation services across NHS Highland
NA9Authors Nadine Lyall and Kerry Guthrie
e- mail contact nadinelyallbordersscotnhsuk kerryguthriebordersscotnhsuk
Phone contact 01896 826637
Title The Developing Role of the NMP in a Satellite Dialysis Unit
Introduction Background
We have been practising as NMPrsquos for nearly 3 years working in the dialysis unit at the BGH The unit is a satellite unit of the ERI and we have expanded over the last 6 years The unit provides haemodialysis for 12 patients at any one time 3 sessions a day 6 days a week We are nurse-led and have 2 renal consultants who are based at the ERI
We saw an opportunity to use our knowledge and experience to develop our role By becoming NMPrsquos we have enhanced our professional development and we feel we meet the changing needs of the dialysis patient in a more holistic manner
Aim Objective
Our aim is to deliver effective care as we are better placed to deal with issues that often arise byacting swiftly this in turn is cost effective and convenient For example good anaemia and bonemanagement is important for their health wellbeing and lifespanTo help understand our role we will use a power point presentation highlighting issues we dealwith and the drugs we prescribe under the following headings Cardiovascular infection painanticoagulant disequilibrium diet renal bone disease and renal anaemia
Method Power point
Outcome Results
In the future we hope to further develop and have greater autonomy in our role We have great support from our renal consultants and have already built up a great relationship with our patients We hope to undertake the Clinical Decision Making course and this in turn will allow us to deal effectively with acute illness giving the dialysis patient better care We are keen to get feedback from other renal nurses in Scotland to enable us to develop our role further and in turn raise awareness of the NMP role in a dialysis unit We record all our prescribing decisions and keep the consultants up to date regularly Currently we are working on auditing our prescribing practice so that we can improve the service we can provide
NA10 Title Komunikacja w szkoleniu dializy ortzewnowej
Author Senior Charge Nurse Rhoda Bell
Address Raigmore Hospital Old Perth Road Inverness IV2 3UJ
Email rhodabellnhsnet Telephone 01463706023
Introduction Background Case study on lady with Polish as her first language she has some English but requires an interpreter to carry out Peritoneal Dialysis training and attend clinic She had some gynaecological issues that we were not aware of which impacted on the functionality of PD and therefore the success of treatment There were areas of concern in low clearance clinic with signs the patient had a reluctance to engage in decision making
AimObjective
Methods Discussion through the case study highlighted issues with communication between different PD staff and patients Areas of concern include different staffing techniques environment factors on training success Also language and communication issues the patient had were not fully apparent so training could not be individualised
Results We plan to trial training at home and have more individualised training schedule for patients The training step by step guides have been reviewed and practise standardised In collaboration with low clearance nurse we have developed a check list which will highlight concerns before the transition to PD ie language issues and need for training aids in another language gynaecological conditions
Conclusions Everyone learns differently and training methodsaids must be individualised for all It may not be apparent until training has commenced that there are concerns Having one to one training with the same nurse will consolidate training and build confidence in the patient Having a close working relationship with members of the MDT will help make a supportive PD journey
Would we do things differently if we knew about prolapse or lack of English both spoken and written
Key words - Peritoneal dialysis patient training communication
N11
Telehealth amp PDAudrey Jones
Advantages
Information on a daily basis about treatment weight and blood pressure
Change programme remotely via computer or mobile
Earlier intervention for machineprogramme issues
Reduction in home visits ie patient trained but still requires volume increases
No need to download cards to see what problems have been
Can have more detailed information available at clinics
Disadvantages
Relying on patient input data correctly
Machine is noisy especially first wave of machine
Still the same bag connection system and patient connection system (difficult for manual
dexterity problems)
Relying on patient having good signal
Modem problems
NA12Autosomal Dominant Polycystic Kidney Disease A cruel inheritance but new hopeAlistair Lawrie Renal Unit Victoria Hospital KirkcaldySadaf Arshad Corry Dunnigan Paul Phelan Neil Turner Renal Unit Royal Infirmary of Edinburgh
Background Autosomal Dominant Polycystic Kidney Disease (ADPKD) is the most prevalent single gene human genetic disorder and the most common of the inherited cystic and interstitial kidney diseases It is estimated to affect 1 in every 1000 individuals worldwide with over 50 of sufferers eventually developing end stage kidney disease and requiring dialysis or transplantation Symptoms include spasmodic severe pain hypertension haematuria infection and kidney failure There is currently no cure for ADPKD Management of the condition has traditionally involved lifestyle modification BP control and analgesia however a recent study (Torres et al 2012) demonstrated that treatment with V2-receptor antagonist drugs slowed increase in total kidney volume reduced the rate of functional decline and showed a reduced incidence of kidney pain
Aim Provision of a tolvaptan prescribing and monitoring service
Methods Experiential finding report of initial twelve months period of multidisciplinary ADPKDtolvaptan clinic
Results Early results are comparable with TEMPO study outcomes
Conclusion Due to the long term nature of this treatment results available at this time are showing only the earliest benefits of the intervention More quantifiable results such as increased time before the necessity for RRT will only be evident in coming years Torres VE et al (2012) Tolvaptan in Patients with Autosomal Dominant Polycystic Kidney Disease New England Journal of Medicine 367 pp 2407-2418 DOI 101056NEJMoa1205311
No funding requirement No conflict of interest
A7 The Role of the Renal Supportive Care Service in Advanced Care Planning JM Sloan CA Douglas S Cathcart L Frame L Stage M Witham ME Lafferty
Renal Service Ninewells Hospital Dundee
Background In 2007 we established a Renal Supportive Care Service for patients with advanced chronic kidney disease who choose not to receive dialysis The service which includes a fortnightly Renal Supportive Care clinic is provided by a Consultant Nephrologist a Consultant Palliative Care Physician and a Renal Supportive Care Specialist nurse The focus of the service is on ongoing management of chronic kidney disease symptom control and improving quality of life while planning for end of life care
Methods We have undertaken a retrospective audit of our Renal Supportive Care Service on all patients known to the Renal Service for whom a conservative care management decision had been made We collected data over a 31-month period from April 2012 until October 2014 We collected data on demographics co-morbidities clinic attendance renal supportive care input anticipatory care planning performance status and mortality data
Results Of the 98 patients for conservative management 62 (6198) were female with a mean age of 837 years During the 31-month period there were 507 documented supportive care consultations with 36 (3598) of patients receiving domiciliary visits from the Renal Supportive care nurse Anticipatory Care Plans (ACP) were in place for 62 (61) of patients with a preferred place of death known for 56 (5598) 65 patients had a documented discussion about their DNACPR status which was communicated in writing to primary care For a further 13 it was not clear whether the discussion had taken place During the study period 61(62) patients died Of those patients with an ACP 29 (1138) died in an acute hospital versus 43 (1023) of those without (p=025) Similarly 24 (834) of patients with a documented preferred place of death died in an acute hospital versus 48 (1327) of those without (p=004)
Conclusions The role of the Renal Supportive Care team is invaluable in providing care and support to patients who have chosen conservative management By discussing and planning for end of life care the Renal Supportive Care team play a role in reducing the number of patients dying within an acute setting
Conflicts None
Funding The Renal Supportive Care Nurse post and one Palliative Care Consultant Programmed activity received 3 years of funding by British Kidney Patients Association
A8 Predictors of transplant failure in patients undergoing indication renal biopsy
Kate Stevens 1 Bruce Mackinnon1 David Kipgen1 Shana Coley1 Marc Clancy1 Colin Geddes1
1Renal and Transplant Unit QEUH NHS GGampC Glasgow United Kingdom
Introduction This study considers indication renal biopsies and factors which may be important
predictors of transplant loss and patient death
Objectives To identify the time line of histological diagnosis from transplant in our population
and to identify predictors of graft and patient survival in those undergoing indication renal biopsy
Methods All indication renal biopsies undertaken between 012011 and 122015 were identified
Demographic data including immunological and outcome data was recorded Statistical analysis
was undertaken in SPSS (v22)
Results 354 patients underwent 549 biopsies Mean patient and transplant age at time of biopsy
was 432 plusmn153 and 42plusmn58 years respectively 449 (n=247) of biopsies showed evidence of
Cell mediated rejection (CMR)ABMR or both 93 (n=51) demonstrated features of chronic
transplant glomerulopathy (CTG) DSA was present at the time of biopsy in 231 (n=127) In
transplants aged le 6 months old histological diagnosis was CMR in 325 (n=69) with ABMR seen
in 28 (n=6) In transplants aged ge10 years CTG was seen in 325 (n=26) with ABMR
accounting for 63 (n=5) 229 (n= 81) of transplants failed at a median of 182 days from most
recent biopsy On cox regression analysis peritubular capillary (PTC) C4d and CTG were
independent predictors of transplant failure Probability of transplant failure was 45 and 50 at
one year if mixed rejection or CTG were present 93 (n=33) patients died at a median of 227
days from most recent biopsy Independent predictors of death included deceased donor
transplant patient age and presence of ABMR on biopsy (plt005)
Conclusion Acute ABMR is a risk factor for patient loss whilst chronic ABMR is a risk factor for
transplant loss This association is independent of DSA but dependent upon PTC C4d staining
indicative of donor humoral activity ndash HLA or otherwise Histological diagnosis in an indication
biopsy is an important factor in predicting outcome This study is limited by the inherent bias in
patient selection with indication biopsy
Disclosure of Interest None Declared
A9 Renal Evaluation of Paediatric Patients with Tuberous Sclerosis Complex (TSC) in aNational TSC Multidisciplinary ClinicDr Jenny Patterson 1 Dr Shelagh Joss 1 Dr Ihab Shaheen 2
1 Clinical Genetics Queen Elizabeth University Hospital Glasgow 2 Paediatric Nephrology Royal Hospital for Sick Children Glasgow
Introduction Tuberous sclerosis complex (TSC) is a dominantly inherited multisystem disorder characterised by development of hamartomas (benign lesions) in multiple organs Previous studies have shown that renal manifestations are common in TSC and also the most frequent cause of TSC-related death in affected individuals With the recent discovery of targeted therapy with mTOR inhibitors early recognition of renal involvement allowing early surveillance and prompt therapy is now more important than ever
AimMethod To review a population of paediatric patients attending a large specialist TSC service in the UK both in terms of key clinical characteristics and current practice for renal radiological surveillance data were collected from electronic medical records pertaining to molecular diagnosis renal surveillance and presence or otherwise of sequelae affecting the renal or other systems Practice was compared to published surveillance recommendations of the International Tuberous Sclerosis Complex Consensus Group (2013)
Results Data were obtained for 41 children (18 males 23 females) Current age range 25 years to 14 years (mean 98 years) Twenty nine patients (707) were diagnosed lt1 year of age Genetic data were available for 29 patients Fifteen patients had a confirmed TSC1 mutation and 14 patients a confirmed TSC2 mutation including one contiguous PKD1 mutation Renal imaging (all US) within a year of diagnosis was documented in 2541(61) performed at a mean age of 3 years Renal symptoms at diagnosis were documented in 741(171) and 941(22) had renal abnormalities on baseline imaging There was wide variability in scanning interval and modality with 1041(243) having previous abdominal MRI with variable documented indication Seventeen (414) of the cohort mean age 102 years had documented renal lesions 917 angiomyolipomas 517 cysts and 317 both These lesions were diagnosed at a mean age of 6 years (range 02 years-142 years) Six patients (353) had normal baseline scans with a mean interval to lesion diagnosis of 1 year One patient had a lesion on MRI not detected on US that required subsequent biopsy Frequency of subsequent scanning ranged from intervals of 2 months to 1 year with a combination of MRIUS in an unclear pattern All patients except one with a contraindication were undergoing current brain surveillance by MRI
Conclusions Our results highlight the significant incidence of renal sequelae within our TSC cohort with renal manifestations ranging both in severity and age of onset International guidelines recommend MRI scanning for renal surveillance at diagnosis and throughout life Benefits of MRI include enhanced accuracy of sizing and characterisation of renal lesions The majority of our cohorts are already undergoing brain MRI surveillance It is our aim to combine and standardise MRI renal surveillance for this cohort to facilitate early and regular monitoring with a view to early intervention is possible
A10 Effect of blood temperature monitoring on intradialytic hypotension in patients with end stage renal disease requiring haemodialysis Heather Walker1 Susan McGeorge1 Drew Henderson2
1 Renal Unit Ninewells Hospital Dundee2 Regional Renal Centre Waikato Hospital Hamilton New Zealand
Background KDIGO define intradialytic hypotension (IDH) as a reduction in systolic bloodpressure (SBP) ge20mmHg or mean arterial pressure (MAP) ge 10mmHg with associatedsymptoms IDH is a common complication of haemodialysis (HD) and is associated with increasedmortality and morbidityStandard dialysis with a set temperature leads to thermal gain during the dialysis session Tocounteract this thermal gain vasodilation occurs and is postulated as one of the causes of IDHActive cooling of dialysis has been shown to reduce IDH but is not routinely applied across wholedialysis populations Isothermic dialysis can be achieved by controlling blood temperature on HDWe report here our experience of doing this using the Blood Temperature Monitoring (BTM)function on Fresenius 5008 dialysis machines
Methods An observational study was performed to assess the rates of IDH in patients with End Stage Kindey Disease (ESKD) undergoing regular satellite HD at NHS Tayside in July 2017 Rates of IDH were assessed (KDIGO definition) for two weeks prior to BTM settings being activated and for a two week study period after introduction SBP and MAP data was collected SBP data was grouped to either SBP decrease lt20mmHg or SBP decrease ge20mmHg compared with Pre HD BP Changes in MAP were also analysed at the same time points Patient reported symptoms related to initiation of BTM were also collected for the same time period
Results 402 dialysis sessions were evaluated in the pre intervention time period and 399 sessions post intervention
IDH 1072 vs 778 (Pre BTM vs Post BTM) p=015 gt20mmg SBP drop Pre vs Post BTM
Mean MAP Change (mmHg) Pre BTM vs Post BTM
1st BP 254 vs 204 (p=005) -522 vs +312 (plt001) 2nd BP 474 vs 435 (p=023) -1589 vs -886 (plt001) 3rd BP 515 vs 435 (p=003) -1862 vs -958 (plt001) Post HD 408 vs 338 (p=003) -1164 vs -077 (plt001)
Following the introduction of blood temperature monitoring only 08 of HD sessions reported experiencing cold or shivering symptoms
Conclusion The use of blood temperature monitoring was not associated with a statistically significant decrease in rates of IDH There was a significant reduction in the number of sessions where SBP decrease by gt20mmHg at the first and third HD BP and a reduction in MAP change across the study group Further evaluation of BTM is required assess its clinical utility in our HD population
Funding No funding was sought for this study
Conflicts of interest None
A11 Evaluating patient satisfaction and clinical outcomes of a new nurse-led dermatology clinic for patients attending the renal transplant clinic Campbell G Naismith K Neil A Rankin A Spalding E (joint first authors) Renal Unit University Hospital Crosshouse Kilmarnock UK
BACKGROUND National Guidelines advise that renal transplant recipients should receive annual skin surveillance to screen for skin cancer In August 2015 a specialist nurse-led dermatology clinic was set-up alongside the renal transplant clinic at University Hospital Crosshouse We aimed to evaluate the success of this joint clinic in terms of clinical outcomes and patient satisfaction
METHODS Clinical records were reviewed to determine the number of patients under dermatology follow-up before and after initiation of the joint clinic and to review cases that were referred for treatment of pathological skin lesions A questionnaire was also distributed to patients attending the new joint renal-dermatology transplant clinic The questionnaire consisted of 5 questions 2 for patient demographics 1 for current understanding of skin care advice and 2 to assess their satisfaction of the new joint clinic
RESULTS A total of 138 and 146 renal transplant recipients were registered on renal transplant clinic lists in 2015 and 2016 respectively Prior to initiation of the new joint-clinic 41 patients had attended dermatology (37 in NHS Ayrshire and Arran and 4 in NHS Greater Glasgow and Clyde) consisting of 30 of the transplant population In September 2016 13 months after initiation of the new clinic 60 patients had attended the new clinic increasing the proportion of patients meeting the national recommendation for skin surveillance to 41 Implementation of the new clinic resulted in patients being 65 more likely to have received the recommended skin checks (odds ratio 165 95 CI 101-270 p=004)
32 patients completed the questionnaire The median age of transplant was 90 years (IQR 38-153) 100 of patients knew to avoid sun exposure and 31 (96) knew to use sunscreen 29 (91) patients were aware of the advice to undergo annual skin surveillance by dermatology with 28 (88) having had a skin check in the last year 29 (91) patients reported that they found the new joint clinic useful although only 18 (56) had attended the clinic so far
CONCLUSIONS Implementation of a new nurse-led dermatology clinic running in parallel with the renal transplant clinic resulted in a considerable increase in the proportion of patients meeting national recommendations for annual skin surveillance The vast majority of patients also found the combined clinic to be useful There is still considerable room for improvement in order to achieve the target of 100 compliance with skin surveillance and ongoing clinical audit is required to assess progress We believe this model would be easily implementable at other units with similar benefits expected
A12 Pneumocystis pneumonia prophylaxis post-renal transplant increased duration of co-trimoxazole is safe and effective FA Chapman JE Dickerson M Clancy C Daly C Geddes Renal amp Transplant Unit Queen Elizabeth University Hospital Glasgow
Introduction All renal transplant recipients receive Pneumocystis jirovecii prophylaxis usually with co-trimoxazole Guidelines suggest this should be continued for 3 to 6 months Our unit previously prescribed 3 months however following an outbreak of Pneumocystis pneumonia (PCP) infection this was increased to 6 months Given its constituents of sulfamethoxazole and trimethoprim co-trimoxazole prophylaxis may influence the frequency of urinary tract infection (UTI) We aimed to compare the frequency of UTI between patients on 3 months vs 6 months prophylaxis and assess rates of multi-drug resistant organisms We also sought to establish if the increased duration of co-trimoxazole was adversely affecting renal function potassium concentration white cell and platelet count and dosing of mycophenolate mofetil
Methods A retrospective search of the West of Scotland Electronic Renal Patient Record was conducted for all renal transplant recipients between 1st January 2012 and 31st May 2016 Patients were grouped according to the intended duration of co-trimoxazole Data were extracted for baseline characteristics co-trimoxazole prescription mycophenolate mofetil (MMF) prescription laboratory results (creatinine potassium white cell count platelets) at 3 6 9 and 12 months post-transplant and microbiology results for 6 months post-transplant Results were analysed on an intention to treat (ITT) basis with a second analysis according to actual duration of co-trimoxazole treatment (AT) Subjects with transplant failure had laboratory results censored from the time of transplant failure and all of their microbiology results were excluded
Results 609 renal transplants were performed over the study period On ITT analysis there were 418 patients in group 1 (ITT1 3 months co-trimoxazole) with 15 transplant failures and 191 patients in group 2 (ITT2 6 months co-trimoxazole) with 12 transplant failures There was a significant difference in the number of patients with at least one UTI with fewer in ITT2 (ITT1 133403 vs ITT2 42179 p = 001) However this was not present when comparing actual treatment duration (AT1 111345 vs AT2 36149 p=007) Overall there was a similar spectrum of organisms cultured There were significantly fewer cultures of multi-resistant organisms in both ITT and AT analyses with 6 months of co-trimoxazole (ITT1 28376 vs ITT2 0106 p= 0004 AT1 22313 vs AT2 198 p = 002) There was no difference in estimated Glomerular Filtration Rate serum potassium concentration platelet count or MMF dose On AT analysis there was a significant difference in the total white cell count (WCC) and lymphocyte count at 6 months post-transplant (WCC 78 x10^5L vs 71 x10^5L p =004 lymphocytes 13 x10^5L vs 12 x10^5L p=002) There were 18 cases of PCP with 7 deaths attributable All cases occurred after cessation of co-trimoxazole prophylaxis (81 ndash 913 days after stopping co-trimoxazole)
Conclusion Although there is a significant difference in UTI frequency on ITT analysis this is not present on AT analysis suggesting no real co-trimoxazole effect There was no increase in frequency of multi-drug resistant organisms with a longer course of co-trimoxazole Renal function and serum potassium were unaffected Our findings support continuing co-trimoxazole prophylaxis for at least 6 months
A13 Kidney transplantation in the over 60rsquos in Scotland 1996-2015 TJW Rennie1 P Phelan1 J Campbell2 JP Traynor2 L Henderson1 W Metcalfe2 On behalf of the Scottish Renal Registry 1Renal transplant unit Royal Infirmary Edinburgh 2NHS National Services Scotland Introduction The proportion of older kidney transplant recipients has increased in the UK but
long term outcome data are scarce We aimed to evaluate patient and graft survival in patients
ge60 years of age receiving a first kidney only transplant in the last 20 years in Scotland
Methods Retrospective analysis of Scottish Renal Registry data of incident Renal Replacement
Therapy (RRT) patients and those in receipt of a kidney only transplant performed 1996-2015
(follow up until 311216) Patients were stratified by age 60-69 ge70 (group 1 and 2 respectively)
and decade of transplantation 1996-2005 2006-2015 (decades 1 and 2 respectively)
Results 6743 patients aged ge60 started RRT from 1996-2016 Of those 108 were ever
transplant-listed 54 had received a transplant by 311216 26 listed and 11 transplanted
were aged ge70
535 patients aged ge60 received a kidney only transplant in 1996-2015 90 patients (168) were
aged ge70 no patients were aged ge80 Mean time from wait listing until transplantation was 33plusmn24
years (plusmnSD) and from starting RRT until transplantation was 38plusmn26 years (plusmnSD) One and five
year graft survival was 97 and 87 in decade 1 95 and 89 in decade 2 (p=NS) there was
no difference in graft survival between age groups 1 and 2 One and five year patient survival was
94 and 78 in age group 1 85 and 56 in group 2 (plt0001) there was no difference in one
and five year patient survival between the two decades
Conclusion One and five year graft and patient survival in renal transplant recipients aged ge60
have not changed significantly in the last 20 years Recipient age ge70 is not associated with
reduced graft survival but patient survival from time of transplant is lower in this age group
compared to recipients aged 60-69
No conflict of interest to be declared No funding received
A14 High Mortality In Older Patients With Primary Nephrotic Syndrome Sarah Beverstock Wendy Metcalfe amp Robert W Hunter Department of Renal Medicine Royal Infirmary of Edinburgh
Introduction
Nephrotic syndrome can develop at any age and may be due to a primary glomerular lesion or secondary to systemic disease The natural history of glomerular disease can be different in older patients For instance minimal change disease (MCD) in children almost always remits promptly with steroid therapy in adulthood it typically remits only after many weeks of steroids or with adjunctive immunosuppression However there are remarkably few published data on the mortality of primary nephrotic syndrome in adults We aimed to study this in our centre
Methods
We enrolled all adult patients who had a kidney biopsy in order to investigate nephrotic syndrome over 38 consecutive months (01 Jan 2014 ndash 28 Feb 2017) We defined nephrotic syndrome as heavy proteinuria (urinary proteincreatinine ratio UPCR gt350 mgmmol or albumincreatinine ratio gt220 mgmmol) and hypoalbuminaemia (serum albumin lt35 gL) In our analysis we included all patients in whom nephrotic syndrome was attributed to a primary glomerular disease We excluded kidney transplant recipients and patients in whom biopsies were performed to follow up a known glomerular disease We collected laboratory data at baseline (time of biopsy) and at 6 and 12 months We assessed patient survival by Kaplan-Meier analysis
Results
Of the 117 patients biopsied for nephrotic syndrome 71 patients (61 ) met the inclusion criteria and were followed up for a median of 469 days We compared outcomes in patients aged under 60 years old (n = 35) with those aged over 60 (n = 36) Mortality was higher in the older group (37 vs 4 mortality at one year p lt005 by logrank test) There were no significant differences between the two groups in serum creatinine or UPCR at any time Serum albumin was similar in both groups at baseline and at 12 months but was lower in the older group at 6 months (27 vs 32 gL p lt 005) Baseline haemoglobin was lower in the older group (114 vs 130 gL p lt005 by unpaired t-test) Primary diagnoses were MCD (n = 10 in younger group amp n = 5 in older group) membranous nephropathy (5 amp 10) IgA nephropathy (9 amp 8) FSGS (5 amp 5) membranoproliferative glomerulonephritis or C3GN (4 amp 7) and other (2 amp 1) Therefore unsurprisingly there were relatively fewer cases of MCD and more cases of membranous nephropathy in the older group otherwise the causative glomerular lesions were similar in both groups In those patients with MCD mortality was significantly higher in the older group none of the 10 patients with MCD diagnosed under 60 yrs old died during the follow-up period whereas 4 of the 5 older patients died 3 patients in the younger group and 1 in the older group were on renal replacement therapy (dialysis or transplant) by the end of follow-up
Conclusions
Primary nephrotic syndrome is associated with high mortality in the over 60s (37 at one year) Mortality was high even for MCD a disease that follows a benign course in childhood and early adulthood The higher mortality in older patients was not associated with greater severity of renal disease at presentation (as assessed by basic blood and urine parameters) This work was not funded we declare no conflicts of interest
A15 Renal biopsies in patients with diabetes mellitus in Scotland
Udana Ratnapala 1 Nicola Joss 2 Colin Geddes 3 Dana Kidder 1
1 Renal Unit Aberdeen Royal Infirmary Aberdeen 2 Renal Unit Raigmore Hospital Inverness 3 Glasgow Renal and Transplant Unit Glasgow
Introduction Diabetes mellitus is the leading cause of end-stage kidney disease (ESKD) requiring renal replacement therapy The utility of renal biopsy in patients with diabetes mellitus is controversial Broadly renal biopsy findings in patients with DM can be divided into diabetic nephropathy (DN) alone DN with non-diabetic renal disease (NDRD) or NDRD alone Timely identification of patients with NDRD is important to provide appropriate therapeutic measures Previously published guidelines on clinical predictors of NDRD have limited specificity and sensitivity The frequency of NDRD in renal biopsies of patients with DM is unclear in ScotlandThis study aimed at identifying the frequency and the pathology spectrum of NDRD in diabetic patients underwent kidney biopsy in 3 renal units
Methods A retrospective observational study was performed on clinical-pathologic findings in all patients with diabetes mellitus who underwent renal biopsy between 01012010 and 31122016 in 3 renal units (Aberdeen Inverness and Greater Glasgow) Data were gathered from electronic patient record systems Scottish Index of Multiple Deprivation (SIMD) 2012 was used to analyse correlation with patient outcomes
Results 247 patients were included 150 men (607) 217 type 2 DM (879) mean age 621 years and mean serum creatinine at the time of renal biopsy of 261 micromolL (+-190 std) On biopsy 92 patients (372) had DN while 127 (514) had NDRD and 28(114) had NDRD superimposed on DN The commonest NDRD aetiologies were IgA nephropathy (187) tubulointerstitial nephritis (168) and idiopathic membranous nephropathy (103) Predictors of NDRD were age (OR 1027 95 CI 1002-1052 p=003) duration of DM (OR 094 95 CI 0900-0987 p=001) and absence of AKI as indication for biopsy (OR 022 95 CI 0059-0826 p=0025) There was no significance difference in renal or patient survival in DN and NDRD Finally no significant correlation was depicted between SIMD quintiles and renal or patient survival in both groups
Conclusions The majority of renal biopsies carried out in patients with DM revealed a NDRD In this study age at the time of biopsy duration of DM and AKI were the main pointers towards NDRD Renal and patient survival were not significantly different between DN and NDRD groups
A16 The Impact of Withdrawal of Maintenance Immunosuppression and Graft Nephrectomy on HLA Sensitisation Ailish Nimmo1 Sophie McIntyre1 Lorna Henderson1 Richard Battle2
(1 Department of Renal Medicine Royal Infirmary of Edinburgh 2 Histocompatibility and Immunogenetics Royal Infirmary of Edinburgh)
Background The development of HLA antibodies towards a failing renal allograft is a barrier to re-transplantation We previously demonstrated an increase in HLA antibodies and calculated reaction frequency (cRF) following nephrectomy but results were confounded by immunosuppression changes occurring in close time proximity We examined the formation of HLA donor specific antibodies (DSA) in patients with failed grafts that remained in situ and compared results with patients undergoing graft nephrectomy to further assess the relative impact of nephrectomy and immunosuppression weaning on sensitisation and chance of transplant
Methods We carried out a single centre retrospective study of all patients with failed grafts in Lothian from 2005 to 2015 Samples were tested for DSA pre-immunosuppression (IS) wean post-IS wean and post-IS cessation Nephrectomy patients also had samples tested for DSA before and after nephrectomy Data on other sensitising events including blood transfusion and rejection were collected cRF was determined at each time point and entered into the ODT chance of transplant calculator with other demographics based on the average patient from the Edinburgh centre
Results 62 grafts failed over this time period Blood samples were available 41 patients (24 with nephrectomy 17 with failed graft left in situ) Patient demographics were similar between groups There was a higher rate of antibody mediated rejection in the nephrectomy group (46 vs 18) 76 of patients with nephrectomy group had received a blood transfusion The pattern of immunosuppression weaning was similar but median time from start of IS wean to cessation was longer in the nephrectomy group (350 vs 298 days) The changes in cRF and chance of transplant (COT) with immunosuppression weaning are shown in Table 1
Pre-IS Wean Post-IS Wean
Failed graft in situ (n=17)
Mean CRF COT at 5
years 15 62 38 59
Nephrectomy (n=24)
Mean cRF COT at 5
years 54 54 69 46
Post-IS Stop 55 53 89 42 Table 1 Mean cRF and Chance of Transplant (COT) at 5 years with IS alterations
Discussion A stepwise increase in cRF with reduced chance of transplant was observed in both groups as immunosuppression was withdrawn with a similar pattern of change irrespective of graft nephrectomy cRF was higher in the nephrectomy group despite a more gradual wean which may reflect a higher rate of antibody mediated rejection and increased number of patients receiving a blood transfusion The risks and benefits of stopping immunosuppression need to be carefully considered on an individual basis to maximise chance of future transplant
The authors have no conflicts of interest No funding was required for this study
A17 Obesity is not associated with progression to end stage renal disease in patients withbiopsy-proven glomerular diseases
Benjamin Elyan Jennifer S Lees Bruce Mackinnon Jonathan G Fox Colin C Geddes Emily PMcQuarrie
Glasgow Renal and Transplant Unit Queen Elizabeth University Hospital Glasgow
Introduction - Addressing risk factors for renal progression is a key aspect of managing chronic kidney disease (CKD) Body mass index (BMI) has been shown to impact on renal progression in unspecified CKD The aim of this study was to evaluate if there was an association between BMI and progression to renal endpoints in patients with biopsy-proven primary glomerular disease (GN)
Methods - We included all adult patients diagnosed with biopsy-proven primary GN (excluding minimal change nephropathy) in Greater Glasgow amp Clyde and Forth Valley between 01012000 and 31122015 Biochemical and anthropometric data were extracted from the electronic patient record at time of biopsy with follow-up data until 20062017 BMI was calculated from height and weight at time of biopsy and categorised into groups BMI le25 kgm2 (G1) gt25 to le30 kgm2 (G2) and gt30 kgm2 (G3 - obese) We assessed factors associated with reaching a combined renal endpoint of CKD5 or renal replacement therapy (RRT) with competing risk of death using the Fine and Gray subdistribution hazard model Analyses were conducted using cmprsk package for R statistical software package and SPSS version 24
Results - 560 patients with primary GN and available BMI data were included The average age was 532 years and 339 were female There were 132 patients in G1 210 in G2 and 207 patients in G3 Those in G2 and G3 were older (p=002) with slightly higher diastolic blood pressure (p=002) than those in G1 There was a greater proportion of focal segmental glomerulosclerosis in G3 but similar proportions of other GN diagnoses across groups There was no significant difference in baseline serum creatinine (sCr) (p=034) or log uPCR (p=045) between BMI groups On multivariate analysis age systolic blood pressure BMI or GN diagnosis were not predictive of renal outcome Higher baseline sCr (SHR 1003 per 1 umoll increase in sCr 1001-1004 plt0001) and log uPCR (SHR 130 per unit increase in log uPCR 95 CI 105-160 p=002) were associated with progression to the combined renal endpoint accounting for competing risk of death BMI was not associated with reaching combined renal endpoint on univariate analysis whether considered as a continuous variable (SHR=100 95 CI 098-102 p=096) or categorised by BMI group
Conclusion - Contrary to our expectations there was no association between BMI and progression to a combined renal endpoint of CKD5 or RRT in this cohort of patients with primary GN Efforts should be directed to managing other known risk factors for CKD progression
Sources of FundingConflicts of Interest - None
A18 Factors influencing long term renal function after living kidney donation
Matthew A Rutherford Norman J Galbraith Marc Clancy Colin C Geddes
Glasgow Renal and Transplant Unit Queen Elizabeth University Hospital Glasgow UK
Background Following live donor nephrectomy the remaining kidney undergoes an increase in filtration capacity known as compensatory hypertrophy Few cohorts with follow up of renal function beyond 5 years have been reported The impact on long term renal function of variability in donor factors such as age sex pre-donation blood pressure and glomerular filtration rate (GFR) is unknown Increasingly kidney donors have potential risk factors for future poor renal function such as hypertension older age and obesity The aim of this study was to analyse factors influencing long-term renal function in living kidney donors from our centre
Method Data were obtained from the electronic patient record Patients with a recorded procedure of lsquolive donor nephrectomyrsquo between 2005 and 2017 were identified GFR after donation (calcGFR) was calculated using the formula lsquocalcGFR = Pre-donation Isotope GFR x (Pre-donation Serum creatinine Serum Creatinine)rsquo which is accurate assuming muscle mass does not change Pre and post donation serum creatinines (two days two weeks three months and one to ten year) were recorded We analysed the influence of age sex pre-donation GFR and blood pressure on post donation GFR compensation
Results 355 live donor nephrectomies were performed between January 2005 and December 2016 The mean age was 469 (plusmn 116) years and 504 (n=179) were female Mean pre-donation isotope GFR was 937 plusmn 156 mlmin173m2 Median follow up was 2 years (IQR 1 to 6 years with range 2 weeks to 10 years) The calculated percentage of pre-donation GFR at 2 days 2 weeks 3 months 1 year 5 years and 10 years were 698 691 712 730 801 and 950 respectively (p lt 0001) Patients aged lt50 y had not only a higher calcGFR (858 plusmn 29 mlmin173m2 compared with 671 plusmn 28 mlmin173m2 p lt 0001) at 5 years following donation but achieved a higher degree of compensation than donors gt 50 y (836 plusmn 16 compared with 756 plusmn 19 (p = 0002) Patients with pre-donation hypertension achieved 774 plusmn 53 of pre-donation GFR compared with 804 plusmn 32 in normotensive patients (p = 0998) Females had equivalent degree of renal compensation achieving 819 plusmn 19 compared with 780 plusmn 16 in males (p = 0131) at 5 years following donation Patients with pre-donation GFR gt 100 mlmin173m2 achieved 844 plusmn 23 of pre-donation function by 5 years compared with 777 plusmn 14 in those with pre-donation GFR lt 100 mlmin173m2 (p = 001)
Conclusion Following live donor nephrectomy renal function has a nadir of 691 at 2 weeks Compensation in GFR occurs rapidly and appears to be maintained regardless of sex and pre-donation blood pressure Younger age and higher pre-donation GFR were associated with a greater degree of compensation
A19 The utility of high-sensitivity cardiac troponin to stratify cardiovascular risk in patients with renal impairment
Eve Miller-Hodges Atul Anand Anoop S V Shah Nicholas L Mills Neeraj Dhaun
Background Cardiovascular disease is the most common outcome of chronic kidney disease1
Declining glomerular filtration rate (GFR) and proteinuria predict increased cardiovascular risk over the long term2 However there are currently no methods to stratify cardiovascular risk in the short or medium term in patients with renal impairment We have already shown that high-sensitivity cardiac troponin I concentrations (hs-cTnI) lt5ngL in patients presenting with symptoms of acute coronary syndrome identifies those at low risk of cardiac events within 30 days and over the next year3 However uncertainty remains over the role of hs-cTnI testing in patients with renal impairment This study investigated whether hs-cTnI could also stratify future cardiovascular risk in patients with renal impairment
Methods In a prospective study of consecutive patients presenting with suspected acute coronary syndrome we evaluated the performance of hs-cTnI in patients with and without renal impairment (estimated glomerular filtration rate lt60mLmin173m2) using an early risk stratification threshold of 5ngL to ldquorule outrdquo acute myocardial infarction at presentation and within 30 days and sex-specific 99th centile diagnostic thresholds for index type 1 myocardial infarction Subsequent type 1 myocardial infarction and cardiac death were reported at one year
Results Of 4726 patients identified 904 (19) had renal impairment Index diagnosis of type 1 and type 2 myocardial infarction was almost twice as likely in patients with renal impairment (30 vs 15) Performance of the early risk stratification threshold of 5ngL to identify patients at low risk of major cardiac events was similar in patients with (NPV 984 95CI 960-997 sensitivity 989 95CI 975-999) and without renal impairment (NPV 997 95CI 994-999 sensitivity 984 95CI 972-994) These patients continued to remain at low risk over the next year The PPV and specificity at the 99th centile for diagnosis of myocardial infarction were lower in patients with renal impairment at 500 (95CI 452-548) and 709 (95CI 675-742) respectively compared to 624 (95CI 588-659) and 921 (95CI 912-930) At one year 24 of patients with renal impairment and troponin gt99th centile regardless of index diagnosis had experienced further myocardial infarction or cardiac death compared with 10 of patients without
Conclusion In suspected acute coronary syndrome hs-cTnI can stratify risk in patients with renal impairment Irrespective of diagnosis patients with renal impairment and elevated cardiac troponin concentrations had two-fold greater risk of a major cardiac event compared to those with normal renal function and should be considered for further investigation and treatment
Funders Wellcome Trust British Heart Foundation and Chest Heart amp Stroke Scotland
1 Gansevoort RT Lancet 2013
2 Chronic Kidney Disease Prognosis Consortium Lancet 2010
3 Shah AS Lancet 2015
A20 lsquoDOES IT DIALYSE OUTrsquo - THE EFFECT OF RENAL REPLACEMENT THERAPY ON THE BRAIN Mark Findlay Jesse Dawson David Dickie Deborah McGlynn Patrick Mark Institute of Cardiovascular and Medical Science University of Glasgow amp Queen Elizabeth University Hospital Glasgow
Introduction Cerebrovascular disease is common in end-stage renal disease (ESRD) on renal replacement therapy (RRT) We investigated the effect of RRT on cerebral structure and cognitive function over 12 months Methods Observational cohort study in ESRD patients receiving HD Prior cognitive impairment or cerebrovascular disease were exclusion criteria Multi-domain cognitive testing was performed at baseline and at follow-up Transcranial Doppler was used to assess intra-dialysis related alterations in mean flow velocity (MFV) ndash a marker of cerebral blood flow MR imaging was performed at 0 and 12 months We performed T1 T2 FLAIR and DWI sequences and used volumetric software to calculate white matter hyperintensity (WMH) burden markers of atrophy mean diffusivity and fractional anisotropy (FA) to describe structural changes at 1 year Results 97 patients median age 59 years 412 female At follow-up 15 patients were transplanted 6 died 4 withdrew and the remainder continued HD Those who were transplanted were younger (median age 51 vs 60 years p=0019) and had been on dialysis for a shorter period (median 06 vs 21 years p=0003) MFV declined during HD median 475cms to 405cms plt0001 and correlated with lower scores of executive and frontal lobe function during HD (Rho 045 p lt0001 and Rho -0313 p lt001 respectively) In all patients MR imaging demonstrated a significant decline in frontal parietal and temporal lobe volume at follow-up Median WMH volume increased in those who remained on HD but not in transplanted patients (median change 023 vs -012ml p=0018) WMH burden correlated with worsening scores of frontal lobe tests Rho 0585 p0005 and worse mood Rho -0485 p0026 FA improved following renal transplant (028 to 029 p=0016) and correlated with improved executive function testing at follow-up Rho 089 p0019 Conclusion Cerebral blood flow is reduced during haemodialysis and correlates with a reduction in intradialytic executive function There is an improvement in FA following transplantation WMH volume increases in those who remain on dialysis and the degree of increase correlates with executive and frontal lobe function This suggests that haemodialysis is associated with clinically significant changes in the brain and that these may be ameliorated by transplantation
Source of fundingconflicts MF is funded by a KRUK fellowship
A21 Pathological classification of IgA nephropathy to predict renal outcomes ndash is there a better way to score tubulointerstitial inflammation
Alastair Rankin David Kipgen Bruce Mackinnon Jonathan Fox Colin Geddes Emily McQuarrie Glasgow Renal and Transplant Unit On behalf of the Scottish Renal Biopsy Registry
Background The Oxford pathological classification of IgA nephropathy (IgAN MEST-C score) is limited by the fact that individual features of the score are not all predictive and its utility in assisting clinical decision-making is questioned The addition of tubulointerstitial inflammation to the existing scoring system is appealing but is not currently included due to reportedly wide inter-observer variability We report a novel method to score percentage of cortex containing tubulo-interstitial inflammation in non-atrophic renal cortex (ATIN) in patients with IgAN similar to that used in transplant biopsy reporting and assess its utility to predict clinical outcomes
Methods All adult patients with a native renal biopsy diagnosis of IgAN between 2010 and 2015 in a unit serving 15 million people were identified Baseline characteristics biopsy reports and outcome data were collected ATIN was calculated by subtracting the percentage of atrophic cortex from the percentage of total cortex with tubulo-interstitial inflammation withge10 representing significant tubulo-interstitial inflammation in non-atrophic cortex The primary outcome was a composite of requiring renal replacement therapy (RRT) or doubling of serum creatinine (sCr)
Results 153 new cases of IgAN were identified 33 were excluded (24 had lt8 glomeruli on biopsy 6 inadequate biopsy for MEST scoring and 3 on RRT at time of biopsy) In addition patients with a tubular atrophy (T) score of 2 were also excluded (n=9) Of the remaining 111 patients 76 (68) were male Mean age at biopsy was 52 years (+- 167) and 18 (16) had a co-existing clinical diagnosis of henoch-schonlein purpura (HSP) Median sCr was 156 micromoll (IQR 101-212) and 54 (49) had ATIN on biopsy During a median follow-up of 23 years 34 (31) reached the primary outcome 20 (18) received immunosuppression and 16 (14) died On univariate Cox regression survival analysis ATIN was associated with a four-fold increase in the primary outcome (HR 49 (21-113)) On multivariate analysis mesangial hypercellularity (M) T and ATIN independently predicted renal outcome while endocapillary proliferation (E) and segmental sclerosis (S) did not (plt002 for ATIN) Excluding patients with HSP or those who received immunosuppression did not change the result
Conclusion Within our centre ATIN predicts renal outcome for IgAN independently of established histological features Assessment of inter-observer reproducibility and validation in other cohorts is still required but these results suggest ATIN could be a worthwhile addition to current pathological scoring systems for IgAN
Source of funding none Conflicts of interest none
P1 Polypharmacy in Renal Replacement Therapy Patients
Jason McMinn Colin Geddes Glasgow Renal and Transplant Unit Queen Elizabeth University Hospital
Introduction
Prescribing is often led by evidence from studies containing participants with single health conditions and without multimorbidity Polypharmacy is becoming increasingly recognised in patients with multiple chronic health conditions Additional medications are more likely to result in diminishing returns in benefit with an increased risk of harm Patients with established renal failure (ERF) are likely to be susceptible to medication-related harm A high pill burden is also likely to contribute adversely to an already restricted quality of life and has been associated with poor medication adherence The aim of this study was to analyse polypharmacy in all patients with ERF attending our service
Methods
We extracted medication records for all prevalent ERF patients attending the Glasgow Renal and Transplant Unit from the West of Scotland Electronic Renal Patient Record (SERPR) as of 01012017 The records were analysed to calculate the number of regular medications and total pill burden of each patient These medications were categorised as being lsquopreventativersquo or lsquosymptomaticrsquo We also analysed the prescription of specific drug classes to examine the prevalence of these medications
Results
We identified 1091 transplant follow-up 529 hospital haemodialysis and 46 peritoneal dialysis patients who were on a mean of 94 13 and 129 different medications respectively Overall pill burden was 139 tablets a day in transplant follow-up patients 141 in haemodialysis patients and 162 in peritoneal dialysis patients There were similar rates of prescribing between the different dialysis units and clinics within our service
The proportions of medications deemed as preventative rather than symptomatic were 76 in transplant 69 in haemodialysis and 60 in peritoneal dialysis
In transplant patients decreasing renal function was associated with a higher pill burden but even patients with a transplant eGFR gt 60 were on a mean of 126 tablets per day including a mean of 14 antihypertensives
Rates of antidepressant prescribing were 15 in transplant patients and 20 in hospital haemodialysis patients 53 of haemodialysis patients were on a statin 39 on aspirin 61 on a proton pump inhibitor and 7 were on warfarin
Conclusion
Patients undergoing all forms of renal replacement therapy are likely to be on a considerable number of medications Whilst these drugs are inevitably prescribed for valid reasons this data demonstrates the need for clinicians to engage with patients to explore opportunities to reduce pill burden
Conflict of Interest None Sources of Funding None
P2 An audit of Acute Kidney Injury (AKI) on an acute stroke ward before and after plannedinterventions to review and maintain hydration
Clare Harris1 Simon Hart2 Fiona Duthie3 1 University of Edinburgh Medical School 2 Stroke Unit Royal Infirmary of Edinburgh 3 Renal Unit Royal Infirmary of Edinburgh
Background Dehydration is an important factor in the development of acute kidney injury which is associated with increased morbidity and mortality particularly in the elderly population Poor fluid intake is common post stroke (1) and dehydration is associated with poorer outcomes 3 months post stroke (2) In late 2014 there was no system of identifying patients with poor oral intake on the stroke ward at the Royal Infirmary of Edinburgh a hydration protocol and education programme were implemented aiming to improve fluid balance This included the use of prescribed water either orally or by nasogastric tube An audit pre and post intervention demonstrated that hydration as measured by ureacreatinine ratio significantly improved after the protocol introduction (3) We aimed to determine whether the incidence of AKI by KDIGO criteria was also reduced as this could have implications for reducing patient morbidity and mortality in this elderly comorbid patient cohort
Method 150 inpatients to the acute stroke ward during JulAug 2014 and JulAug 2015 were selected (n= 80 2014 n=70 2015) Patient data and creatinine values were collected from the electronic patient record and medical notes and retrospectively analysed Baseline creatinine values were calculated and cases of AKI were identified and staged using KDIGO criteria (4) Chi-Squared tests were performed to determine P values Individual patient notes were reviewed for both quantitative and qualitative data of patient management
Results Incidence of AKI (of any stage) was 263 pre-protocol and 200 post-protocol (P=03646) Incidence of AKI stages 23 was 100 pre-protocol and 715 post-protocol (P=05374) In hospital post stroke mortality was 338 pre-protocol and 1286 post protocol (P=00028) AKI was also associated with increased length of stay
Conclusions Despite a trend in benefit there was no significant difference in incidence of AKI pre and post hydration protocol nor in incidence of severe AKI (stage 23) AKI is influenced by many factors one of which is hydration status Further studies are needed to determine whether the trend of benefit exhibited in this sample is significant in a greater sample size if this were the case such a protocol could have great benefit to patient care on stroke units and elsewhere There was a significant difference in inpatient post stroke mortality following introduction of the hydration protocol Further investigations are needed to explain underlying reasons for this factors other than hydration may play an important role
References 1 Whelan K Inadequate fluid intakes in dysphagic acute stroke Clinical Nutrition (2001) 20(5)
423-428 2 Bhalla A Sankaralingam S Dundas R Swaminathan R Wolfe CDA Rudd AG The influence of
raised plasma osmolality on clinical outcome after acute stroke Stroke (2000) 312043ndash2048 3 Hart SR Craig R Berry E Lane N Gad A Farrugia M Burton L Paquay A What Happens to
Acute Stroke Patientsrsquo Fluid Balance Renal Status and Dehydration in the First Two Weeks How Can They Be Markedly Improved doi 101111ijs12634_13
4 KDIGO Clinical Practice Guideline for Acute Kidney InjuryKidney international supplements (2012) 2(1) 1-138
No funding or conflict of interest to declare
P3NHS Highland-Improving the management of hyperkalaemia using a kit Initial resultsCantley N1 Abedin T2 Lambie S3
1FY2 NHS Highland 2ST4 Renal Medicine NHS Grampian 3Renal Consultant Renal unitRaigmore Hospital Inverness
Introduction The incidence of hyperkalaemia in hospitalised in patients is between 1 and 10 Guidelines in Northern Ireland promote the use of a Hyperkalaemia Kit to improve management of hyperkalaemia We assessed the management of hyperkalaemia in Raigmore Hospital including post-treatment monitoring of serum potassium and blood glucose at baseline and after the introduction of a lsquoHyperkalaemia Kitrsquo which contains a pro forma for the management of hyperkalaemia and all the relevant equipment and drugs for treatment
Method Between July and September 2016 an automated algorithm identified 34 patients with a potassium result 65 mmoll or above on laboratory results 12 received no specific treatment of these 6 results were spurious 4 patients died before treatment could be started and 2 patients were chronic haemodialysis patients We introduced the Hyperkalaemia Kit to the Acute Medical Admissions Unit in Raigmore Hospital Since then 15 patients have been identified with serum potassium measurements above 65 and the pro forma and kit was used with eight of these patients One of these patients proceeded straight to acute renal replacement therapy
Results Prior to our intervention all 22 patients that were actively treated received at least one prescription of appropriate doses of Insulin with Dextrose However only 16 patients received intravenous calcium and only 7 received nebulised Salbutamol Potassium was measured at 4 hours in 5 cases and by 12 hours in 17 cases Monitoring of any capillary blood glucose was only documented in 8 cases Of the 22 treated 2 needed acute renal replacement therapy 3 required further doses of insulin and dextrose 2 were treated with Calcium Resonium
Eight cases of hyperkalaemia have been managed with the use of the kit and pro-forma so far An initial ECG was performed in all eight and four patients had continuous cardiac monitoring Intravenous calcium was given in seven and nebulised Salbutamol was given in five out of the eight cases Six out of eight patients had at least three blood sugar measurements One had two measurements documented and one patient was stopped from further monitoring following senior review and decision to palliate Seven patients had appropriate monitoring of their serum potassium by 4h and 12h again one patient was not monitored due to palliation
Conclusion Baseline results showed very low rates of prescription of nebulised Salbutamol low rates of Calcium Gluconate use and very low monitoring of blood sugars and potassium post treatment This has the potential for serious adverse outcomes particularly the potential for iatrogenic hypoglycaemia Our initial data shows the use of a Hyperkalaemia pro forma and kit improves the rate of prescription of intravenous calcium and nebulised Salbutamol and the post-treatment monitoring of serum potassium and blood sugar levels
P4Rituximab as maintenance therapy in ANCA associated vasculitisndash a single centre experience Rathnamalala NK Mcmenamin J Robertson S Almond A Kelly M Muniraju T M Renal Unit Dumfries and Galloway Royal Infirmary NHS Dumfries and Galloway Background The introduction of Cyclophosphamide and high dose steroids transformed ANCA associate vasculitis (AAV) from a disease of high mortality to a relapsing remitting disease Maintenance of remission however still remains a major challenge A two randomised clinical trials have looked at the use of Rituximab in remission induction in AAV and reported similar remission rates between Cyclophosphamide and Rituximab 12 Both these trials used Azathioprine as maintenance therapy and in the follow up showed similar remission rates with either agent for induction The role of Rituximab for maintenance therapy after cyclophosphamide induction was studied in the MAINRITSAN trial 3 Rituximab was compared with azathioprine and found that the relapse rate was significantly lower in the Rituximab group There have been several other retrospective studies that have suggested regular Rituximab infusions are successful in maintaining remission however has not been thoroughly evaluated 4 5678910 Here we share our centrersquos experience using Rituximab for maintenance of remission of AAV Materials and methods We conducted a retrospective review of electronic medical records of all patients who had received Rituximab as maintenance therapy for 12 months or longer between January 2014 to July 2016 Disease activity was assessed using Birmingham Vasculitis Activity Score ( BVAS) Version 3 and complete remission was defined as a score of 0 and partial remission as a score of lt50 of the value at diagnosis Due to uncertainties associated with sub classification we did not assign specific diagnosis but broadly classified as ANCA associated vasculitis Results 6 patients received Rituximab as maintenance therapy during the study period 3 (50) of them had eye ear nose and upper airway manifestations consistent with Granulomatosis with Polyangitis (GPA) All patients were PR3 ANCA positive except for one at initial diagnosis The mean BVAS score at the time of initiation of Rituximab was 4 All patients were initiated on Rituximab for relapses while on maintenance therapy with Azathioprine 4 patients received 6 monthly doses of Rituximab while two received annual doses All of them were also maintained on 5-10 mg of Prednisolone The mean BVAS score by 6 months was 0 and remained 0 at 12 months The mean PR3 titre was 562 at the initiation of treatment while at 12 months it had come down to 68 All patients remained in complete clinical remission at the end of 12 months after initiation of therapy Rituximab was well tolerated by all patients except one who developed pyrexia during an administration
Conclusions All patients had sustained remission at 6 months and 12 months after initiating Rituximab Rituximab has a potential role as maintenance therapy in AAV
P5 Chronic Myelo-Monocytic Leukaemia (CMML) as a contraindication to renal biopsy Alastair Rankin Emily McQuarrie Jennifer Lees Bruce MacKinnon Glasgow Renal and Transplant Unit On behalf of the Scottish Renal Biopsy Registry
Abstract Chronic Myelo-Monocytic Leukaemia (CMML) is a relatively rare mixed myelodysplastic myeloproliferative disorder that predominately affects patients over the age of 65 years Renal impairment in patients with CMML is well described with several different mechanisms reported including tumour infiltration lysozyme-induced injury amyloid deposition and tubulointerstitial nephritis From anecdotal evidence within our centre we are concerned that patients with CMML have an excessive risk of clinically significant bleeding following native renal biopsy This risk appears disproportionate to the degree of any co-existing thrombocytopenia or coagulopathy
We review the cases of 4 patients with an existing diagnosis of CMML who were referred to the renal clinic with proteinuria and excretory renal dysfunction Two of these patients underwent renal biopsy with subsequent major haemorrhage post-procedure despite normal bleeding parameters pre-procedure Patient 1 presented with flank pain 8 days post-biopsy A CT confirmed peri-nephric haematoma with retroperitoneal extension A total of 6 units of packed red cells (PRCs) were transfused prior to successful CT-guided emoblisation Histology from the biopsy revealed chronic tubulointerstitial nephritis Patient 2 experienced haemodynamic instability and haematuria one hour post-biopsy A total of 11 units of PRCs 7 units of fresh frozen plasma 2 pools of platelets intravenous tranexamic acid and 2 attempts at CT-guided embolization were required until haemostasis was achieved Histology later showed evidence of tumour infiltration with associated vasculitis Patient 3 presented with renal impairment and proteinuria on the background of known CMML Following discussion with haematology the risk of bleeding following renal biopsy was considered unjustifiable despite their platelets and coagulation screen being within normal range The patient was treated for presumed renal tumour infiltration with hydroxycarbamide Patient 4 was referred to the renal clinic with acute onset nephrotic syndrome Urinary proteincreatinine ratio was elevated over 800 mgmmol with serum albumin of 23 gL but normal excretory renal function The patient attends the haematology clinic with suspected CMML and chronic thrombocytopenia but previously declined bone marrow biopsy Following discussion with the patient there are no plans to proceed with renal biopsy given potential risks These cases highlight that while CMML is rare these patients are being referred to renal clinics with features that would commonly justify renal biopsy in other settings but in whom there may be an increased risk of bleeding post-procedure Our in-centre risk of major bleeding is 2 therefore to have such extreme amounts of bleeding in 2 patients with this underlying diagnosis is remarkable This creates a dilemma for the clinician as there is a wide range of potential renal pathology associated with CMML some of which will have disease specific but relatively toxic treatments available
Source of funding none Conflicts of interest none
P6 NHS Highland-Prograf to Adoport switch McCulloch K1 Peel R2 Lambie S3
1Renal Pharmacist Renal unit Raigmore Hospital Inverness 23Renal Consultant Renal unit Raigmore Hospital Inverness
Introduction NHS Highland (NHSH) is the first health board in Scotland to implement a switch from Prograf to Adoport for renal transplant patients This will provide considerable cost savings Adoport meets the bioequivalence criteria for drugs with a narrow therapeutic index set by the European Medicines agency and studies indicate therapeutic equivalence1 with the proviso that brands are non- interchangeable unless the switch is overseen by a Renal Consultant and post-conversion therapeutic drug monitoring is conducted23 The switch has been undertaken by a majority of transplant centres in England the main difference being that they have undergone repatriation NHSH Patients receive their transplant primarily at Royal Infirmary of Edinburgh and occasionally at Queen Elizabeth University Hospital Glasgow Care is transferred to NHS Highland on discharge NHS Highland cares for approximately 170 renal transplant patients 110 being prescribed Prograf These patients may live as far as 110 miles from Raigmore Hospital Given that prescribing is carried out by primary care clear communication with patients GPs and community pharmacy is essential to avoid inadvertent switching between brands
Method Clinically it was agreed a switch could be safely undertaken A business case was submitted and funding secured for pharmacist time laboratory costs and primary care time GPs have been informed via GP subgroup and local prescribing bulletin lsquoThe Pink Onersquo Community pharmacies are being informed by phone A protocol has been agreed Eligible patients selected by Renal Consultant and Renal Pharmacist Patients sent letter signed by Renal Consultant and Renal pharmacist Patients phoned prior to clinic to agree Adoport start date and address concerns Patient seen by Renal Consultant and pharmacist + given 1 month of Adoport Tacrolimus level and UampEs checked 5-7 days after commencing Adoport and patient
contacted by phone to check if tolerated If stable letter sent to GP and community pharmacy to continue supply
Results and Evaluation Letters have been sent to all eligible patients Seven patients have been reviewed One has received a one month supply of Adoport and 5 others are due to switch One patient was deemed non-eligible at present as they have a 6 month surplus of Prograf A database will be maintained and analysed at the end and primary care savings will be monitored Extra pharmacist input will give us the opportunity to review how immunosuppression is managed and to evaluate the benefit of having a renal transplant pharmacist Conclusion The switch is at an early stage Ultimately we hope to show that the switch from Prograf to Adoport can be managed safely with extra pharmacist input to a remote and rural population with prescribing being conducted by primary care
Fundingconflicts of interest none 1 McDevitt-Potter LM Sadaka B Tichy EM Rogers CC Gabardi S Transplantation 2011 A multicenter experience with
generic tacrolimus conversion 2 Medicines and Health Products Regulatory Agency Drug Safety Update 2012 Accessed online via
wwwmhragovukSafetyinformationDrugSafetyUpdateCON1557563 ESPRIT Guidance on management of repatriation and immunosuppressant switches in transplant patients 2015
Accessed online via httpwwwespritorgukwp-contentuploads201508Switch-guidance-document-final-Aug-31-2015pdf
P7 NHS Highland-Tacrolimus baseline dataMcCulloch K1 Peel R2 Lambie S3
1Renal Pharmacist Renal unit Raigmore Hospital Inverness 2Renal Consultant Renal unitRaigmore Hospital Inverness 3Renal Consultant Renal unit Raigmore Hospital Inverness
BackgroundAs part of planning a switch from using tacrolimus Prograf to Adoport we assessed baseline data for our transplant patients currently using Prograf After converting patients to Adoport we will compare their tacrolimus levels to their individual target range We assessed our use of appropriate target ranges and our current performance in achieving tacrolimus levels within target range on Prograf therapy
Method 107 renal transplant patients taking Prograf were identified a sample of 19 of these were analysed using electronic patient records and results Time from transplant ranged from 1 month to 18 years All tacrolimus levels for the preceding year were analysed and compared to the target range specified at the time of the level being done The assay used has a Coefficient of Variation of lt5 at the lower limit of the assay
Results All 19 patients had a target range for tacrolimus clearly identified and recorded in clinic letterswhich are routinely copied to the patients themselves A variety of target ranges were specifiedThe commonest used was 5-8 microgramsl in 7 patients followed by 5-7 in a further 4 patientswith another 6 different target ranges being used for the remaining 8 patients The ranges usedhad a breadth of 3 microgramsl in 2 cases the rest had a breadth of 2 microgramslPatients had a median of 12 (range 3-72) tacrolimus levels over the preceding year Results werewithin specified target ranges for 54 +- 22 (Medan +- SD) of results checked
Conclusion We currently use a large number of different target ranges The majority of the ranges used had a breadth of just 2 microgramsl These factors help to account for the low proportion of test results which were within the specified target ranges This is important to bear in mind when interpreting whether tacrolimus levels are within target ranges after switching to Adoport We should consider aligning our target ranges and widening them
P8 Eculizumab use in Scottish paediatric dense deposit disease Stewart D1 David Hughes1 Lynne Riach2 Craig Oxley2 Athavale D1
1Royal Hospital for Children Glasgow 2Royal Aberdeen Childrenrsquos Hospital Aberdeen
Introduction The revised MPGN classification and increasing recognition of Dense Deposit Disease (DDD) a C3 glomerulopathy as an alternative complement pathway disorder suggests Eculizumab an anti-C5 monoclonal antibody may be beneficial in treatment However the experience of Eculizumab as an off-label and expensive treatment in children with DDD is limited with variable clinical response reported in the literature
Method We present the outcomes of the only 2 paediatric patients in Scotland who have received Eculizumab for the management of DDD
Results Case 1 A 10 year old male presented with proteinuria and haematuria resistant to steroid treatment with preserved renal function Initial biopsy confirmed DDD Conservative management with an angiotensin converting enzyme inhibitor and diuretics for symptom control continued until 14 years Due to worsening symptoms (oedema lethargy poor growth) and renal function deterioration along with elevated terminal complement complex (TCC) Eculizumab was commenced A repeat biopsy whilst suggestive of chronic irreversible damage showed 25 glomerular architecture preservation Symptom improvement was noted There was a reduction in proteinuria and renal function stabilisation fall in TCC and discontinuation of diuretics Eculizumab was discontinued after 24 months Progression of renal function decline was seen in the final months of Eculizumab therapy With recurrence of symptoms and increasing proteinuria following discontinuation Eculizumab was recommenced after 6 months Symptomatic improvement has since been noted
Case 2 A 5 year old girl presented with painless frank haematuria and proteinuria Initial biopsy confirmed DDD Proteinuria was unresponsive to steroid therapy and 5 months following diagnosis she rapidly progressed towards end stage renal disease despite the introduction of Mycophenolate Mofetil and plasmapheresis Haemodialysis was subsequently commenced TCC level was elevated and Eculizumab treatment was started 7 months after diagnosis Renal biopsy prior to treatment demonstrated continued severe pathological changes in all visible glomeruli However due to lack of clinical response Eculizumab was discontinued after 2 months and the patient remained dialysis dependent
Conclusions Our experience with Eculizumab in Scotland has demonstrated variable results in our 2 patients with one patient showing a positive response whilst the other experienced no improvement Eculizumab was administered to both patients at varying points in their clinical journey with differing progressive features on biopsy To date the outcomes of 9 paediatric patients with DDD treated with Eculizumab have been described in the literature with 8 experiencing some positive response to treatment including 2 patients who were able to stop renal replacement therapy within 12 weeks of treatment A role for Eculizumab in DDD may be guided by clinical and pathological features Well designed clinical trials will be necessary to define the role of complement inhibition therapy in DDD
No conflict of interest and no funding requested
P9 Examining markers of safety in the use of non-tunnelled central venous catheters
James WT Millar (Speciality Registrar) Scott W Oliver (Speciality Registrar) Peter C Thomson (Consultant Nephrologist) Glasgow Renal and Transplant Unit Queen Elizabeth University Hospital Glasgow
Background Non-tunnelled central venous catheters (NTCVC) remain an essential means of vascular access for incident haemodialysis Associated morbidity is well recognised for example in the form of Staphylococcus aureus bloodstream infections (SAB)[1]
Previous quality improvement initiatives in our unit have sought to both improve traditional markers of quality (such as SAB) and to identify additional areas of clinical risk In 2014 Oliver et al [2] suggested several additional quality measures including peri-procedure haemoglobin drop the need for a further NTCVC during the same clinical episode and the NTCVC insertion site This study further evaluated NTCVC related clinical practice within our unit
Methods The potential markers of clinical quality identified in a previous project were examined using prospectively collected data stored in the electronic patient record Identified cases of SAB significant peri-procedure haemoglobin drop and multiple NTCVC insertion were investigated by case note review
Results Between March 2016 and March 2017 a total of 222 patients received 346 NTCVC 54 patients (243) had more than one NTCVC inserted in a 21-day period (range 2-5) When considering NTCVC insertion site there were 159 (459) femoral vein catheters and 183 (541) internal jugular vein catheters No pneumothoraces were reported
15 SABrsquos were reported during this period equating to 43 of all NTCVC 5 arose in patients with femoral NTCVC (333) and 10 from internal jugular catheters (667) Mean time from line insertion to positive blood culture was 86 days 15 (67) patients had a drop in haemoglobin of greater than 20mgdl with no other source of blood loss identified on review of clinical notes
Discussion These data demonstrate that NTCVC-associated SAB rates remain low and significantly below Scottish government audit standards [3] Of interest is the continued trend towards the use of femoral catheters at 45 of lines compared with 38 in 2014 [2] Although traditionally thought of as having a higher incidence of infectious complications our data has shown fewer bacteraemia events associated with femoral catheters compared with internal jugular Our data also demonstrates a significant rate of peri-procedure haemorrhage arising in up to 1 in 20 cases Together these findings present opportunities to development practice and improve patient safety
References
[1] Murray E Deighan C Geddes CC Thomson PC Reducing haemodialysis bacteraemia rates Scottish Renal Association Glasgow November 2013 [2] Oliver SW Thomson PC Jardine AG defining safe effective and patient-centred dialysis catheter placement Scottish Renal Association Edinburgh September 2014 [3] The Staphylococcus aureus bacteraemia quarterly report of cumulative data from all NHS Boards in Scotland Health Protection Scotland January 2015
Sources of funding none Conflicts of interest none
P10 Prescribing of tolvaptan-The NHS Highland experience Lambie S1 McCulloch K2 Garrod J3
1Renal Consultant Renal unit Raigmore Hospital Inverness 2Renal Pharmacist Renal unit Raigmore Hospital Inverness 3Renal Pharmacist Renal unit Raigmore Hospital Inverness
Introduction Tolvaptan is a vasopressin antagonist It was accepted for use in Scotland by SMC in Jan 2016 to slow the progression of cyst development and renal insufficiency of autosomal dominant polycystic kidney disease in adults with chronic kidney disease (CKD) stage 1 to 3 at initiation of treatment with evidence of rapidly progressing disease1 Adverse effects related to aquaresis may affect patientsrsquo ability to achieve the optimum therapeutic dose and the risk of hepatic toxicity necessitates regular LFT monitoring The geography of NHS Highland required the implementation of novel methods of managing these patients and as a result a MDT approach with an emphasis on pharmacist input was adopted Consultant role Patient selection on the basis of evidence of rapidly progressing kidney disease declining
eGFR large volume kidneys on ultrasound and evidence of complications of PKD Side effects and potential benefits discussed Potential medication interactions reviewed Jinarc risk management prescriber training
Pharmacist role Undertook Jinarc risk management pharmacist training Prepares accurate drug history and reviews for potential drug interactions Carries out patient counselling and supplies patient education material sick day rules card
and lsquogot to gorsquo card Supplies GP education leaflet Provides advice on selection of new drug therapies eg for gout Manages stock and coordinates supply to patients
Results Prescribing commenced May 2016 patients currently prescribed tolvaptan 11 7 Female 4 male Number on target dose 73 n = 811 2 patients are still being titrated One patient did
not tolerate target dose due to aquaresis side effects and is being trialled on the middle dose
Withdrawals One patient has withdrawn due to agoraphobia and an inability to attend for monitoring and another is on hold due to having major surgery
Conclusion The MDT approach between the Renal Consultant and Pharmacist at Raigmore Hospital has enabled tolvaptan prescribing to be efficiently and safely implemented to patients living within a challenging geographical location
1 Scottish Medicines Consortium Detailed Advice Document tolvaptan 15mg 30mg 45mg 60mg and 90mg tablets (Jinarcreg) SMC No 111415 January 2016
NA1 Authors SCN Jacqueline Ross NHS Grampian
SCN Alan Somerville NHS Lanarkshire SCN Jane Humphrey NHS Lanarkshire
e- mail contact jacquelinerossnhsnet Alansommervillelanarkshirescotnhsuk
Janehumphreylanarkshirescotnhsuk
Phone contact 01224 552927 01236 712644
Title Sharing of Adverse Events in Renal Units across Scotland
Introduction Background The Scottish Renal Nurses Strategy Group (SRNSG) are a group of senior nurses from Renal
Units across Scotland who meet 3-4 times per year to discuss and implement best practice At the last meeting it was agreed that it would be good practice for each Health Board to share
their adverse events reported on the Datix System and deliver a presentation with an action plan to prevent incidents and improve patient safety across Scotland NHS Grampian and NHS Lanarkshire will be the first to deliver this presentation discussing adverse events from both Health Boards with an action plan
Top 5 adverse events over the past 12 months Renal Unit NHS Grampian 1 Violence and Aggression 2 Accidents including needlesticks slips trips and falls 3 Medication Errors 4 Infrastructure Staffing and Estates 5 Machines and Equipment
Top 5 adverse events over past 12 months Renal Unit NHS Lanarkshire
1 Slips Trips or Falls 2 Medicine errors 3 Treatment problems 4 Transfer problems 5 Breach of policy
The presentation will also focus on any serious adverse events which may not be in the top 5 categories
Aim Objective Each Health Board to share their adverse events with the aim to prevent them from occurring in other units to improve staff and patient safety and wellbeing across Scotland
Method Power Point Presentation
Outcome Results Sharing of adverse events resulting in the development of a national Action Plan to prevent these incidents improving safety and well being of staff and patients in Renal Units across Scotland
NA2
SRA Oct 2017 Abstract
BBV Never Event - The whats whys and hows
Staff Nurse Gillian Wilson Aberdeen Royal Infirmary
This presentation shares our experience of a never event that occurred and was not picked up for
a period of 18 months
Hepatitis C (HCV) positive antibodies were found in a previously negative patient
These results were a low positive with no biochemistry changes to suggest any liver damage
however steps were put immediately in place to isolate and investigate
Was it contamination from a dialysis machine was it related to a blood transfusion given prior to
first positive result was it faulty diagnostic tests in the laboratory
In Aberdeen we go over and above national guidelines and isolate all our BBV patients whether
they have positive blood results or are PCR negative
Further bloods tested at an external laboratory confirmed negative results
It highlighted that communication errors were to blame for the lack of speed in detecting this issue
Investigations concluded no real answers as to why this happened
NA3
Living Donation Scotland Changing attitudes towards living donor kidney transplantation
Jen Lumsdaine Julie Glen On behalf of the Living Donation Scotland Project Board
Background and aims
The rate of living donor transplantation has remained fairly static in Scotland over the past 10 years
Recent data has shown inequity of access to living donor transplantation throughout the UK so
there is potential to significantly increase this optimum form of treatment for patients with end-stage
renal failure in Scotland The Living Donation Project Board was formed in 2016 aiming to double
the number of living donor transplants by 2020
Method
The two key areas
1 Do recipients receive adequate and appropriate information at the right time about living
kidney donation
2 Informing the general public about altruistic donation
All patients active on the transplant list in Scotland were invited to an information event A follow-up
questionnaire was performed in the East of Scotland examining outcome or reasons for not
attending A scoping exercise looked at information provided by each unit was performed and link
nephrologists and low clearance nurses attended meeting to discuss strategies for early education
Outcome
An information pack containing both recipient and donor written information and short films on DVD
has been produced with the support of the Scottish Government for all recipients and potential
donors in Scotland A new website with comprehensive information both written and visual and
postcode finder to improve ease of access to local unit contact details has been developed
Two national media campaigns have been launched with a significant rise in the number of enquiries
from potential donors and actual increase in altruistic donor numbers
Nursing abstract ndash no conflict of interest
NA4Authors Susan Easson Charge Nurse Ward 4C QEUH Glasgow
e- mail contact SusanEassonggcscotnhsuk
Phone contact 0141 452 3300
Title A Conversational approach to find out ldquoWhat matters to yourdquo in a Renal Transplant ward
Introduction Background Finding out ldquo What Mattersrdquo to people using health and careservices is crucial to delivering safe effective and person centred care It is a simple yet profoundconcept and tries to get to the essence of person centred care by creating deeply personalengagements with patients and their families through a conversational approach However careexperience feedback all too often provides innumerable examples of where what really matters topatients and their family members is poorly understood or not addressed Using care experienceas the driver for change the nursing staff in Ward 4C used improvement approaches to explorehow to hold more meaningful ldquoWhat Matters to yourdquo conversations on a daily basis
Aim Objective To improve the patient experience by utilising a person centred approach
Method Using Care experience feedback What Matters to Me boards and the conversationalapproach
Outcome Results Improvements in patient experience will be shared using examples ofpractice and care experience feedback
There was no additional funding required for this project We worked in collaboration with theperson centred team whorsquos aim is to improve patient experience
NA5
The implementation of a renal education programme and its impact on clinical practice
The purpose was to implement a Renal Education Programme and to evaluate its impact on
clinical practise
It was identified that there was a need for an educational programme to be set up within Forth
Valley Royal Hospital There is no inpatient renal unit in FVRH on site for our renal patients they
attend Queen Elizabeth University Hospital We are an outpatient haemodialysis unit with
outpatient clinics on site Therefore it was identified that there was a need for nursing staff within
FVRH to be educated on all renal complexities for the benefit of our patients
This was done through a work-based learning approach which brought tangible benefits for our
patients However it did not come without pitfalls as educational programmes are often seen as
making very little difference to clinical practise
T
his study describes what methods were used and examines the advantages and disadvantages in
setting up an educational programme and evaluating its impact on clinical practise
NA6
Nursing Abstract ndash SRA Meeting ndash 26 October 2017
Chris McGee Tonya Broe Ken Weir
Renal Unit Forth Valley Royal Hospital
Use of the Therapy Monitor Haemodialysis Patient Record System Can we aim for a paper-
free dialysis unit
We are trialling a new haemodialysis patient monitoring system to work in conjunction with SERPR
and which is intended to supersede the Finesse system used previously
We are in the early stages of this process but with continuing staff education and regular tech
support we are hoping to gather sufficient evidence to evaluate whether the use of paper case
notes needs to continue
Is it a realistic goal to aim for a completely paper-free unit
NA7
THE CLINICAL USES OF APHERESIS WITHIN NHS TAYSIDE
Laura Thomson CN
Ninewells Hospital Dundee
NHS Tayside took over the apheresis service from BTS in 2012 The service has since expanded
with the benefits of carrying out this treatment has been widely recognised within NHS Tayside
and is now more commonly being offered to treat a wider range of conditions with the number of
treatments carried out each year rising
This presentation will highlight the progression of the apheresis service within NHS Tayside We
will identify the various conditions it is currently being used to treat and also identify the decision
making process involved in carrying out these treatments ie which replacement fluid will be used
anticoagulation medication administered
We will highlight the benefits and challenges we face in providing this expanding service within the
Renal Service
NA8Authors Linda McDougall Renal Physiotherapist NHS Highland
e- mail contact lindamcdougall1nhsnet
Phone contact 01463 706022
Title lsquoExercise on Haemodialysis- Keeping the Wheels in Motionrsquo
Introduction Background The impact of CKD on physical fitness functional ability independence amp ultimately quality of life cannot be underestimated Current national guidelines recommend that all individuals with CKD are encouraged to participate in regular exercise programmes between or during dialysis sessions if on HD Following a successful pilot study funding was approved to establish an lsquoExercise on Dialysisrsquo (EOD) programme across NHS Highland through the appointment of a dedicated renal physiotherapist in 2008 A successful programme was soon established but for several years post-vacancies and increasing in-patient demands limited the physiotherapy servicersquos ability to deliver the programme The need to improve the long-term sustainability of the service was recognised and in late 2016 funding was approved to develop a Band 4 PT HCSW role for this purpose
Aim ObjectiveTo optimise the sustainability and continuity of the lsquoExercise on Dialysisrsquo service across NHSHighland through development of a Band 4 PT HCSW role
Method The potential parameters of the role and limits of autonomy were scoped out using current NES resources and guidelines Service and task analysis was then carried out to establish which components of the EOD protocol could be undertaken by a Band 4 A series of competencies were developed in line with the clinical protocol and one-to-one training and supervision provided to the post-holder to ensure competency achieved in delivering the programme
Outcome Results A 10 WTE Band 4 PT HCSW was appointed in Jan 2017 with a dual role between the renal unit and acute medical wards Although training is not yet complete the post-holder is already running the day-to-day delivery and monthly audit of the EOD service with senior physiotherapist input only required for individual patient safety queries and general discussion around patientsrsquo progress and goals The benefit to the unit has been considerable as the band 4 is available to support patients and staff with EOD provision 5 days a week This allows for one-to-one supervision of patients who need more support to participate in EOD regular feedback on performance and reviews of outcome measures and goals to maintain motivation levels Feedback on the post has been very positive and its scope will only continue to expand as we look to further develop renal rehabilitation services across NHS Highland
NA9Authors Nadine Lyall and Kerry Guthrie
e- mail contact nadinelyallbordersscotnhsuk kerryguthriebordersscotnhsuk
Phone contact 01896 826637
Title The Developing Role of the NMP in a Satellite Dialysis Unit
Introduction Background
We have been practising as NMPrsquos for nearly 3 years working in the dialysis unit at the BGH The unit is a satellite unit of the ERI and we have expanded over the last 6 years The unit provides haemodialysis for 12 patients at any one time 3 sessions a day 6 days a week We are nurse-led and have 2 renal consultants who are based at the ERI
We saw an opportunity to use our knowledge and experience to develop our role By becoming NMPrsquos we have enhanced our professional development and we feel we meet the changing needs of the dialysis patient in a more holistic manner
Aim Objective
Our aim is to deliver effective care as we are better placed to deal with issues that often arise byacting swiftly this in turn is cost effective and convenient For example good anaemia and bonemanagement is important for their health wellbeing and lifespanTo help understand our role we will use a power point presentation highlighting issues we dealwith and the drugs we prescribe under the following headings Cardiovascular infection painanticoagulant disequilibrium diet renal bone disease and renal anaemia
Method Power point
Outcome Results
In the future we hope to further develop and have greater autonomy in our role We have great support from our renal consultants and have already built up a great relationship with our patients We hope to undertake the Clinical Decision Making course and this in turn will allow us to deal effectively with acute illness giving the dialysis patient better care We are keen to get feedback from other renal nurses in Scotland to enable us to develop our role further and in turn raise awareness of the NMP role in a dialysis unit We record all our prescribing decisions and keep the consultants up to date regularly Currently we are working on auditing our prescribing practice so that we can improve the service we can provide
NA10 Title Komunikacja w szkoleniu dializy ortzewnowej
Author Senior Charge Nurse Rhoda Bell
Address Raigmore Hospital Old Perth Road Inverness IV2 3UJ
Email rhodabellnhsnet Telephone 01463706023
Introduction Background Case study on lady with Polish as her first language she has some English but requires an interpreter to carry out Peritoneal Dialysis training and attend clinic She had some gynaecological issues that we were not aware of which impacted on the functionality of PD and therefore the success of treatment There were areas of concern in low clearance clinic with signs the patient had a reluctance to engage in decision making
AimObjective
Methods Discussion through the case study highlighted issues with communication between different PD staff and patients Areas of concern include different staffing techniques environment factors on training success Also language and communication issues the patient had were not fully apparent so training could not be individualised
Results We plan to trial training at home and have more individualised training schedule for patients The training step by step guides have been reviewed and practise standardised In collaboration with low clearance nurse we have developed a check list which will highlight concerns before the transition to PD ie language issues and need for training aids in another language gynaecological conditions
Conclusions Everyone learns differently and training methodsaids must be individualised for all It may not be apparent until training has commenced that there are concerns Having one to one training with the same nurse will consolidate training and build confidence in the patient Having a close working relationship with members of the MDT will help make a supportive PD journey
Would we do things differently if we knew about prolapse or lack of English both spoken and written
Key words - Peritoneal dialysis patient training communication
N11
Telehealth amp PDAudrey Jones
Advantages
Information on a daily basis about treatment weight and blood pressure
Change programme remotely via computer or mobile
Earlier intervention for machineprogramme issues
Reduction in home visits ie patient trained but still requires volume increases
No need to download cards to see what problems have been
Can have more detailed information available at clinics
Disadvantages
Relying on patient input data correctly
Machine is noisy especially first wave of machine
Still the same bag connection system and patient connection system (difficult for manual
dexterity problems)
Relying on patient having good signal
Modem problems
NA12Autosomal Dominant Polycystic Kidney Disease A cruel inheritance but new hopeAlistair Lawrie Renal Unit Victoria Hospital KirkcaldySadaf Arshad Corry Dunnigan Paul Phelan Neil Turner Renal Unit Royal Infirmary of Edinburgh
Background Autosomal Dominant Polycystic Kidney Disease (ADPKD) is the most prevalent single gene human genetic disorder and the most common of the inherited cystic and interstitial kidney diseases It is estimated to affect 1 in every 1000 individuals worldwide with over 50 of sufferers eventually developing end stage kidney disease and requiring dialysis or transplantation Symptoms include spasmodic severe pain hypertension haematuria infection and kidney failure There is currently no cure for ADPKD Management of the condition has traditionally involved lifestyle modification BP control and analgesia however a recent study (Torres et al 2012) demonstrated that treatment with V2-receptor antagonist drugs slowed increase in total kidney volume reduced the rate of functional decline and showed a reduced incidence of kidney pain
Aim Provision of a tolvaptan prescribing and monitoring service
Methods Experiential finding report of initial twelve months period of multidisciplinary ADPKDtolvaptan clinic
Results Early results are comparable with TEMPO study outcomes
Conclusion Due to the long term nature of this treatment results available at this time are showing only the earliest benefits of the intervention More quantifiable results such as increased time before the necessity for RRT will only be evident in coming years Torres VE et al (2012) Tolvaptan in Patients with Autosomal Dominant Polycystic Kidney Disease New England Journal of Medicine 367 pp 2407-2418 DOI 101056NEJMoa1205311
No funding requirement No conflict of interest
A8 Predictors of transplant failure in patients undergoing indication renal biopsy
Kate Stevens 1 Bruce Mackinnon1 David Kipgen1 Shana Coley1 Marc Clancy1 Colin Geddes1
1Renal and Transplant Unit QEUH NHS GGampC Glasgow United Kingdom
Introduction This study considers indication renal biopsies and factors which may be important
predictors of transplant loss and patient death
Objectives To identify the time line of histological diagnosis from transplant in our population
and to identify predictors of graft and patient survival in those undergoing indication renal biopsy
Methods All indication renal biopsies undertaken between 012011 and 122015 were identified
Demographic data including immunological and outcome data was recorded Statistical analysis
was undertaken in SPSS (v22)
Results 354 patients underwent 549 biopsies Mean patient and transplant age at time of biopsy
was 432 plusmn153 and 42plusmn58 years respectively 449 (n=247) of biopsies showed evidence of
Cell mediated rejection (CMR)ABMR or both 93 (n=51) demonstrated features of chronic
transplant glomerulopathy (CTG) DSA was present at the time of biopsy in 231 (n=127) In
transplants aged le 6 months old histological diagnosis was CMR in 325 (n=69) with ABMR seen
in 28 (n=6) In transplants aged ge10 years CTG was seen in 325 (n=26) with ABMR
accounting for 63 (n=5) 229 (n= 81) of transplants failed at a median of 182 days from most
recent biopsy On cox regression analysis peritubular capillary (PTC) C4d and CTG were
independent predictors of transplant failure Probability of transplant failure was 45 and 50 at
one year if mixed rejection or CTG were present 93 (n=33) patients died at a median of 227
days from most recent biopsy Independent predictors of death included deceased donor
transplant patient age and presence of ABMR on biopsy (plt005)
Conclusion Acute ABMR is a risk factor for patient loss whilst chronic ABMR is a risk factor for
transplant loss This association is independent of DSA but dependent upon PTC C4d staining
indicative of donor humoral activity ndash HLA or otherwise Histological diagnosis in an indication
biopsy is an important factor in predicting outcome This study is limited by the inherent bias in
patient selection with indication biopsy
Disclosure of Interest None Declared
A9 Renal Evaluation of Paediatric Patients with Tuberous Sclerosis Complex (TSC) in aNational TSC Multidisciplinary ClinicDr Jenny Patterson 1 Dr Shelagh Joss 1 Dr Ihab Shaheen 2
1 Clinical Genetics Queen Elizabeth University Hospital Glasgow 2 Paediatric Nephrology Royal Hospital for Sick Children Glasgow
Introduction Tuberous sclerosis complex (TSC) is a dominantly inherited multisystem disorder characterised by development of hamartomas (benign lesions) in multiple organs Previous studies have shown that renal manifestations are common in TSC and also the most frequent cause of TSC-related death in affected individuals With the recent discovery of targeted therapy with mTOR inhibitors early recognition of renal involvement allowing early surveillance and prompt therapy is now more important than ever
AimMethod To review a population of paediatric patients attending a large specialist TSC service in the UK both in terms of key clinical characteristics and current practice for renal radiological surveillance data were collected from electronic medical records pertaining to molecular diagnosis renal surveillance and presence or otherwise of sequelae affecting the renal or other systems Practice was compared to published surveillance recommendations of the International Tuberous Sclerosis Complex Consensus Group (2013)
Results Data were obtained for 41 children (18 males 23 females) Current age range 25 years to 14 years (mean 98 years) Twenty nine patients (707) were diagnosed lt1 year of age Genetic data were available for 29 patients Fifteen patients had a confirmed TSC1 mutation and 14 patients a confirmed TSC2 mutation including one contiguous PKD1 mutation Renal imaging (all US) within a year of diagnosis was documented in 2541(61) performed at a mean age of 3 years Renal symptoms at diagnosis were documented in 741(171) and 941(22) had renal abnormalities on baseline imaging There was wide variability in scanning interval and modality with 1041(243) having previous abdominal MRI with variable documented indication Seventeen (414) of the cohort mean age 102 years had documented renal lesions 917 angiomyolipomas 517 cysts and 317 both These lesions were diagnosed at a mean age of 6 years (range 02 years-142 years) Six patients (353) had normal baseline scans with a mean interval to lesion diagnosis of 1 year One patient had a lesion on MRI not detected on US that required subsequent biopsy Frequency of subsequent scanning ranged from intervals of 2 months to 1 year with a combination of MRIUS in an unclear pattern All patients except one with a contraindication were undergoing current brain surveillance by MRI
Conclusions Our results highlight the significant incidence of renal sequelae within our TSC cohort with renal manifestations ranging both in severity and age of onset International guidelines recommend MRI scanning for renal surveillance at diagnosis and throughout life Benefits of MRI include enhanced accuracy of sizing and characterisation of renal lesions The majority of our cohorts are already undergoing brain MRI surveillance It is our aim to combine and standardise MRI renal surveillance for this cohort to facilitate early and regular monitoring with a view to early intervention is possible
A10 Effect of blood temperature monitoring on intradialytic hypotension in patients with end stage renal disease requiring haemodialysis Heather Walker1 Susan McGeorge1 Drew Henderson2
1 Renal Unit Ninewells Hospital Dundee2 Regional Renal Centre Waikato Hospital Hamilton New Zealand
Background KDIGO define intradialytic hypotension (IDH) as a reduction in systolic bloodpressure (SBP) ge20mmHg or mean arterial pressure (MAP) ge 10mmHg with associatedsymptoms IDH is a common complication of haemodialysis (HD) and is associated with increasedmortality and morbidityStandard dialysis with a set temperature leads to thermal gain during the dialysis session Tocounteract this thermal gain vasodilation occurs and is postulated as one of the causes of IDHActive cooling of dialysis has been shown to reduce IDH but is not routinely applied across wholedialysis populations Isothermic dialysis can be achieved by controlling blood temperature on HDWe report here our experience of doing this using the Blood Temperature Monitoring (BTM)function on Fresenius 5008 dialysis machines
Methods An observational study was performed to assess the rates of IDH in patients with End Stage Kindey Disease (ESKD) undergoing regular satellite HD at NHS Tayside in July 2017 Rates of IDH were assessed (KDIGO definition) for two weeks prior to BTM settings being activated and for a two week study period after introduction SBP and MAP data was collected SBP data was grouped to either SBP decrease lt20mmHg or SBP decrease ge20mmHg compared with Pre HD BP Changes in MAP were also analysed at the same time points Patient reported symptoms related to initiation of BTM were also collected for the same time period
Results 402 dialysis sessions were evaluated in the pre intervention time period and 399 sessions post intervention
IDH 1072 vs 778 (Pre BTM vs Post BTM) p=015 gt20mmg SBP drop Pre vs Post BTM
Mean MAP Change (mmHg) Pre BTM vs Post BTM
1st BP 254 vs 204 (p=005) -522 vs +312 (plt001) 2nd BP 474 vs 435 (p=023) -1589 vs -886 (plt001) 3rd BP 515 vs 435 (p=003) -1862 vs -958 (plt001) Post HD 408 vs 338 (p=003) -1164 vs -077 (plt001)
Following the introduction of blood temperature monitoring only 08 of HD sessions reported experiencing cold or shivering symptoms
Conclusion The use of blood temperature monitoring was not associated with a statistically significant decrease in rates of IDH There was a significant reduction in the number of sessions where SBP decrease by gt20mmHg at the first and third HD BP and a reduction in MAP change across the study group Further evaluation of BTM is required assess its clinical utility in our HD population
Funding No funding was sought for this study
Conflicts of interest None
A11 Evaluating patient satisfaction and clinical outcomes of a new nurse-led dermatology clinic for patients attending the renal transplant clinic Campbell G Naismith K Neil A Rankin A Spalding E (joint first authors) Renal Unit University Hospital Crosshouse Kilmarnock UK
BACKGROUND National Guidelines advise that renal transplant recipients should receive annual skin surveillance to screen for skin cancer In August 2015 a specialist nurse-led dermatology clinic was set-up alongside the renal transplant clinic at University Hospital Crosshouse We aimed to evaluate the success of this joint clinic in terms of clinical outcomes and patient satisfaction
METHODS Clinical records were reviewed to determine the number of patients under dermatology follow-up before and after initiation of the joint clinic and to review cases that were referred for treatment of pathological skin lesions A questionnaire was also distributed to patients attending the new joint renal-dermatology transplant clinic The questionnaire consisted of 5 questions 2 for patient demographics 1 for current understanding of skin care advice and 2 to assess their satisfaction of the new joint clinic
RESULTS A total of 138 and 146 renal transplant recipients were registered on renal transplant clinic lists in 2015 and 2016 respectively Prior to initiation of the new joint-clinic 41 patients had attended dermatology (37 in NHS Ayrshire and Arran and 4 in NHS Greater Glasgow and Clyde) consisting of 30 of the transplant population In September 2016 13 months after initiation of the new clinic 60 patients had attended the new clinic increasing the proportion of patients meeting the national recommendation for skin surveillance to 41 Implementation of the new clinic resulted in patients being 65 more likely to have received the recommended skin checks (odds ratio 165 95 CI 101-270 p=004)
32 patients completed the questionnaire The median age of transplant was 90 years (IQR 38-153) 100 of patients knew to avoid sun exposure and 31 (96) knew to use sunscreen 29 (91) patients were aware of the advice to undergo annual skin surveillance by dermatology with 28 (88) having had a skin check in the last year 29 (91) patients reported that they found the new joint clinic useful although only 18 (56) had attended the clinic so far
CONCLUSIONS Implementation of a new nurse-led dermatology clinic running in parallel with the renal transplant clinic resulted in a considerable increase in the proportion of patients meeting national recommendations for annual skin surveillance The vast majority of patients also found the combined clinic to be useful There is still considerable room for improvement in order to achieve the target of 100 compliance with skin surveillance and ongoing clinical audit is required to assess progress We believe this model would be easily implementable at other units with similar benefits expected
A12 Pneumocystis pneumonia prophylaxis post-renal transplant increased duration of co-trimoxazole is safe and effective FA Chapman JE Dickerson M Clancy C Daly C Geddes Renal amp Transplant Unit Queen Elizabeth University Hospital Glasgow
Introduction All renal transplant recipients receive Pneumocystis jirovecii prophylaxis usually with co-trimoxazole Guidelines suggest this should be continued for 3 to 6 months Our unit previously prescribed 3 months however following an outbreak of Pneumocystis pneumonia (PCP) infection this was increased to 6 months Given its constituents of sulfamethoxazole and trimethoprim co-trimoxazole prophylaxis may influence the frequency of urinary tract infection (UTI) We aimed to compare the frequency of UTI between patients on 3 months vs 6 months prophylaxis and assess rates of multi-drug resistant organisms We also sought to establish if the increased duration of co-trimoxazole was adversely affecting renal function potassium concentration white cell and platelet count and dosing of mycophenolate mofetil
Methods A retrospective search of the West of Scotland Electronic Renal Patient Record was conducted for all renal transplant recipients between 1st January 2012 and 31st May 2016 Patients were grouped according to the intended duration of co-trimoxazole Data were extracted for baseline characteristics co-trimoxazole prescription mycophenolate mofetil (MMF) prescription laboratory results (creatinine potassium white cell count platelets) at 3 6 9 and 12 months post-transplant and microbiology results for 6 months post-transplant Results were analysed on an intention to treat (ITT) basis with a second analysis according to actual duration of co-trimoxazole treatment (AT) Subjects with transplant failure had laboratory results censored from the time of transplant failure and all of their microbiology results were excluded
Results 609 renal transplants were performed over the study period On ITT analysis there were 418 patients in group 1 (ITT1 3 months co-trimoxazole) with 15 transplant failures and 191 patients in group 2 (ITT2 6 months co-trimoxazole) with 12 transplant failures There was a significant difference in the number of patients with at least one UTI with fewer in ITT2 (ITT1 133403 vs ITT2 42179 p = 001) However this was not present when comparing actual treatment duration (AT1 111345 vs AT2 36149 p=007) Overall there was a similar spectrum of organisms cultured There were significantly fewer cultures of multi-resistant organisms in both ITT and AT analyses with 6 months of co-trimoxazole (ITT1 28376 vs ITT2 0106 p= 0004 AT1 22313 vs AT2 198 p = 002) There was no difference in estimated Glomerular Filtration Rate serum potassium concentration platelet count or MMF dose On AT analysis there was a significant difference in the total white cell count (WCC) and lymphocyte count at 6 months post-transplant (WCC 78 x10^5L vs 71 x10^5L p =004 lymphocytes 13 x10^5L vs 12 x10^5L p=002) There were 18 cases of PCP with 7 deaths attributable All cases occurred after cessation of co-trimoxazole prophylaxis (81 ndash 913 days after stopping co-trimoxazole)
Conclusion Although there is a significant difference in UTI frequency on ITT analysis this is not present on AT analysis suggesting no real co-trimoxazole effect There was no increase in frequency of multi-drug resistant organisms with a longer course of co-trimoxazole Renal function and serum potassium were unaffected Our findings support continuing co-trimoxazole prophylaxis for at least 6 months
A13 Kidney transplantation in the over 60rsquos in Scotland 1996-2015 TJW Rennie1 P Phelan1 J Campbell2 JP Traynor2 L Henderson1 W Metcalfe2 On behalf of the Scottish Renal Registry 1Renal transplant unit Royal Infirmary Edinburgh 2NHS National Services Scotland Introduction The proportion of older kidney transplant recipients has increased in the UK but
long term outcome data are scarce We aimed to evaluate patient and graft survival in patients
ge60 years of age receiving a first kidney only transplant in the last 20 years in Scotland
Methods Retrospective analysis of Scottish Renal Registry data of incident Renal Replacement
Therapy (RRT) patients and those in receipt of a kidney only transplant performed 1996-2015
(follow up until 311216) Patients were stratified by age 60-69 ge70 (group 1 and 2 respectively)
and decade of transplantation 1996-2005 2006-2015 (decades 1 and 2 respectively)
Results 6743 patients aged ge60 started RRT from 1996-2016 Of those 108 were ever
transplant-listed 54 had received a transplant by 311216 26 listed and 11 transplanted
were aged ge70
535 patients aged ge60 received a kidney only transplant in 1996-2015 90 patients (168) were
aged ge70 no patients were aged ge80 Mean time from wait listing until transplantation was 33plusmn24
years (plusmnSD) and from starting RRT until transplantation was 38plusmn26 years (plusmnSD) One and five
year graft survival was 97 and 87 in decade 1 95 and 89 in decade 2 (p=NS) there was
no difference in graft survival between age groups 1 and 2 One and five year patient survival was
94 and 78 in age group 1 85 and 56 in group 2 (plt0001) there was no difference in one
and five year patient survival between the two decades
Conclusion One and five year graft and patient survival in renal transplant recipients aged ge60
have not changed significantly in the last 20 years Recipient age ge70 is not associated with
reduced graft survival but patient survival from time of transplant is lower in this age group
compared to recipients aged 60-69
No conflict of interest to be declared No funding received
A14 High Mortality In Older Patients With Primary Nephrotic Syndrome Sarah Beverstock Wendy Metcalfe amp Robert W Hunter Department of Renal Medicine Royal Infirmary of Edinburgh
Introduction
Nephrotic syndrome can develop at any age and may be due to a primary glomerular lesion or secondary to systemic disease The natural history of glomerular disease can be different in older patients For instance minimal change disease (MCD) in children almost always remits promptly with steroid therapy in adulthood it typically remits only after many weeks of steroids or with adjunctive immunosuppression However there are remarkably few published data on the mortality of primary nephrotic syndrome in adults We aimed to study this in our centre
Methods
We enrolled all adult patients who had a kidney biopsy in order to investigate nephrotic syndrome over 38 consecutive months (01 Jan 2014 ndash 28 Feb 2017) We defined nephrotic syndrome as heavy proteinuria (urinary proteincreatinine ratio UPCR gt350 mgmmol or albumincreatinine ratio gt220 mgmmol) and hypoalbuminaemia (serum albumin lt35 gL) In our analysis we included all patients in whom nephrotic syndrome was attributed to a primary glomerular disease We excluded kidney transplant recipients and patients in whom biopsies were performed to follow up a known glomerular disease We collected laboratory data at baseline (time of biopsy) and at 6 and 12 months We assessed patient survival by Kaplan-Meier analysis
Results
Of the 117 patients biopsied for nephrotic syndrome 71 patients (61 ) met the inclusion criteria and were followed up for a median of 469 days We compared outcomes in patients aged under 60 years old (n = 35) with those aged over 60 (n = 36) Mortality was higher in the older group (37 vs 4 mortality at one year p lt005 by logrank test) There were no significant differences between the two groups in serum creatinine or UPCR at any time Serum albumin was similar in both groups at baseline and at 12 months but was lower in the older group at 6 months (27 vs 32 gL p lt 005) Baseline haemoglobin was lower in the older group (114 vs 130 gL p lt005 by unpaired t-test) Primary diagnoses were MCD (n = 10 in younger group amp n = 5 in older group) membranous nephropathy (5 amp 10) IgA nephropathy (9 amp 8) FSGS (5 amp 5) membranoproliferative glomerulonephritis or C3GN (4 amp 7) and other (2 amp 1) Therefore unsurprisingly there were relatively fewer cases of MCD and more cases of membranous nephropathy in the older group otherwise the causative glomerular lesions were similar in both groups In those patients with MCD mortality was significantly higher in the older group none of the 10 patients with MCD diagnosed under 60 yrs old died during the follow-up period whereas 4 of the 5 older patients died 3 patients in the younger group and 1 in the older group were on renal replacement therapy (dialysis or transplant) by the end of follow-up
Conclusions
Primary nephrotic syndrome is associated with high mortality in the over 60s (37 at one year) Mortality was high even for MCD a disease that follows a benign course in childhood and early adulthood The higher mortality in older patients was not associated with greater severity of renal disease at presentation (as assessed by basic blood and urine parameters) This work was not funded we declare no conflicts of interest
A15 Renal biopsies in patients with diabetes mellitus in Scotland
Udana Ratnapala 1 Nicola Joss 2 Colin Geddes 3 Dana Kidder 1
1 Renal Unit Aberdeen Royal Infirmary Aberdeen 2 Renal Unit Raigmore Hospital Inverness 3 Glasgow Renal and Transplant Unit Glasgow
Introduction Diabetes mellitus is the leading cause of end-stage kidney disease (ESKD) requiring renal replacement therapy The utility of renal biopsy in patients with diabetes mellitus is controversial Broadly renal biopsy findings in patients with DM can be divided into diabetic nephropathy (DN) alone DN with non-diabetic renal disease (NDRD) or NDRD alone Timely identification of patients with NDRD is important to provide appropriate therapeutic measures Previously published guidelines on clinical predictors of NDRD have limited specificity and sensitivity The frequency of NDRD in renal biopsies of patients with DM is unclear in ScotlandThis study aimed at identifying the frequency and the pathology spectrum of NDRD in diabetic patients underwent kidney biopsy in 3 renal units
Methods A retrospective observational study was performed on clinical-pathologic findings in all patients with diabetes mellitus who underwent renal biopsy between 01012010 and 31122016 in 3 renal units (Aberdeen Inverness and Greater Glasgow) Data were gathered from electronic patient record systems Scottish Index of Multiple Deprivation (SIMD) 2012 was used to analyse correlation with patient outcomes
Results 247 patients were included 150 men (607) 217 type 2 DM (879) mean age 621 years and mean serum creatinine at the time of renal biopsy of 261 micromolL (+-190 std) On biopsy 92 patients (372) had DN while 127 (514) had NDRD and 28(114) had NDRD superimposed on DN The commonest NDRD aetiologies were IgA nephropathy (187) tubulointerstitial nephritis (168) and idiopathic membranous nephropathy (103) Predictors of NDRD were age (OR 1027 95 CI 1002-1052 p=003) duration of DM (OR 094 95 CI 0900-0987 p=001) and absence of AKI as indication for biopsy (OR 022 95 CI 0059-0826 p=0025) There was no significance difference in renal or patient survival in DN and NDRD Finally no significant correlation was depicted between SIMD quintiles and renal or patient survival in both groups
Conclusions The majority of renal biopsies carried out in patients with DM revealed a NDRD In this study age at the time of biopsy duration of DM and AKI were the main pointers towards NDRD Renal and patient survival were not significantly different between DN and NDRD groups
A16 The Impact of Withdrawal of Maintenance Immunosuppression and Graft Nephrectomy on HLA Sensitisation Ailish Nimmo1 Sophie McIntyre1 Lorna Henderson1 Richard Battle2
(1 Department of Renal Medicine Royal Infirmary of Edinburgh 2 Histocompatibility and Immunogenetics Royal Infirmary of Edinburgh)
Background The development of HLA antibodies towards a failing renal allograft is a barrier to re-transplantation We previously demonstrated an increase in HLA antibodies and calculated reaction frequency (cRF) following nephrectomy but results were confounded by immunosuppression changes occurring in close time proximity We examined the formation of HLA donor specific antibodies (DSA) in patients with failed grafts that remained in situ and compared results with patients undergoing graft nephrectomy to further assess the relative impact of nephrectomy and immunosuppression weaning on sensitisation and chance of transplant
Methods We carried out a single centre retrospective study of all patients with failed grafts in Lothian from 2005 to 2015 Samples were tested for DSA pre-immunosuppression (IS) wean post-IS wean and post-IS cessation Nephrectomy patients also had samples tested for DSA before and after nephrectomy Data on other sensitising events including blood transfusion and rejection were collected cRF was determined at each time point and entered into the ODT chance of transplant calculator with other demographics based on the average patient from the Edinburgh centre
Results 62 grafts failed over this time period Blood samples were available 41 patients (24 with nephrectomy 17 with failed graft left in situ) Patient demographics were similar between groups There was a higher rate of antibody mediated rejection in the nephrectomy group (46 vs 18) 76 of patients with nephrectomy group had received a blood transfusion The pattern of immunosuppression weaning was similar but median time from start of IS wean to cessation was longer in the nephrectomy group (350 vs 298 days) The changes in cRF and chance of transplant (COT) with immunosuppression weaning are shown in Table 1
Pre-IS Wean Post-IS Wean
Failed graft in situ (n=17)
Mean CRF COT at 5
years 15 62 38 59
Nephrectomy (n=24)
Mean cRF COT at 5
years 54 54 69 46
Post-IS Stop 55 53 89 42 Table 1 Mean cRF and Chance of Transplant (COT) at 5 years with IS alterations
Discussion A stepwise increase in cRF with reduced chance of transplant was observed in both groups as immunosuppression was withdrawn with a similar pattern of change irrespective of graft nephrectomy cRF was higher in the nephrectomy group despite a more gradual wean which may reflect a higher rate of antibody mediated rejection and increased number of patients receiving a blood transfusion The risks and benefits of stopping immunosuppression need to be carefully considered on an individual basis to maximise chance of future transplant
The authors have no conflicts of interest No funding was required for this study
A17 Obesity is not associated with progression to end stage renal disease in patients withbiopsy-proven glomerular diseases
Benjamin Elyan Jennifer S Lees Bruce Mackinnon Jonathan G Fox Colin C Geddes Emily PMcQuarrie
Glasgow Renal and Transplant Unit Queen Elizabeth University Hospital Glasgow
Introduction - Addressing risk factors for renal progression is a key aspect of managing chronic kidney disease (CKD) Body mass index (BMI) has been shown to impact on renal progression in unspecified CKD The aim of this study was to evaluate if there was an association between BMI and progression to renal endpoints in patients with biopsy-proven primary glomerular disease (GN)
Methods - We included all adult patients diagnosed with biopsy-proven primary GN (excluding minimal change nephropathy) in Greater Glasgow amp Clyde and Forth Valley between 01012000 and 31122015 Biochemical and anthropometric data were extracted from the electronic patient record at time of biopsy with follow-up data until 20062017 BMI was calculated from height and weight at time of biopsy and categorised into groups BMI le25 kgm2 (G1) gt25 to le30 kgm2 (G2) and gt30 kgm2 (G3 - obese) We assessed factors associated with reaching a combined renal endpoint of CKD5 or renal replacement therapy (RRT) with competing risk of death using the Fine and Gray subdistribution hazard model Analyses were conducted using cmprsk package for R statistical software package and SPSS version 24
Results - 560 patients with primary GN and available BMI data were included The average age was 532 years and 339 were female There were 132 patients in G1 210 in G2 and 207 patients in G3 Those in G2 and G3 were older (p=002) with slightly higher diastolic blood pressure (p=002) than those in G1 There was a greater proportion of focal segmental glomerulosclerosis in G3 but similar proportions of other GN diagnoses across groups There was no significant difference in baseline serum creatinine (sCr) (p=034) or log uPCR (p=045) between BMI groups On multivariate analysis age systolic blood pressure BMI or GN diagnosis were not predictive of renal outcome Higher baseline sCr (SHR 1003 per 1 umoll increase in sCr 1001-1004 plt0001) and log uPCR (SHR 130 per unit increase in log uPCR 95 CI 105-160 p=002) were associated with progression to the combined renal endpoint accounting for competing risk of death BMI was not associated with reaching combined renal endpoint on univariate analysis whether considered as a continuous variable (SHR=100 95 CI 098-102 p=096) or categorised by BMI group
Conclusion - Contrary to our expectations there was no association between BMI and progression to a combined renal endpoint of CKD5 or RRT in this cohort of patients with primary GN Efforts should be directed to managing other known risk factors for CKD progression
Sources of FundingConflicts of Interest - None
A18 Factors influencing long term renal function after living kidney donation
Matthew A Rutherford Norman J Galbraith Marc Clancy Colin C Geddes
Glasgow Renal and Transplant Unit Queen Elizabeth University Hospital Glasgow UK
Background Following live donor nephrectomy the remaining kidney undergoes an increase in filtration capacity known as compensatory hypertrophy Few cohorts with follow up of renal function beyond 5 years have been reported The impact on long term renal function of variability in donor factors such as age sex pre-donation blood pressure and glomerular filtration rate (GFR) is unknown Increasingly kidney donors have potential risk factors for future poor renal function such as hypertension older age and obesity The aim of this study was to analyse factors influencing long-term renal function in living kidney donors from our centre
Method Data were obtained from the electronic patient record Patients with a recorded procedure of lsquolive donor nephrectomyrsquo between 2005 and 2017 were identified GFR after donation (calcGFR) was calculated using the formula lsquocalcGFR = Pre-donation Isotope GFR x (Pre-donation Serum creatinine Serum Creatinine)rsquo which is accurate assuming muscle mass does not change Pre and post donation serum creatinines (two days two weeks three months and one to ten year) were recorded We analysed the influence of age sex pre-donation GFR and blood pressure on post donation GFR compensation
Results 355 live donor nephrectomies were performed between January 2005 and December 2016 The mean age was 469 (plusmn 116) years and 504 (n=179) were female Mean pre-donation isotope GFR was 937 plusmn 156 mlmin173m2 Median follow up was 2 years (IQR 1 to 6 years with range 2 weeks to 10 years) The calculated percentage of pre-donation GFR at 2 days 2 weeks 3 months 1 year 5 years and 10 years were 698 691 712 730 801 and 950 respectively (p lt 0001) Patients aged lt50 y had not only a higher calcGFR (858 plusmn 29 mlmin173m2 compared with 671 plusmn 28 mlmin173m2 p lt 0001) at 5 years following donation but achieved a higher degree of compensation than donors gt 50 y (836 plusmn 16 compared with 756 plusmn 19 (p = 0002) Patients with pre-donation hypertension achieved 774 plusmn 53 of pre-donation GFR compared with 804 plusmn 32 in normotensive patients (p = 0998) Females had equivalent degree of renal compensation achieving 819 plusmn 19 compared with 780 plusmn 16 in males (p = 0131) at 5 years following donation Patients with pre-donation GFR gt 100 mlmin173m2 achieved 844 plusmn 23 of pre-donation function by 5 years compared with 777 plusmn 14 in those with pre-donation GFR lt 100 mlmin173m2 (p = 001)
Conclusion Following live donor nephrectomy renal function has a nadir of 691 at 2 weeks Compensation in GFR occurs rapidly and appears to be maintained regardless of sex and pre-donation blood pressure Younger age and higher pre-donation GFR were associated with a greater degree of compensation
A19 The utility of high-sensitivity cardiac troponin to stratify cardiovascular risk in patients with renal impairment
Eve Miller-Hodges Atul Anand Anoop S V Shah Nicholas L Mills Neeraj Dhaun
Background Cardiovascular disease is the most common outcome of chronic kidney disease1
Declining glomerular filtration rate (GFR) and proteinuria predict increased cardiovascular risk over the long term2 However there are currently no methods to stratify cardiovascular risk in the short or medium term in patients with renal impairment We have already shown that high-sensitivity cardiac troponin I concentrations (hs-cTnI) lt5ngL in patients presenting with symptoms of acute coronary syndrome identifies those at low risk of cardiac events within 30 days and over the next year3 However uncertainty remains over the role of hs-cTnI testing in patients with renal impairment This study investigated whether hs-cTnI could also stratify future cardiovascular risk in patients with renal impairment
Methods In a prospective study of consecutive patients presenting with suspected acute coronary syndrome we evaluated the performance of hs-cTnI in patients with and without renal impairment (estimated glomerular filtration rate lt60mLmin173m2) using an early risk stratification threshold of 5ngL to ldquorule outrdquo acute myocardial infarction at presentation and within 30 days and sex-specific 99th centile diagnostic thresholds for index type 1 myocardial infarction Subsequent type 1 myocardial infarction and cardiac death were reported at one year
Results Of 4726 patients identified 904 (19) had renal impairment Index diagnosis of type 1 and type 2 myocardial infarction was almost twice as likely in patients with renal impairment (30 vs 15) Performance of the early risk stratification threshold of 5ngL to identify patients at low risk of major cardiac events was similar in patients with (NPV 984 95CI 960-997 sensitivity 989 95CI 975-999) and without renal impairment (NPV 997 95CI 994-999 sensitivity 984 95CI 972-994) These patients continued to remain at low risk over the next year The PPV and specificity at the 99th centile for diagnosis of myocardial infarction were lower in patients with renal impairment at 500 (95CI 452-548) and 709 (95CI 675-742) respectively compared to 624 (95CI 588-659) and 921 (95CI 912-930) At one year 24 of patients with renal impairment and troponin gt99th centile regardless of index diagnosis had experienced further myocardial infarction or cardiac death compared with 10 of patients without
Conclusion In suspected acute coronary syndrome hs-cTnI can stratify risk in patients with renal impairment Irrespective of diagnosis patients with renal impairment and elevated cardiac troponin concentrations had two-fold greater risk of a major cardiac event compared to those with normal renal function and should be considered for further investigation and treatment
Funders Wellcome Trust British Heart Foundation and Chest Heart amp Stroke Scotland
1 Gansevoort RT Lancet 2013
2 Chronic Kidney Disease Prognosis Consortium Lancet 2010
3 Shah AS Lancet 2015
A20 lsquoDOES IT DIALYSE OUTrsquo - THE EFFECT OF RENAL REPLACEMENT THERAPY ON THE BRAIN Mark Findlay Jesse Dawson David Dickie Deborah McGlynn Patrick Mark Institute of Cardiovascular and Medical Science University of Glasgow amp Queen Elizabeth University Hospital Glasgow
Introduction Cerebrovascular disease is common in end-stage renal disease (ESRD) on renal replacement therapy (RRT) We investigated the effect of RRT on cerebral structure and cognitive function over 12 months Methods Observational cohort study in ESRD patients receiving HD Prior cognitive impairment or cerebrovascular disease were exclusion criteria Multi-domain cognitive testing was performed at baseline and at follow-up Transcranial Doppler was used to assess intra-dialysis related alterations in mean flow velocity (MFV) ndash a marker of cerebral blood flow MR imaging was performed at 0 and 12 months We performed T1 T2 FLAIR and DWI sequences and used volumetric software to calculate white matter hyperintensity (WMH) burden markers of atrophy mean diffusivity and fractional anisotropy (FA) to describe structural changes at 1 year Results 97 patients median age 59 years 412 female At follow-up 15 patients were transplanted 6 died 4 withdrew and the remainder continued HD Those who were transplanted were younger (median age 51 vs 60 years p=0019) and had been on dialysis for a shorter period (median 06 vs 21 years p=0003) MFV declined during HD median 475cms to 405cms plt0001 and correlated with lower scores of executive and frontal lobe function during HD (Rho 045 p lt0001 and Rho -0313 p lt001 respectively) In all patients MR imaging demonstrated a significant decline in frontal parietal and temporal lobe volume at follow-up Median WMH volume increased in those who remained on HD but not in transplanted patients (median change 023 vs -012ml p=0018) WMH burden correlated with worsening scores of frontal lobe tests Rho 0585 p0005 and worse mood Rho -0485 p0026 FA improved following renal transplant (028 to 029 p=0016) and correlated with improved executive function testing at follow-up Rho 089 p0019 Conclusion Cerebral blood flow is reduced during haemodialysis and correlates with a reduction in intradialytic executive function There is an improvement in FA following transplantation WMH volume increases in those who remain on dialysis and the degree of increase correlates with executive and frontal lobe function This suggests that haemodialysis is associated with clinically significant changes in the brain and that these may be ameliorated by transplantation
Source of fundingconflicts MF is funded by a KRUK fellowship
A21 Pathological classification of IgA nephropathy to predict renal outcomes ndash is there a better way to score tubulointerstitial inflammation
Alastair Rankin David Kipgen Bruce Mackinnon Jonathan Fox Colin Geddes Emily McQuarrie Glasgow Renal and Transplant Unit On behalf of the Scottish Renal Biopsy Registry
Background The Oxford pathological classification of IgA nephropathy (IgAN MEST-C score) is limited by the fact that individual features of the score are not all predictive and its utility in assisting clinical decision-making is questioned The addition of tubulointerstitial inflammation to the existing scoring system is appealing but is not currently included due to reportedly wide inter-observer variability We report a novel method to score percentage of cortex containing tubulo-interstitial inflammation in non-atrophic renal cortex (ATIN) in patients with IgAN similar to that used in transplant biopsy reporting and assess its utility to predict clinical outcomes
Methods All adult patients with a native renal biopsy diagnosis of IgAN between 2010 and 2015 in a unit serving 15 million people were identified Baseline characteristics biopsy reports and outcome data were collected ATIN was calculated by subtracting the percentage of atrophic cortex from the percentage of total cortex with tubulo-interstitial inflammation withge10 representing significant tubulo-interstitial inflammation in non-atrophic cortex The primary outcome was a composite of requiring renal replacement therapy (RRT) or doubling of serum creatinine (sCr)
Results 153 new cases of IgAN were identified 33 were excluded (24 had lt8 glomeruli on biopsy 6 inadequate biopsy for MEST scoring and 3 on RRT at time of biopsy) In addition patients with a tubular atrophy (T) score of 2 were also excluded (n=9) Of the remaining 111 patients 76 (68) were male Mean age at biopsy was 52 years (+- 167) and 18 (16) had a co-existing clinical diagnosis of henoch-schonlein purpura (HSP) Median sCr was 156 micromoll (IQR 101-212) and 54 (49) had ATIN on biopsy During a median follow-up of 23 years 34 (31) reached the primary outcome 20 (18) received immunosuppression and 16 (14) died On univariate Cox regression survival analysis ATIN was associated with a four-fold increase in the primary outcome (HR 49 (21-113)) On multivariate analysis mesangial hypercellularity (M) T and ATIN independently predicted renal outcome while endocapillary proliferation (E) and segmental sclerosis (S) did not (plt002 for ATIN) Excluding patients with HSP or those who received immunosuppression did not change the result
Conclusion Within our centre ATIN predicts renal outcome for IgAN independently of established histological features Assessment of inter-observer reproducibility and validation in other cohorts is still required but these results suggest ATIN could be a worthwhile addition to current pathological scoring systems for IgAN
Source of funding none Conflicts of interest none
P1 Polypharmacy in Renal Replacement Therapy Patients
Jason McMinn Colin Geddes Glasgow Renal and Transplant Unit Queen Elizabeth University Hospital
Introduction
Prescribing is often led by evidence from studies containing participants with single health conditions and without multimorbidity Polypharmacy is becoming increasingly recognised in patients with multiple chronic health conditions Additional medications are more likely to result in diminishing returns in benefit with an increased risk of harm Patients with established renal failure (ERF) are likely to be susceptible to medication-related harm A high pill burden is also likely to contribute adversely to an already restricted quality of life and has been associated with poor medication adherence The aim of this study was to analyse polypharmacy in all patients with ERF attending our service
Methods
We extracted medication records for all prevalent ERF patients attending the Glasgow Renal and Transplant Unit from the West of Scotland Electronic Renal Patient Record (SERPR) as of 01012017 The records were analysed to calculate the number of regular medications and total pill burden of each patient These medications were categorised as being lsquopreventativersquo or lsquosymptomaticrsquo We also analysed the prescription of specific drug classes to examine the prevalence of these medications
Results
We identified 1091 transplant follow-up 529 hospital haemodialysis and 46 peritoneal dialysis patients who were on a mean of 94 13 and 129 different medications respectively Overall pill burden was 139 tablets a day in transplant follow-up patients 141 in haemodialysis patients and 162 in peritoneal dialysis patients There were similar rates of prescribing between the different dialysis units and clinics within our service
The proportions of medications deemed as preventative rather than symptomatic were 76 in transplant 69 in haemodialysis and 60 in peritoneal dialysis
In transplant patients decreasing renal function was associated with a higher pill burden but even patients with a transplant eGFR gt 60 were on a mean of 126 tablets per day including a mean of 14 antihypertensives
Rates of antidepressant prescribing were 15 in transplant patients and 20 in hospital haemodialysis patients 53 of haemodialysis patients were on a statin 39 on aspirin 61 on a proton pump inhibitor and 7 were on warfarin
Conclusion
Patients undergoing all forms of renal replacement therapy are likely to be on a considerable number of medications Whilst these drugs are inevitably prescribed for valid reasons this data demonstrates the need for clinicians to engage with patients to explore opportunities to reduce pill burden
Conflict of Interest None Sources of Funding None
P2 An audit of Acute Kidney Injury (AKI) on an acute stroke ward before and after plannedinterventions to review and maintain hydration
Clare Harris1 Simon Hart2 Fiona Duthie3 1 University of Edinburgh Medical School 2 Stroke Unit Royal Infirmary of Edinburgh 3 Renal Unit Royal Infirmary of Edinburgh
Background Dehydration is an important factor in the development of acute kidney injury which is associated with increased morbidity and mortality particularly in the elderly population Poor fluid intake is common post stroke (1) and dehydration is associated with poorer outcomes 3 months post stroke (2) In late 2014 there was no system of identifying patients with poor oral intake on the stroke ward at the Royal Infirmary of Edinburgh a hydration protocol and education programme were implemented aiming to improve fluid balance This included the use of prescribed water either orally or by nasogastric tube An audit pre and post intervention demonstrated that hydration as measured by ureacreatinine ratio significantly improved after the protocol introduction (3) We aimed to determine whether the incidence of AKI by KDIGO criteria was also reduced as this could have implications for reducing patient morbidity and mortality in this elderly comorbid patient cohort
Method 150 inpatients to the acute stroke ward during JulAug 2014 and JulAug 2015 were selected (n= 80 2014 n=70 2015) Patient data and creatinine values were collected from the electronic patient record and medical notes and retrospectively analysed Baseline creatinine values were calculated and cases of AKI were identified and staged using KDIGO criteria (4) Chi-Squared tests were performed to determine P values Individual patient notes were reviewed for both quantitative and qualitative data of patient management
Results Incidence of AKI (of any stage) was 263 pre-protocol and 200 post-protocol (P=03646) Incidence of AKI stages 23 was 100 pre-protocol and 715 post-protocol (P=05374) In hospital post stroke mortality was 338 pre-protocol and 1286 post protocol (P=00028) AKI was also associated with increased length of stay
Conclusions Despite a trend in benefit there was no significant difference in incidence of AKI pre and post hydration protocol nor in incidence of severe AKI (stage 23) AKI is influenced by many factors one of which is hydration status Further studies are needed to determine whether the trend of benefit exhibited in this sample is significant in a greater sample size if this were the case such a protocol could have great benefit to patient care on stroke units and elsewhere There was a significant difference in inpatient post stroke mortality following introduction of the hydration protocol Further investigations are needed to explain underlying reasons for this factors other than hydration may play an important role
References 1 Whelan K Inadequate fluid intakes in dysphagic acute stroke Clinical Nutrition (2001) 20(5)
423-428 2 Bhalla A Sankaralingam S Dundas R Swaminathan R Wolfe CDA Rudd AG The influence of
raised plasma osmolality on clinical outcome after acute stroke Stroke (2000) 312043ndash2048 3 Hart SR Craig R Berry E Lane N Gad A Farrugia M Burton L Paquay A What Happens to
Acute Stroke Patientsrsquo Fluid Balance Renal Status and Dehydration in the First Two Weeks How Can They Be Markedly Improved doi 101111ijs12634_13
4 KDIGO Clinical Practice Guideline for Acute Kidney InjuryKidney international supplements (2012) 2(1) 1-138
No funding or conflict of interest to declare
P3NHS Highland-Improving the management of hyperkalaemia using a kit Initial resultsCantley N1 Abedin T2 Lambie S3
1FY2 NHS Highland 2ST4 Renal Medicine NHS Grampian 3Renal Consultant Renal unitRaigmore Hospital Inverness
Introduction The incidence of hyperkalaemia in hospitalised in patients is between 1 and 10 Guidelines in Northern Ireland promote the use of a Hyperkalaemia Kit to improve management of hyperkalaemia We assessed the management of hyperkalaemia in Raigmore Hospital including post-treatment monitoring of serum potassium and blood glucose at baseline and after the introduction of a lsquoHyperkalaemia Kitrsquo which contains a pro forma for the management of hyperkalaemia and all the relevant equipment and drugs for treatment
Method Between July and September 2016 an automated algorithm identified 34 patients with a potassium result 65 mmoll or above on laboratory results 12 received no specific treatment of these 6 results were spurious 4 patients died before treatment could be started and 2 patients were chronic haemodialysis patients We introduced the Hyperkalaemia Kit to the Acute Medical Admissions Unit in Raigmore Hospital Since then 15 patients have been identified with serum potassium measurements above 65 and the pro forma and kit was used with eight of these patients One of these patients proceeded straight to acute renal replacement therapy
Results Prior to our intervention all 22 patients that were actively treated received at least one prescription of appropriate doses of Insulin with Dextrose However only 16 patients received intravenous calcium and only 7 received nebulised Salbutamol Potassium was measured at 4 hours in 5 cases and by 12 hours in 17 cases Monitoring of any capillary blood glucose was only documented in 8 cases Of the 22 treated 2 needed acute renal replacement therapy 3 required further doses of insulin and dextrose 2 were treated with Calcium Resonium
Eight cases of hyperkalaemia have been managed with the use of the kit and pro-forma so far An initial ECG was performed in all eight and four patients had continuous cardiac monitoring Intravenous calcium was given in seven and nebulised Salbutamol was given in five out of the eight cases Six out of eight patients had at least three blood sugar measurements One had two measurements documented and one patient was stopped from further monitoring following senior review and decision to palliate Seven patients had appropriate monitoring of their serum potassium by 4h and 12h again one patient was not monitored due to palliation
Conclusion Baseline results showed very low rates of prescription of nebulised Salbutamol low rates of Calcium Gluconate use and very low monitoring of blood sugars and potassium post treatment This has the potential for serious adverse outcomes particularly the potential for iatrogenic hypoglycaemia Our initial data shows the use of a Hyperkalaemia pro forma and kit improves the rate of prescription of intravenous calcium and nebulised Salbutamol and the post-treatment monitoring of serum potassium and blood sugar levels
P4Rituximab as maintenance therapy in ANCA associated vasculitisndash a single centre experience Rathnamalala NK Mcmenamin J Robertson S Almond A Kelly M Muniraju T M Renal Unit Dumfries and Galloway Royal Infirmary NHS Dumfries and Galloway Background The introduction of Cyclophosphamide and high dose steroids transformed ANCA associate vasculitis (AAV) from a disease of high mortality to a relapsing remitting disease Maintenance of remission however still remains a major challenge A two randomised clinical trials have looked at the use of Rituximab in remission induction in AAV and reported similar remission rates between Cyclophosphamide and Rituximab 12 Both these trials used Azathioprine as maintenance therapy and in the follow up showed similar remission rates with either agent for induction The role of Rituximab for maintenance therapy after cyclophosphamide induction was studied in the MAINRITSAN trial 3 Rituximab was compared with azathioprine and found that the relapse rate was significantly lower in the Rituximab group There have been several other retrospective studies that have suggested regular Rituximab infusions are successful in maintaining remission however has not been thoroughly evaluated 4 5678910 Here we share our centrersquos experience using Rituximab for maintenance of remission of AAV Materials and methods We conducted a retrospective review of electronic medical records of all patients who had received Rituximab as maintenance therapy for 12 months or longer between January 2014 to July 2016 Disease activity was assessed using Birmingham Vasculitis Activity Score ( BVAS) Version 3 and complete remission was defined as a score of 0 and partial remission as a score of lt50 of the value at diagnosis Due to uncertainties associated with sub classification we did not assign specific diagnosis but broadly classified as ANCA associated vasculitis Results 6 patients received Rituximab as maintenance therapy during the study period 3 (50) of them had eye ear nose and upper airway manifestations consistent with Granulomatosis with Polyangitis (GPA) All patients were PR3 ANCA positive except for one at initial diagnosis The mean BVAS score at the time of initiation of Rituximab was 4 All patients were initiated on Rituximab for relapses while on maintenance therapy with Azathioprine 4 patients received 6 monthly doses of Rituximab while two received annual doses All of them were also maintained on 5-10 mg of Prednisolone The mean BVAS score by 6 months was 0 and remained 0 at 12 months The mean PR3 titre was 562 at the initiation of treatment while at 12 months it had come down to 68 All patients remained in complete clinical remission at the end of 12 months after initiation of therapy Rituximab was well tolerated by all patients except one who developed pyrexia during an administration
Conclusions All patients had sustained remission at 6 months and 12 months after initiating Rituximab Rituximab has a potential role as maintenance therapy in AAV
P5 Chronic Myelo-Monocytic Leukaemia (CMML) as a contraindication to renal biopsy Alastair Rankin Emily McQuarrie Jennifer Lees Bruce MacKinnon Glasgow Renal and Transplant Unit On behalf of the Scottish Renal Biopsy Registry
Abstract Chronic Myelo-Monocytic Leukaemia (CMML) is a relatively rare mixed myelodysplastic myeloproliferative disorder that predominately affects patients over the age of 65 years Renal impairment in patients with CMML is well described with several different mechanisms reported including tumour infiltration lysozyme-induced injury amyloid deposition and tubulointerstitial nephritis From anecdotal evidence within our centre we are concerned that patients with CMML have an excessive risk of clinically significant bleeding following native renal biopsy This risk appears disproportionate to the degree of any co-existing thrombocytopenia or coagulopathy
We review the cases of 4 patients with an existing diagnosis of CMML who were referred to the renal clinic with proteinuria and excretory renal dysfunction Two of these patients underwent renal biopsy with subsequent major haemorrhage post-procedure despite normal bleeding parameters pre-procedure Patient 1 presented with flank pain 8 days post-biopsy A CT confirmed peri-nephric haematoma with retroperitoneal extension A total of 6 units of packed red cells (PRCs) were transfused prior to successful CT-guided emoblisation Histology from the biopsy revealed chronic tubulointerstitial nephritis Patient 2 experienced haemodynamic instability and haematuria one hour post-biopsy A total of 11 units of PRCs 7 units of fresh frozen plasma 2 pools of platelets intravenous tranexamic acid and 2 attempts at CT-guided embolization were required until haemostasis was achieved Histology later showed evidence of tumour infiltration with associated vasculitis Patient 3 presented with renal impairment and proteinuria on the background of known CMML Following discussion with haematology the risk of bleeding following renal biopsy was considered unjustifiable despite their platelets and coagulation screen being within normal range The patient was treated for presumed renal tumour infiltration with hydroxycarbamide Patient 4 was referred to the renal clinic with acute onset nephrotic syndrome Urinary proteincreatinine ratio was elevated over 800 mgmmol with serum albumin of 23 gL but normal excretory renal function The patient attends the haematology clinic with suspected CMML and chronic thrombocytopenia but previously declined bone marrow biopsy Following discussion with the patient there are no plans to proceed with renal biopsy given potential risks These cases highlight that while CMML is rare these patients are being referred to renal clinics with features that would commonly justify renal biopsy in other settings but in whom there may be an increased risk of bleeding post-procedure Our in-centre risk of major bleeding is 2 therefore to have such extreme amounts of bleeding in 2 patients with this underlying diagnosis is remarkable This creates a dilemma for the clinician as there is a wide range of potential renal pathology associated with CMML some of which will have disease specific but relatively toxic treatments available
Source of funding none Conflicts of interest none
P6 NHS Highland-Prograf to Adoport switch McCulloch K1 Peel R2 Lambie S3
1Renal Pharmacist Renal unit Raigmore Hospital Inverness 23Renal Consultant Renal unit Raigmore Hospital Inverness
Introduction NHS Highland (NHSH) is the first health board in Scotland to implement a switch from Prograf to Adoport for renal transplant patients This will provide considerable cost savings Adoport meets the bioequivalence criteria for drugs with a narrow therapeutic index set by the European Medicines agency and studies indicate therapeutic equivalence1 with the proviso that brands are non- interchangeable unless the switch is overseen by a Renal Consultant and post-conversion therapeutic drug monitoring is conducted23 The switch has been undertaken by a majority of transplant centres in England the main difference being that they have undergone repatriation NHSH Patients receive their transplant primarily at Royal Infirmary of Edinburgh and occasionally at Queen Elizabeth University Hospital Glasgow Care is transferred to NHS Highland on discharge NHS Highland cares for approximately 170 renal transplant patients 110 being prescribed Prograf These patients may live as far as 110 miles from Raigmore Hospital Given that prescribing is carried out by primary care clear communication with patients GPs and community pharmacy is essential to avoid inadvertent switching between brands
Method Clinically it was agreed a switch could be safely undertaken A business case was submitted and funding secured for pharmacist time laboratory costs and primary care time GPs have been informed via GP subgroup and local prescribing bulletin lsquoThe Pink Onersquo Community pharmacies are being informed by phone A protocol has been agreed Eligible patients selected by Renal Consultant and Renal Pharmacist Patients sent letter signed by Renal Consultant and Renal pharmacist Patients phoned prior to clinic to agree Adoport start date and address concerns Patient seen by Renal Consultant and pharmacist + given 1 month of Adoport Tacrolimus level and UampEs checked 5-7 days after commencing Adoport and patient
contacted by phone to check if tolerated If stable letter sent to GP and community pharmacy to continue supply
Results and Evaluation Letters have been sent to all eligible patients Seven patients have been reviewed One has received a one month supply of Adoport and 5 others are due to switch One patient was deemed non-eligible at present as they have a 6 month surplus of Prograf A database will be maintained and analysed at the end and primary care savings will be monitored Extra pharmacist input will give us the opportunity to review how immunosuppression is managed and to evaluate the benefit of having a renal transplant pharmacist Conclusion The switch is at an early stage Ultimately we hope to show that the switch from Prograf to Adoport can be managed safely with extra pharmacist input to a remote and rural population with prescribing being conducted by primary care
Fundingconflicts of interest none 1 McDevitt-Potter LM Sadaka B Tichy EM Rogers CC Gabardi S Transplantation 2011 A multicenter experience with
generic tacrolimus conversion 2 Medicines and Health Products Regulatory Agency Drug Safety Update 2012 Accessed online via
wwwmhragovukSafetyinformationDrugSafetyUpdateCON1557563 ESPRIT Guidance on management of repatriation and immunosuppressant switches in transplant patients 2015
Accessed online via httpwwwespritorgukwp-contentuploads201508Switch-guidance-document-final-Aug-31-2015pdf
P7 NHS Highland-Tacrolimus baseline dataMcCulloch K1 Peel R2 Lambie S3
1Renal Pharmacist Renal unit Raigmore Hospital Inverness 2Renal Consultant Renal unitRaigmore Hospital Inverness 3Renal Consultant Renal unit Raigmore Hospital Inverness
BackgroundAs part of planning a switch from using tacrolimus Prograf to Adoport we assessed baseline data for our transplant patients currently using Prograf After converting patients to Adoport we will compare their tacrolimus levels to their individual target range We assessed our use of appropriate target ranges and our current performance in achieving tacrolimus levels within target range on Prograf therapy
Method 107 renal transplant patients taking Prograf were identified a sample of 19 of these were analysed using electronic patient records and results Time from transplant ranged from 1 month to 18 years All tacrolimus levels for the preceding year were analysed and compared to the target range specified at the time of the level being done The assay used has a Coefficient of Variation of lt5 at the lower limit of the assay
Results All 19 patients had a target range for tacrolimus clearly identified and recorded in clinic letterswhich are routinely copied to the patients themselves A variety of target ranges were specifiedThe commonest used was 5-8 microgramsl in 7 patients followed by 5-7 in a further 4 patientswith another 6 different target ranges being used for the remaining 8 patients The ranges usedhad a breadth of 3 microgramsl in 2 cases the rest had a breadth of 2 microgramslPatients had a median of 12 (range 3-72) tacrolimus levels over the preceding year Results werewithin specified target ranges for 54 +- 22 (Medan +- SD) of results checked
Conclusion We currently use a large number of different target ranges The majority of the ranges used had a breadth of just 2 microgramsl These factors help to account for the low proportion of test results which were within the specified target ranges This is important to bear in mind when interpreting whether tacrolimus levels are within target ranges after switching to Adoport We should consider aligning our target ranges and widening them
P8 Eculizumab use in Scottish paediatric dense deposit disease Stewart D1 David Hughes1 Lynne Riach2 Craig Oxley2 Athavale D1
1Royal Hospital for Children Glasgow 2Royal Aberdeen Childrenrsquos Hospital Aberdeen
Introduction The revised MPGN classification and increasing recognition of Dense Deposit Disease (DDD) a C3 glomerulopathy as an alternative complement pathway disorder suggests Eculizumab an anti-C5 monoclonal antibody may be beneficial in treatment However the experience of Eculizumab as an off-label and expensive treatment in children with DDD is limited with variable clinical response reported in the literature
Method We present the outcomes of the only 2 paediatric patients in Scotland who have received Eculizumab for the management of DDD
Results Case 1 A 10 year old male presented with proteinuria and haematuria resistant to steroid treatment with preserved renal function Initial biopsy confirmed DDD Conservative management with an angiotensin converting enzyme inhibitor and diuretics for symptom control continued until 14 years Due to worsening symptoms (oedema lethargy poor growth) and renal function deterioration along with elevated terminal complement complex (TCC) Eculizumab was commenced A repeat biopsy whilst suggestive of chronic irreversible damage showed 25 glomerular architecture preservation Symptom improvement was noted There was a reduction in proteinuria and renal function stabilisation fall in TCC and discontinuation of diuretics Eculizumab was discontinued after 24 months Progression of renal function decline was seen in the final months of Eculizumab therapy With recurrence of symptoms and increasing proteinuria following discontinuation Eculizumab was recommenced after 6 months Symptomatic improvement has since been noted
Case 2 A 5 year old girl presented with painless frank haematuria and proteinuria Initial biopsy confirmed DDD Proteinuria was unresponsive to steroid therapy and 5 months following diagnosis she rapidly progressed towards end stage renal disease despite the introduction of Mycophenolate Mofetil and plasmapheresis Haemodialysis was subsequently commenced TCC level was elevated and Eculizumab treatment was started 7 months after diagnosis Renal biopsy prior to treatment demonstrated continued severe pathological changes in all visible glomeruli However due to lack of clinical response Eculizumab was discontinued after 2 months and the patient remained dialysis dependent
Conclusions Our experience with Eculizumab in Scotland has demonstrated variable results in our 2 patients with one patient showing a positive response whilst the other experienced no improvement Eculizumab was administered to both patients at varying points in their clinical journey with differing progressive features on biopsy To date the outcomes of 9 paediatric patients with DDD treated with Eculizumab have been described in the literature with 8 experiencing some positive response to treatment including 2 patients who were able to stop renal replacement therapy within 12 weeks of treatment A role for Eculizumab in DDD may be guided by clinical and pathological features Well designed clinical trials will be necessary to define the role of complement inhibition therapy in DDD
No conflict of interest and no funding requested
P9 Examining markers of safety in the use of non-tunnelled central venous catheters
James WT Millar (Speciality Registrar) Scott W Oliver (Speciality Registrar) Peter C Thomson (Consultant Nephrologist) Glasgow Renal and Transplant Unit Queen Elizabeth University Hospital Glasgow
Background Non-tunnelled central venous catheters (NTCVC) remain an essential means of vascular access for incident haemodialysis Associated morbidity is well recognised for example in the form of Staphylococcus aureus bloodstream infections (SAB)[1]
Previous quality improvement initiatives in our unit have sought to both improve traditional markers of quality (such as SAB) and to identify additional areas of clinical risk In 2014 Oliver et al [2] suggested several additional quality measures including peri-procedure haemoglobin drop the need for a further NTCVC during the same clinical episode and the NTCVC insertion site This study further evaluated NTCVC related clinical practice within our unit
Methods The potential markers of clinical quality identified in a previous project were examined using prospectively collected data stored in the electronic patient record Identified cases of SAB significant peri-procedure haemoglobin drop and multiple NTCVC insertion were investigated by case note review
Results Between March 2016 and March 2017 a total of 222 patients received 346 NTCVC 54 patients (243) had more than one NTCVC inserted in a 21-day period (range 2-5) When considering NTCVC insertion site there were 159 (459) femoral vein catheters and 183 (541) internal jugular vein catheters No pneumothoraces were reported
15 SABrsquos were reported during this period equating to 43 of all NTCVC 5 arose in patients with femoral NTCVC (333) and 10 from internal jugular catheters (667) Mean time from line insertion to positive blood culture was 86 days 15 (67) patients had a drop in haemoglobin of greater than 20mgdl with no other source of blood loss identified on review of clinical notes
Discussion These data demonstrate that NTCVC-associated SAB rates remain low and significantly below Scottish government audit standards [3] Of interest is the continued trend towards the use of femoral catheters at 45 of lines compared with 38 in 2014 [2] Although traditionally thought of as having a higher incidence of infectious complications our data has shown fewer bacteraemia events associated with femoral catheters compared with internal jugular Our data also demonstrates a significant rate of peri-procedure haemorrhage arising in up to 1 in 20 cases Together these findings present opportunities to development practice and improve patient safety
References
[1] Murray E Deighan C Geddes CC Thomson PC Reducing haemodialysis bacteraemia rates Scottish Renal Association Glasgow November 2013 [2] Oliver SW Thomson PC Jardine AG defining safe effective and patient-centred dialysis catheter placement Scottish Renal Association Edinburgh September 2014 [3] The Staphylococcus aureus bacteraemia quarterly report of cumulative data from all NHS Boards in Scotland Health Protection Scotland January 2015
Sources of funding none Conflicts of interest none
P10 Prescribing of tolvaptan-The NHS Highland experience Lambie S1 McCulloch K2 Garrod J3
1Renal Consultant Renal unit Raigmore Hospital Inverness 2Renal Pharmacist Renal unit Raigmore Hospital Inverness 3Renal Pharmacist Renal unit Raigmore Hospital Inverness
Introduction Tolvaptan is a vasopressin antagonist It was accepted for use in Scotland by SMC in Jan 2016 to slow the progression of cyst development and renal insufficiency of autosomal dominant polycystic kidney disease in adults with chronic kidney disease (CKD) stage 1 to 3 at initiation of treatment with evidence of rapidly progressing disease1 Adverse effects related to aquaresis may affect patientsrsquo ability to achieve the optimum therapeutic dose and the risk of hepatic toxicity necessitates regular LFT monitoring The geography of NHS Highland required the implementation of novel methods of managing these patients and as a result a MDT approach with an emphasis on pharmacist input was adopted Consultant role Patient selection on the basis of evidence of rapidly progressing kidney disease declining
eGFR large volume kidneys on ultrasound and evidence of complications of PKD Side effects and potential benefits discussed Potential medication interactions reviewed Jinarc risk management prescriber training
Pharmacist role Undertook Jinarc risk management pharmacist training Prepares accurate drug history and reviews for potential drug interactions Carries out patient counselling and supplies patient education material sick day rules card
and lsquogot to gorsquo card Supplies GP education leaflet Provides advice on selection of new drug therapies eg for gout Manages stock and coordinates supply to patients
Results Prescribing commenced May 2016 patients currently prescribed tolvaptan 11 7 Female 4 male Number on target dose 73 n = 811 2 patients are still being titrated One patient did
not tolerate target dose due to aquaresis side effects and is being trialled on the middle dose
Withdrawals One patient has withdrawn due to agoraphobia and an inability to attend for monitoring and another is on hold due to having major surgery
Conclusion The MDT approach between the Renal Consultant and Pharmacist at Raigmore Hospital has enabled tolvaptan prescribing to be efficiently and safely implemented to patients living within a challenging geographical location
1 Scottish Medicines Consortium Detailed Advice Document tolvaptan 15mg 30mg 45mg 60mg and 90mg tablets (Jinarcreg) SMC No 111415 January 2016
NA1 Authors SCN Jacqueline Ross NHS Grampian
SCN Alan Somerville NHS Lanarkshire SCN Jane Humphrey NHS Lanarkshire
e- mail contact jacquelinerossnhsnet Alansommervillelanarkshirescotnhsuk
Janehumphreylanarkshirescotnhsuk
Phone contact 01224 552927 01236 712644
Title Sharing of Adverse Events in Renal Units across Scotland
Introduction Background The Scottish Renal Nurses Strategy Group (SRNSG) are a group of senior nurses from Renal
Units across Scotland who meet 3-4 times per year to discuss and implement best practice At the last meeting it was agreed that it would be good practice for each Health Board to share
their adverse events reported on the Datix System and deliver a presentation with an action plan to prevent incidents and improve patient safety across Scotland NHS Grampian and NHS Lanarkshire will be the first to deliver this presentation discussing adverse events from both Health Boards with an action plan
Top 5 adverse events over the past 12 months Renal Unit NHS Grampian 1 Violence and Aggression 2 Accidents including needlesticks slips trips and falls 3 Medication Errors 4 Infrastructure Staffing and Estates 5 Machines and Equipment
Top 5 adverse events over past 12 months Renal Unit NHS Lanarkshire
1 Slips Trips or Falls 2 Medicine errors 3 Treatment problems 4 Transfer problems 5 Breach of policy
The presentation will also focus on any serious adverse events which may not be in the top 5 categories
Aim Objective Each Health Board to share their adverse events with the aim to prevent them from occurring in other units to improve staff and patient safety and wellbeing across Scotland
Method Power Point Presentation
Outcome Results Sharing of adverse events resulting in the development of a national Action Plan to prevent these incidents improving safety and well being of staff and patients in Renal Units across Scotland
NA2
SRA Oct 2017 Abstract
BBV Never Event - The whats whys and hows
Staff Nurse Gillian Wilson Aberdeen Royal Infirmary
This presentation shares our experience of a never event that occurred and was not picked up for
a period of 18 months
Hepatitis C (HCV) positive antibodies were found in a previously negative patient
These results were a low positive with no biochemistry changes to suggest any liver damage
however steps were put immediately in place to isolate and investigate
Was it contamination from a dialysis machine was it related to a blood transfusion given prior to
first positive result was it faulty diagnostic tests in the laboratory
In Aberdeen we go over and above national guidelines and isolate all our BBV patients whether
they have positive blood results or are PCR negative
Further bloods tested at an external laboratory confirmed negative results
It highlighted that communication errors were to blame for the lack of speed in detecting this issue
Investigations concluded no real answers as to why this happened
NA3
Living Donation Scotland Changing attitudes towards living donor kidney transplantation
Jen Lumsdaine Julie Glen On behalf of the Living Donation Scotland Project Board
Background and aims
The rate of living donor transplantation has remained fairly static in Scotland over the past 10 years
Recent data has shown inequity of access to living donor transplantation throughout the UK so
there is potential to significantly increase this optimum form of treatment for patients with end-stage
renal failure in Scotland The Living Donation Project Board was formed in 2016 aiming to double
the number of living donor transplants by 2020
Method
The two key areas
1 Do recipients receive adequate and appropriate information at the right time about living
kidney donation
2 Informing the general public about altruistic donation
All patients active on the transplant list in Scotland were invited to an information event A follow-up
questionnaire was performed in the East of Scotland examining outcome or reasons for not
attending A scoping exercise looked at information provided by each unit was performed and link
nephrologists and low clearance nurses attended meeting to discuss strategies for early education
Outcome
An information pack containing both recipient and donor written information and short films on DVD
has been produced with the support of the Scottish Government for all recipients and potential
donors in Scotland A new website with comprehensive information both written and visual and
postcode finder to improve ease of access to local unit contact details has been developed
Two national media campaigns have been launched with a significant rise in the number of enquiries
from potential donors and actual increase in altruistic donor numbers
Nursing abstract ndash no conflict of interest
NA4Authors Susan Easson Charge Nurse Ward 4C QEUH Glasgow
e- mail contact SusanEassonggcscotnhsuk
Phone contact 0141 452 3300
Title A Conversational approach to find out ldquoWhat matters to yourdquo in a Renal Transplant ward
Introduction Background Finding out ldquo What Mattersrdquo to people using health and careservices is crucial to delivering safe effective and person centred care It is a simple yet profoundconcept and tries to get to the essence of person centred care by creating deeply personalengagements with patients and their families through a conversational approach However careexperience feedback all too often provides innumerable examples of where what really matters topatients and their family members is poorly understood or not addressed Using care experienceas the driver for change the nursing staff in Ward 4C used improvement approaches to explorehow to hold more meaningful ldquoWhat Matters to yourdquo conversations on a daily basis
Aim Objective To improve the patient experience by utilising a person centred approach
Method Using Care experience feedback What Matters to Me boards and the conversationalapproach
Outcome Results Improvements in patient experience will be shared using examples ofpractice and care experience feedback
There was no additional funding required for this project We worked in collaboration with theperson centred team whorsquos aim is to improve patient experience
NA5
The implementation of a renal education programme and its impact on clinical practice
The purpose was to implement a Renal Education Programme and to evaluate its impact on
clinical practise
It was identified that there was a need for an educational programme to be set up within Forth
Valley Royal Hospital There is no inpatient renal unit in FVRH on site for our renal patients they
attend Queen Elizabeth University Hospital We are an outpatient haemodialysis unit with
outpatient clinics on site Therefore it was identified that there was a need for nursing staff within
FVRH to be educated on all renal complexities for the benefit of our patients
This was done through a work-based learning approach which brought tangible benefits for our
patients However it did not come without pitfalls as educational programmes are often seen as
making very little difference to clinical practise
T
his study describes what methods were used and examines the advantages and disadvantages in
setting up an educational programme and evaluating its impact on clinical practise
NA6
Nursing Abstract ndash SRA Meeting ndash 26 October 2017
Chris McGee Tonya Broe Ken Weir
Renal Unit Forth Valley Royal Hospital
Use of the Therapy Monitor Haemodialysis Patient Record System Can we aim for a paper-
free dialysis unit
We are trialling a new haemodialysis patient monitoring system to work in conjunction with SERPR
and which is intended to supersede the Finesse system used previously
We are in the early stages of this process but with continuing staff education and regular tech
support we are hoping to gather sufficient evidence to evaluate whether the use of paper case
notes needs to continue
Is it a realistic goal to aim for a completely paper-free unit
NA7
THE CLINICAL USES OF APHERESIS WITHIN NHS TAYSIDE
Laura Thomson CN
Ninewells Hospital Dundee
NHS Tayside took over the apheresis service from BTS in 2012 The service has since expanded
with the benefits of carrying out this treatment has been widely recognised within NHS Tayside
and is now more commonly being offered to treat a wider range of conditions with the number of
treatments carried out each year rising
This presentation will highlight the progression of the apheresis service within NHS Tayside We
will identify the various conditions it is currently being used to treat and also identify the decision
making process involved in carrying out these treatments ie which replacement fluid will be used
anticoagulation medication administered
We will highlight the benefits and challenges we face in providing this expanding service within the
Renal Service
NA8Authors Linda McDougall Renal Physiotherapist NHS Highland
e- mail contact lindamcdougall1nhsnet
Phone contact 01463 706022
Title lsquoExercise on Haemodialysis- Keeping the Wheels in Motionrsquo
Introduction Background The impact of CKD on physical fitness functional ability independence amp ultimately quality of life cannot be underestimated Current national guidelines recommend that all individuals with CKD are encouraged to participate in regular exercise programmes between or during dialysis sessions if on HD Following a successful pilot study funding was approved to establish an lsquoExercise on Dialysisrsquo (EOD) programme across NHS Highland through the appointment of a dedicated renal physiotherapist in 2008 A successful programme was soon established but for several years post-vacancies and increasing in-patient demands limited the physiotherapy servicersquos ability to deliver the programme The need to improve the long-term sustainability of the service was recognised and in late 2016 funding was approved to develop a Band 4 PT HCSW role for this purpose
Aim ObjectiveTo optimise the sustainability and continuity of the lsquoExercise on Dialysisrsquo service across NHSHighland through development of a Band 4 PT HCSW role
Method The potential parameters of the role and limits of autonomy were scoped out using current NES resources and guidelines Service and task analysis was then carried out to establish which components of the EOD protocol could be undertaken by a Band 4 A series of competencies were developed in line with the clinical protocol and one-to-one training and supervision provided to the post-holder to ensure competency achieved in delivering the programme
Outcome Results A 10 WTE Band 4 PT HCSW was appointed in Jan 2017 with a dual role between the renal unit and acute medical wards Although training is not yet complete the post-holder is already running the day-to-day delivery and monthly audit of the EOD service with senior physiotherapist input only required for individual patient safety queries and general discussion around patientsrsquo progress and goals The benefit to the unit has been considerable as the band 4 is available to support patients and staff with EOD provision 5 days a week This allows for one-to-one supervision of patients who need more support to participate in EOD regular feedback on performance and reviews of outcome measures and goals to maintain motivation levels Feedback on the post has been very positive and its scope will only continue to expand as we look to further develop renal rehabilitation services across NHS Highland
NA9Authors Nadine Lyall and Kerry Guthrie
e- mail contact nadinelyallbordersscotnhsuk kerryguthriebordersscotnhsuk
Phone contact 01896 826637
Title The Developing Role of the NMP in a Satellite Dialysis Unit
Introduction Background
We have been practising as NMPrsquos for nearly 3 years working in the dialysis unit at the BGH The unit is a satellite unit of the ERI and we have expanded over the last 6 years The unit provides haemodialysis for 12 patients at any one time 3 sessions a day 6 days a week We are nurse-led and have 2 renal consultants who are based at the ERI
We saw an opportunity to use our knowledge and experience to develop our role By becoming NMPrsquos we have enhanced our professional development and we feel we meet the changing needs of the dialysis patient in a more holistic manner
Aim Objective
Our aim is to deliver effective care as we are better placed to deal with issues that often arise byacting swiftly this in turn is cost effective and convenient For example good anaemia and bonemanagement is important for their health wellbeing and lifespanTo help understand our role we will use a power point presentation highlighting issues we dealwith and the drugs we prescribe under the following headings Cardiovascular infection painanticoagulant disequilibrium diet renal bone disease and renal anaemia
Method Power point
Outcome Results
In the future we hope to further develop and have greater autonomy in our role We have great support from our renal consultants and have already built up a great relationship with our patients We hope to undertake the Clinical Decision Making course and this in turn will allow us to deal effectively with acute illness giving the dialysis patient better care We are keen to get feedback from other renal nurses in Scotland to enable us to develop our role further and in turn raise awareness of the NMP role in a dialysis unit We record all our prescribing decisions and keep the consultants up to date regularly Currently we are working on auditing our prescribing practice so that we can improve the service we can provide
NA10 Title Komunikacja w szkoleniu dializy ortzewnowej
Author Senior Charge Nurse Rhoda Bell
Address Raigmore Hospital Old Perth Road Inverness IV2 3UJ
Email rhodabellnhsnet Telephone 01463706023
Introduction Background Case study on lady with Polish as her first language she has some English but requires an interpreter to carry out Peritoneal Dialysis training and attend clinic She had some gynaecological issues that we were not aware of which impacted on the functionality of PD and therefore the success of treatment There were areas of concern in low clearance clinic with signs the patient had a reluctance to engage in decision making
AimObjective
Methods Discussion through the case study highlighted issues with communication between different PD staff and patients Areas of concern include different staffing techniques environment factors on training success Also language and communication issues the patient had were not fully apparent so training could not be individualised
Results We plan to trial training at home and have more individualised training schedule for patients The training step by step guides have been reviewed and practise standardised In collaboration with low clearance nurse we have developed a check list which will highlight concerns before the transition to PD ie language issues and need for training aids in another language gynaecological conditions
Conclusions Everyone learns differently and training methodsaids must be individualised for all It may not be apparent until training has commenced that there are concerns Having one to one training with the same nurse will consolidate training and build confidence in the patient Having a close working relationship with members of the MDT will help make a supportive PD journey
Would we do things differently if we knew about prolapse or lack of English both spoken and written
Key words - Peritoneal dialysis patient training communication
N11
Telehealth amp PDAudrey Jones
Advantages
Information on a daily basis about treatment weight and blood pressure
Change programme remotely via computer or mobile
Earlier intervention for machineprogramme issues
Reduction in home visits ie patient trained but still requires volume increases
No need to download cards to see what problems have been
Can have more detailed information available at clinics
Disadvantages
Relying on patient input data correctly
Machine is noisy especially first wave of machine
Still the same bag connection system and patient connection system (difficult for manual
dexterity problems)
Relying on patient having good signal
Modem problems
NA12Autosomal Dominant Polycystic Kidney Disease A cruel inheritance but new hopeAlistair Lawrie Renal Unit Victoria Hospital KirkcaldySadaf Arshad Corry Dunnigan Paul Phelan Neil Turner Renal Unit Royal Infirmary of Edinburgh
Background Autosomal Dominant Polycystic Kidney Disease (ADPKD) is the most prevalent single gene human genetic disorder and the most common of the inherited cystic and interstitial kidney diseases It is estimated to affect 1 in every 1000 individuals worldwide with over 50 of sufferers eventually developing end stage kidney disease and requiring dialysis or transplantation Symptoms include spasmodic severe pain hypertension haematuria infection and kidney failure There is currently no cure for ADPKD Management of the condition has traditionally involved lifestyle modification BP control and analgesia however a recent study (Torres et al 2012) demonstrated that treatment with V2-receptor antagonist drugs slowed increase in total kidney volume reduced the rate of functional decline and showed a reduced incidence of kidney pain
Aim Provision of a tolvaptan prescribing and monitoring service
Methods Experiential finding report of initial twelve months period of multidisciplinary ADPKDtolvaptan clinic
Results Early results are comparable with TEMPO study outcomes
Conclusion Due to the long term nature of this treatment results available at this time are showing only the earliest benefits of the intervention More quantifiable results such as increased time before the necessity for RRT will only be evident in coming years Torres VE et al (2012) Tolvaptan in Patients with Autosomal Dominant Polycystic Kidney Disease New England Journal of Medicine 367 pp 2407-2418 DOI 101056NEJMoa1205311
No funding requirement No conflict of interest
A9 Renal Evaluation of Paediatric Patients with Tuberous Sclerosis Complex (TSC) in aNational TSC Multidisciplinary ClinicDr Jenny Patterson 1 Dr Shelagh Joss 1 Dr Ihab Shaheen 2
1 Clinical Genetics Queen Elizabeth University Hospital Glasgow 2 Paediatric Nephrology Royal Hospital for Sick Children Glasgow
Introduction Tuberous sclerosis complex (TSC) is a dominantly inherited multisystem disorder characterised by development of hamartomas (benign lesions) in multiple organs Previous studies have shown that renal manifestations are common in TSC and also the most frequent cause of TSC-related death in affected individuals With the recent discovery of targeted therapy with mTOR inhibitors early recognition of renal involvement allowing early surveillance and prompt therapy is now more important than ever
AimMethod To review a population of paediatric patients attending a large specialist TSC service in the UK both in terms of key clinical characteristics and current practice for renal radiological surveillance data were collected from electronic medical records pertaining to molecular diagnosis renal surveillance and presence or otherwise of sequelae affecting the renal or other systems Practice was compared to published surveillance recommendations of the International Tuberous Sclerosis Complex Consensus Group (2013)
Results Data were obtained for 41 children (18 males 23 females) Current age range 25 years to 14 years (mean 98 years) Twenty nine patients (707) were diagnosed lt1 year of age Genetic data were available for 29 patients Fifteen patients had a confirmed TSC1 mutation and 14 patients a confirmed TSC2 mutation including one contiguous PKD1 mutation Renal imaging (all US) within a year of diagnosis was documented in 2541(61) performed at a mean age of 3 years Renal symptoms at diagnosis were documented in 741(171) and 941(22) had renal abnormalities on baseline imaging There was wide variability in scanning interval and modality with 1041(243) having previous abdominal MRI with variable documented indication Seventeen (414) of the cohort mean age 102 years had documented renal lesions 917 angiomyolipomas 517 cysts and 317 both These lesions were diagnosed at a mean age of 6 years (range 02 years-142 years) Six patients (353) had normal baseline scans with a mean interval to lesion diagnosis of 1 year One patient had a lesion on MRI not detected on US that required subsequent biopsy Frequency of subsequent scanning ranged from intervals of 2 months to 1 year with a combination of MRIUS in an unclear pattern All patients except one with a contraindication were undergoing current brain surveillance by MRI
Conclusions Our results highlight the significant incidence of renal sequelae within our TSC cohort with renal manifestations ranging both in severity and age of onset International guidelines recommend MRI scanning for renal surveillance at diagnosis and throughout life Benefits of MRI include enhanced accuracy of sizing and characterisation of renal lesions The majority of our cohorts are already undergoing brain MRI surveillance It is our aim to combine and standardise MRI renal surveillance for this cohort to facilitate early and regular monitoring with a view to early intervention is possible
A10 Effect of blood temperature monitoring on intradialytic hypotension in patients with end stage renal disease requiring haemodialysis Heather Walker1 Susan McGeorge1 Drew Henderson2
1 Renal Unit Ninewells Hospital Dundee2 Regional Renal Centre Waikato Hospital Hamilton New Zealand
Background KDIGO define intradialytic hypotension (IDH) as a reduction in systolic bloodpressure (SBP) ge20mmHg or mean arterial pressure (MAP) ge 10mmHg with associatedsymptoms IDH is a common complication of haemodialysis (HD) and is associated with increasedmortality and morbidityStandard dialysis with a set temperature leads to thermal gain during the dialysis session Tocounteract this thermal gain vasodilation occurs and is postulated as one of the causes of IDHActive cooling of dialysis has been shown to reduce IDH but is not routinely applied across wholedialysis populations Isothermic dialysis can be achieved by controlling blood temperature on HDWe report here our experience of doing this using the Blood Temperature Monitoring (BTM)function on Fresenius 5008 dialysis machines
Methods An observational study was performed to assess the rates of IDH in patients with End Stage Kindey Disease (ESKD) undergoing regular satellite HD at NHS Tayside in July 2017 Rates of IDH were assessed (KDIGO definition) for two weeks prior to BTM settings being activated and for a two week study period after introduction SBP and MAP data was collected SBP data was grouped to either SBP decrease lt20mmHg or SBP decrease ge20mmHg compared with Pre HD BP Changes in MAP were also analysed at the same time points Patient reported symptoms related to initiation of BTM were also collected for the same time period
Results 402 dialysis sessions were evaluated in the pre intervention time period and 399 sessions post intervention
IDH 1072 vs 778 (Pre BTM vs Post BTM) p=015 gt20mmg SBP drop Pre vs Post BTM
Mean MAP Change (mmHg) Pre BTM vs Post BTM
1st BP 254 vs 204 (p=005) -522 vs +312 (plt001) 2nd BP 474 vs 435 (p=023) -1589 vs -886 (plt001) 3rd BP 515 vs 435 (p=003) -1862 vs -958 (plt001) Post HD 408 vs 338 (p=003) -1164 vs -077 (plt001)
Following the introduction of blood temperature monitoring only 08 of HD sessions reported experiencing cold or shivering symptoms
Conclusion The use of blood temperature monitoring was not associated with a statistically significant decrease in rates of IDH There was a significant reduction in the number of sessions where SBP decrease by gt20mmHg at the first and third HD BP and a reduction in MAP change across the study group Further evaluation of BTM is required assess its clinical utility in our HD population
Funding No funding was sought for this study
Conflicts of interest None
A11 Evaluating patient satisfaction and clinical outcomes of a new nurse-led dermatology clinic for patients attending the renal transplant clinic Campbell G Naismith K Neil A Rankin A Spalding E (joint first authors) Renal Unit University Hospital Crosshouse Kilmarnock UK
BACKGROUND National Guidelines advise that renal transplant recipients should receive annual skin surveillance to screen for skin cancer In August 2015 a specialist nurse-led dermatology clinic was set-up alongside the renal transplant clinic at University Hospital Crosshouse We aimed to evaluate the success of this joint clinic in terms of clinical outcomes and patient satisfaction
METHODS Clinical records were reviewed to determine the number of patients under dermatology follow-up before and after initiation of the joint clinic and to review cases that were referred for treatment of pathological skin lesions A questionnaire was also distributed to patients attending the new joint renal-dermatology transplant clinic The questionnaire consisted of 5 questions 2 for patient demographics 1 for current understanding of skin care advice and 2 to assess their satisfaction of the new joint clinic
RESULTS A total of 138 and 146 renal transplant recipients were registered on renal transplant clinic lists in 2015 and 2016 respectively Prior to initiation of the new joint-clinic 41 patients had attended dermatology (37 in NHS Ayrshire and Arran and 4 in NHS Greater Glasgow and Clyde) consisting of 30 of the transplant population In September 2016 13 months after initiation of the new clinic 60 patients had attended the new clinic increasing the proportion of patients meeting the national recommendation for skin surveillance to 41 Implementation of the new clinic resulted in patients being 65 more likely to have received the recommended skin checks (odds ratio 165 95 CI 101-270 p=004)
32 patients completed the questionnaire The median age of transplant was 90 years (IQR 38-153) 100 of patients knew to avoid sun exposure and 31 (96) knew to use sunscreen 29 (91) patients were aware of the advice to undergo annual skin surveillance by dermatology with 28 (88) having had a skin check in the last year 29 (91) patients reported that they found the new joint clinic useful although only 18 (56) had attended the clinic so far
CONCLUSIONS Implementation of a new nurse-led dermatology clinic running in parallel with the renal transplant clinic resulted in a considerable increase in the proportion of patients meeting national recommendations for annual skin surveillance The vast majority of patients also found the combined clinic to be useful There is still considerable room for improvement in order to achieve the target of 100 compliance with skin surveillance and ongoing clinical audit is required to assess progress We believe this model would be easily implementable at other units with similar benefits expected
A12 Pneumocystis pneumonia prophylaxis post-renal transplant increased duration of co-trimoxazole is safe and effective FA Chapman JE Dickerson M Clancy C Daly C Geddes Renal amp Transplant Unit Queen Elizabeth University Hospital Glasgow
Introduction All renal transplant recipients receive Pneumocystis jirovecii prophylaxis usually with co-trimoxazole Guidelines suggest this should be continued for 3 to 6 months Our unit previously prescribed 3 months however following an outbreak of Pneumocystis pneumonia (PCP) infection this was increased to 6 months Given its constituents of sulfamethoxazole and trimethoprim co-trimoxazole prophylaxis may influence the frequency of urinary tract infection (UTI) We aimed to compare the frequency of UTI between patients on 3 months vs 6 months prophylaxis and assess rates of multi-drug resistant organisms We also sought to establish if the increased duration of co-trimoxazole was adversely affecting renal function potassium concentration white cell and platelet count and dosing of mycophenolate mofetil
Methods A retrospective search of the West of Scotland Electronic Renal Patient Record was conducted for all renal transplant recipients between 1st January 2012 and 31st May 2016 Patients were grouped according to the intended duration of co-trimoxazole Data were extracted for baseline characteristics co-trimoxazole prescription mycophenolate mofetil (MMF) prescription laboratory results (creatinine potassium white cell count platelets) at 3 6 9 and 12 months post-transplant and microbiology results for 6 months post-transplant Results were analysed on an intention to treat (ITT) basis with a second analysis according to actual duration of co-trimoxazole treatment (AT) Subjects with transplant failure had laboratory results censored from the time of transplant failure and all of their microbiology results were excluded
Results 609 renal transplants were performed over the study period On ITT analysis there were 418 patients in group 1 (ITT1 3 months co-trimoxazole) with 15 transplant failures and 191 patients in group 2 (ITT2 6 months co-trimoxazole) with 12 transplant failures There was a significant difference in the number of patients with at least one UTI with fewer in ITT2 (ITT1 133403 vs ITT2 42179 p = 001) However this was not present when comparing actual treatment duration (AT1 111345 vs AT2 36149 p=007) Overall there was a similar spectrum of organisms cultured There were significantly fewer cultures of multi-resistant organisms in both ITT and AT analyses with 6 months of co-trimoxazole (ITT1 28376 vs ITT2 0106 p= 0004 AT1 22313 vs AT2 198 p = 002) There was no difference in estimated Glomerular Filtration Rate serum potassium concentration platelet count or MMF dose On AT analysis there was a significant difference in the total white cell count (WCC) and lymphocyte count at 6 months post-transplant (WCC 78 x10^5L vs 71 x10^5L p =004 lymphocytes 13 x10^5L vs 12 x10^5L p=002) There were 18 cases of PCP with 7 deaths attributable All cases occurred after cessation of co-trimoxazole prophylaxis (81 ndash 913 days after stopping co-trimoxazole)
Conclusion Although there is a significant difference in UTI frequency on ITT analysis this is not present on AT analysis suggesting no real co-trimoxazole effect There was no increase in frequency of multi-drug resistant organisms with a longer course of co-trimoxazole Renal function and serum potassium were unaffected Our findings support continuing co-trimoxazole prophylaxis for at least 6 months
A13 Kidney transplantation in the over 60rsquos in Scotland 1996-2015 TJW Rennie1 P Phelan1 J Campbell2 JP Traynor2 L Henderson1 W Metcalfe2 On behalf of the Scottish Renal Registry 1Renal transplant unit Royal Infirmary Edinburgh 2NHS National Services Scotland Introduction The proportion of older kidney transplant recipients has increased in the UK but
long term outcome data are scarce We aimed to evaluate patient and graft survival in patients
ge60 years of age receiving a first kidney only transplant in the last 20 years in Scotland
Methods Retrospective analysis of Scottish Renal Registry data of incident Renal Replacement
Therapy (RRT) patients and those in receipt of a kidney only transplant performed 1996-2015
(follow up until 311216) Patients were stratified by age 60-69 ge70 (group 1 and 2 respectively)
and decade of transplantation 1996-2005 2006-2015 (decades 1 and 2 respectively)
Results 6743 patients aged ge60 started RRT from 1996-2016 Of those 108 were ever
transplant-listed 54 had received a transplant by 311216 26 listed and 11 transplanted
were aged ge70
535 patients aged ge60 received a kidney only transplant in 1996-2015 90 patients (168) were
aged ge70 no patients were aged ge80 Mean time from wait listing until transplantation was 33plusmn24
years (plusmnSD) and from starting RRT until transplantation was 38plusmn26 years (plusmnSD) One and five
year graft survival was 97 and 87 in decade 1 95 and 89 in decade 2 (p=NS) there was
no difference in graft survival between age groups 1 and 2 One and five year patient survival was
94 and 78 in age group 1 85 and 56 in group 2 (plt0001) there was no difference in one
and five year patient survival between the two decades
Conclusion One and five year graft and patient survival in renal transplant recipients aged ge60
have not changed significantly in the last 20 years Recipient age ge70 is not associated with
reduced graft survival but patient survival from time of transplant is lower in this age group
compared to recipients aged 60-69
No conflict of interest to be declared No funding received
A14 High Mortality In Older Patients With Primary Nephrotic Syndrome Sarah Beverstock Wendy Metcalfe amp Robert W Hunter Department of Renal Medicine Royal Infirmary of Edinburgh
Introduction
Nephrotic syndrome can develop at any age and may be due to a primary glomerular lesion or secondary to systemic disease The natural history of glomerular disease can be different in older patients For instance minimal change disease (MCD) in children almost always remits promptly with steroid therapy in adulthood it typically remits only after many weeks of steroids or with adjunctive immunosuppression However there are remarkably few published data on the mortality of primary nephrotic syndrome in adults We aimed to study this in our centre
Methods
We enrolled all adult patients who had a kidney biopsy in order to investigate nephrotic syndrome over 38 consecutive months (01 Jan 2014 ndash 28 Feb 2017) We defined nephrotic syndrome as heavy proteinuria (urinary proteincreatinine ratio UPCR gt350 mgmmol or albumincreatinine ratio gt220 mgmmol) and hypoalbuminaemia (serum albumin lt35 gL) In our analysis we included all patients in whom nephrotic syndrome was attributed to a primary glomerular disease We excluded kidney transplant recipients and patients in whom biopsies were performed to follow up a known glomerular disease We collected laboratory data at baseline (time of biopsy) and at 6 and 12 months We assessed patient survival by Kaplan-Meier analysis
Results
Of the 117 patients biopsied for nephrotic syndrome 71 patients (61 ) met the inclusion criteria and were followed up for a median of 469 days We compared outcomes in patients aged under 60 years old (n = 35) with those aged over 60 (n = 36) Mortality was higher in the older group (37 vs 4 mortality at one year p lt005 by logrank test) There were no significant differences between the two groups in serum creatinine or UPCR at any time Serum albumin was similar in both groups at baseline and at 12 months but was lower in the older group at 6 months (27 vs 32 gL p lt 005) Baseline haemoglobin was lower in the older group (114 vs 130 gL p lt005 by unpaired t-test) Primary diagnoses were MCD (n = 10 in younger group amp n = 5 in older group) membranous nephropathy (5 amp 10) IgA nephropathy (9 amp 8) FSGS (5 amp 5) membranoproliferative glomerulonephritis or C3GN (4 amp 7) and other (2 amp 1) Therefore unsurprisingly there were relatively fewer cases of MCD and more cases of membranous nephropathy in the older group otherwise the causative glomerular lesions were similar in both groups In those patients with MCD mortality was significantly higher in the older group none of the 10 patients with MCD diagnosed under 60 yrs old died during the follow-up period whereas 4 of the 5 older patients died 3 patients in the younger group and 1 in the older group were on renal replacement therapy (dialysis or transplant) by the end of follow-up
Conclusions
Primary nephrotic syndrome is associated with high mortality in the over 60s (37 at one year) Mortality was high even for MCD a disease that follows a benign course in childhood and early adulthood The higher mortality in older patients was not associated with greater severity of renal disease at presentation (as assessed by basic blood and urine parameters) This work was not funded we declare no conflicts of interest
A15 Renal biopsies in patients with diabetes mellitus in Scotland
Udana Ratnapala 1 Nicola Joss 2 Colin Geddes 3 Dana Kidder 1
1 Renal Unit Aberdeen Royal Infirmary Aberdeen 2 Renal Unit Raigmore Hospital Inverness 3 Glasgow Renal and Transplant Unit Glasgow
Introduction Diabetes mellitus is the leading cause of end-stage kidney disease (ESKD) requiring renal replacement therapy The utility of renal biopsy in patients with diabetes mellitus is controversial Broadly renal biopsy findings in patients with DM can be divided into diabetic nephropathy (DN) alone DN with non-diabetic renal disease (NDRD) or NDRD alone Timely identification of patients with NDRD is important to provide appropriate therapeutic measures Previously published guidelines on clinical predictors of NDRD have limited specificity and sensitivity The frequency of NDRD in renal biopsies of patients with DM is unclear in ScotlandThis study aimed at identifying the frequency and the pathology spectrum of NDRD in diabetic patients underwent kidney biopsy in 3 renal units
Methods A retrospective observational study was performed on clinical-pathologic findings in all patients with diabetes mellitus who underwent renal biopsy between 01012010 and 31122016 in 3 renal units (Aberdeen Inverness and Greater Glasgow) Data were gathered from electronic patient record systems Scottish Index of Multiple Deprivation (SIMD) 2012 was used to analyse correlation with patient outcomes
Results 247 patients were included 150 men (607) 217 type 2 DM (879) mean age 621 years and mean serum creatinine at the time of renal biopsy of 261 micromolL (+-190 std) On biopsy 92 patients (372) had DN while 127 (514) had NDRD and 28(114) had NDRD superimposed on DN The commonest NDRD aetiologies were IgA nephropathy (187) tubulointerstitial nephritis (168) and idiopathic membranous nephropathy (103) Predictors of NDRD were age (OR 1027 95 CI 1002-1052 p=003) duration of DM (OR 094 95 CI 0900-0987 p=001) and absence of AKI as indication for biopsy (OR 022 95 CI 0059-0826 p=0025) There was no significance difference in renal or patient survival in DN and NDRD Finally no significant correlation was depicted between SIMD quintiles and renal or patient survival in both groups
Conclusions The majority of renal biopsies carried out in patients with DM revealed a NDRD In this study age at the time of biopsy duration of DM and AKI were the main pointers towards NDRD Renal and patient survival were not significantly different between DN and NDRD groups
A16 The Impact of Withdrawal of Maintenance Immunosuppression and Graft Nephrectomy on HLA Sensitisation Ailish Nimmo1 Sophie McIntyre1 Lorna Henderson1 Richard Battle2
(1 Department of Renal Medicine Royal Infirmary of Edinburgh 2 Histocompatibility and Immunogenetics Royal Infirmary of Edinburgh)
Background The development of HLA antibodies towards a failing renal allograft is a barrier to re-transplantation We previously demonstrated an increase in HLA antibodies and calculated reaction frequency (cRF) following nephrectomy but results were confounded by immunosuppression changes occurring in close time proximity We examined the formation of HLA donor specific antibodies (DSA) in patients with failed grafts that remained in situ and compared results with patients undergoing graft nephrectomy to further assess the relative impact of nephrectomy and immunosuppression weaning on sensitisation and chance of transplant
Methods We carried out a single centre retrospective study of all patients with failed grafts in Lothian from 2005 to 2015 Samples were tested for DSA pre-immunosuppression (IS) wean post-IS wean and post-IS cessation Nephrectomy patients also had samples tested for DSA before and after nephrectomy Data on other sensitising events including blood transfusion and rejection were collected cRF was determined at each time point and entered into the ODT chance of transplant calculator with other demographics based on the average patient from the Edinburgh centre
Results 62 grafts failed over this time period Blood samples were available 41 patients (24 with nephrectomy 17 with failed graft left in situ) Patient demographics were similar between groups There was a higher rate of antibody mediated rejection in the nephrectomy group (46 vs 18) 76 of patients with nephrectomy group had received a blood transfusion The pattern of immunosuppression weaning was similar but median time from start of IS wean to cessation was longer in the nephrectomy group (350 vs 298 days) The changes in cRF and chance of transplant (COT) with immunosuppression weaning are shown in Table 1
Pre-IS Wean Post-IS Wean
Failed graft in situ (n=17)
Mean CRF COT at 5
years 15 62 38 59
Nephrectomy (n=24)
Mean cRF COT at 5
years 54 54 69 46
Post-IS Stop 55 53 89 42 Table 1 Mean cRF and Chance of Transplant (COT) at 5 years with IS alterations
Discussion A stepwise increase in cRF with reduced chance of transplant was observed in both groups as immunosuppression was withdrawn with a similar pattern of change irrespective of graft nephrectomy cRF was higher in the nephrectomy group despite a more gradual wean which may reflect a higher rate of antibody mediated rejection and increased number of patients receiving a blood transfusion The risks and benefits of stopping immunosuppression need to be carefully considered on an individual basis to maximise chance of future transplant
The authors have no conflicts of interest No funding was required for this study
A17 Obesity is not associated with progression to end stage renal disease in patients withbiopsy-proven glomerular diseases
Benjamin Elyan Jennifer S Lees Bruce Mackinnon Jonathan G Fox Colin C Geddes Emily PMcQuarrie
Glasgow Renal and Transplant Unit Queen Elizabeth University Hospital Glasgow
Introduction - Addressing risk factors for renal progression is a key aspect of managing chronic kidney disease (CKD) Body mass index (BMI) has been shown to impact on renal progression in unspecified CKD The aim of this study was to evaluate if there was an association between BMI and progression to renal endpoints in patients with biopsy-proven primary glomerular disease (GN)
Methods - We included all adult patients diagnosed with biopsy-proven primary GN (excluding minimal change nephropathy) in Greater Glasgow amp Clyde and Forth Valley between 01012000 and 31122015 Biochemical and anthropometric data were extracted from the electronic patient record at time of biopsy with follow-up data until 20062017 BMI was calculated from height and weight at time of biopsy and categorised into groups BMI le25 kgm2 (G1) gt25 to le30 kgm2 (G2) and gt30 kgm2 (G3 - obese) We assessed factors associated with reaching a combined renal endpoint of CKD5 or renal replacement therapy (RRT) with competing risk of death using the Fine and Gray subdistribution hazard model Analyses were conducted using cmprsk package for R statistical software package and SPSS version 24
Results - 560 patients with primary GN and available BMI data were included The average age was 532 years and 339 were female There were 132 patients in G1 210 in G2 and 207 patients in G3 Those in G2 and G3 were older (p=002) with slightly higher diastolic blood pressure (p=002) than those in G1 There was a greater proportion of focal segmental glomerulosclerosis in G3 but similar proportions of other GN diagnoses across groups There was no significant difference in baseline serum creatinine (sCr) (p=034) or log uPCR (p=045) between BMI groups On multivariate analysis age systolic blood pressure BMI or GN diagnosis were not predictive of renal outcome Higher baseline sCr (SHR 1003 per 1 umoll increase in sCr 1001-1004 plt0001) and log uPCR (SHR 130 per unit increase in log uPCR 95 CI 105-160 p=002) were associated with progression to the combined renal endpoint accounting for competing risk of death BMI was not associated with reaching combined renal endpoint on univariate analysis whether considered as a continuous variable (SHR=100 95 CI 098-102 p=096) or categorised by BMI group
Conclusion - Contrary to our expectations there was no association between BMI and progression to a combined renal endpoint of CKD5 or RRT in this cohort of patients with primary GN Efforts should be directed to managing other known risk factors for CKD progression
Sources of FundingConflicts of Interest - None
A18 Factors influencing long term renal function after living kidney donation
Matthew A Rutherford Norman J Galbraith Marc Clancy Colin C Geddes
Glasgow Renal and Transplant Unit Queen Elizabeth University Hospital Glasgow UK
Background Following live donor nephrectomy the remaining kidney undergoes an increase in filtration capacity known as compensatory hypertrophy Few cohorts with follow up of renal function beyond 5 years have been reported The impact on long term renal function of variability in donor factors such as age sex pre-donation blood pressure and glomerular filtration rate (GFR) is unknown Increasingly kidney donors have potential risk factors for future poor renal function such as hypertension older age and obesity The aim of this study was to analyse factors influencing long-term renal function in living kidney donors from our centre
Method Data were obtained from the electronic patient record Patients with a recorded procedure of lsquolive donor nephrectomyrsquo between 2005 and 2017 were identified GFR after donation (calcGFR) was calculated using the formula lsquocalcGFR = Pre-donation Isotope GFR x (Pre-donation Serum creatinine Serum Creatinine)rsquo which is accurate assuming muscle mass does not change Pre and post donation serum creatinines (two days two weeks three months and one to ten year) were recorded We analysed the influence of age sex pre-donation GFR and blood pressure on post donation GFR compensation
Results 355 live donor nephrectomies were performed between January 2005 and December 2016 The mean age was 469 (plusmn 116) years and 504 (n=179) were female Mean pre-donation isotope GFR was 937 plusmn 156 mlmin173m2 Median follow up was 2 years (IQR 1 to 6 years with range 2 weeks to 10 years) The calculated percentage of pre-donation GFR at 2 days 2 weeks 3 months 1 year 5 years and 10 years were 698 691 712 730 801 and 950 respectively (p lt 0001) Patients aged lt50 y had not only a higher calcGFR (858 plusmn 29 mlmin173m2 compared with 671 plusmn 28 mlmin173m2 p lt 0001) at 5 years following donation but achieved a higher degree of compensation than donors gt 50 y (836 plusmn 16 compared with 756 plusmn 19 (p = 0002) Patients with pre-donation hypertension achieved 774 plusmn 53 of pre-donation GFR compared with 804 plusmn 32 in normotensive patients (p = 0998) Females had equivalent degree of renal compensation achieving 819 plusmn 19 compared with 780 plusmn 16 in males (p = 0131) at 5 years following donation Patients with pre-donation GFR gt 100 mlmin173m2 achieved 844 plusmn 23 of pre-donation function by 5 years compared with 777 plusmn 14 in those with pre-donation GFR lt 100 mlmin173m2 (p = 001)
Conclusion Following live donor nephrectomy renal function has a nadir of 691 at 2 weeks Compensation in GFR occurs rapidly and appears to be maintained regardless of sex and pre-donation blood pressure Younger age and higher pre-donation GFR were associated with a greater degree of compensation
A19 The utility of high-sensitivity cardiac troponin to stratify cardiovascular risk in patients with renal impairment
Eve Miller-Hodges Atul Anand Anoop S V Shah Nicholas L Mills Neeraj Dhaun
Background Cardiovascular disease is the most common outcome of chronic kidney disease1
Declining glomerular filtration rate (GFR) and proteinuria predict increased cardiovascular risk over the long term2 However there are currently no methods to stratify cardiovascular risk in the short or medium term in patients with renal impairment We have already shown that high-sensitivity cardiac troponin I concentrations (hs-cTnI) lt5ngL in patients presenting with symptoms of acute coronary syndrome identifies those at low risk of cardiac events within 30 days and over the next year3 However uncertainty remains over the role of hs-cTnI testing in patients with renal impairment This study investigated whether hs-cTnI could also stratify future cardiovascular risk in patients with renal impairment
Methods In a prospective study of consecutive patients presenting with suspected acute coronary syndrome we evaluated the performance of hs-cTnI in patients with and without renal impairment (estimated glomerular filtration rate lt60mLmin173m2) using an early risk stratification threshold of 5ngL to ldquorule outrdquo acute myocardial infarction at presentation and within 30 days and sex-specific 99th centile diagnostic thresholds for index type 1 myocardial infarction Subsequent type 1 myocardial infarction and cardiac death were reported at one year
Results Of 4726 patients identified 904 (19) had renal impairment Index diagnosis of type 1 and type 2 myocardial infarction was almost twice as likely in patients with renal impairment (30 vs 15) Performance of the early risk stratification threshold of 5ngL to identify patients at low risk of major cardiac events was similar in patients with (NPV 984 95CI 960-997 sensitivity 989 95CI 975-999) and without renal impairment (NPV 997 95CI 994-999 sensitivity 984 95CI 972-994) These patients continued to remain at low risk over the next year The PPV and specificity at the 99th centile for diagnosis of myocardial infarction were lower in patients with renal impairment at 500 (95CI 452-548) and 709 (95CI 675-742) respectively compared to 624 (95CI 588-659) and 921 (95CI 912-930) At one year 24 of patients with renal impairment and troponin gt99th centile regardless of index diagnosis had experienced further myocardial infarction or cardiac death compared with 10 of patients without
Conclusion In suspected acute coronary syndrome hs-cTnI can stratify risk in patients with renal impairment Irrespective of diagnosis patients with renal impairment and elevated cardiac troponin concentrations had two-fold greater risk of a major cardiac event compared to those with normal renal function and should be considered for further investigation and treatment
Funders Wellcome Trust British Heart Foundation and Chest Heart amp Stroke Scotland
1 Gansevoort RT Lancet 2013
2 Chronic Kidney Disease Prognosis Consortium Lancet 2010
3 Shah AS Lancet 2015
A20 lsquoDOES IT DIALYSE OUTrsquo - THE EFFECT OF RENAL REPLACEMENT THERAPY ON THE BRAIN Mark Findlay Jesse Dawson David Dickie Deborah McGlynn Patrick Mark Institute of Cardiovascular and Medical Science University of Glasgow amp Queen Elizabeth University Hospital Glasgow
Introduction Cerebrovascular disease is common in end-stage renal disease (ESRD) on renal replacement therapy (RRT) We investigated the effect of RRT on cerebral structure and cognitive function over 12 months Methods Observational cohort study in ESRD patients receiving HD Prior cognitive impairment or cerebrovascular disease were exclusion criteria Multi-domain cognitive testing was performed at baseline and at follow-up Transcranial Doppler was used to assess intra-dialysis related alterations in mean flow velocity (MFV) ndash a marker of cerebral blood flow MR imaging was performed at 0 and 12 months We performed T1 T2 FLAIR and DWI sequences and used volumetric software to calculate white matter hyperintensity (WMH) burden markers of atrophy mean diffusivity and fractional anisotropy (FA) to describe structural changes at 1 year Results 97 patients median age 59 years 412 female At follow-up 15 patients were transplanted 6 died 4 withdrew and the remainder continued HD Those who were transplanted were younger (median age 51 vs 60 years p=0019) and had been on dialysis for a shorter period (median 06 vs 21 years p=0003) MFV declined during HD median 475cms to 405cms plt0001 and correlated with lower scores of executive and frontal lobe function during HD (Rho 045 p lt0001 and Rho -0313 p lt001 respectively) In all patients MR imaging demonstrated a significant decline in frontal parietal and temporal lobe volume at follow-up Median WMH volume increased in those who remained on HD but not in transplanted patients (median change 023 vs -012ml p=0018) WMH burden correlated with worsening scores of frontal lobe tests Rho 0585 p0005 and worse mood Rho -0485 p0026 FA improved following renal transplant (028 to 029 p=0016) and correlated with improved executive function testing at follow-up Rho 089 p0019 Conclusion Cerebral blood flow is reduced during haemodialysis and correlates with a reduction in intradialytic executive function There is an improvement in FA following transplantation WMH volume increases in those who remain on dialysis and the degree of increase correlates with executive and frontal lobe function This suggests that haemodialysis is associated with clinically significant changes in the brain and that these may be ameliorated by transplantation
Source of fundingconflicts MF is funded by a KRUK fellowship
A21 Pathological classification of IgA nephropathy to predict renal outcomes ndash is there a better way to score tubulointerstitial inflammation
Alastair Rankin David Kipgen Bruce Mackinnon Jonathan Fox Colin Geddes Emily McQuarrie Glasgow Renal and Transplant Unit On behalf of the Scottish Renal Biopsy Registry
Background The Oxford pathological classification of IgA nephropathy (IgAN MEST-C score) is limited by the fact that individual features of the score are not all predictive and its utility in assisting clinical decision-making is questioned The addition of tubulointerstitial inflammation to the existing scoring system is appealing but is not currently included due to reportedly wide inter-observer variability We report a novel method to score percentage of cortex containing tubulo-interstitial inflammation in non-atrophic renal cortex (ATIN) in patients with IgAN similar to that used in transplant biopsy reporting and assess its utility to predict clinical outcomes
Methods All adult patients with a native renal biopsy diagnosis of IgAN between 2010 and 2015 in a unit serving 15 million people were identified Baseline characteristics biopsy reports and outcome data were collected ATIN was calculated by subtracting the percentage of atrophic cortex from the percentage of total cortex with tubulo-interstitial inflammation withge10 representing significant tubulo-interstitial inflammation in non-atrophic cortex The primary outcome was a composite of requiring renal replacement therapy (RRT) or doubling of serum creatinine (sCr)
Results 153 new cases of IgAN were identified 33 were excluded (24 had lt8 glomeruli on biopsy 6 inadequate biopsy for MEST scoring and 3 on RRT at time of biopsy) In addition patients with a tubular atrophy (T) score of 2 were also excluded (n=9) Of the remaining 111 patients 76 (68) were male Mean age at biopsy was 52 years (+- 167) and 18 (16) had a co-existing clinical diagnosis of henoch-schonlein purpura (HSP) Median sCr was 156 micromoll (IQR 101-212) and 54 (49) had ATIN on biopsy During a median follow-up of 23 years 34 (31) reached the primary outcome 20 (18) received immunosuppression and 16 (14) died On univariate Cox regression survival analysis ATIN was associated with a four-fold increase in the primary outcome (HR 49 (21-113)) On multivariate analysis mesangial hypercellularity (M) T and ATIN independently predicted renal outcome while endocapillary proliferation (E) and segmental sclerosis (S) did not (plt002 for ATIN) Excluding patients with HSP or those who received immunosuppression did not change the result
Conclusion Within our centre ATIN predicts renal outcome for IgAN independently of established histological features Assessment of inter-observer reproducibility and validation in other cohorts is still required but these results suggest ATIN could be a worthwhile addition to current pathological scoring systems for IgAN
Source of funding none Conflicts of interest none
P1 Polypharmacy in Renal Replacement Therapy Patients
Jason McMinn Colin Geddes Glasgow Renal and Transplant Unit Queen Elizabeth University Hospital
Introduction
Prescribing is often led by evidence from studies containing participants with single health conditions and without multimorbidity Polypharmacy is becoming increasingly recognised in patients with multiple chronic health conditions Additional medications are more likely to result in diminishing returns in benefit with an increased risk of harm Patients with established renal failure (ERF) are likely to be susceptible to medication-related harm A high pill burden is also likely to contribute adversely to an already restricted quality of life and has been associated with poor medication adherence The aim of this study was to analyse polypharmacy in all patients with ERF attending our service
Methods
We extracted medication records for all prevalent ERF patients attending the Glasgow Renal and Transplant Unit from the West of Scotland Electronic Renal Patient Record (SERPR) as of 01012017 The records were analysed to calculate the number of regular medications and total pill burden of each patient These medications were categorised as being lsquopreventativersquo or lsquosymptomaticrsquo We also analysed the prescription of specific drug classes to examine the prevalence of these medications
Results
We identified 1091 transplant follow-up 529 hospital haemodialysis and 46 peritoneal dialysis patients who were on a mean of 94 13 and 129 different medications respectively Overall pill burden was 139 tablets a day in transplant follow-up patients 141 in haemodialysis patients and 162 in peritoneal dialysis patients There were similar rates of prescribing between the different dialysis units and clinics within our service
The proportions of medications deemed as preventative rather than symptomatic were 76 in transplant 69 in haemodialysis and 60 in peritoneal dialysis
In transplant patients decreasing renal function was associated with a higher pill burden but even patients with a transplant eGFR gt 60 were on a mean of 126 tablets per day including a mean of 14 antihypertensives
Rates of antidepressant prescribing were 15 in transplant patients and 20 in hospital haemodialysis patients 53 of haemodialysis patients were on a statin 39 on aspirin 61 on a proton pump inhibitor and 7 were on warfarin
Conclusion
Patients undergoing all forms of renal replacement therapy are likely to be on a considerable number of medications Whilst these drugs are inevitably prescribed for valid reasons this data demonstrates the need for clinicians to engage with patients to explore opportunities to reduce pill burden
Conflict of Interest None Sources of Funding None
P2 An audit of Acute Kidney Injury (AKI) on an acute stroke ward before and after plannedinterventions to review and maintain hydration
Clare Harris1 Simon Hart2 Fiona Duthie3 1 University of Edinburgh Medical School 2 Stroke Unit Royal Infirmary of Edinburgh 3 Renal Unit Royal Infirmary of Edinburgh
Background Dehydration is an important factor in the development of acute kidney injury which is associated with increased morbidity and mortality particularly in the elderly population Poor fluid intake is common post stroke (1) and dehydration is associated with poorer outcomes 3 months post stroke (2) In late 2014 there was no system of identifying patients with poor oral intake on the stroke ward at the Royal Infirmary of Edinburgh a hydration protocol and education programme were implemented aiming to improve fluid balance This included the use of prescribed water either orally or by nasogastric tube An audit pre and post intervention demonstrated that hydration as measured by ureacreatinine ratio significantly improved after the protocol introduction (3) We aimed to determine whether the incidence of AKI by KDIGO criteria was also reduced as this could have implications for reducing patient morbidity and mortality in this elderly comorbid patient cohort
Method 150 inpatients to the acute stroke ward during JulAug 2014 and JulAug 2015 were selected (n= 80 2014 n=70 2015) Patient data and creatinine values were collected from the electronic patient record and medical notes and retrospectively analysed Baseline creatinine values were calculated and cases of AKI were identified and staged using KDIGO criteria (4) Chi-Squared tests were performed to determine P values Individual patient notes were reviewed for both quantitative and qualitative data of patient management
Results Incidence of AKI (of any stage) was 263 pre-protocol and 200 post-protocol (P=03646) Incidence of AKI stages 23 was 100 pre-protocol and 715 post-protocol (P=05374) In hospital post stroke mortality was 338 pre-protocol and 1286 post protocol (P=00028) AKI was also associated with increased length of stay
Conclusions Despite a trend in benefit there was no significant difference in incidence of AKI pre and post hydration protocol nor in incidence of severe AKI (stage 23) AKI is influenced by many factors one of which is hydration status Further studies are needed to determine whether the trend of benefit exhibited in this sample is significant in a greater sample size if this were the case such a protocol could have great benefit to patient care on stroke units and elsewhere There was a significant difference in inpatient post stroke mortality following introduction of the hydration protocol Further investigations are needed to explain underlying reasons for this factors other than hydration may play an important role
References 1 Whelan K Inadequate fluid intakes in dysphagic acute stroke Clinical Nutrition (2001) 20(5)
423-428 2 Bhalla A Sankaralingam S Dundas R Swaminathan R Wolfe CDA Rudd AG The influence of
raised plasma osmolality on clinical outcome after acute stroke Stroke (2000) 312043ndash2048 3 Hart SR Craig R Berry E Lane N Gad A Farrugia M Burton L Paquay A What Happens to
Acute Stroke Patientsrsquo Fluid Balance Renal Status and Dehydration in the First Two Weeks How Can They Be Markedly Improved doi 101111ijs12634_13
4 KDIGO Clinical Practice Guideline for Acute Kidney InjuryKidney international supplements (2012) 2(1) 1-138
No funding or conflict of interest to declare
P3NHS Highland-Improving the management of hyperkalaemia using a kit Initial resultsCantley N1 Abedin T2 Lambie S3
1FY2 NHS Highland 2ST4 Renal Medicine NHS Grampian 3Renal Consultant Renal unitRaigmore Hospital Inverness
Introduction The incidence of hyperkalaemia in hospitalised in patients is between 1 and 10 Guidelines in Northern Ireland promote the use of a Hyperkalaemia Kit to improve management of hyperkalaemia We assessed the management of hyperkalaemia in Raigmore Hospital including post-treatment monitoring of serum potassium and blood glucose at baseline and after the introduction of a lsquoHyperkalaemia Kitrsquo which contains a pro forma for the management of hyperkalaemia and all the relevant equipment and drugs for treatment
Method Between July and September 2016 an automated algorithm identified 34 patients with a potassium result 65 mmoll or above on laboratory results 12 received no specific treatment of these 6 results were spurious 4 patients died before treatment could be started and 2 patients were chronic haemodialysis patients We introduced the Hyperkalaemia Kit to the Acute Medical Admissions Unit in Raigmore Hospital Since then 15 patients have been identified with serum potassium measurements above 65 and the pro forma and kit was used with eight of these patients One of these patients proceeded straight to acute renal replacement therapy
Results Prior to our intervention all 22 patients that were actively treated received at least one prescription of appropriate doses of Insulin with Dextrose However only 16 patients received intravenous calcium and only 7 received nebulised Salbutamol Potassium was measured at 4 hours in 5 cases and by 12 hours in 17 cases Monitoring of any capillary blood glucose was only documented in 8 cases Of the 22 treated 2 needed acute renal replacement therapy 3 required further doses of insulin and dextrose 2 were treated with Calcium Resonium
Eight cases of hyperkalaemia have been managed with the use of the kit and pro-forma so far An initial ECG was performed in all eight and four patients had continuous cardiac monitoring Intravenous calcium was given in seven and nebulised Salbutamol was given in five out of the eight cases Six out of eight patients had at least three blood sugar measurements One had two measurements documented and one patient was stopped from further monitoring following senior review and decision to palliate Seven patients had appropriate monitoring of their serum potassium by 4h and 12h again one patient was not monitored due to palliation
Conclusion Baseline results showed very low rates of prescription of nebulised Salbutamol low rates of Calcium Gluconate use and very low monitoring of blood sugars and potassium post treatment This has the potential for serious adverse outcomes particularly the potential for iatrogenic hypoglycaemia Our initial data shows the use of a Hyperkalaemia pro forma and kit improves the rate of prescription of intravenous calcium and nebulised Salbutamol and the post-treatment monitoring of serum potassium and blood sugar levels
P4Rituximab as maintenance therapy in ANCA associated vasculitisndash a single centre experience Rathnamalala NK Mcmenamin J Robertson S Almond A Kelly M Muniraju T M Renal Unit Dumfries and Galloway Royal Infirmary NHS Dumfries and Galloway Background The introduction of Cyclophosphamide and high dose steroids transformed ANCA associate vasculitis (AAV) from a disease of high mortality to a relapsing remitting disease Maintenance of remission however still remains a major challenge A two randomised clinical trials have looked at the use of Rituximab in remission induction in AAV and reported similar remission rates between Cyclophosphamide and Rituximab 12 Both these trials used Azathioprine as maintenance therapy and in the follow up showed similar remission rates with either agent for induction The role of Rituximab for maintenance therapy after cyclophosphamide induction was studied in the MAINRITSAN trial 3 Rituximab was compared with azathioprine and found that the relapse rate was significantly lower in the Rituximab group There have been several other retrospective studies that have suggested regular Rituximab infusions are successful in maintaining remission however has not been thoroughly evaluated 4 5678910 Here we share our centrersquos experience using Rituximab for maintenance of remission of AAV Materials and methods We conducted a retrospective review of electronic medical records of all patients who had received Rituximab as maintenance therapy for 12 months or longer between January 2014 to July 2016 Disease activity was assessed using Birmingham Vasculitis Activity Score ( BVAS) Version 3 and complete remission was defined as a score of 0 and partial remission as a score of lt50 of the value at diagnosis Due to uncertainties associated with sub classification we did not assign specific diagnosis but broadly classified as ANCA associated vasculitis Results 6 patients received Rituximab as maintenance therapy during the study period 3 (50) of them had eye ear nose and upper airway manifestations consistent with Granulomatosis with Polyangitis (GPA) All patients were PR3 ANCA positive except for one at initial diagnosis The mean BVAS score at the time of initiation of Rituximab was 4 All patients were initiated on Rituximab for relapses while on maintenance therapy with Azathioprine 4 patients received 6 monthly doses of Rituximab while two received annual doses All of them were also maintained on 5-10 mg of Prednisolone The mean BVAS score by 6 months was 0 and remained 0 at 12 months The mean PR3 titre was 562 at the initiation of treatment while at 12 months it had come down to 68 All patients remained in complete clinical remission at the end of 12 months after initiation of therapy Rituximab was well tolerated by all patients except one who developed pyrexia during an administration
Conclusions All patients had sustained remission at 6 months and 12 months after initiating Rituximab Rituximab has a potential role as maintenance therapy in AAV
P5 Chronic Myelo-Monocytic Leukaemia (CMML) as a contraindication to renal biopsy Alastair Rankin Emily McQuarrie Jennifer Lees Bruce MacKinnon Glasgow Renal and Transplant Unit On behalf of the Scottish Renal Biopsy Registry
Abstract Chronic Myelo-Monocytic Leukaemia (CMML) is a relatively rare mixed myelodysplastic myeloproliferative disorder that predominately affects patients over the age of 65 years Renal impairment in patients with CMML is well described with several different mechanisms reported including tumour infiltration lysozyme-induced injury amyloid deposition and tubulointerstitial nephritis From anecdotal evidence within our centre we are concerned that patients with CMML have an excessive risk of clinically significant bleeding following native renal biopsy This risk appears disproportionate to the degree of any co-existing thrombocytopenia or coagulopathy
We review the cases of 4 patients with an existing diagnosis of CMML who were referred to the renal clinic with proteinuria and excretory renal dysfunction Two of these patients underwent renal biopsy with subsequent major haemorrhage post-procedure despite normal bleeding parameters pre-procedure Patient 1 presented with flank pain 8 days post-biopsy A CT confirmed peri-nephric haematoma with retroperitoneal extension A total of 6 units of packed red cells (PRCs) were transfused prior to successful CT-guided emoblisation Histology from the biopsy revealed chronic tubulointerstitial nephritis Patient 2 experienced haemodynamic instability and haematuria one hour post-biopsy A total of 11 units of PRCs 7 units of fresh frozen plasma 2 pools of platelets intravenous tranexamic acid and 2 attempts at CT-guided embolization were required until haemostasis was achieved Histology later showed evidence of tumour infiltration with associated vasculitis Patient 3 presented with renal impairment and proteinuria on the background of known CMML Following discussion with haematology the risk of bleeding following renal biopsy was considered unjustifiable despite their platelets and coagulation screen being within normal range The patient was treated for presumed renal tumour infiltration with hydroxycarbamide Patient 4 was referred to the renal clinic with acute onset nephrotic syndrome Urinary proteincreatinine ratio was elevated over 800 mgmmol with serum albumin of 23 gL but normal excretory renal function The patient attends the haematology clinic with suspected CMML and chronic thrombocytopenia but previously declined bone marrow biopsy Following discussion with the patient there are no plans to proceed with renal biopsy given potential risks These cases highlight that while CMML is rare these patients are being referred to renal clinics with features that would commonly justify renal biopsy in other settings but in whom there may be an increased risk of bleeding post-procedure Our in-centre risk of major bleeding is 2 therefore to have such extreme amounts of bleeding in 2 patients with this underlying diagnosis is remarkable This creates a dilemma for the clinician as there is a wide range of potential renal pathology associated with CMML some of which will have disease specific but relatively toxic treatments available
Source of funding none Conflicts of interest none
P6 NHS Highland-Prograf to Adoport switch McCulloch K1 Peel R2 Lambie S3
1Renal Pharmacist Renal unit Raigmore Hospital Inverness 23Renal Consultant Renal unit Raigmore Hospital Inverness
Introduction NHS Highland (NHSH) is the first health board in Scotland to implement a switch from Prograf to Adoport for renal transplant patients This will provide considerable cost savings Adoport meets the bioequivalence criteria for drugs with a narrow therapeutic index set by the European Medicines agency and studies indicate therapeutic equivalence1 with the proviso that brands are non- interchangeable unless the switch is overseen by a Renal Consultant and post-conversion therapeutic drug monitoring is conducted23 The switch has been undertaken by a majority of transplant centres in England the main difference being that they have undergone repatriation NHSH Patients receive their transplant primarily at Royal Infirmary of Edinburgh and occasionally at Queen Elizabeth University Hospital Glasgow Care is transferred to NHS Highland on discharge NHS Highland cares for approximately 170 renal transplant patients 110 being prescribed Prograf These patients may live as far as 110 miles from Raigmore Hospital Given that prescribing is carried out by primary care clear communication with patients GPs and community pharmacy is essential to avoid inadvertent switching between brands
Method Clinically it was agreed a switch could be safely undertaken A business case was submitted and funding secured for pharmacist time laboratory costs and primary care time GPs have been informed via GP subgroup and local prescribing bulletin lsquoThe Pink Onersquo Community pharmacies are being informed by phone A protocol has been agreed Eligible patients selected by Renal Consultant and Renal Pharmacist Patients sent letter signed by Renal Consultant and Renal pharmacist Patients phoned prior to clinic to agree Adoport start date and address concerns Patient seen by Renal Consultant and pharmacist + given 1 month of Adoport Tacrolimus level and UampEs checked 5-7 days after commencing Adoport and patient
contacted by phone to check if tolerated If stable letter sent to GP and community pharmacy to continue supply
Results and Evaluation Letters have been sent to all eligible patients Seven patients have been reviewed One has received a one month supply of Adoport and 5 others are due to switch One patient was deemed non-eligible at present as they have a 6 month surplus of Prograf A database will be maintained and analysed at the end and primary care savings will be monitored Extra pharmacist input will give us the opportunity to review how immunosuppression is managed and to evaluate the benefit of having a renal transplant pharmacist Conclusion The switch is at an early stage Ultimately we hope to show that the switch from Prograf to Adoport can be managed safely with extra pharmacist input to a remote and rural population with prescribing being conducted by primary care
Fundingconflicts of interest none 1 McDevitt-Potter LM Sadaka B Tichy EM Rogers CC Gabardi S Transplantation 2011 A multicenter experience with
generic tacrolimus conversion 2 Medicines and Health Products Regulatory Agency Drug Safety Update 2012 Accessed online via
wwwmhragovukSafetyinformationDrugSafetyUpdateCON1557563 ESPRIT Guidance on management of repatriation and immunosuppressant switches in transplant patients 2015
Accessed online via httpwwwespritorgukwp-contentuploads201508Switch-guidance-document-final-Aug-31-2015pdf
P7 NHS Highland-Tacrolimus baseline dataMcCulloch K1 Peel R2 Lambie S3
1Renal Pharmacist Renal unit Raigmore Hospital Inverness 2Renal Consultant Renal unitRaigmore Hospital Inverness 3Renal Consultant Renal unit Raigmore Hospital Inverness
BackgroundAs part of planning a switch from using tacrolimus Prograf to Adoport we assessed baseline data for our transplant patients currently using Prograf After converting patients to Adoport we will compare their tacrolimus levels to their individual target range We assessed our use of appropriate target ranges and our current performance in achieving tacrolimus levels within target range on Prograf therapy
Method 107 renal transplant patients taking Prograf were identified a sample of 19 of these were analysed using electronic patient records and results Time from transplant ranged from 1 month to 18 years All tacrolimus levels for the preceding year were analysed and compared to the target range specified at the time of the level being done The assay used has a Coefficient of Variation of lt5 at the lower limit of the assay
Results All 19 patients had a target range for tacrolimus clearly identified and recorded in clinic letterswhich are routinely copied to the patients themselves A variety of target ranges were specifiedThe commonest used was 5-8 microgramsl in 7 patients followed by 5-7 in a further 4 patientswith another 6 different target ranges being used for the remaining 8 patients The ranges usedhad a breadth of 3 microgramsl in 2 cases the rest had a breadth of 2 microgramslPatients had a median of 12 (range 3-72) tacrolimus levels over the preceding year Results werewithin specified target ranges for 54 +- 22 (Medan +- SD) of results checked
Conclusion We currently use a large number of different target ranges The majority of the ranges used had a breadth of just 2 microgramsl These factors help to account for the low proportion of test results which were within the specified target ranges This is important to bear in mind when interpreting whether tacrolimus levels are within target ranges after switching to Adoport We should consider aligning our target ranges and widening them
P8 Eculizumab use in Scottish paediatric dense deposit disease Stewart D1 David Hughes1 Lynne Riach2 Craig Oxley2 Athavale D1
1Royal Hospital for Children Glasgow 2Royal Aberdeen Childrenrsquos Hospital Aberdeen
Introduction The revised MPGN classification and increasing recognition of Dense Deposit Disease (DDD) a C3 glomerulopathy as an alternative complement pathway disorder suggests Eculizumab an anti-C5 monoclonal antibody may be beneficial in treatment However the experience of Eculizumab as an off-label and expensive treatment in children with DDD is limited with variable clinical response reported in the literature
Method We present the outcomes of the only 2 paediatric patients in Scotland who have received Eculizumab for the management of DDD
Results Case 1 A 10 year old male presented with proteinuria and haematuria resistant to steroid treatment with preserved renal function Initial biopsy confirmed DDD Conservative management with an angiotensin converting enzyme inhibitor and diuretics for symptom control continued until 14 years Due to worsening symptoms (oedema lethargy poor growth) and renal function deterioration along with elevated terminal complement complex (TCC) Eculizumab was commenced A repeat biopsy whilst suggestive of chronic irreversible damage showed 25 glomerular architecture preservation Symptom improvement was noted There was a reduction in proteinuria and renal function stabilisation fall in TCC and discontinuation of diuretics Eculizumab was discontinued after 24 months Progression of renal function decline was seen in the final months of Eculizumab therapy With recurrence of symptoms and increasing proteinuria following discontinuation Eculizumab was recommenced after 6 months Symptomatic improvement has since been noted
Case 2 A 5 year old girl presented with painless frank haematuria and proteinuria Initial biopsy confirmed DDD Proteinuria was unresponsive to steroid therapy and 5 months following diagnosis she rapidly progressed towards end stage renal disease despite the introduction of Mycophenolate Mofetil and plasmapheresis Haemodialysis was subsequently commenced TCC level was elevated and Eculizumab treatment was started 7 months after diagnosis Renal biopsy prior to treatment demonstrated continued severe pathological changes in all visible glomeruli However due to lack of clinical response Eculizumab was discontinued after 2 months and the patient remained dialysis dependent
Conclusions Our experience with Eculizumab in Scotland has demonstrated variable results in our 2 patients with one patient showing a positive response whilst the other experienced no improvement Eculizumab was administered to both patients at varying points in their clinical journey with differing progressive features on biopsy To date the outcomes of 9 paediatric patients with DDD treated with Eculizumab have been described in the literature with 8 experiencing some positive response to treatment including 2 patients who were able to stop renal replacement therapy within 12 weeks of treatment A role for Eculizumab in DDD may be guided by clinical and pathological features Well designed clinical trials will be necessary to define the role of complement inhibition therapy in DDD
No conflict of interest and no funding requested
P9 Examining markers of safety in the use of non-tunnelled central venous catheters
James WT Millar (Speciality Registrar) Scott W Oliver (Speciality Registrar) Peter C Thomson (Consultant Nephrologist) Glasgow Renal and Transplant Unit Queen Elizabeth University Hospital Glasgow
Background Non-tunnelled central venous catheters (NTCVC) remain an essential means of vascular access for incident haemodialysis Associated morbidity is well recognised for example in the form of Staphylococcus aureus bloodstream infections (SAB)[1]
Previous quality improvement initiatives in our unit have sought to both improve traditional markers of quality (such as SAB) and to identify additional areas of clinical risk In 2014 Oliver et al [2] suggested several additional quality measures including peri-procedure haemoglobin drop the need for a further NTCVC during the same clinical episode and the NTCVC insertion site This study further evaluated NTCVC related clinical practice within our unit
Methods The potential markers of clinical quality identified in a previous project were examined using prospectively collected data stored in the electronic patient record Identified cases of SAB significant peri-procedure haemoglobin drop and multiple NTCVC insertion were investigated by case note review
Results Between March 2016 and March 2017 a total of 222 patients received 346 NTCVC 54 patients (243) had more than one NTCVC inserted in a 21-day period (range 2-5) When considering NTCVC insertion site there were 159 (459) femoral vein catheters and 183 (541) internal jugular vein catheters No pneumothoraces were reported
15 SABrsquos were reported during this period equating to 43 of all NTCVC 5 arose in patients with femoral NTCVC (333) and 10 from internal jugular catheters (667) Mean time from line insertion to positive blood culture was 86 days 15 (67) patients had a drop in haemoglobin of greater than 20mgdl with no other source of blood loss identified on review of clinical notes
Discussion These data demonstrate that NTCVC-associated SAB rates remain low and significantly below Scottish government audit standards [3] Of interest is the continued trend towards the use of femoral catheters at 45 of lines compared with 38 in 2014 [2] Although traditionally thought of as having a higher incidence of infectious complications our data has shown fewer bacteraemia events associated with femoral catheters compared with internal jugular Our data also demonstrates a significant rate of peri-procedure haemorrhage arising in up to 1 in 20 cases Together these findings present opportunities to development practice and improve patient safety
References
[1] Murray E Deighan C Geddes CC Thomson PC Reducing haemodialysis bacteraemia rates Scottish Renal Association Glasgow November 2013 [2] Oliver SW Thomson PC Jardine AG defining safe effective and patient-centred dialysis catheter placement Scottish Renal Association Edinburgh September 2014 [3] The Staphylococcus aureus bacteraemia quarterly report of cumulative data from all NHS Boards in Scotland Health Protection Scotland January 2015
Sources of funding none Conflicts of interest none
P10 Prescribing of tolvaptan-The NHS Highland experience Lambie S1 McCulloch K2 Garrod J3
1Renal Consultant Renal unit Raigmore Hospital Inverness 2Renal Pharmacist Renal unit Raigmore Hospital Inverness 3Renal Pharmacist Renal unit Raigmore Hospital Inverness
Introduction Tolvaptan is a vasopressin antagonist It was accepted for use in Scotland by SMC in Jan 2016 to slow the progression of cyst development and renal insufficiency of autosomal dominant polycystic kidney disease in adults with chronic kidney disease (CKD) stage 1 to 3 at initiation of treatment with evidence of rapidly progressing disease1 Adverse effects related to aquaresis may affect patientsrsquo ability to achieve the optimum therapeutic dose and the risk of hepatic toxicity necessitates regular LFT monitoring The geography of NHS Highland required the implementation of novel methods of managing these patients and as a result a MDT approach with an emphasis on pharmacist input was adopted Consultant role Patient selection on the basis of evidence of rapidly progressing kidney disease declining
eGFR large volume kidneys on ultrasound and evidence of complications of PKD Side effects and potential benefits discussed Potential medication interactions reviewed Jinarc risk management prescriber training
Pharmacist role Undertook Jinarc risk management pharmacist training Prepares accurate drug history and reviews for potential drug interactions Carries out patient counselling and supplies patient education material sick day rules card
and lsquogot to gorsquo card Supplies GP education leaflet Provides advice on selection of new drug therapies eg for gout Manages stock and coordinates supply to patients
Results Prescribing commenced May 2016 patients currently prescribed tolvaptan 11 7 Female 4 male Number on target dose 73 n = 811 2 patients are still being titrated One patient did
not tolerate target dose due to aquaresis side effects and is being trialled on the middle dose
Withdrawals One patient has withdrawn due to agoraphobia and an inability to attend for monitoring and another is on hold due to having major surgery
Conclusion The MDT approach between the Renal Consultant and Pharmacist at Raigmore Hospital has enabled tolvaptan prescribing to be efficiently and safely implemented to patients living within a challenging geographical location
1 Scottish Medicines Consortium Detailed Advice Document tolvaptan 15mg 30mg 45mg 60mg and 90mg tablets (Jinarcreg) SMC No 111415 January 2016
NA1 Authors SCN Jacqueline Ross NHS Grampian
SCN Alan Somerville NHS Lanarkshire SCN Jane Humphrey NHS Lanarkshire
e- mail contact jacquelinerossnhsnet Alansommervillelanarkshirescotnhsuk
Janehumphreylanarkshirescotnhsuk
Phone contact 01224 552927 01236 712644
Title Sharing of Adverse Events in Renal Units across Scotland
Introduction Background The Scottish Renal Nurses Strategy Group (SRNSG) are a group of senior nurses from Renal
Units across Scotland who meet 3-4 times per year to discuss and implement best practice At the last meeting it was agreed that it would be good practice for each Health Board to share
their adverse events reported on the Datix System and deliver a presentation with an action plan to prevent incidents and improve patient safety across Scotland NHS Grampian and NHS Lanarkshire will be the first to deliver this presentation discussing adverse events from both Health Boards with an action plan
Top 5 adverse events over the past 12 months Renal Unit NHS Grampian 1 Violence and Aggression 2 Accidents including needlesticks slips trips and falls 3 Medication Errors 4 Infrastructure Staffing and Estates 5 Machines and Equipment
Top 5 adverse events over past 12 months Renal Unit NHS Lanarkshire
1 Slips Trips or Falls 2 Medicine errors 3 Treatment problems 4 Transfer problems 5 Breach of policy
The presentation will also focus on any serious adverse events which may not be in the top 5 categories
Aim Objective Each Health Board to share their adverse events with the aim to prevent them from occurring in other units to improve staff and patient safety and wellbeing across Scotland
Method Power Point Presentation
Outcome Results Sharing of adverse events resulting in the development of a national Action Plan to prevent these incidents improving safety and well being of staff and patients in Renal Units across Scotland
NA2
SRA Oct 2017 Abstract
BBV Never Event - The whats whys and hows
Staff Nurse Gillian Wilson Aberdeen Royal Infirmary
This presentation shares our experience of a never event that occurred and was not picked up for
a period of 18 months
Hepatitis C (HCV) positive antibodies were found in a previously negative patient
These results were a low positive with no biochemistry changes to suggest any liver damage
however steps were put immediately in place to isolate and investigate
Was it contamination from a dialysis machine was it related to a blood transfusion given prior to
first positive result was it faulty diagnostic tests in the laboratory
In Aberdeen we go over and above national guidelines and isolate all our BBV patients whether
they have positive blood results or are PCR negative
Further bloods tested at an external laboratory confirmed negative results
It highlighted that communication errors were to blame for the lack of speed in detecting this issue
Investigations concluded no real answers as to why this happened
NA3
Living Donation Scotland Changing attitudes towards living donor kidney transplantation
Jen Lumsdaine Julie Glen On behalf of the Living Donation Scotland Project Board
Background and aims
The rate of living donor transplantation has remained fairly static in Scotland over the past 10 years
Recent data has shown inequity of access to living donor transplantation throughout the UK so
there is potential to significantly increase this optimum form of treatment for patients with end-stage
renal failure in Scotland The Living Donation Project Board was formed in 2016 aiming to double
the number of living donor transplants by 2020
Method
The two key areas
1 Do recipients receive adequate and appropriate information at the right time about living
kidney donation
2 Informing the general public about altruistic donation
All patients active on the transplant list in Scotland were invited to an information event A follow-up
questionnaire was performed in the East of Scotland examining outcome or reasons for not
attending A scoping exercise looked at information provided by each unit was performed and link
nephrologists and low clearance nurses attended meeting to discuss strategies for early education
Outcome
An information pack containing both recipient and donor written information and short films on DVD
has been produced with the support of the Scottish Government for all recipients and potential
donors in Scotland A new website with comprehensive information both written and visual and
postcode finder to improve ease of access to local unit contact details has been developed
Two national media campaigns have been launched with a significant rise in the number of enquiries
from potential donors and actual increase in altruistic donor numbers
Nursing abstract ndash no conflict of interest
NA4Authors Susan Easson Charge Nurse Ward 4C QEUH Glasgow
e- mail contact SusanEassonggcscotnhsuk
Phone contact 0141 452 3300
Title A Conversational approach to find out ldquoWhat matters to yourdquo in a Renal Transplant ward
Introduction Background Finding out ldquo What Mattersrdquo to people using health and careservices is crucial to delivering safe effective and person centred care It is a simple yet profoundconcept and tries to get to the essence of person centred care by creating deeply personalengagements with patients and their families through a conversational approach However careexperience feedback all too often provides innumerable examples of where what really matters topatients and their family members is poorly understood or not addressed Using care experienceas the driver for change the nursing staff in Ward 4C used improvement approaches to explorehow to hold more meaningful ldquoWhat Matters to yourdquo conversations on a daily basis
Aim Objective To improve the patient experience by utilising a person centred approach
Method Using Care experience feedback What Matters to Me boards and the conversationalapproach
Outcome Results Improvements in patient experience will be shared using examples ofpractice and care experience feedback
There was no additional funding required for this project We worked in collaboration with theperson centred team whorsquos aim is to improve patient experience
NA5
The implementation of a renal education programme and its impact on clinical practice
The purpose was to implement a Renal Education Programme and to evaluate its impact on
clinical practise
It was identified that there was a need for an educational programme to be set up within Forth
Valley Royal Hospital There is no inpatient renal unit in FVRH on site for our renal patients they
attend Queen Elizabeth University Hospital We are an outpatient haemodialysis unit with
outpatient clinics on site Therefore it was identified that there was a need for nursing staff within
FVRH to be educated on all renal complexities for the benefit of our patients
This was done through a work-based learning approach which brought tangible benefits for our
patients However it did not come without pitfalls as educational programmes are often seen as
making very little difference to clinical practise
T
his study describes what methods were used and examines the advantages and disadvantages in
setting up an educational programme and evaluating its impact on clinical practise
NA6
Nursing Abstract ndash SRA Meeting ndash 26 October 2017
Chris McGee Tonya Broe Ken Weir
Renal Unit Forth Valley Royal Hospital
Use of the Therapy Monitor Haemodialysis Patient Record System Can we aim for a paper-
free dialysis unit
We are trialling a new haemodialysis patient monitoring system to work in conjunction with SERPR
and which is intended to supersede the Finesse system used previously
We are in the early stages of this process but with continuing staff education and regular tech
support we are hoping to gather sufficient evidence to evaluate whether the use of paper case
notes needs to continue
Is it a realistic goal to aim for a completely paper-free unit
NA7
THE CLINICAL USES OF APHERESIS WITHIN NHS TAYSIDE
Laura Thomson CN
Ninewells Hospital Dundee
NHS Tayside took over the apheresis service from BTS in 2012 The service has since expanded
with the benefits of carrying out this treatment has been widely recognised within NHS Tayside
and is now more commonly being offered to treat a wider range of conditions with the number of
treatments carried out each year rising
This presentation will highlight the progression of the apheresis service within NHS Tayside We
will identify the various conditions it is currently being used to treat and also identify the decision
making process involved in carrying out these treatments ie which replacement fluid will be used
anticoagulation medication administered
We will highlight the benefits and challenges we face in providing this expanding service within the
Renal Service
NA8Authors Linda McDougall Renal Physiotherapist NHS Highland
e- mail contact lindamcdougall1nhsnet
Phone contact 01463 706022
Title lsquoExercise on Haemodialysis- Keeping the Wheels in Motionrsquo
Introduction Background The impact of CKD on physical fitness functional ability independence amp ultimately quality of life cannot be underestimated Current national guidelines recommend that all individuals with CKD are encouraged to participate in regular exercise programmes between or during dialysis sessions if on HD Following a successful pilot study funding was approved to establish an lsquoExercise on Dialysisrsquo (EOD) programme across NHS Highland through the appointment of a dedicated renal physiotherapist in 2008 A successful programme was soon established but for several years post-vacancies and increasing in-patient demands limited the physiotherapy servicersquos ability to deliver the programme The need to improve the long-term sustainability of the service was recognised and in late 2016 funding was approved to develop a Band 4 PT HCSW role for this purpose
Aim ObjectiveTo optimise the sustainability and continuity of the lsquoExercise on Dialysisrsquo service across NHSHighland through development of a Band 4 PT HCSW role
Method The potential parameters of the role and limits of autonomy were scoped out using current NES resources and guidelines Service and task analysis was then carried out to establish which components of the EOD protocol could be undertaken by a Band 4 A series of competencies were developed in line with the clinical protocol and one-to-one training and supervision provided to the post-holder to ensure competency achieved in delivering the programme
Outcome Results A 10 WTE Band 4 PT HCSW was appointed in Jan 2017 with a dual role between the renal unit and acute medical wards Although training is not yet complete the post-holder is already running the day-to-day delivery and monthly audit of the EOD service with senior physiotherapist input only required for individual patient safety queries and general discussion around patientsrsquo progress and goals The benefit to the unit has been considerable as the band 4 is available to support patients and staff with EOD provision 5 days a week This allows for one-to-one supervision of patients who need more support to participate in EOD regular feedback on performance and reviews of outcome measures and goals to maintain motivation levels Feedback on the post has been very positive and its scope will only continue to expand as we look to further develop renal rehabilitation services across NHS Highland
NA9Authors Nadine Lyall and Kerry Guthrie
e- mail contact nadinelyallbordersscotnhsuk kerryguthriebordersscotnhsuk
Phone contact 01896 826637
Title The Developing Role of the NMP in a Satellite Dialysis Unit
Introduction Background
We have been practising as NMPrsquos for nearly 3 years working in the dialysis unit at the BGH The unit is a satellite unit of the ERI and we have expanded over the last 6 years The unit provides haemodialysis for 12 patients at any one time 3 sessions a day 6 days a week We are nurse-led and have 2 renal consultants who are based at the ERI
We saw an opportunity to use our knowledge and experience to develop our role By becoming NMPrsquos we have enhanced our professional development and we feel we meet the changing needs of the dialysis patient in a more holistic manner
Aim Objective
Our aim is to deliver effective care as we are better placed to deal with issues that often arise byacting swiftly this in turn is cost effective and convenient For example good anaemia and bonemanagement is important for their health wellbeing and lifespanTo help understand our role we will use a power point presentation highlighting issues we dealwith and the drugs we prescribe under the following headings Cardiovascular infection painanticoagulant disequilibrium diet renal bone disease and renal anaemia
Method Power point
Outcome Results
In the future we hope to further develop and have greater autonomy in our role We have great support from our renal consultants and have already built up a great relationship with our patients We hope to undertake the Clinical Decision Making course and this in turn will allow us to deal effectively with acute illness giving the dialysis patient better care We are keen to get feedback from other renal nurses in Scotland to enable us to develop our role further and in turn raise awareness of the NMP role in a dialysis unit We record all our prescribing decisions and keep the consultants up to date regularly Currently we are working on auditing our prescribing practice so that we can improve the service we can provide
NA10 Title Komunikacja w szkoleniu dializy ortzewnowej
Author Senior Charge Nurse Rhoda Bell
Address Raigmore Hospital Old Perth Road Inverness IV2 3UJ
Email rhodabellnhsnet Telephone 01463706023
Introduction Background Case study on lady with Polish as her first language she has some English but requires an interpreter to carry out Peritoneal Dialysis training and attend clinic She had some gynaecological issues that we were not aware of which impacted on the functionality of PD and therefore the success of treatment There were areas of concern in low clearance clinic with signs the patient had a reluctance to engage in decision making
AimObjective
Methods Discussion through the case study highlighted issues with communication between different PD staff and patients Areas of concern include different staffing techniques environment factors on training success Also language and communication issues the patient had were not fully apparent so training could not be individualised
Results We plan to trial training at home and have more individualised training schedule for patients The training step by step guides have been reviewed and practise standardised In collaboration with low clearance nurse we have developed a check list which will highlight concerns before the transition to PD ie language issues and need for training aids in another language gynaecological conditions
Conclusions Everyone learns differently and training methodsaids must be individualised for all It may not be apparent until training has commenced that there are concerns Having one to one training with the same nurse will consolidate training and build confidence in the patient Having a close working relationship with members of the MDT will help make a supportive PD journey
Would we do things differently if we knew about prolapse or lack of English both spoken and written
Key words - Peritoneal dialysis patient training communication
N11
Telehealth amp PDAudrey Jones
Advantages
Information on a daily basis about treatment weight and blood pressure
Change programme remotely via computer or mobile
Earlier intervention for machineprogramme issues
Reduction in home visits ie patient trained but still requires volume increases
No need to download cards to see what problems have been
Can have more detailed information available at clinics
Disadvantages
Relying on patient input data correctly
Machine is noisy especially first wave of machine
Still the same bag connection system and patient connection system (difficult for manual
dexterity problems)
Relying on patient having good signal
Modem problems
NA12Autosomal Dominant Polycystic Kidney Disease A cruel inheritance but new hopeAlistair Lawrie Renal Unit Victoria Hospital KirkcaldySadaf Arshad Corry Dunnigan Paul Phelan Neil Turner Renal Unit Royal Infirmary of Edinburgh
Background Autosomal Dominant Polycystic Kidney Disease (ADPKD) is the most prevalent single gene human genetic disorder and the most common of the inherited cystic and interstitial kidney diseases It is estimated to affect 1 in every 1000 individuals worldwide with over 50 of sufferers eventually developing end stage kidney disease and requiring dialysis or transplantation Symptoms include spasmodic severe pain hypertension haematuria infection and kidney failure There is currently no cure for ADPKD Management of the condition has traditionally involved lifestyle modification BP control and analgesia however a recent study (Torres et al 2012) demonstrated that treatment with V2-receptor antagonist drugs slowed increase in total kidney volume reduced the rate of functional decline and showed a reduced incidence of kidney pain
Aim Provision of a tolvaptan prescribing and monitoring service
Methods Experiential finding report of initial twelve months period of multidisciplinary ADPKDtolvaptan clinic
Results Early results are comparable with TEMPO study outcomes
Conclusion Due to the long term nature of this treatment results available at this time are showing only the earliest benefits of the intervention More quantifiable results such as increased time before the necessity for RRT will only be evident in coming years Torres VE et al (2012) Tolvaptan in Patients with Autosomal Dominant Polycystic Kidney Disease New England Journal of Medicine 367 pp 2407-2418 DOI 101056NEJMoa1205311
No funding requirement No conflict of interest
A10 Effect of blood temperature monitoring on intradialytic hypotension in patients with end stage renal disease requiring haemodialysis Heather Walker1 Susan McGeorge1 Drew Henderson2
1 Renal Unit Ninewells Hospital Dundee2 Regional Renal Centre Waikato Hospital Hamilton New Zealand
Background KDIGO define intradialytic hypotension (IDH) as a reduction in systolic bloodpressure (SBP) ge20mmHg or mean arterial pressure (MAP) ge 10mmHg with associatedsymptoms IDH is a common complication of haemodialysis (HD) and is associated with increasedmortality and morbidityStandard dialysis with a set temperature leads to thermal gain during the dialysis session Tocounteract this thermal gain vasodilation occurs and is postulated as one of the causes of IDHActive cooling of dialysis has been shown to reduce IDH but is not routinely applied across wholedialysis populations Isothermic dialysis can be achieved by controlling blood temperature on HDWe report here our experience of doing this using the Blood Temperature Monitoring (BTM)function on Fresenius 5008 dialysis machines
Methods An observational study was performed to assess the rates of IDH in patients with End Stage Kindey Disease (ESKD) undergoing regular satellite HD at NHS Tayside in July 2017 Rates of IDH were assessed (KDIGO definition) for two weeks prior to BTM settings being activated and for a two week study period after introduction SBP and MAP data was collected SBP data was grouped to either SBP decrease lt20mmHg or SBP decrease ge20mmHg compared with Pre HD BP Changes in MAP were also analysed at the same time points Patient reported symptoms related to initiation of BTM were also collected for the same time period
Results 402 dialysis sessions were evaluated in the pre intervention time period and 399 sessions post intervention
IDH 1072 vs 778 (Pre BTM vs Post BTM) p=015 gt20mmg SBP drop Pre vs Post BTM
Mean MAP Change (mmHg) Pre BTM vs Post BTM
1st BP 254 vs 204 (p=005) -522 vs +312 (plt001) 2nd BP 474 vs 435 (p=023) -1589 vs -886 (plt001) 3rd BP 515 vs 435 (p=003) -1862 vs -958 (plt001) Post HD 408 vs 338 (p=003) -1164 vs -077 (plt001)
Following the introduction of blood temperature monitoring only 08 of HD sessions reported experiencing cold or shivering symptoms
Conclusion The use of blood temperature monitoring was not associated with a statistically significant decrease in rates of IDH There was a significant reduction in the number of sessions where SBP decrease by gt20mmHg at the first and third HD BP and a reduction in MAP change across the study group Further evaluation of BTM is required assess its clinical utility in our HD population
Funding No funding was sought for this study
Conflicts of interest None
A11 Evaluating patient satisfaction and clinical outcomes of a new nurse-led dermatology clinic for patients attending the renal transplant clinic Campbell G Naismith K Neil A Rankin A Spalding E (joint first authors) Renal Unit University Hospital Crosshouse Kilmarnock UK
BACKGROUND National Guidelines advise that renal transplant recipients should receive annual skin surveillance to screen for skin cancer In August 2015 a specialist nurse-led dermatology clinic was set-up alongside the renal transplant clinic at University Hospital Crosshouse We aimed to evaluate the success of this joint clinic in terms of clinical outcomes and patient satisfaction
METHODS Clinical records were reviewed to determine the number of patients under dermatology follow-up before and after initiation of the joint clinic and to review cases that were referred for treatment of pathological skin lesions A questionnaire was also distributed to patients attending the new joint renal-dermatology transplant clinic The questionnaire consisted of 5 questions 2 for patient demographics 1 for current understanding of skin care advice and 2 to assess their satisfaction of the new joint clinic
RESULTS A total of 138 and 146 renal transplant recipients were registered on renal transplant clinic lists in 2015 and 2016 respectively Prior to initiation of the new joint-clinic 41 patients had attended dermatology (37 in NHS Ayrshire and Arran and 4 in NHS Greater Glasgow and Clyde) consisting of 30 of the transplant population In September 2016 13 months after initiation of the new clinic 60 patients had attended the new clinic increasing the proportion of patients meeting the national recommendation for skin surveillance to 41 Implementation of the new clinic resulted in patients being 65 more likely to have received the recommended skin checks (odds ratio 165 95 CI 101-270 p=004)
32 patients completed the questionnaire The median age of transplant was 90 years (IQR 38-153) 100 of patients knew to avoid sun exposure and 31 (96) knew to use sunscreen 29 (91) patients were aware of the advice to undergo annual skin surveillance by dermatology with 28 (88) having had a skin check in the last year 29 (91) patients reported that they found the new joint clinic useful although only 18 (56) had attended the clinic so far
CONCLUSIONS Implementation of a new nurse-led dermatology clinic running in parallel with the renal transplant clinic resulted in a considerable increase in the proportion of patients meeting national recommendations for annual skin surveillance The vast majority of patients also found the combined clinic to be useful There is still considerable room for improvement in order to achieve the target of 100 compliance with skin surveillance and ongoing clinical audit is required to assess progress We believe this model would be easily implementable at other units with similar benefits expected
A12 Pneumocystis pneumonia prophylaxis post-renal transplant increased duration of co-trimoxazole is safe and effective FA Chapman JE Dickerson M Clancy C Daly C Geddes Renal amp Transplant Unit Queen Elizabeth University Hospital Glasgow
Introduction All renal transplant recipients receive Pneumocystis jirovecii prophylaxis usually with co-trimoxazole Guidelines suggest this should be continued for 3 to 6 months Our unit previously prescribed 3 months however following an outbreak of Pneumocystis pneumonia (PCP) infection this was increased to 6 months Given its constituents of sulfamethoxazole and trimethoprim co-trimoxazole prophylaxis may influence the frequency of urinary tract infection (UTI) We aimed to compare the frequency of UTI between patients on 3 months vs 6 months prophylaxis and assess rates of multi-drug resistant organisms We also sought to establish if the increased duration of co-trimoxazole was adversely affecting renal function potassium concentration white cell and platelet count and dosing of mycophenolate mofetil
Methods A retrospective search of the West of Scotland Electronic Renal Patient Record was conducted for all renal transplant recipients between 1st January 2012 and 31st May 2016 Patients were grouped according to the intended duration of co-trimoxazole Data were extracted for baseline characteristics co-trimoxazole prescription mycophenolate mofetil (MMF) prescription laboratory results (creatinine potassium white cell count platelets) at 3 6 9 and 12 months post-transplant and microbiology results for 6 months post-transplant Results were analysed on an intention to treat (ITT) basis with a second analysis according to actual duration of co-trimoxazole treatment (AT) Subjects with transplant failure had laboratory results censored from the time of transplant failure and all of their microbiology results were excluded
Results 609 renal transplants were performed over the study period On ITT analysis there were 418 patients in group 1 (ITT1 3 months co-trimoxazole) with 15 transplant failures and 191 patients in group 2 (ITT2 6 months co-trimoxazole) with 12 transplant failures There was a significant difference in the number of patients with at least one UTI with fewer in ITT2 (ITT1 133403 vs ITT2 42179 p = 001) However this was not present when comparing actual treatment duration (AT1 111345 vs AT2 36149 p=007) Overall there was a similar spectrum of organisms cultured There were significantly fewer cultures of multi-resistant organisms in both ITT and AT analyses with 6 months of co-trimoxazole (ITT1 28376 vs ITT2 0106 p= 0004 AT1 22313 vs AT2 198 p = 002) There was no difference in estimated Glomerular Filtration Rate serum potassium concentration platelet count or MMF dose On AT analysis there was a significant difference in the total white cell count (WCC) and lymphocyte count at 6 months post-transplant (WCC 78 x10^5L vs 71 x10^5L p =004 lymphocytes 13 x10^5L vs 12 x10^5L p=002) There were 18 cases of PCP with 7 deaths attributable All cases occurred after cessation of co-trimoxazole prophylaxis (81 ndash 913 days after stopping co-trimoxazole)
Conclusion Although there is a significant difference in UTI frequency on ITT analysis this is not present on AT analysis suggesting no real co-trimoxazole effect There was no increase in frequency of multi-drug resistant organisms with a longer course of co-trimoxazole Renal function and serum potassium were unaffected Our findings support continuing co-trimoxazole prophylaxis for at least 6 months
A13 Kidney transplantation in the over 60rsquos in Scotland 1996-2015 TJW Rennie1 P Phelan1 J Campbell2 JP Traynor2 L Henderson1 W Metcalfe2 On behalf of the Scottish Renal Registry 1Renal transplant unit Royal Infirmary Edinburgh 2NHS National Services Scotland Introduction The proportion of older kidney transplant recipients has increased in the UK but
long term outcome data are scarce We aimed to evaluate patient and graft survival in patients
ge60 years of age receiving a first kidney only transplant in the last 20 years in Scotland
Methods Retrospective analysis of Scottish Renal Registry data of incident Renal Replacement
Therapy (RRT) patients and those in receipt of a kidney only transplant performed 1996-2015
(follow up until 311216) Patients were stratified by age 60-69 ge70 (group 1 and 2 respectively)
and decade of transplantation 1996-2005 2006-2015 (decades 1 and 2 respectively)
Results 6743 patients aged ge60 started RRT from 1996-2016 Of those 108 were ever
transplant-listed 54 had received a transplant by 311216 26 listed and 11 transplanted
were aged ge70
535 patients aged ge60 received a kidney only transplant in 1996-2015 90 patients (168) were
aged ge70 no patients were aged ge80 Mean time from wait listing until transplantation was 33plusmn24
years (plusmnSD) and from starting RRT until transplantation was 38plusmn26 years (plusmnSD) One and five
year graft survival was 97 and 87 in decade 1 95 and 89 in decade 2 (p=NS) there was
no difference in graft survival between age groups 1 and 2 One and five year patient survival was
94 and 78 in age group 1 85 and 56 in group 2 (plt0001) there was no difference in one
and five year patient survival between the two decades
Conclusion One and five year graft and patient survival in renal transplant recipients aged ge60
have not changed significantly in the last 20 years Recipient age ge70 is not associated with
reduced graft survival but patient survival from time of transplant is lower in this age group
compared to recipients aged 60-69
No conflict of interest to be declared No funding received
A14 High Mortality In Older Patients With Primary Nephrotic Syndrome Sarah Beverstock Wendy Metcalfe amp Robert W Hunter Department of Renal Medicine Royal Infirmary of Edinburgh
Introduction
Nephrotic syndrome can develop at any age and may be due to a primary glomerular lesion or secondary to systemic disease The natural history of glomerular disease can be different in older patients For instance minimal change disease (MCD) in children almost always remits promptly with steroid therapy in adulthood it typically remits only after many weeks of steroids or with adjunctive immunosuppression However there are remarkably few published data on the mortality of primary nephrotic syndrome in adults We aimed to study this in our centre
Methods
We enrolled all adult patients who had a kidney biopsy in order to investigate nephrotic syndrome over 38 consecutive months (01 Jan 2014 ndash 28 Feb 2017) We defined nephrotic syndrome as heavy proteinuria (urinary proteincreatinine ratio UPCR gt350 mgmmol or albumincreatinine ratio gt220 mgmmol) and hypoalbuminaemia (serum albumin lt35 gL) In our analysis we included all patients in whom nephrotic syndrome was attributed to a primary glomerular disease We excluded kidney transplant recipients and patients in whom biopsies were performed to follow up a known glomerular disease We collected laboratory data at baseline (time of biopsy) and at 6 and 12 months We assessed patient survival by Kaplan-Meier analysis
Results
Of the 117 patients biopsied for nephrotic syndrome 71 patients (61 ) met the inclusion criteria and were followed up for a median of 469 days We compared outcomes in patients aged under 60 years old (n = 35) with those aged over 60 (n = 36) Mortality was higher in the older group (37 vs 4 mortality at one year p lt005 by logrank test) There were no significant differences between the two groups in serum creatinine or UPCR at any time Serum albumin was similar in both groups at baseline and at 12 months but was lower in the older group at 6 months (27 vs 32 gL p lt 005) Baseline haemoglobin was lower in the older group (114 vs 130 gL p lt005 by unpaired t-test) Primary diagnoses were MCD (n = 10 in younger group amp n = 5 in older group) membranous nephropathy (5 amp 10) IgA nephropathy (9 amp 8) FSGS (5 amp 5) membranoproliferative glomerulonephritis or C3GN (4 amp 7) and other (2 amp 1) Therefore unsurprisingly there were relatively fewer cases of MCD and more cases of membranous nephropathy in the older group otherwise the causative glomerular lesions were similar in both groups In those patients with MCD mortality was significantly higher in the older group none of the 10 patients with MCD diagnosed under 60 yrs old died during the follow-up period whereas 4 of the 5 older patients died 3 patients in the younger group and 1 in the older group were on renal replacement therapy (dialysis or transplant) by the end of follow-up
Conclusions
Primary nephrotic syndrome is associated with high mortality in the over 60s (37 at one year) Mortality was high even for MCD a disease that follows a benign course in childhood and early adulthood The higher mortality in older patients was not associated with greater severity of renal disease at presentation (as assessed by basic blood and urine parameters) This work was not funded we declare no conflicts of interest
A15 Renal biopsies in patients with diabetes mellitus in Scotland
Udana Ratnapala 1 Nicola Joss 2 Colin Geddes 3 Dana Kidder 1
1 Renal Unit Aberdeen Royal Infirmary Aberdeen 2 Renal Unit Raigmore Hospital Inverness 3 Glasgow Renal and Transplant Unit Glasgow
Introduction Diabetes mellitus is the leading cause of end-stage kidney disease (ESKD) requiring renal replacement therapy The utility of renal biopsy in patients with diabetes mellitus is controversial Broadly renal biopsy findings in patients with DM can be divided into diabetic nephropathy (DN) alone DN with non-diabetic renal disease (NDRD) or NDRD alone Timely identification of patients with NDRD is important to provide appropriate therapeutic measures Previously published guidelines on clinical predictors of NDRD have limited specificity and sensitivity The frequency of NDRD in renal biopsies of patients with DM is unclear in ScotlandThis study aimed at identifying the frequency and the pathology spectrum of NDRD in diabetic patients underwent kidney biopsy in 3 renal units
Methods A retrospective observational study was performed on clinical-pathologic findings in all patients with diabetes mellitus who underwent renal biopsy between 01012010 and 31122016 in 3 renal units (Aberdeen Inverness and Greater Glasgow) Data were gathered from electronic patient record systems Scottish Index of Multiple Deprivation (SIMD) 2012 was used to analyse correlation with patient outcomes
Results 247 patients were included 150 men (607) 217 type 2 DM (879) mean age 621 years and mean serum creatinine at the time of renal biopsy of 261 micromolL (+-190 std) On biopsy 92 patients (372) had DN while 127 (514) had NDRD and 28(114) had NDRD superimposed on DN The commonest NDRD aetiologies were IgA nephropathy (187) tubulointerstitial nephritis (168) and idiopathic membranous nephropathy (103) Predictors of NDRD were age (OR 1027 95 CI 1002-1052 p=003) duration of DM (OR 094 95 CI 0900-0987 p=001) and absence of AKI as indication for biopsy (OR 022 95 CI 0059-0826 p=0025) There was no significance difference in renal or patient survival in DN and NDRD Finally no significant correlation was depicted between SIMD quintiles and renal or patient survival in both groups
Conclusions The majority of renal biopsies carried out in patients with DM revealed a NDRD In this study age at the time of biopsy duration of DM and AKI were the main pointers towards NDRD Renal and patient survival were not significantly different between DN and NDRD groups
A16 The Impact of Withdrawal of Maintenance Immunosuppression and Graft Nephrectomy on HLA Sensitisation Ailish Nimmo1 Sophie McIntyre1 Lorna Henderson1 Richard Battle2
(1 Department of Renal Medicine Royal Infirmary of Edinburgh 2 Histocompatibility and Immunogenetics Royal Infirmary of Edinburgh)
Background The development of HLA antibodies towards a failing renal allograft is a barrier to re-transplantation We previously demonstrated an increase in HLA antibodies and calculated reaction frequency (cRF) following nephrectomy but results were confounded by immunosuppression changes occurring in close time proximity We examined the formation of HLA donor specific antibodies (DSA) in patients with failed grafts that remained in situ and compared results with patients undergoing graft nephrectomy to further assess the relative impact of nephrectomy and immunosuppression weaning on sensitisation and chance of transplant
Methods We carried out a single centre retrospective study of all patients with failed grafts in Lothian from 2005 to 2015 Samples were tested for DSA pre-immunosuppression (IS) wean post-IS wean and post-IS cessation Nephrectomy patients also had samples tested for DSA before and after nephrectomy Data on other sensitising events including blood transfusion and rejection were collected cRF was determined at each time point and entered into the ODT chance of transplant calculator with other demographics based on the average patient from the Edinburgh centre
Results 62 grafts failed over this time period Blood samples were available 41 patients (24 with nephrectomy 17 with failed graft left in situ) Patient demographics were similar between groups There was a higher rate of antibody mediated rejection in the nephrectomy group (46 vs 18) 76 of patients with nephrectomy group had received a blood transfusion The pattern of immunosuppression weaning was similar but median time from start of IS wean to cessation was longer in the nephrectomy group (350 vs 298 days) The changes in cRF and chance of transplant (COT) with immunosuppression weaning are shown in Table 1
Pre-IS Wean Post-IS Wean
Failed graft in situ (n=17)
Mean CRF COT at 5
years 15 62 38 59
Nephrectomy (n=24)
Mean cRF COT at 5
years 54 54 69 46
Post-IS Stop 55 53 89 42 Table 1 Mean cRF and Chance of Transplant (COT) at 5 years with IS alterations
Discussion A stepwise increase in cRF with reduced chance of transplant was observed in both groups as immunosuppression was withdrawn with a similar pattern of change irrespective of graft nephrectomy cRF was higher in the nephrectomy group despite a more gradual wean which may reflect a higher rate of antibody mediated rejection and increased number of patients receiving a blood transfusion The risks and benefits of stopping immunosuppression need to be carefully considered on an individual basis to maximise chance of future transplant
The authors have no conflicts of interest No funding was required for this study
A17 Obesity is not associated with progression to end stage renal disease in patients withbiopsy-proven glomerular diseases
Benjamin Elyan Jennifer S Lees Bruce Mackinnon Jonathan G Fox Colin C Geddes Emily PMcQuarrie
Glasgow Renal and Transplant Unit Queen Elizabeth University Hospital Glasgow
Introduction - Addressing risk factors for renal progression is a key aspect of managing chronic kidney disease (CKD) Body mass index (BMI) has been shown to impact on renal progression in unspecified CKD The aim of this study was to evaluate if there was an association between BMI and progression to renal endpoints in patients with biopsy-proven primary glomerular disease (GN)
Methods - We included all adult patients diagnosed with biopsy-proven primary GN (excluding minimal change nephropathy) in Greater Glasgow amp Clyde and Forth Valley between 01012000 and 31122015 Biochemical and anthropometric data were extracted from the electronic patient record at time of biopsy with follow-up data until 20062017 BMI was calculated from height and weight at time of biopsy and categorised into groups BMI le25 kgm2 (G1) gt25 to le30 kgm2 (G2) and gt30 kgm2 (G3 - obese) We assessed factors associated with reaching a combined renal endpoint of CKD5 or renal replacement therapy (RRT) with competing risk of death using the Fine and Gray subdistribution hazard model Analyses were conducted using cmprsk package for R statistical software package and SPSS version 24
Results - 560 patients with primary GN and available BMI data were included The average age was 532 years and 339 were female There were 132 patients in G1 210 in G2 and 207 patients in G3 Those in G2 and G3 were older (p=002) with slightly higher diastolic blood pressure (p=002) than those in G1 There was a greater proportion of focal segmental glomerulosclerosis in G3 but similar proportions of other GN diagnoses across groups There was no significant difference in baseline serum creatinine (sCr) (p=034) or log uPCR (p=045) between BMI groups On multivariate analysis age systolic blood pressure BMI or GN diagnosis were not predictive of renal outcome Higher baseline sCr (SHR 1003 per 1 umoll increase in sCr 1001-1004 plt0001) and log uPCR (SHR 130 per unit increase in log uPCR 95 CI 105-160 p=002) were associated with progression to the combined renal endpoint accounting for competing risk of death BMI was not associated with reaching combined renal endpoint on univariate analysis whether considered as a continuous variable (SHR=100 95 CI 098-102 p=096) or categorised by BMI group
Conclusion - Contrary to our expectations there was no association between BMI and progression to a combined renal endpoint of CKD5 or RRT in this cohort of patients with primary GN Efforts should be directed to managing other known risk factors for CKD progression
Sources of FundingConflicts of Interest - None
A18 Factors influencing long term renal function after living kidney donation
Matthew A Rutherford Norman J Galbraith Marc Clancy Colin C Geddes
Glasgow Renal and Transplant Unit Queen Elizabeth University Hospital Glasgow UK
Background Following live donor nephrectomy the remaining kidney undergoes an increase in filtration capacity known as compensatory hypertrophy Few cohorts with follow up of renal function beyond 5 years have been reported The impact on long term renal function of variability in donor factors such as age sex pre-donation blood pressure and glomerular filtration rate (GFR) is unknown Increasingly kidney donors have potential risk factors for future poor renal function such as hypertension older age and obesity The aim of this study was to analyse factors influencing long-term renal function in living kidney donors from our centre
Method Data were obtained from the electronic patient record Patients with a recorded procedure of lsquolive donor nephrectomyrsquo between 2005 and 2017 were identified GFR after donation (calcGFR) was calculated using the formula lsquocalcGFR = Pre-donation Isotope GFR x (Pre-donation Serum creatinine Serum Creatinine)rsquo which is accurate assuming muscle mass does not change Pre and post donation serum creatinines (two days two weeks three months and one to ten year) were recorded We analysed the influence of age sex pre-donation GFR and blood pressure on post donation GFR compensation
Results 355 live donor nephrectomies were performed between January 2005 and December 2016 The mean age was 469 (plusmn 116) years and 504 (n=179) were female Mean pre-donation isotope GFR was 937 plusmn 156 mlmin173m2 Median follow up was 2 years (IQR 1 to 6 years with range 2 weeks to 10 years) The calculated percentage of pre-donation GFR at 2 days 2 weeks 3 months 1 year 5 years and 10 years were 698 691 712 730 801 and 950 respectively (p lt 0001) Patients aged lt50 y had not only a higher calcGFR (858 plusmn 29 mlmin173m2 compared with 671 plusmn 28 mlmin173m2 p lt 0001) at 5 years following donation but achieved a higher degree of compensation than donors gt 50 y (836 plusmn 16 compared with 756 plusmn 19 (p = 0002) Patients with pre-donation hypertension achieved 774 plusmn 53 of pre-donation GFR compared with 804 plusmn 32 in normotensive patients (p = 0998) Females had equivalent degree of renal compensation achieving 819 plusmn 19 compared with 780 plusmn 16 in males (p = 0131) at 5 years following donation Patients with pre-donation GFR gt 100 mlmin173m2 achieved 844 plusmn 23 of pre-donation function by 5 years compared with 777 plusmn 14 in those with pre-donation GFR lt 100 mlmin173m2 (p = 001)
Conclusion Following live donor nephrectomy renal function has a nadir of 691 at 2 weeks Compensation in GFR occurs rapidly and appears to be maintained regardless of sex and pre-donation blood pressure Younger age and higher pre-donation GFR were associated with a greater degree of compensation
A19 The utility of high-sensitivity cardiac troponin to stratify cardiovascular risk in patients with renal impairment
Eve Miller-Hodges Atul Anand Anoop S V Shah Nicholas L Mills Neeraj Dhaun
Background Cardiovascular disease is the most common outcome of chronic kidney disease1
Declining glomerular filtration rate (GFR) and proteinuria predict increased cardiovascular risk over the long term2 However there are currently no methods to stratify cardiovascular risk in the short or medium term in patients with renal impairment We have already shown that high-sensitivity cardiac troponin I concentrations (hs-cTnI) lt5ngL in patients presenting with symptoms of acute coronary syndrome identifies those at low risk of cardiac events within 30 days and over the next year3 However uncertainty remains over the role of hs-cTnI testing in patients with renal impairment This study investigated whether hs-cTnI could also stratify future cardiovascular risk in patients with renal impairment
Methods In a prospective study of consecutive patients presenting with suspected acute coronary syndrome we evaluated the performance of hs-cTnI in patients with and without renal impairment (estimated glomerular filtration rate lt60mLmin173m2) using an early risk stratification threshold of 5ngL to ldquorule outrdquo acute myocardial infarction at presentation and within 30 days and sex-specific 99th centile diagnostic thresholds for index type 1 myocardial infarction Subsequent type 1 myocardial infarction and cardiac death were reported at one year
Results Of 4726 patients identified 904 (19) had renal impairment Index diagnosis of type 1 and type 2 myocardial infarction was almost twice as likely in patients with renal impairment (30 vs 15) Performance of the early risk stratification threshold of 5ngL to identify patients at low risk of major cardiac events was similar in patients with (NPV 984 95CI 960-997 sensitivity 989 95CI 975-999) and without renal impairment (NPV 997 95CI 994-999 sensitivity 984 95CI 972-994) These patients continued to remain at low risk over the next year The PPV and specificity at the 99th centile for diagnosis of myocardial infarction were lower in patients with renal impairment at 500 (95CI 452-548) and 709 (95CI 675-742) respectively compared to 624 (95CI 588-659) and 921 (95CI 912-930) At one year 24 of patients with renal impairment and troponin gt99th centile regardless of index diagnosis had experienced further myocardial infarction or cardiac death compared with 10 of patients without
Conclusion In suspected acute coronary syndrome hs-cTnI can stratify risk in patients with renal impairment Irrespective of diagnosis patients with renal impairment and elevated cardiac troponin concentrations had two-fold greater risk of a major cardiac event compared to those with normal renal function and should be considered for further investigation and treatment
Funders Wellcome Trust British Heart Foundation and Chest Heart amp Stroke Scotland
1 Gansevoort RT Lancet 2013
2 Chronic Kidney Disease Prognosis Consortium Lancet 2010
3 Shah AS Lancet 2015
A20 lsquoDOES IT DIALYSE OUTrsquo - THE EFFECT OF RENAL REPLACEMENT THERAPY ON THE BRAIN Mark Findlay Jesse Dawson David Dickie Deborah McGlynn Patrick Mark Institute of Cardiovascular and Medical Science University of Glasgow amp Queen Elizabeth University Hospital Glasgow
Introduction Cerebrovascular disease is common in end-stage renal disease (ESRD) on renal replacement therapy (RRT) We investigated the effect of RRT on cerebral structure and cognitive function over 12 months Methods Observational cohort study in ESRD patients receiving HD Prior cognitive impairment or cerebrovascular disease were exclusion criteria Multi-domain cognitive testing was performed at baseline and at follow-up Transcranial Doppler was used to assess intra-dialysis related alterations in mean flow velocity (MFV) ndash a marker of cerebral blood flow MR imaging was performed at 0 and 12 months We performed T1 T2 FLAIR and DWI sequences and used volumetric software to calculate white matter hyperintensity (WMH) burden markers of atrophy mean diffusivity and fractional anisotropy (FA) to describe structural changes at 1 year Results 97 patients median age 59 years 412 female At follow-up 15 patients were transplanted 6 died 4 withdrew and the remainder continued HD Those who were transplanted were younger (median age 51 vs 60 years p=0019) and had been on dialysis for a shorter period (median 06 vs 21 years p=0003) MFV declined during HD median 475cms to 405cms plt0001 and correlated with lower scores of executive and frontal lobe function during HD (Rho 045 p lt0001 and Rho -0313 p lt001 respectively) In all patients MR imaging demonstrated a significant decline in frontal parietal and temporal lobe volume at follow-up Median WMH volume increased in those who remained on HD but not in transplanted patients (median change 023 vs -012ml p=0018) WMH burden correlated with worsening scores of frontal lobe tests Rho 0585 p0005 and worse mood Rho -0485 p0026 FA improved following renal transplant (028 to 029 p=0016) and correlated with improved executive function testing at follow-up Rho 089 p0019 Conclusion Cerebral blood flow is reduced during haemodialysis and correlates with a reduction in intradialytic executive function There is an improvement in FA following transplantation WMH volume increases in those who remain on dialysis and the degree of increase correlates with executive and frontal lobe function This suggests that haemodialysis is associated with clinically significant changes in the brain and that these may be ameliorated by transplantation
Source of fundingconflicts MF is funded by a KRUK fellowship
A21 Pathological classification of IgA nephropathy to predict renal outcomes ndash is there a better way to score tubulointerstitial inflammation
Alastair Rankin David Kipgen Bruce Mackinnon Jonathan Fox Colin Geddes Emily McQuarrie Glasgow Renal and Transplant Unit On behalf of the Scottish Renal Biopsy Registry
Background The Oxford pathological classification of IgA nephropathy (IgAN MEST-C score) is limited by the fact that individual features of the score are not all predictive and its utility in assisting clinical decision-making is questioned The addition of tubulointerstitial inflammation to the existing scoring system is appealing but is not currently included due to reportedly wide inter-observer variability We report a novel method to score percentage of cortex containing tubulo-interstitial inflammation in non-atrophic renal cortex (ATIN) in patients with IgAN similar to that used in transplant biopsy reporting and assess its utility to predict clinical outcomes
Methods All adult patients with a native renal biopsy diagnosis of IgAN between 2010 and 2015 in a unit serving 15 million people were identified Baseline characteristics biopsy reports and outcome data were collected ATIN was calculated by subtracting the percentage of atrophic cortex from the percentage of total cortex with tubulo-interstitial inflammation withge10 representing significant tubulo-interstitial inflammation in non-atrophic cortex The primary outcome was a composite of requiring renal replacement therapy (RRT) or doubling of serum creatinine (sCr)
Results 153 new cases of IgAN were identified 33 were excluded (24 had lt8 glomeruli on biopsy 6 inadequate biopsy for MEST scoring and 3 on RRT at time of biopsy) In addition patients with a tubular atrophy (T) score of 2 were also excluded (n=9) Of the remaining 111 patients 76 (68) were male Mean age at biopsy was 52 years (+- 167) and 18 (16) had a co-existing clinical diagnosis of henoch-schonlein purpura (HSP) Median sCr was 156 micromoll (IQR 101-212) and 54 (49) had ATIN on biopsy During a median follow-up of 23 years 34 (31) reached the primary outcome 20 (18) received immunosuppression and 16 (14) died On univariate Cox regression survival analysis ATIN was associated with a four-fold increase in the primary outcome (HR 49 (21-113)) On multivariate analysis mesangial hypercellularity (M) T and ATIN independently predicted renal outcome while endocapillary proliferation (E) and segmental sclerosis (S) did not (plt002 for ATIN) Excluding patients with HSP or those who received immunosuppression did not change the result
Conclusion Within our centre ATIN predicts renal outcome for IgAN independently of established histological features Assessment of inter-observer reproducibility and validation in other cohorts is still required but these results suggest ATIN could be a worthwhile addition to current pathological scoring systems for IgAN
Source of funding none Conflicts of interest none
P1 Polypharmacy in Renal Replacement Therapy Patients
Jason McMinn Colin Geddes Glasgow Renal and Transplant Unit Queen Elizabeth University Hospital
Introduction
Prescribing is often led by evidence from studies containing participants with single health conditions and without multimorbidity Polypharmacy is becoming increasingly recognised in patients with multiple chronic health conditions Additional medications are more likely to result in diminishing returns in benefit with an increased risk of harm Patients with established renal failure (ERF) are likely to be susceptible to medication-related harm A high pill burden is also likely to contribute adversely to an already restricted quality of life and has been associated with poor medication adherence The aim of this study was to analyse polypharmacy in all patients with ERF attending our service
Methods
We extracted medication records for all prevalent ERF patients attending the Glasgow Renal and Transplant Unit from the West of Scotland Electronic Renal Patient Record (SERPR) as of 01012017 The records were analysed to calculate the number of regular medications and total pill burden of each patient These medications were categorised as being lsquopreventativersquo or lsquosymptomaticrsquo We also analysed the prescription of specific drug classes to examine the prevalence of these medications
Results
We identified 1091 transplant follow-up 529 hospital haemodialysis and 46 peritoneal dialysis patients who were on a mean of 94 13 and 129 different medications respectively Overall pill burden was 139 tablets a day in transplant follow-up patients 141 in haemodialysis patients and 162 in peritoneal dialysis patients There were similar rates of prescribing between the different dialysis units and clinics within our service
The proportions of medications deemed as preventative rather than symptomatic were 76 in transplant 69 in haemodialysis and 60 in peritoneal dialysis
In transplant patients decreasing renal function was associated with a higher pill burden but even patients with a transplant eGFR gt 60 were on a mean of 126 tablets per day including a mean of 14 antihypertensives
Rates of antidepressant prescribing were 15 in transplant patients and 20 in hospital haemodialysis patients 53 of haemodialysis patients were on a statin 39 on aspirin 61 on a proton pump inhibitor and 7 were on warfarin
Conclusion
Patients undergoing all forms of renal replacement therapy are likely to be on a considerable number of medications Whilst these drugs are inevitably prescribed for valid reasons this data demonstrates the need for clinicians to engage with patients to explore opportunities to reduce pill burden
Conflict of Interest None Sources of Funding None
P2 An audit of Acute Kidney Injury (AKI) on an acute stroke ward before and after plannedinterventions to review and maintain hydration
Clare Harris1 Simon Hart2 Fiona Duthie3 1 University of Edinburgh Medical School 2 Stroke Unit Royal Infirmary of Edinburgh 3 Renal Unit Royal Infirmary of Edinburgh
Background Dehydration is an important factor in the development of acute kidney injury which is associated with increased morbidity and mortality particularly in the elderly population Poor fluid intake is common post stroke (1) and dehydration is associated with poorer outcomes 3 months post stroke (2) In late 2014 there was no system of identifying patients with poor oral intake on the stroke ward at the Royal Infirmary of Edinburgh a hydration protocol and education programme were implemented aiming to improve fluid balance This included the use of prescribed water either orally or by nasogastric tube An audit pre and post intervention demonstrated that hydration as measured by ureacreatinine ratio significantly improved after the protocol introduction (3) We aimed to determine whether the incidence of AKI by KDIGO criteria was also reduced as this could have implications for reducing patient morbidity and mortality in this elderly comorbid patient cohort
Method 150 inpatients to the acute stroke ward during JulAug 2014 and JulAug 2015 were selected (n= 80 2014 n=70 2015) Patient data and creatinine values were collected from the electronic patient record and medical notes and retrospectively analysed Baseline creatinine values were calculated and cases of AKI were identified and staged using KDIGO criteria (4) Chi-Squared tests were performed to determine P values Individual patient notes were reviewed for both quantitative and qualitative data of patient management
Results Incidence of AKI (of any stage) was 263 pre-protocol and 200 post-protocol (P=03646) Incidence of AKI stages 23 was 100 pre-protocol and 715 post-protocol (P=05374) In hospital post stroke mortality was 338 pre-protocol and 1286 post protocol (P=00028) AKI was also associated with increased length of stay
Conclusions Despite a trend in benefit there was no significant difference in incidence of AKI pre and post hydration protocol nor in incidence of severe AKI (stage 23) AKI is influenced by many factors one of which is hydration status Further studies are needed to determine whether the trend of benefit exhibited in this sample is significant in a greater sample size if this were the case such a protocol could have great benefit to patient care on stroke units and elsewhere There was a significant difference in inpatient post stroke mortality following introduction of the hydration protocol Further investigations are needed to explain underlying reasons for this factors other than hydration may play an important role
References 1 Whelan K Inadequate fluid intakes in dysphagic acute stroke Clinical Nutrition (2001) 20(5)
423-428 2 Bhalla A Sankaralingam S Dundas R Swaminathan R Wolfe CDA Rudd AG The influence of
raised plasma osmolality on clinical outcome after acute stroke Stroke (2000) 312043ndash2048 3 Hart SR Craig R Berry E Lane N Gad A Farrugia M Burton L Paquay A What Happens to
Acute Stroke Patientsrsquo Fluid Balance Renal Status and Dehydration in the First Two Weeks How Can They Be Markedly Improved doi 101111ijs12634_13
4 KDIGO Clinical Practice Guideline for Acute Kidney InjuryKidney international supplements (2012) 2(1) 1-138
No funding or conflict of interest to declare
P3NHS Highland-Improving the management of hyperkalaemia using a kit Initial resultsCantley N1 Abedin T2 Lambie S3
1FY2 NHS Highland 2ST4 Renal Medicine NHS Grampian 3Renal Consultant Renal unitRaigmore Hospital Inverness
Introduction The incidence of hyperkalaemia in hospitalised in patients is between 1 and 10 Guidelines in Northern Ireland promote the use of a Hyperkalaemia Kit to improve management of hyperkalaemia We assessed the management of hyperkalaemia in Raigmore Hospital including post-treatment monitoring of serum potassium and blood glucose at baseline and after the introduction of a lsquoHyperkalaemia Kitrsquo which contains a pro forma for the management of hyperkalaemia and all the relevant equipment and drugs for treatment
Method Between July and September 2016 an automated algorithm identified 34 patients with a potassium result 65 mmoll or above on laboratory results 12 received no specific treatment of these 6 results were spurious 4 patients died before treatment could be started and 2 patients were chronic haemodialysis patients We introduced the Hyperkalaemia Kit to the Acute Medical Admissions Unit in Raigmore Hospital Since then 15 patients have been identified with serum potassium measurements above 65 and the pro forma and kit was used with eight of these patients One of these patients proceeded straight to acute renal replacement therapy
Results Prior to our intervention all 22 patients that were actively treated received at least one prescription of appropriate doses of Insulin with Dextrose However only 16 patients received intravenous calcium and only 7 received nebulised Salbutamol Potassium was measured at 4 hours in 5 cases and by 12 hours in 17 cases Monitoring of any capillary blood glucose was only documented in 8 cases Of the 22 treated 2 needed acute renal replacement therapy 3 required further doses of insulin and dextrose 2 were treated with Calcium Resonium
Eight cases of hyperkalaemia have been managed with the use of the kit and pro-forma so far An initial ECG was performed in all eight and four patients had continuous cardiac monitoring Intravenous calcium was given in seven and nebulised Salbutamol was given in five out of the eight cases Six out of eight patients had at least three blood sugar measurements One had two measurements documented and one patient was stopped from further monitoring following senior review and decision to palliate Seven patients had appropriate monitoring of their serum potassium by 4h and 12h again one patient was not monitored due to palliation
Conclusion Baseline results showed very low rates of prescription of nebulised Salbutamol low rates of Calcium Gluconate use and very low monitoring of blood sugars and potassium post treatment This has the potential for serious adverse outcomes particularly the potential for iatrogenic hypoglycaemia Our initial data shows the use of a Hyperkalaemia pro forma and kit improves the rate of prescription of intravenous calcium and nebulised Salbutamol and the post-treatment monitoring of serum potassium and blood sugar levels
P4Rituximab as maintenance therapy in ANCA associated vasculitisndash a single centre experience Rathnamalala NK Mcmenamin J Robertson S Almond A Kelly M Muniraju T M Renal Unit Dumfries and Galloway Royal Infirmary NHS Dumfries and Galloway Background The introduction of Cyclophosphamide and high dose steroids transformed ANCA associate vasculitis (AAV) from a disease of high mortality to a relapsing remitting disease Maintenance of remission however still remains a major challenge A two randomised clinical trials have looked at the use of Rituximab in remission induction in AAV and reported similar remission rates between Cyclophosphamide and Rituximab 12 Both these trials used Azathioprine as maintenance therapy and in the follow up showed similar remission rates with either agent for induction The role of Rituximab for maintenance therapy after cyclophosphamide induction was studied in the MAINRITSAN trial 3 Rituximab was compared with azathioprine and found that the relapse rate was significantly lower in the Rituximab group There have been several other retrospective studies that have suggested regular Rituximab infusions are successful in maintaining remission however has not been thoroughly evaluated 4 5678910 Here we share our centrersquos experience using Rituximab for maintenance of remission of AAV Materials and methods We conducted a retrospective review of electronic medical records of all patients who had received Rituximab as maintenance therapy for 12 months or longer between January 2014 to July 2016 Disease activity was assessed using Birmingham Vasculitis Activity Score ( BVAS) Version 3 and complete remission was defined as a score of 0 and partial remission as a score of lt50 of the value at diagnosis Due to uncertainties associated with sub classification we did not assign specific diagnosis but broadly classified as ANCA associated vasculitis Results 6 patients received Rituximab as maintenance therapy during the study period 3 (50) of them had eye ear nose and upper airway manifestations consistent with Granulomatosis with Polyangitis (GPA) All patients were PR3 ANCA positive except for one at initial diagnosis The mean BVAS score at the time of initiation of Rituximab was 4 All patients were initiated on Rituximab for relapses while on maintenance therapy with Azathioprine 4 patients received 6 monthly doses of Rituximab while two received annual doses All of them were also maintained on 5-10 mg of Prednisolone The mean BVAS score by 6 months was 0 and remained 0 at 12 months The mean PR3 titre was 562 at the initiation of treatment while at 12 months it had come down to 68 All patients remained in complete clinical remission at the end of 12 months after initiation of therapy Rituximab was well tolerated by all patients except one who developed pyrexia during an administration
Conclusions All patients had sustained remission at 6 months and 12 months after initiating Rituximab Rituximab has a potential role as maintenance therapy in AAV
P5 Chronic Myelo-Monocytic Leukaemia (CMML) as a contraindication to renal biopsy Alastair Rankin Emily McQuarrie Jennifer Lees Bruce MacKinnon Glasgow Renal and Transplant Unit On behalf of the Scottish Renal Biopsy Registry
Abstract Chronic Myelo-Monocytic Leukaemia (CMML) is a relatively rare mixed myelodysplastic myeloproliferative disorder that predominately affects patients over the age of 65 years Renal impairment in patients with CMML is well described with several different mechanisms reported including tumour infiltration lysozyme-induced injury amyloid deposition and tubulointerstitial nephritis From anecdotal evidence within our centre we are concerned that patients with CMML have an excessive risk of clinically significant bleeding following native renal biopsy This risk appears disproportionate to the degree of any co-existing thrombocytopenia or coagulopathy
We review the cases of 4 patients with an existing diagnosis of CMML who were referred to the renal clinic with proteinuria and excretory renal dysfunction Two of these patients underwent renal biopsy with subsequent major haemorrhage post-procedure despite normal bleeding parameters pre-procedure Patient 1 presented with flank pain 8 days post-biopsy A CT confirmed peri-nephric haematoma with retroperitoneal extension A total of 6 units of packed red cells (PRCs) were transfused prior to successful CT-guided emoblisation Histology from the biopsy revealed chronic tubulointerstitial nephritis Patient 2 experienced haemodynamic instability and haematuria one hour post-biopsy A total of 11 units of PRCs 7 units of fresh frozen plasma 2 pools of platelets intravenous tranexamic acid and 2 attempts at CT-guided embolization were required until haemostasis was achieved Histology later showed evidence of tumour infiltration with associated vasculitis Patient 3 presented with renal impairment and proteinuria on the background of known CMML Following discussion with haematology the risk of bleeding following renal biopsy was considered unjustifiable despite their platelets and coagulation screen being within normal range The patient was treated for presumed renal tumour infiltration with hydroxycarbamide Patient 4 was referred to the renal clinic with acute onset nephrotic syndrome Urinary proteincreatinine ratio was elevated over 800 mgmmol with serum albumin of 23 gL but normal excretory renal function The patient attends the haematology clinic with suspected CMML and chronic thrombocytopenia but previously declined bone marrow biopsy Following discussion with the patient there are no plans to proceed with renal biopsy given potential risks These cases highlight that while CMML is rare these patients are being referred to renal clinics with features that would commonly justify renal biopsy in other settings but in whom there may be an increased risk of bleeding post-procedure Our in-centre risk of major bleeding is 2 therefore to have such extreme amounts of bleeding in 2 patients with this underlying diagnosis is remarkable This creates a dilemma for the clinician as there is a wide range of potential renal pathology associated with CMML some of which will have disease specific but relatively toxic treatments available
Source of funding none Conflicts of interest none
P6 NHS Highland-Prograf to Adoport switch McCulloch K1 Peel R2 Lambie S3
1Renal Pharmacist Renal unit Raigmore Hospital Inverness 23Renal Consultant Renal unit Raigmore Hospital Inverness
Introduction NHS Highland (NHSH) is the first health board in Scotland to implement a switch from Prograf to Adoport for renal transplant patients This will provide considerable cost savings Adoport meets the bioequivalence criteria for drugs with a narrow therapeutic index set by the European Medicines agency and studies indicate therapeutic equivalence1 with the proviso that brands are non- interchangeable unless the switch is overseen by a Renal Consultant and post-conversion therapeutic drug monitoring is conducted23 The switch has been undertaken by a majority of transplant centres in England the main difference being that they have undergone repatriation NHSH Patients receive their transplant primarily at Royal Infirmary of Edinburgh and occasionally at Queen Elizabeth University Hospital Glasgow Care is transferred to NHS Highland on discharge NHS Highland cares for approximately 170 renal transplant patients 110 being prescribed Prograf These patients may live as far as 110 miles from Raigmore Hospital Given that prescribing is carried out by primary care clear communication with patients GPs and community pharmacy is essential to avoid inadvertent switching between brands
Method Clinically it was agreed a switch could be safely undertaken A business case was submitted and funding secured for pharmacist time laboratory costs and primary care time GPs have been informed via GP subgroup and local prescribing bulletin lsquoThe Pink Onersquo Community pharmacies are being informed by phone A protocol has been agreed Eligible patients selected by Renal Consultant and Renal Pharmacist Patients sent letter signed by Renal Consultant and Renal pharmacist Patients phoned prior to clinic to agree Adoport start date and address concerns Patient seen by Renal Consultant and pharmacist + given 1 month of Adoport Tacrolimus level and UampEs checked 5-7 days after commencing Adoport and patient
contacted by phone to check if tolerated If stable letter sent to GP and community pharmacy to continue supply
Results and Evaluation Letters have been sent to all eligible patients Seven patients have been reviewed One has received a one month supply of Adoport and 5 others are due to switch One patient was deemed non-eligible at present as they have a 6 month surplus of Prograf A database will be maintained and analysed at the end and primary care savings will be monitored Extra pharmacist input will give us the opportunity to review how immunosuppression is managed and to evaluate the benefit of having a renal transplant pharmacist Conclusion The switch is at an early stage Ultimately we hope to show that the switch from Prograf to Adoport can be managed safely with extra pharmacist input to a remote and rural population with prescribing being conducted by primary care
Fundingconflicts of interest none 1 McDevitt-Potter LM Sadaka B Tichy EM Rogers CC Gabardi S Transplantation 2011 A multicenter experience with
generic tacrolimus conversion 2 Medicines and Health Products Regulatory Agency Drug Safety Update 2012 Accessed online via
wwwmhragovukSafetyinformationDrugSafetyUpdateCON1557563 ESPRIT Guidance on management of repatriation and immunosuppressant switches in transplant patients 2015
Accessed online via httpwwwespritorgukwp-contentuploads201508Switch-guidance-document-final-Aug-31-2015pdf
P7 NHS Highland-Tacrolimus baseline dataMcCulloch K1 Peel R2 Lambie S3
1Renal Pharmacist Renal unit Raigmore Hospital Inverness 2Renal Consultant Renal unitRaigmore Hospital Inverness 3Renal Consultant Renal unit Raigmore Hospital Inverness
BackgroundAs part of planning a switch from using tacrolimus Prograf to Adoport we assessed baseline data for our transplant patients currently using Prograf After converting patients to Adoport we will compare their tacrolimus levels to their individual target range We assessed our use of appropriate target ranges and our current performance in achieving tacrolimus levels within target range on Prograf therapy
Method 107 renal transplant patients taking Prograf were identified a sample of 19 of these were analysed using electronic patient records and results Time from transplant ranged from 1 month to 18 years All tacrolimus levels for the preceding year were analysed and compared to the target range specified at the time of the level being done The assay used has a Coefficient of Variation of lt5 at the lower limit of the assay
Results All 19 patients had a target range for tacrolimus clearly identified and recorded in clinic letterswhich are routinely copied to the patients themselves A variety of target ranges were specifiedThe commonest used was 5-8 microgramsl in 7 patients followed by 5-7 in a further 4 patientswith another 6 different target ranges being used for the remaining 8 patients The ranges usedhad a breadth of 3 microgramsl in 2 cases the rest had a breadth of 2 microgramslPatients had a median of 12 (range 3-72) tacrolimus levels over the preceding year Results werewithin specified target ranges for 54 +- 22 (Medan +- SD) of results checked
Conclusion We currently use a large number of different target ranges The majority of the ranges used had a breadth of just 2 microgramsl These factors help to account for the low proportion of test results which were within the specified target ranges This is important to bear in mind when interpreting whether tacrolimus levels are within target ranges after switching to Adoport We should consider aligning our target ranges and widening them
P8 Eculizumab use in Scottish paediatric dense deposit disease Stewart D1 David Hughes1 Lynne Riach2 Craig Oxley2 Athavale D1
1Royal Hospital for Children Glasgow 2Royal Aberdeen Childrenrsquos Hospital Aberdeen
Introduction The revised MPGN classification and increasing recognition of Dense Deposit Disease (DDD) a C3 glomerulopathy as an alternative complement pathway disorder suggests Eculizumab an anti-C5 monoclonal antibody may be beneficial in treatment However the experience of Eculizumab as an off-label and expensive treatment in children with DDD is limited with variable clinical response reported in the literature
Method We present the outcomes of the only 2 paediatric patients in Scotland who have received Eculizumab for the management of DDD
Results Case 1 A 10 year old male presented with proteinuria and haematuria resistant to steroid treatment with preserved renal function Initial biopsy confirmed DDD Conservative management with an angiotensin converting enzyme inhibitor and diuretics for symptom control continued until 14 years Due to worsening symptoms (oedema lethargy poor growth) and renal function deterioration along with elevated terminal complement complex (TCC) Eculizumab was commenced A repeat biopsy whilst suggestive of chronic irreversible damage showed 25 glomerular architecture preservation Symptom improvement was noted There was a reduction in proteinuria and renal function stabilisation fall in TCC and discontinuation of diuretics Eculizumab was discontinued after 24 months Progression of renal function decline was seen in the final months of Eculizumab therapy With recurrence of symptoms and increasing proteinuria following discontinuation Eculizumab was recommenced after 6 months Symptomatic improvement has since been noted
Case 2 A 5 year old girl presented with painless frank haematuria and proteinuria Initial biopsy confirmed DDD Proteinuria was unresponsive to steroid therapy and 5 months following diagnosis she rapidly progressed towards end stage renal disease despite the introduction of Mycophenolate Mofetil and plasmapheresis Haemodialysis was subsequently commenced TCC level was elevated and Eculizumab treatment was started 7 months after diagnosis Renal biopsy prior to treatment demonstrated continued severe pathological changes in all visible glomeruli However due to lack of clinical response Eculizumab was discontinued after 2 months and the patient remained dialysis dependent
Conclusions Our experience with Eculizumab in Scotland has demonstrated variable results in our 2 patients with one patient showing a positive response whilst the other experienced no improvement Eculizumab was administered to both patients at varying points in their clinical journey with differing progressive features on biopsy To date the outcomes of 9 paediatric patients with DDD treated with Eculizumab have been described in the literature with 8 experiencing some positive response to treatment including 2 patients who were able to stop renal replacement therapy within 12 weeks of treatment A role for Eculizumab in DDD may be guided by clinical and pathological features Well designed clinical trials will be necessary to define the role of complement inhibition therapy in DDD
No conflict of interest and no funding requested
P9 Examining markers of safety in the use of non-tunnelled central venous catheters
James WT Millar (Speciality Registrar) Scott W Oliver (Speciality Registrar) Peter C Thomson (Consultant Nephrologist) Glasgow Renal and Transplant Unit Queen Elizabeth University Hospital Glasgow
Background Non-tunnelled central venous catheters (NTCVC) remain an essential means of vascular access for incident haemodialysis Associated morbidity is well recognised for example in the form of Staphylococcus aureus bloodstream infections (SAB)[1]
Previous quality improvement initiatives in our unit have sought to both improve traditional markers of quality (such as SAB) and to identify additional areas of clinical risk In 2014 Oliver et al [2] suggested several additional quality measures including peri-procedure haemoglobin drop the need for a further NTCVC during the same clinical episode and the NTCVC insertion site This study further evaluated NTCVC related clinical practice within our unit
Methods The potential markers of clinical quality identified in a previous project were examined using prospectively collected data stored in the electronic patient record Identified cases of SAB significant peri-procedure haemoglobin drop and multiple NTCVC insertion were investigated by case note review
Results Between March 2016 and March 2017 a total of 222 patients received 346 NTCVC 54 patients (243) had more than one NTCVC inserted in a 21-day period (range 2-5) When considering NTCVC insertion site there were 159 (459) femoral vein catheters and 183 (541) internal jugular vein catheters No pneumothoraces were reported
15 SABrsquos were reported during this period equating to 43 of all NTCVC 5 arose in patients with femoral NTCVC (333) and 10 from internal jugular catheters (667) Mean time from line insertion to positive blood culture was 86 days 15 (67) patients had a drop in haemoglobin of greater than 20mgdl with no other source of blood loss identified on review of clinical notes
Discussion These data demonstrate that NTCVC-associated SAB rates remain low and significantly below Scottish government audit standards [3] Of interest is the continued trend towards the use of femoral catheters at 45 of lines compared with 38 in 2014 [2] Although traditionally thought of as having a higher incidence of infectious complications our data has shown fewer bacteraemia events associated with femoral catheters compared with internal jugular Our data also demonstrates a significant rate of peri-procedure haemorrhage arising in up to 1 in 20 cases Together these findings present opportunities to development practice and improve patient safety
References
[1] Murray E Deighan C Geddes CC Thomson PC Reducing haemodialysis bacteraemia rates Scottish Renal Association Glasgow November 2013 [2] Oliver SW Thomson PC Jardine AG defining safe effective and patient-centred dialysis catheter placement Scottish Renal Association Edinburgh September 2014 [3] The Staphylococcus aureus bacteraemia quarterly report of cumulative data from all NHS Boards in Scotland Health Protection Scotland January 2015
Sources of funding none Conflicts of interest none
P10 Prescribing of tolvaptan-The NHS Highland experience Lambie S1 McCulloch K2 Garrod J3
1Renal Consultant Renal unit Raigmore Hospital Inverness 2Renal Pharmacist Renal unit Raigmore Hospital Inverness 3Renal Pharmacist Renal unit Raigmore Hospital Inverness
Introduction Tolvaptan is a vasopressin antagonist It was accepted for use in Scotland by SMC in Jan 2016 to slow the progression of cyst development and renal insufficiency of autosomal dominant polycystic kidney disease in adults with chronic kidney disease (CKD) stage 1 to 3 at initiation of treatment with evidence of rapidly progressing disease1 Adverse effects related to aquaresis may affect patientsrsquo ability to achieve the optimum therapeutic dose and the risk of hepatic toxicity necessitates regular LFT monitoring The geography of NHS Highland required the implementation of novel methods of managing these patients and as a result a MDT approach with an emphasis on pharmacist input was adopted Consultant role Patient selection on the basis of evidence of rapidly progressing kidney disease declining
eGFR large volume kidneys on ultrasound and evidence of complications of PKD Side effects and potential benefits discussed Potential medication interactions reviewed Jinarc risk management prescriber training
Pharmacist role Undertook Jinarc risk management pharmacist training Prepares accurate drug history and reviews for potential drug interactions Carries out patient counselling and supplies patient education material sick day rules card
and lsquogot to gorsquo card Supplies GP education leaflet Provides advice on selection of new drug therapies eg for gout Manages stock and coordinates supply to patients
Results Prescribing commenced May 2016 patients currently prescribed tolvaptan 11 7 Female 4 male Number on target dose 73 n = 811 2 patients are still being titrated One patient did
not tolerate target dose due to aquaresis side effects and is being trialled on the middle dose
Withdrawals One patient has withdrawn due to agoraphobia and an inability to attend for monitoring and another is on hold due to having major surgery
Conclusion The MDT approach between the Renal Consultant and Pharmacist at Raigmore Hospital has enabled tolvaptan prescribing to be efficiently and safely implemented to patients living within a challenging geographical location
1 Scottish Medicines Consortium Detailed Advice Document tolvaptan 15mg 30mg 45mg 60mg and 90mg tablets (Jinarcreg) SMC No 111415 January 2016
NA1 Authors SCN Jacqueline Ross NHS Grampian
SCN Alan Somerville NHS Lanarkshire SCN Jane Humphrey NHS Lanarkshire
e- mail contact jacquelinerossnhsnet Alansommervillelanarkshirescotnhsuk
Janehumphreylanarkshirescotnhsuk
Phone contact 01224 552927 01236 712644
Title Sharing of Adverse Events in Renal Units across Scotland
Introduction Background The Scottish Renal Nurses Strategy Group (SRNSG) are a group of senior nurses from Renal
Units across Scotland who meet 3-4 times per year to discuss and implement best practice At the last meeting it was agreed that it would be good practice for each Health Board to share
their adverse events reported on the Datix System and deliver a presentation with an action plan to prevent incidents and improve patient safety across Scotland NHS Grampian and NHS Lanarkshire will be the first to deliver this presentation discussing adverse events from both Health Boards with an action plan
Top 5 adverse events over the past 12 months Renal Unit NHS Grampian 1 Violence and Aggression 2 Accidents including needlesticks slips trips and falls 3 Medication Errors 4 Infrastructure Staffing and Estates 5 Machines and Equipment
Top 5 adverse events over past 12 months Renal Unit NHS Lanarkshire
1 Slips Trips or Falls 2 Medicine errors 3 Treatment problems 4 Transfer problems 5 Breach of policy
The presentation will also focus on any serious adverse events which may not be in the top 5 categories
Aim Objective Each Health Board to share their adverse events with the aim to prevent them from occurring in other units to improve staff and patient safety and wellbeing across Scotland
Method Power Point Presentation
Outcome Results Sharing of adverse events resulting in the development of a national Action Plan to prevent these incidents improving safety and well being of staff and patients in Renal Units across Scotland
NA2
SRA Oct 2017 Abstract
BBV Never Event - The whats whys and hows
Staff Nurse Gillian Wilson Aberdeen Royal Infirmary
This presentation shares our experience of a never event that occurred and was not picked up for
a period of 18 months
Hepatitis C (HCV) positive antibodies were found in a previously negative patient
These results were a low positive with no biochemistry changes to suggest any liver damage
however steps were put immediately in place to isolate and investigate
Was it contamination from a dialysis machine was it related to a blood transfusion given prior to
first positive result was it faulty diagnostic tests in the laboratory
In Aberdeen we go over and above national guidelines and isolate all our BBV patients whether
they have positive blood results or are PCR negative
Further bloods tested at an external laboratory confirmed negative results
It highlighted that communication errors were to blame for the lack of speed in detecting this issue
Investigations concluded no real answers as to why this happened
NA3
Living Donation Scotland Changing attitudes towards living donor kidney transplantation
Jen Lumsdaine Julie Glen On behalf of the Living Donation Scotland Project Board
Background and aims
The rate of living donor transplantation has remained fairly static in Scotland over the past 10 years
Recent data has shown inequity of access to living donor transplantation throughout the UK so
there is potential to significantly increase this optimum form of treatment for patients with end-stage
renal failure in Scotland The Living Donation Project Board was formed in 2016 aiming to double
the number of living donor transplants by 2020
Method
The two key areas
1 Do recipients receive adequate and appropriate information at the right time about living
kidney donation
2 Informing the general public about altruistic donation
All patients active on the transplant list in Scotland were invited to an information event A follow-up
questionnaire was performed in the East of Scotland examining outcome or reasons for not
attending A scoping exercise looked at information provided by each unit was performed and link
nephrologists and low clearance nurses attended meeting to discuss strategies for early education
Outcome
An information pack containing both recipient and donor written information and short films on DVD
has been produced with the support of the Scottish Government for all recipients and potential
donors in Scotland A new website with comprehensive information both written and visual and
postcode finder to improve ease of access to local unit contact details has been developed
Two national media campaigns have been launched with a significant rise in the number of enquiries
from potential donors and actual increase in altruistic donor numbers
Nursing abstract ndash no conflict of interest
NA4Authors Susan Easson Charge Nurse Ward 4C QEUH Glasgow
e- mail contact SusanEassonggcscotnhsuk
Phone contact 0141 452 3300
Title A Conversational approach to find out ldquoWhat matters to yourdquo in a Renal Transplant ward
Introduction Background Finding out ldquo What Mattersrdquo to people using health and careservices is crucial to delivering safe effective and person centred care It is a simple yet profoundconcept and tries to get to the essence of person centred care by creating deeply personalengagements with patients and their families through a conversational approach However careexperience feedback all too often provides innumerable examples of where what really matters topatients and their family members is poorly understood or not addressed Using care experienceas the driver for change the nursing staff in Ward 4C used improvement approaches to explorehow to hold more meaningful ldquoWhat Matters to yourdquo conversations on a daily basis
Aim Objective To improve the patient experience by utilising a person centred approach
Method Using Care experience feedback What Matters to Me boards and the conversationalapproach
Outcome Results Improvements in patient experience will be shared using examples ofpractice and care experience feedback
There was no additional funding required for this project We worked in collaboration with theperson centred team whorsquos aim is to improve patient experience
NA5
The implementation of a renal education programme and its impact on clinical practice
The purpose was to implement a Renal Education Programme and to evaluate its impact on
clinical practise
It was identified that there was a need for an educational programme to be set up within Forth
Valley Royal Hospital There is no inpatient renal unit in FVRH on site for our renal patients they
attend Queen Elizabeth University Hospital We are an outpatient haemodialysis unit with
outpatient clinics on site Therefore it was identified that there was a need for nursing staff within
FVRH to be educated on all renal complexities for the benefit of our patients
This was done through a work-based learning approach which brought tangible benefits for our
patients However it did not come without pitfalls as educational programmes are often seen as
making very little difference to clinical practise
T
his study describes what methods were used and examines the advantages and disadvantages in
setting up an educational programme and evaluating its impact on clinical practise
NA6
Nursing Abstract ndash SRA Meeting ndash 26 October 2017
Chris McGee Tonya Broe Ken Weir
Renal Unit Forth Valley Royal Hospital
Use of the Therapy Monitor Haemodialysis Patient Record System Can we aim for a paper-
free dialysis unit
We are trialling a new haemodialysis patient monitoring system to work in conjunction with SERPR
and which is intended to supersede the Finesse system used previously
We are in the early stages of this process but with continuing staff education and regular tech
support we are hoping to gather sufficient evidence to evaluate whether the use of paper case
notes needs to continue
Is it a realistic goal to aim for a completely paper-free unit
NA7
THE CLINICAL USES OF APHERESIS WITHIN NHS TAYSIDE
Laura Thomson CN
Ninewells Hospital Dundee
NHS Tayside took over the apheresis service from BTS in 2012 The service has since expanded
with the benefits of carrying out this treatment has been widely recognised within NHS Tayside
and is now more commonly being offered to treat a wider range of conditions with the number of
treatments carried out each year rising
This presentation will highlight the progression of the apheresis service within NHS Tayside We
will identify the various conditions it is currently being used to treat and also identify the decision
making process involved in carrying out these treatments ie which replacement fluid will be used
anticoagulation medication administered
We will highlight the benefits and challenges we face in providing this expanding service within the
Renal Service
NA8Authors Linda McDougall Renal Physiotherapist NHS Highland
e- mail contact lindamcdougall1nhsnet
Phone contact 01463 706022
Title lsquoExercise on Haemodialysis- Keeping the Wheels in Motionrsquo
Introduction Background The impact of CKD on physical fitness functional ability independence amp ultimately quality of life cannot be underestimated Current national guidelines recommend that all individuals with CKD are encouraged to participate in regular exercise programmes between or during dialysis sessions if on HD Following a successful pilot study funding was approved to establish an lsquoExercise on Dialysisrsquo (EOD) programme across NHS Highland through the appointment of a dedicated renal physiotherapist in 2008 A successful programme was soon established but for several years post-vacancies and increasing in-patient demands limited the physiotherapy servicersquos ability to deliver the programme The need to improve the long-term sustainability of the service was recognised and in late 2016 funding was approved to develop a Band 4 PT HCSW role for this purpose
Aim ObjectiveTo optimise the sustainability and continuity of the lsquoExercise on Dialysisrsquo service across NHSHighland through development of a Band 4 PT HCSW role
Method The potential parameters of the role and limits of autonomy were scoped out using current NES resources and guidelines Service and task analysis was then carried out to establish which components of the EOD protocol could be undertaken by a Band 4 A series of competencies were developed in line with the clinical protocol and one-to-one training and supervision provided to the post-holder to ensure competency achieved in delivering the programme
Outcome Results A 10 WTE Band 4 PT HCSW was appointed in Jan 2017 with a dual role between the renal unit and acute medical wards Although training is not yet complete the post-holder is already running the day-to-day delivery and monthly audit of the EOD service with senior physiotherapist input only required for individual patient safety queries and general discussion around patientsrsquo progress and goals The benefit to the unit has been considerable as the band 4 is available to support patients and staff with EOD provision 5 days a week This allows for one-to-one supervision of patients who need more support to participate in EOD regular feedback on performance and reviews of outcome measures and goals to maintain motivation levels Feedback on the post has been very positive and its scope will only continue to expand as we look to further develop renal rehabilitation services across NHS Highland
NA9Authors Nadine Lyall and Kerry Guthrie
e- mail contact nadinelyallbordersscotnhsuk kerryguthriebordersscotnhsuk
Phone contact 01896 826637
Title The Developing Role of the NMP in a Satellite Dialysis Unit
Introduction Background
We have been practising as NMPrsquos for nearly 3 years working in the dialysis unit at the BGH The unit is a satellite unit of the ERI and we have expanded over the last 6 years The unit provides haemodialysis for 12 patients at any one time 3 sessions a day 6 days a week We are nurse-led and have 2 renal consultants who are based at the ERI
We saw an opportunity to use our knowledge and experience to develop our role By becoming NMPrsquos we have enhanced our professional development and we feel we meet the changing needs of the dialysis patient in a more holistic manner
Aim Objective
Our aim is to deliver effective care as we are better placed to deal with issues that often arise byacting swiftly this in turn is cost effective and convenient For example good anaemia and bonemanagement is important for their health wellbeing and lifespanTo help understand our role we will use a power point presentation highlighting issues we dealwith and the drugs we prescribe under the following headings Cardiovascular infection painanticoagulant disequilibrium diet renal bone disease and renal anaemia
Method Power point
Outcome Results
In the future we hope to further develop and have greater autonomy in our role We have great support from our renal consultants and have already built up a great relationship with our patients We hope to undertake the Clinical Decision Making course and this in turn will allow us to deal effectively with acute illness giving the dialysis patient better care We are keen to get feedback from other renal nurses in Scotland to enable us to develop our role further and in turn raise awareness of the NMP role in a dialysis unit We record all our prescribing decisions and keep the consultants up to date regularly Currently we are working on auditing our prescribing practice so that we can improve the service we can provide
NA10 Title Komunikacja w szkoleniu dializy ortzewnowej
Author Senior Charge Nurse Rhoda Bell
Address Raigmore Hospital Old Perth Road Inverness IV2 3UJ
Email rhodabellnhsnet Telephone 01463706023
Introduction Background Case study on lady with Polish as her first language she has some English but requires an interpreter to carry out Peritoneal Dialysis training and attend clinic She had some gynaecological issues that we were not aware of which impacted on the functionality of PD and therefore the success of treatment There were areas of concern in low clearance clinic with signs the patient had a reluctance to engage in decision making
AimObjective
Methods Discussion through the case study highlighted issues with communication between different PD staff and patients Areas of concern include different staffing techniques environment factors on training success Also language and communication issues the patient had were not fully apparent so training could not be individualised
Results We plan to trial training at home and have more individualised training schedule for patients The training step by step guides have been reviewed and practise standardised In collaboration with low clearance nurse we have developed a check list which will highlight concerns before the transition to PD ie language issues and need for training aids in another language gynaecological conditions
Conclusions Everyone learns differently and training methodsaids must be individualised for all It may not be apparent until training has commenced that there are concerns Having one to one training with the same nurse will consolidate training and build confidence in the patient Having a close working relationship with members of the MDT will help make a supportive PD journey
Would we do things differently if we knew about prolapse or lack of English both spoken and written
Key words - Peritoneal dialysis patient training communication
N11
Telehealth amp PDAudrey Jones
Advantages
Information on a daily basis about treatment weight and blood pressure
Change programme remotely via computer or mobile
Earlier intervention for machineprogramme issues
Reduction in home visits ie patient trained but still requires volume increases
No need to download cards to see what problems have been
Can have more detailed information available at clinics
Disadvantages
Relying on patient input data correctly
Machine is noisy especially first wave of machine
Still the same bag connection system and patient connection system (difficult for manual
dexterity problems)
Relying on patient having good signal
Modem problems
NA12Autosomal Dominant Polycystic Kidney Disease A cruel inheritance but new hopeAlistair Lawrie Renal Unit Victoria Hospital KirkcaldySadaf Arshad Corry Dunnigan Paul Phelan Neil Turner Renal Unit Royal Infirmary of Edinburgh
Background Autosomal Dominant Polycystic Kidney Disease (ADPKD) is the most prevalent single gene human genetic disorder and the most common of the inherited cystic and interstitial kidney diseases It is estimated to affect 1 in every 1000 individuals worldwide with over 50 of sufferers eventually developing end stage kidney disease and requiring dialysis or transplantation Symptoms include spasmodic severe pain hypertension haematuria infection and kidney failure There is currently no cure for ADPKD Management of the condition has traditionally involved lifestyle modification BP control and analgesia however a recent study (Torres et al 2012) demonstrated that treatment with V2-receptor antagonist drugs slowed increase in total kidney volume reduced the rate of functional decline and showed a reduced incidence of kidney pain
Aim Provision of a tolvaptan prescribing and monitoring service
Methods Experiential finding report of initial twelve months period of multidisciplinary ADPKDtolvaptan clinic
Results Early results are comparable with TEMPO study outcomes
Conclusion Due to the long term nature of this treatment results available at this time are showing only the earliest benefits of the intervention More quantifiable results such as increased time before the necessity for RRT will only be evident in coming years Torres VE et al (2012) Tolvaptan in Patients with Autosomal Dominant Polycystic Kidney Disease New England Journal of Medicine 367 pp 2407-2418 DOI 101056NEJMoa1205311
No funding requirement No conflict of interest
A11 Evaluating patient satisfaction and clinical outcomes of a new nurse-led dermatology clinic for patients attending the renal transplant clinic Campbell G Naismith K Neil A Rankin A Spalding E (joint first authors) Renal Unit University Hospital Crosshouse Kilmarnock UK
BACKGROUND National Guidelines advise that renal transplant recipients should receive annual skin surveillance to screen for skin cancer In August 2015 a specialist nurse-led dermatology clinic was set-up alongside the renal transplant clinic at University Hospital Crosshouse We aimed to evaluate the success of this joint clinic in terms of clinical outcomes and patient satisfaction
METHODS Clinical records were reviewed to determine the number of patients under dermatology follow-up before and after initiation of the joint clinic and to review cases that were referred for treatment of pathological skin lesions A questionnaire was also distributed to patients attending the new joint renal-dermatology transplant clinic The questionnaire consisted of 5 questions 2 for patient demographics 1 for current understanding of skin care advice and 2 to assess their satisfaction of the new joint clinic
RESULTS A total of 138 and 146 renal transplant recipients were registered on renal transplant clinic lists in 2015 and 2016 respectively Prior to initiation of the new joint-clinic 41 patients had attended dermatology (37 in NHS Ayrshire and Arran and 4 in NHS Greater Glasgow and Clyde) consisting of 30 of the transplant population In September 2016 13 months after initiation of the new clinic 60 patients had attended the new clinic increasing the proportion of patients meeting the national recommendation for skin surveillance to 41 Implementation of the new clinic resulted in patients being 65 more likely to have received the recommended skin checks (odds ratio 165 95 CI 101-270 p=004)
32 patients completed the questionnaire The median age of transplant was 90 years (IQR 38-153) 100 of patients knew to avoid sun exposure and 31 (96) knew to use sunscreen 29 (91) patients were aware of the advice to undergo annual skin surveillance by dermatology with 28 (88) having had a skin check in the last year 29 (91) patients reported that they found the new joint clinic useful although only 18 (56) had attended the clinic so far
CONCLUSIONS Implementation of a new nurse-led dermatology clinic running in parallel with the renal transplant clinic resulted in a considerable increase in the proportion of patients meeting national recommendations for annual skin surveillance The vast majority of patients also found the combined clinic to be useful There is still considerable room for improvement in order to achieve the target of 100 compliance with skin surveillance and ongoing clinical audit is required to assess progress We believe this model would be easily implementable at other units with similar benefits expected
A12 Pneumocystis pneumonia prophylaxis post-renal transplant increased duration of co-trimoxazole is safe and effective FA Chapman JE Dickerson M Clancy C Daly C Geddes Renal amp Transplant Unit Queen Elizabeth University Hospital Glasgow
Introduction All renal transplant recipients receive Pneumocystis jirovecii prophylaxis usually with co-trimoxazole Guidelines suggest this should be continued for 3 to 6 months Our unit previously prescribed 3 months however following an outbreak of Pneumocystis pneumonia (PCP) infection this was increased to 6 months Given its constituents of sulfamethoxazole and trimethoprim co-trimoxazole prophylaxis may influence the frequency of urinary tract infection (UTI) We aimed to compare the frequency of UTI between patients on 3 months vs 6 months prophylaxis and assess rates of multi-drug resistant organisms We also sought to establish if the increased duration of co-trimoxazole was adversely affecting renal function potassium concentration white cell and platelet count and dosing of mycophenolate mofetil
Methods A retrospective search of the West of Scotland Electronic Renal Patient Record was conducted for all renal transplant recipients between 1st January 2012 and 31st May 2016 Patients were grouped according to the intended duration of co-trimoxazole Data were extracted for baseline characteristics co-trimoxazole prescription mycophenolate mofetil (MMF) prescription laboratory results (creatinine potassium white cell count platelets) at 3 6 9 and 12 months post-transplant and microbiology results for 6 months post-transplant Results were analysed on an intention to treat (ITT) basis with a second analysis according to actual duration of co-trimoxazole treatment (AT) Subjects with transplant failure had laboratory results censored from the time of transplant failure and all of their microbiology results were excluded
Results 609 renal transplants were performed over the study period On ITT analysis there were 418 patients in group 1 (ITT1 3 months co-trimoxazole) with 15 transplant failures and 191 patients in group 2 (ITT2 6 months co-trimoxazole) with 12 transplant failures There was a significant difference in the number of patients with at least one UTI with fewer in ITT2 (ITT1 133403 vs ITT2 42179 p = 001) However this was not present when comparing actual treatment duration (AT1 111345 vs AT2 36149 p=007) Overall there was a similar spectrum of organisms cultured There were significantly fewer cultures of multi-resistant organisms in both ITT and AT analyses with 6 months of co-trimoxazole (ITT1 28376 vs ITT2 0106 p= 0004 AT1 22313 vs AT2 198 p = 002) There was no difference in estimated Glomerular Filtration Rate serum potassium concentration platelet count or MMF dose On AT analysis there was a significant difference in the total white cell count (WCC) and lymphocyte count at 6 months post-transplant (WCC 78 x10^5L vs 71 x10^5L p =004 lymphocytes 13 x10^5L vs 12 x10^5L p=002) There were 18 cases of PCP with 7 deaths attributable All cases occurred after cessation of co-trimoxazole prophylaxis (81 ndash 913 days after stopping co-trimoxazole)
Conclusion Although there is a significant difference in UTI frequency on ITT analysis this is not present on AT analysis suggesting no real co-trimoxazole effect There was no increase in frequency of multi-drug resistant organisms with a longer course of co-trimoxazole Renal function and serum potassium were unaffected Our findings support continuing co-trimoxazole prophylaxis for at least 6 months
A13 Kidney transplantation in the over 60rsquos in Scotland 1996-2015 TJW Rennie1 P Phelan1 J Campbell2 JP Traynor2 L Henderson1 W Metcalfe2 On behalf of the Scottish Renal Registry 1Renal transplant unit Royal Infirmary Edinburgh 2NHS National Services Scotland Introduction The proportion of older kidney transplant recipients has increased in the UK but
long term outcome data are scarce We aimed to evaluate patient and graft survival in patients
ge60 years of age receiving a first kidney only transplant in the last 20 years in Scotland
Methods Retrospective analysis of Scottish Renal Registry data of incident Renal Replacement
Therapy (RRT) patients and those in receipt of a kidney only transplant performed 1996-2015
(follow up until 311216) Patients were stratified by age 60-69 ge70 (group 1 and 2 respectively)
and decade of transplantation 1996-2005 2006-2015 (decades 1 and 2 respectively)
Results 6743 patients aged ge60 started RRT from 1996-2016 Of those 108 were ever
transplant-listed 54 had received a transplant by 311216 26 listed and 11 transplanted
were aged ge70
535 patients aged ge60 received a kidney only transplant in 1996-2015 90 patients (168) were
aged ge70 no patients were aged ge80 Mean time from wait listing until transplantation was 33plusmn24
years (plusmnSD) and from starting RRT until transplantation was 38plusmn26 years (plusmnSD) One and five
year graft survival was 97 and 87 in decade 1 95 and 89 in decade 2 (p=NS) there was
no difference in graft survival between age groups 1 and 2 One and five year patient survival was
94 and 78 in age group 1 85 and 56 in group 2 (plt0001) there was no difference in one
and five year patient survival between the two decades
Conclusion One and five year graft and patient survival in renal transplant recipients aged ge60
have not changed significantly in the last 20 years Recipient age ge70 is not associated with
reduced graft survival but patient survival from time of transplant is lower in this age group
compared to recipients aged 60-69
No conflict of interest to be declared No funding received
A14 High Mortality In Older Patients With Primary Nephrotic Syndrome Sarah Beverstock Wendy Metcalfe amp Robert W Hunter Department of Renal Medicine Royal Infirmary of Edinburgh
Introduction
Nephrotic syndrome can develop at any age and may be due to a primary glomerular lesion or secondary to systemic disease The natural history of glomerular disease can be different in older patients For instance minimal change disease (MCD) in children almost always remits promptly with steroid therapy in adulthood it typically remits only after many weeks of steroids or with adjunctive immunosuppression However there are remarkably few published data on the mortality of primary nephrotic syndrome in adults We aimed to study this in our centre
Methods
We enrolled all adult patients who had a kidney biopsy in order to investigate nephrotic syndrome over 38 consecutive months (01 Jan 2014 ndash 28 Feb 2017) We defined nephrotic syndrome as heavy proteinuria (urinary proteincreatinine ratio UPCR gt350 mgmmol or albumincreatinine ratio gt220 mgmmol) and hypoalbuminaemia (serum albumin lt35 gL) In our analysis we included all patients in whom nephrotic syndrome was attributed to a primary glomerular disease We excluded kidney transplant recipients and patients in whom biopsies were performed to follow up a known glomerular disease We collected laboratory data at baseline (time of biopsy) and at 6 and 12 months We assessed patient survival by Kaplan-Meier analysis
Results
Of the 117 patients biopsied for nephrotic syndrome 71 patients (61 ) met the inclusion criteria and were followed up for a median of 469 days We compared outcomes in patients aged under 60 years old (n = 35) with those aged over 60 (n = 36) Mortality was higher in the older group (37 vs 4 mortality at one year p lt005 by logrank test) There were no significant differences between the two groups in serum creatinine or UPCR at any time Serum albumin was similar in both groups at baseline and at 12 months but was lower in the older group at 6 months (27 vs 32 gL p lt 005) Baseline haemoglobin was lower in the older group (114 vs 130 gL p lt005 by unpaired t-test) Primary diagnoses were MCD (n = 10 in younger group amp n = 5 in older group) membranous nephropathy (5 amp 10) IgA nephropathy (9 amp 8) FSGS (5 amp 5) membranoproliferative glomerulonephritis or C3GN (4 amp 7) and other (2 amp 1) Therefore unsurprisingly there were relatively fewer cases of MCD and more cases of membranous nephropathy in the older group otherwise the causative glomerular lesions were similar in both groups In those patients with MCD mortality was significantly higher in the older group none of the 10 patients with MCD diagnosed under 60 yrs old died during the follow-up period whereas 4 of the 5 older patients died 3 patients in the younger group and 1 in the older group were on renal replacement therapy (dialysis or transplant) by the end of follow-up
Conclusions
Primary nephrotic syndrome is associated with high mortality in the over 60s (37 at one year) Mortality was high even for MCD a disease that follows a benign course in childhood and early adulthood The higher mortality in older patients was not associated with greater severity of renal disease at presentation (as assessed by basic blood and urine parameters) This work was not funded we declare no conflicts of interest
A15 Renal biopsies in patients with diabetes mellitus in Scotland
Udana Ratnapala 1 Nicola Joss 2 Colin Geddes 3 Dana Kidder 1
1 Renal Unit Aberdeen Royal Infirmary Aberdeen 2 Renal Unit Raigmore Hospital Inverness 3 Glasgow Renal and Transplant Unit Glasgow
Introduction Diabetes mellitus is the leading cause of end-stage kidney disease (ESKD) requiring renal replacement therapy The utility of renal biopsy in patients with diabetes mellitus is controversial Broadly renal biopsy findings in patients with DM can be divided into diabetic nephropathy (DN) alone DN with non-diabetic renal disease (NDRD) or NDRD alone Timely identification of patients with NDRD is important to provide appropriate therapeutic measures Previously published guidelines on clinical predictors of NDRD have limited specificity and sensitivity The frequency of NDRD in renal biopsies of patients with DM is unclear in ScotlandThis study aimed at identifying the frequency and the pathology spectrum of NDRD in diabetic patients underwent kidney biopsy in 3 renal units
Methods A retrospective observational study was performed on clinical-pathologic findings in all patients with diabetes mellitus who underwent renal biopsy between 01012010 and 31122016 in 3 renal units (Aberdeen Inverness and Greater Glasgow) Data were gathered from electronic patient record systems Scottish Index of Multiple Deprivation (SIMD) 2012 was used to analyse correlation with patient outcomes
Results 247 patients were included 150 men (607) 217 type 2 DM (879) mean age 621 years and mean serum creatinine at the time of renal biopsy of 261 micromolL (+-190 std) On biopsy 92 patients (372) had DN while 127 (514) had NDRD and 28(114) had NDRD superimposed on DN The commonest NDRD aetiologies were IgA nephropathy (187) tubulointerstitial nephritis (168) and idiopathic membranous nephropathy (103) Predictors of NDRD were age (OR 1027 95 CI 1002-1052 p=003) duration of DM (OR 094 95 CI 0900-0987 p=001) and absence of AKI as indication for biopsy (OR 022 95 CI 0059-0826 p=0025) There was no significance difference in renal or patient survival in DN and NDRD Finally no significant correlation was depicted between SIMD quintiles and renal or patient survival in both groups
Conclusions The majority of renal biopsies carried out in patients with DM revealed a NDRD In this study age at the time of biopsy duration of DM and AKI were the main pointers towards NDRD Renal and patient survival were not significantly different between DN and NDRD groups
A16 The Impact of Withdrawal of Maintenance Immunosuppression and Graft Nephrectomy on HLA Sensitisation Ailish Nimmo1 Sophie McIntyre1 Lorna Henderson1 Richard Battle2
(1 Department of Renal Medicine Royal Infirmary of Edinburgh 2 Histocompatibility and Immunogenetics Royal Infirmary of Edinburgh)
Background The development of HLA antibodies towards a failing renal allograft is a barrier to re-transplantation We previously demonstrated an increase in HLA antibodies and calculated reaction frequency (cRF) following nephrectomy but results were confounded by immunosuppression changes occurring in close time proximity We examined the formation of HLA donor specific antibodies (DSA) in patients with failed grafts that remained in situ and compared results with patients undergoing graft nephrectomy to further assess the relative impact of nephrectomy and immunosuppression weaning on sensitisation and chance of transplant
Methods We carried out a single centre retrospective study of all patients with failed grafts in Lothian from 2005 to 2015 Samples were tested for DSA pre-immunosuppression (IS) wean post-IS wean and post-IS cessation Nephrectomy patients also had samples tested for DSA before and after nephrectomy Data on other sensitising events including blood transfusion and rejection were collected cRF was determined at each time point and entered into the ODT chance of transplant calculator with other demographics based on the average patient from the Edinburgh centre
Results 62 grafts failed over this time period Blood samples were available 41 patients (24 with nephrectomy 17 with failed graft left in situ) Patient demographics were similar between groups There was a higher rate of antibody mediated rejection in the nephrectomy group (46 vs 18) 76 of patients with nephrectomy group had received a blood transfusion The pattern of immunosuppression weaning was similar but median time from start of IS wean to cessation was longer in the nephrectomy group (350 vs 298 days) The changes in cRF and chance of transplant (COT) with immunosuppression weaning are shown in Table 1
Pre-IS Wean Post-IS Wean
Failed graft in situ (n=17)
Mean CRF COT at 5
years 15 62 38 59
Nephrectomy (n=24)
Mean cRF COT at 5
years 54 54 69 46
Post-IS Stop 55 53 89 42 Table 1 Mean cRF and Chance of Transplant (COT) at 5 years with IS alterations
Discussion A stepwise increase in cRF with reduced chance of transplant was observed in both groups as immunosuppression was withdrawn with a similar pattern of change irrespective of graft nephrectomy cRF was higher in the nephrectomy group despite a more gradual wean which may reflect a higher rate of antibody mediated rejection and increased number of patients receiving a blood transfusion The risks and benefits of stopping immunosuppression need to be carefully considered on an individual basis to maximise chance of future transplant
The authors have no conflicts of interest No funding was required for this study
A17 Obesity is not associated with progression to end stage renal disease in patients withbiopsy-proven glomerular diseases
Benjamin Elyan Jennifer S Lees Bruce Mackinnon Jonathan G Fox Colin C Geddes Emily PMcQuarrie
Glasgow Renal and Transplant Unit Queen Elizabeth University Hospital Glasgow
Introduction - Addressing risk factors for renal progression is a key aspect of managing chronic kidney disease (CKD) Body mass index (BMI) has been shown to impact on renal progression in unspecified CKD The aim of this study was to evaluate if there was an association between BMI and progression to renal endpoints in patients with biopsy-proven primary glomerular disease (GN)
Methods - We included all adult patients diagnosed with biopsy-proven primary GN (excluding minimal change nephropathy) in Greater Glasgow amp Clyde and Forth Valley between 01012000 and 31122015 Biochemical and anthropometric data were extracted from the electronic patient record at time of biopsy with follow-up data until 20062017 BMI was calculated from height and weight at time of biopsy and categorised into groups BMI le25 kgm2 (G1) gt25 to le30 kgm2 (G2) and gt30 kgm2 (G3 - obese) We assessed factors associated with reaching a combined renal endpoint of CKD5 or renal replacement therapy (RRT) with competing risk of death using the Fine and Gray subdistribution hazard model Analyses were conducted using cmprsk package for R statistical software package and SPSS version 24
Results - 560 patients with primary GN and available BMI data were included The average age was 532 years and 339 were female There were 132 patients in G1 210 in G2 and 207 patients in G3 Those in G2 and G3 were older (p=002) with slightly higher diastolic blood pressure (p=002) than those in G1 There was a greater proportion of focal segmental glomerulosclerosis in G3 but similar proportions of other GN diagnoses across groups There was no significant difference in baseline serum creatinine (sCr) (p=034) or log uPCR (p=045) between BMI groups On multivariate analysis age systolic blood pressure BMI or GN diagnosis were not predictive of renal outcome Higher baseline sCr (SHR 1003 per 1 umoll increase in sCr 1001-1004 plt0001) and log uPCR (SHR 130 per unit increase in log uPCR 95 CI 105-160 p=002) were associated with progression to the combined renal endpoint accounting for competing risk of death BMI was not associated with reaching combined renal endpoint on univariate analysis whether considered as a continuous variable (SHR=100 95 CI 098-102 p=096) or categorised by BMI group
Conclusion - Contrary to our expectations there was no association between BMI and progression to a combined renal endpoint of CKD5 or RRT in this cohort of patients with primary GN Efforts should be directed to managing other known risk factors for CKD progression
Sources of FundingConflicts of Interest - None
A18 Factors influencing long term renal function after living kidney donation
Matthew A Rutherford Norman J Galbraith Marc Clancy Colin C Geddes
Glasgow Renal and Transplant Unit Queen Elizabeth University Hospital Glasgow UK
Background Following live donor nephrectomy the remaining kidney undergoes an increase in filtration capacity known as compensatory hypertrophy Few cohorts with follow up of renal function beyond 5 years have been reported The impact on long term renal function of variability in donor factors such as age sex pre-donation blood pressure and glomerular filtration rate (GFR) is unknown Increasingly kidney donors have potential risk factors for future poor renal function such as hypertension older age and obesity The aim of this study was to analyse factors influencing long-term renal function in living kidney donors from our centre
Method Data were obtained from the electronic patient record Patients with a recorded procedure of lsquolive donor nephrectomyrsquo between 2005 and 2017 were identified GFR after donation (calcGFR) was calculated using the formula lsquocalcGFR = Pre-donation Isotope GFR x (Pre-donation Serum creatinine Serum Creatinine)rsquo which is accurate assuming muscle mass does not change Pre and post donation serum creatinines (two days two weeks three months and one to ten year) were recorded We analysed the influence of age sex pre-donation GFR and blood pressure on post donation GFR compensation
Results 355 live donor nephrectomies were performed between January 2005 and December 2016 The mean age was 469 (plusmn 116) years and 504 (n=179) were female Mean pre-donation isotope GFR was 937 plusmn 156 mlmin173m2 Median follow up was 2 years (IQR 1 to 6 years with range 2 weeks to 10 years) The calculated percentage of pre-donation GFR at 2 days 2 weeks 3 months 1 year 5 years and 10 years were 698 691 712 730 801 and 950 respectively (p lt 0001) Patients aged lt50 y had not only a higher calcGFR (858 plusmn 29 mlmin173m2 compared with 671 plusmn 28 mlmin173m2 p lt 0001) at 5 years following donation but achieved a higher degree of compensation than donors gt 50 y (836 plusmn 16 compared with 756 plusmn 19 (p = 0002) Patients with pre-donation hypertension achieved 774 plusmn 53 of pre-donation GFR compared with 804 plusmn 32 in normotensive patients (p = 0998) Females had equivalent degree of renal compensation achieving 819 plusmn 19 compared with 780 plusmn 16 in males (p = 0131) at 5 years following donation Patients with pre-donation GFR gt 100 mlmin173m2 achieved 844 plusmn 23 of pre-donation function by 5 years compared with 777 plusmn 14 in those with pre-donation GFR lt 100 mlmin173m2 (p = 001)
Conclusion Following live donor nephrectomy renal function has a nadir of 691 at 2 weeks Compensation in GFR occurs rapidly and appears to be maintained regardless of sex and pre-donation blood pressure Younger age and higher pre-donation GFR were associated with a greater degree of compensation
A19 The utility of high-sensitivity cardiac troponin to stratify cardiovascular risk in patients with renal impairment
Eve Miller-Hodges Atul Anand Anoop S V Shah Nicholas L Mills Neeraj Dhaun
Background Cardiovascular disease is the most common outcome of chronic kidney disease1
Declining glomerular filtration rate (GFR) and proteinuria predict increased cardiovascular risk over the long term2 However there are currently no methods to stratify cardiovascular risk in the short or medium term in patients with renal impairment We have already shown that high-sensitivity cardiac troponin I concentrations (hs-cTnI) lt5ngL in patients presenting with symptoms of acute coronary syndrome identifies those at low risk of cardiac events within 30 days and over the next year3 However uncertainty remains over the role of hs-cTnI testing in patients with renal impairment This study investigated whether hs-cTnI could also stratify future cardiovascular risk in patients with renal impairment
Methods In a prospective study of consecutive patients presenting with suspected acute coronary syndrome we evaluated the performance of hs-cTnI in patients with and without renal impairment (estimated glomerular filtration rate lt60mLmin173m2) using an early risk stratification threshold of 5ngL to ldquorule outrdquo acute myocardial infarction at presentation and within 30 days and sex-specific 99th centile diagnostic thresholds for index type 1 myocardial infarction Subsequent type 1 myocardial infarction and cardiac death were reported at one year
Results Of 4726 patients identified 904 (19) had renal impairment Index diagnosis of type 1 and type 2 myocardial infarction was almost twice as likely in patients with renal impairment (30 vs 15) Performance of the early risk stratification threshold of 5ngL to identify patients at low risk of major cardiac events was similar in patients with (NPV 984 95CI 960-997 sensitivity 989 95CI 975-999) and without renal impairment (NPV 997 95CI 994-999 sensitivity 984 95CI 972-994) These patients continued to remain at low risk over the next year The PPV and specificity at the 99th centile for diagnosis of myocardial infarction were lower in patients with renal impairment at 500 (95CI 452-548) and 709 (95CI 675-742) respectively compared to 624 (95CI 588-659) and 921 (95CI 912-930) At one year 24 of patients with renal impairment and troponin gt99th centile regardless of index diagnosis had experienced further myocardial infarction or cardiac death compared with 10 of patients without
Conclusion In suspected acute coronary syndrome hs-cTnI can stratify risk in patients with renal impairment Irrespective of diagnosis patients with renal impairment and elevated cardiac troponin concentrations had two-fold greater risk of a major cardiac event compared to those with normal renal function and should be considered for further investigation and treatment
Funders Wellcome Trust British Heart Foundation and Chest Heart amp Stroke Scotland
1 Gansevoort RT Lancet 2013
2 Chronic Kidney Disease Prognosis Consortium Lancet 2010
3 Shah AS Lancet 2015
A20 lsquoDOES IT DIALYSE OUTrsquo - THE EFFECT OF RENAL REPLACEMENT THERAPY ON THE BRAIN Mark Findlay Jesse Dawson David Dickie Deborah McGlynn Patrick Mark Institute of Cardiovascular and Medical Science University of Glasgow amp Queen Elizabeth University Hospital Glasgow
Introduction Cerebrovascular disease is common in end-stage renal disease (ESRD) on renal replacement therapy (RRT) We investigated the effect of RRT on cerebral structure and cognitive function over 12 months Methods Observational cohort study in ESRD patients receiving HD Prior cognitive impairment or cerebrovascular disease were exclusion criteria Multi-domain cognitive testing was performed at baseline and at follow-up Transcranial Doppler was used to assess intra-dialysis related alterations in mean flow velocity (MFV) ndash a marker of cerebral blood flow MR imaging was performed at 0 and 12 months We performed T1 T2 FLAIR and DWI sequences and used volumetric software to calculate white matter hyperintensity (WMH) burden markers of atrophy mean diffusivity and fractional anisotropy (FA) to describe structural changes at 1 year Results 97 patients median age 59 years 412 female At follow-up 15 patients were transplanted 6 died 4 withdrew and the remainder continued HD Those who were transplanted were younger (median age 51 vs 60 years p=0019) and had been on dialysis for a shorter period (median 06 vs 21 years p=0003) MFV declined during HD median 475cms to 405cms plt0001 and correlated with lower scores of executive and frontal lobe function during HD (Rho 045 p lt0001 and Rho -0313 p lt001 respectively) In all patients MR imaging demonstrated a significant decline in frontal parietal and temporal lobe volume at follow-up Median WMH volume increased in those who remained on HD but not in transplanted patients (median change 023 vs -012ml p=0018) WMH burden correlated with worsening scores of frontal lobe tests Rho 0585 p0005 and worse mood Rho -0485 p0026 FA improved following renal transplant (028 to 029 p=0016) and correlated with improved executive function testing at follow-up Rho 089 p0019 Conclusion Cerebral blood flow is reduced during haemodialysis and correlates with a reduction in intradialytic executive function There is an improvement in FA following transplantation WMH volume increases in those who remain on dialysis and the degree of increase correlates with executive and frontal lobe function This suggests that haemodialysis is associated with clinically significant changes in the brain and that these may be ameliorated by transplantation
Source of fundingconflicts MF is funded by a KRUK fellowship
A21 Pathological classification of IgA nephropathy to predict renal outcomes ndash is there a better way to score tubulointerstitial inflammation
Alastair Rankin David Kipgen Bruce Mackinnon Jonathan Fox Colin Geddes Emily McQuarrie Glasgow Renal and Transplant Unit On behalf of the Scottish Renal Biopsy Registry
Background The Oxford pathological classification of IgA nephropathy (IgAN MEST-C score) is limited by the fact that individual features of the score are not all predictive and its utility in assisting clinical decision-making is questioned The addition of tubulointerstitial inflammation to the existing scoring system is appealing but is not currently included due to reportedly wide inter-observer variability We report a novel method to score percentage of cortex containing tubulo-interstitial inflammation in non-atrophic renal cortex (ATIN) in patients with IgAN similar to that used in transplant biopsy reporting and assess its utility to predict clinical outcomes
Methods All adult patients with a native renal biopsy diagnosis of IgAN between 2010 and 2015 in a unit serving 15 million people were identified Baseline characteristics biopsy reports and outcome data were collected ATIN was calculated by subtracting the percentage of atrophic cortex from the percentage of total cortex with tubulo-interstitial inflammation withge10 representing significant tubulo-interstitial inflammation in non-atrophic cortex The primary outcome was a composite of requiring renal replacement therapy (RRT) or doubling of serum creatinine (sCr)
Results 153 new cases of IgAN were identified 33 were excluded (24 had lt8 glomeruli on biopsy 6 inadequate biopsy for MEST scoring and 3 on RRT at time of biopsy) In addition patients with a tubular atrophy (T) score of 2 were also excluded (n=9) Of the remaining 111 patients 76 (68) were male Mean age at biopsy was 52 years (+- 167) and 18 (16) had a co-existing clinical diagnosis of henoch-schonlein purpura (HSP) Median sCr was 156 micromoll (IQR 101-212) and 54 (49) had ATIN on biopsy During a median follow-up of 23 years 34 (31) reached the primary outcome 20 (18) received immunosuppression and 16 (14) died On univariate Cox regression survival analysis ATIN was associated with a four-fold increase in the primary outcome (HR 49 (21-113)) On multivariate analysis mesangial hypercellularity (M) T and ATIN independently predicted renal outcome while endocapillary proliferation (E) and segmental sclerosis (S) did not (plt002 for ATIN) Excluding patients with HSP or those who received immunosuppression did not change the result
Conclusion Within our centre ATIN predicts renal outcome for IgAN independently of established histological features Assessment of inter-observer reproducibility and validation in other cohorts is still required but these results suggest ATIN could be a worthwhile addition to current pathological scoring systems for IgAN
Source of funding none Conflicts of interest none
P1 Polypharmacy in Renal Replacement Therapy Patients
Jason McMinn Colin Geddes Glasgow Renal and Transplant Unit Queen Elizabeth University Hospital
Introduction
Prescribing is often led by evidence from studies containing participants with single health conditions and without multimorbidity Polypharmacy is becoming increasingly recognised in patients with multiple chronic health conditions Additional medications are more likely to result in diminishing returns in benefit with an increased risk of harm Patients with established renal failure (ERF) are likely to be susceptible to medication-related harm A high pill burden is also likely to contribute adversely to an already restricted quality of life and has been associated with poor medication adherence The aim of this study was to analyse polypharmacy in all patients with ERF attending our service
Methods
We extracted medication records for all prevalent ERF patients attending the Glasgow Renal and Transplant Unit from the West of Scotland Electronic Renal Patient Record (SERPR) as of 01012017 The records were analysed to calculate the number of regular medications and total pill burden of each patient These medications were categorised as being lsquopreventativersquo or lsquosymptomaticrsquo We also analysed the prescription of specific drug classes to examine the prevalence of these medications
Results
We identified 1091 transplant follow-up 529 hospital haemodialysis and 46 peritoneal dialysis patients who were on a mean of 94 13 and 129 different medications respectively Overall pill burden was 139 tablets a day in transplant follow-up patients 141 in haemodialysis patients and 162 in peritoneal dialysis patients There were similar rates of prescribing between the different dialysis units and clinics within our service
The proportions of medications deemed as preventative rather than symptomatic were 76 in transplant 69 in haemodialysis and 60 in peritoneal dialysis
In transplant patients decreasing renal function was associated with a higher pill burden but even patients with a transplant eGFR gt 60 were on a mean of 126 tablets per day including a mean of 14 antihypertensives
Rates of antidepressant prescribing were 15 in transplant patients and 20 in hospital haemodialysis patients 53 of haemodialysis patients were on a statin 39 on aspirin 61 on a proton pump inhibitor and 7 were on warfarin
Conclusion
Patients undergoing all forms of renal replacement therapy are likely to be on a considerable number of medications Whilst these drugs are inevitably prescribed for valid reasons this data demonstrates the need for clinicians to engage with patients to explore opportunities to reduce pill burden
Conflict of Interest None Sources of Funding None
P2 An audit of Acute Kidney Injury (AKI) on an acute stroke ward before and after plannedinterventions to review and maintain hydration
Clare Harris1 Simon Hart2 Fiona Duthie3 1 University of Edinburgh Medical School 2 Stroke Unit Royal Infirmary of Edinburgh 3 Renal Unit Royal Infirmary of Edinburgh
Background Dehydration is an important factor in the development of acute kidney injury which is associated with increased morbidity and mortality particularly in the elderly population Poor fluid intake is common post stroke (1) and dehydration is associated with poorer outcomes 3 months post stroke (2) In late 2014 there was no system of identifying patients with poor oral intake on the stroke ward at the Royal Infirmary of Edinburgh a hydration protocol and education programme were implemented aiming to improve fluid balance This included the use of prescribed water either orally or by nasogastric tube An audit pre and post intervention demonstrated that hydration as measured by ureacreatinine ratio significantly improved after the protocol introduction (3) We aimed to determine whether the incidence of AKI by KDIGO criteria was also reduced as this could have implications for reducing patient morbidity and mortality in this elderly comorbid patient cohort
Method 150 inpatients to the acute stroke ward during JulAug 2014 and JulAug 2015 were selected (n= 80 2014 n=70 2015) Patient data and creatinine values were collected from the electronic patient record and medical notes and retrospectively analysed Baseline creatinine values were calculated and cases of AKI were identified and staged using KDIGO criteria (4) Chi-Squared tests were performed to determine P values Individual patient notes were reviewed for both quantitative and qualitative data of patient management
Results Incidence of AKI (of any stage) was 263 pre-protocol and 200 post-protocol (P=03646) Incidence of AKI stages 23 was 100 pre-protocol and 715 post-protocol (P=05374) In hospital post stroke mortality was 338 pre-protocol and 1286 post protocol (P=00028) AKI was also associated with increased length of stay
Conclusions Despite a trend in benefit there was no significant difference in incidence of AKI pre and post hydration protocol nor in incidence of severe AKI (stage 23) AKI is influenced by many factors one of which is hydration status Further studies are needed to determine whether the trend of benefit exhibited in this sample is significant in a greater sample size if this were the case such a protocol could have great benefit to patient care on stroke units and elsewhere There was a significant difference in inpatient post stroke mortality following introduction of the hydration protocol Further investigations are needed to explain underlying reasons for this factors other than hydration may play an important role
References 1 Whelan K Inadequate fluid intakes in dysphagic acute stroke Clinical Nutrition (2001) 20(5)
423-428 2 Bhalla A Sankaralingam S Dundas R Swaminathan R Wolfe CDA Rudd AG The influence of
raised plasma osmolality on clinical outcome after acute stroke Stroke (2000) 312043ndash2048 3 Hart SR Craig R Berry E Lane N Gad A Farrugia M Burton L Paquay A What Happens to
Acute Stroke Patientsrsquo Fluid Balance Renal Status and Dehydration in the First Two Weeks How Can They Be Markedly Improved doi 101111ijs12634_13
4 KDIGO Clinical Practice Guideline for Acute Kidney InjuryKidney international supplements (2012) 2(1) 1-138
No funding or conflict of interest to declare
P3NHS Highland-Improving the management of hyperkalaemia using a kit Initial resultsCantley N1 Abedin T2 Lambie S3
1FY2 NHS Highland 2ST4 Renal Medicine NHS Grampian 3Renal Consultant Renal unitRaigmore Hospital Inverness
Introduction The incidence of hyperkalaemia in hospitalised in patients is between 1 and 10 Guidelines in Northern Ireland promote the use of a Hyperkalaemia Kit to improve management of hyperkalaemia We assessed the management of hyperkalaemia in Raigmore Hospital including post-treatment monitoring of serum potassium and blood glucose at baseline and after the introduction of a lsquoHyperkalaemia Kitrsquo which contains a pro forma for the management of hyperkalaemia and all the relevant equipment and drugs for treatment
Method Between July and September 2016 an automated algorithm identified 34 patients with a potassium result 65 mmoll or above on laboratory results 12 received no specific treatment of these 6 results were spurious 4 patients died before treatment could be started and 2 patients were chronic haemodialysis patients We introduced the Hyperkalaemia Kit to the Acute Medical Admissions Unit in Raigmore Hospital Since then 15 patients have been identified with serum potassium measurements above 65 and the pro forma and kit was used with eight of these patients One of these patients proceeded straight to acute renal replacement therapy
Results Prior to our intervention all 22 patients that were actively treated received at least one prescription of appropriate doses of Insulin with Dextrose However only 16 patients received intravenous calcium and only 7 received nebulised Salbutamol Potassium was measured at 4 hours in 5 cases and by 12 hours in 17 cases Monitoring of any capillary blood glucose was only documented in 8 cases Of the 22 treated 2 needed acute renal replacement therapy 3 required further doses of insulin and dextrose 2 were treated with Calcium Resonium
Eight cases of hyperkalaemia have been managed with the use of the kit and pro-forma so far An initial ECG was performed in all eight and four patients had continuous cardiac monitoring Intravenous calcium was given in seven and nebulised Salbutamol was given in five out of the eight cases Six out of eight patients had at least three blood sugar measurements One had two measurements documented and one patient was stopped from further monitoring following senior review and decision to palliate Seven patients had appropriate monitoring of their serum potassium by 4h and 12h again one patient was not monitored due to palliation
Conclusion Baseline results showed very low rates of prescription of nebulised Salbutamol low rates of Calcium Gluconate use and very low monitoring of blood sugars and potassium post treatment This has the potential for serious adverse outcomes particularly the potential for iatrogenic hypoglycaemia Our initial data shows the use of a Hyperkalaemia pro forma and kit improves the rate of prescription of intravenous calcium and nebulised Salbutamol and the post-treatment monitoring of serum potassium and blood sugar levels
P4Rituximab as maintenance therapy in ANCA associated vasculitisndash a single centre experience Rathnamalala NK Mcmenamin J Robertson S Almond A Kelly M Muniraju T M Renal Unit Dumfries and Galloway Royal Infirmary NHS Dumfries and Galloway Background The introduction of Cyclophosphamide and high dose steroids transformed ANCA associate vasculitis (AAV) from a disease of high mortality to a relapsing remitting disease Maintenance of remission however still remains a major challenge A two randomised clinical trials have looked at the use of Rituximab in remission induction in AAV and reported similar remission rates between Cyclophosphamide and Rituximab 12 Both these trials used Azathioprine as maintenance therapy and in the follow up showed similar remission rates with either agent for induction The role of Rituximab for maintenance therapy after cyclophosphamide induction was studied in the MAINRITSAN trial 3 Rituximab was compared with azathioprine and found that the relapse rate was significantly lower in the Rituximab group There have been several other retrospective studies that have suggested regular Rituximab infusions are successful in maintaining remission however has not been thoroughly evaluated 4 5678910 Here we share our centrersquos experience using Rituximab for maintenance of remission of AAV Materials and methods We conducted a retrospective review of electronic medical records of all patients who had received Rituximab as maintenance therapy for 12 months or longer between January 2014 to July 2016 Disease activity was assessed using Birmingham Vasculitis Activity Score ( BVAS) Version 3 and complete remission was defined as a score of 0 and partial remission as a score of lt50 of the value at diagnosis Due to uncertainties associated with sub classification we did not assign specific diagnosis but broadly classified as ANCA associated vasculitis Results 6 patients received Rituximab as maintenance therapy during the study period 3 (50) of them had eye ear nose and upper airway manifestations consistent with Granulomatosis with Polyangitis (GPA) All patients were PR3 ANCA positive except for one at initial diagnosis The mean BVAS score at the time of initiation of Rituximab was 4 All patients were initiated on Rituximab for relapses while on maintenance therapy with Azathioprine 4 patients received 6 monthly doses of Rituximab while two received annual doses All of them were also maintained on 5-10 mg of Prednisolone The mean BVAS score by 6 months was 0 and remained 0 at 12 months The mean PR3 titre was 562 at the initiation of treatment while at 12 months it had come down to 68 All patients remained in complete clinical remission at the end of 12 months after initiation of therapy Rituximab was well tolerated by all patients except one who developed pyrexia during an administration
Conclusions All patients had sustained remission at 6 months and 12 months after initiating Rituximab Rituximab has a potential role as maintenance therapy in AAV
P5 Chronic Myelo-Monocytic Leukaemia (CMML) as a contraindication to renal biopsy Alastair Rankin Emily McQuarrie Jennifer Lees Bruce MacKinnon Glasgow Renal and Transplant Unit On behalf of the Scottish Renal Biopsy Registry
Abstract Chronic Myelo-Monocytic Leukaemia (CMML) is a relatively rare mixed myelodysplastic myeloproliferative disorder that predominately affects patients over the age of 65 years Renal impairment in patients with CMML is well described with several different mechanisms reported including tumour infiltration lysozyme-induced injury amyloid deposition and tubulointerstitial nephritis From anecdotal evidence within our centre we are concerned that patients with CMML have an excessive risk of clinically significant bleeding following native renal biopsy This risk appears disproportionate to the degree of any co-existing thrombocytopenia or coagulopathy
We review the cases of 4 patients with an existing diagnosis of CMML who were referred to the renal clinic with proteinuria and excretory renal dysfunction Two of these patients underwent renal biopsy with subsequent major haemorrhage post-procedure despite normal bleeding parameters pre-procedure Patient 1 presented with flank pain 8 days post-biopsy A CT confirmed peri-nephric haematoma with retroperitoneal extension A total of 6 units of packed red cells (PRCs) were transfused prior to successful CT-guided emoblisation Histology from the biopsy revealed chronic tubulointerstitial nephritis Patient 2 experienced haemodynamic instability and haematuria one hour post-biopsy A total of 11 units of PRCs 7 units of fresh frozen plasma 2 pools of platelets intravenous tranexamic acid and 2 attempts at CT-guided embolization were required until haemostasis was achieved Histology later showed evidence of tumour infiltration with associated vasculitis Patient 3 presented with renal impairment and proteinuria on the background of known CMML Following discussion with haematology the risk of bleeding following renal biopsy was considered unjustifiable despite their platelets and coagulation screen being within normal range The patient was treated for presumed renal tumour infiltration with hydroxycarbamide Patient 4 was referred to the renal clinic with acute onset nephrotic syndrome Urinary proteincreatinine ratio was elevated over 800 mgmmol with serum albumin of 23 gL but normal excretory renal function The patient attends the haematology clinic with suspected CMML and chronic thrombocytopenia but previously declined bone marrow biopsy Following discussion with the patient there are no plans to proceed with renal biopsy given potential risks These cases highlight that while CMML is rare these patients are being referred to renal clinics with features that would commonly justify renal biopsy in other settings but in whom there may be an increased risk of bleeding post-procedure Our in-centre risk of major bleeding is 2 therefore to have such extreme amounts of bleeding in 2 patients with this underlying diagnosis is remarkable This creates a dilemma for the clinician as there is a wide range of potential renal pathology associated with CMML some of which will have disease specific but relatively toxic treatments available
Source of funding none Conflicts of interest none
P6 NHS Highland-Prograf to Adoport switch McCulloch K1 Peel R2 Lambie S3
1Renal Pharmacist Renal unit Raigmore Hospital Inverness 23Renal Consultant Renal unit Raigmore Hospital Inverness
Introduction NHS Highland (NHSH) is the first health board in Scotland to implement a switch from Prograf to Adoport for renal transplant patients This will provide considerable cost savings Adoport meets the bioequivalence criteria for drugs with a narrow therapeutic index set by the European Medicines agency and studies indicate therapeutic equivalence1 with the proviso that brands are non- interchangeable unless the switch is overseen by a Renal Consultant and post-conversion therapeutic drug monitoring is conducted23 The switch has been undertaken by a majority of transplant centres in England the main difference being that they have undergone repatriation NHSH Patients receive their transplant primarily at Royal Infirmary of Edinburgh and occasionally at Queen Elizabeth University Hospital Glasgow Care is transferred to NHS Highland on discharge NHS Highland cares for approximately 170 renal transplant patients 110 being prescribed Prograf These patients may live as far as 110 miles from Raigmore Hospital Given that prescribing is carried out by primary care clear communication with patients GPs and community pharmacy is essential to avoid inadvertent switching between brands
Method Clinically it was agreed a switch could be safely undertaken A business case was submitted and funding secured for pharmacist time laboratory costs and primary care time GPs have been informed via GP subgroup and local prescribing bulletin lsquoThe Pink Onersquo Community pharmacies are being informed by phone A protocol has been agreed Eligible patients selected by Renal Consultant and Renal Pharmacist Patients sent letter signed by Renal Consultant and Renal pharmacist Patients phoned prior to clinic to agree Adoport start date and address concerns Patient seen by Renal Consultant and pharmacist + given 1 month of Adoport Tacrolimus level and UampEs checked 5-7 days after commencing Adoport and patient
contacted by phone to check if tolerated If stable letter sent to GP and community pharmacy to continue supply
Results and Evaluation Letters have been sent to all eligible patients Seven patients have been reviewed One has received a one month supply of Adoport and 5 others are due to switch One patient was deemed non-eligible at present as they have a 6 month surplus of Prograf A database will be maintained and analysed at the end and primary care savings will be monitored Extra pharmacist input will give us the opportunity to review how immunosuppression is managed and to evaluate the benefit of having a renal transplant pharmacist Conclusion The switch is at an early stage Ultimately we hope to show that the switch from Prograf to Adoport can be managed safely with extra pharmacist input to a remote and rural population with prescribing being conducted by primary care
Fundingconflicts of interest none 1 McDevitt-Potter LM Sadaka B Tichy EM Rogers CC Gabardi S Transplantation 2011 A multicenter experience with
generic tacrolimus conversion 2 Medicines and Health Products Regulatory Agency Drug Safety Update 2012 Accessed online via
wwwmhragovukSafetyinformationDrugSafetyUpdateCON1557563 ESPRIT Guidance on management of repatriation and immunosuppressant switches in transplant patients 2015
Accessed online via httpwwwespritorgukwp-contentuploads201508Switch-guidance-document-final-Aug-31-2015pdf
P7 NHS Highland-Tacrolimus baseline dataMcCulloch K1 Peel R2 Lambie S3
1Renal Pharmacist Renal unit Raigmore Hospital Inverness 2Renal Consultant Renal unitRaigmore Hospital Inverness 3Renal Consultant Renal unit Raigmore Hospital Inverness
BackgroundAs part of planning a switch from using tacrolimus Prograf to Adoport we assessed baseline data for our transplant patients currently using Prograf After converting patients to Adoport we will compare their tacrolimus levels to their individual target range We assessed our use of appropriate target ranges and our current performance in achieving tacrolimus levels within target range on Prograf therapy
Method 107 renal transplant patients taking Prograf were identified a sample of 19 of these were analysed using electronic patient records and results Time from transplant ranged from 1 month to 18 years All tacrolimus levels for the preceding year were analysed and compared to the target range specified at the time of the level being done The assay used has a Coefficient of Variation of lt5 at the lower limit of the assay
Results All 19 patients had a target range for tacrolimus clearly identified and recorded in clinic letterswhich are routinely copied to the patients themselves A variety of target ranges were specifiedThe commonest used was 5-8 microgramsl in 7 patients followed by 5-7 in a further 4 patientswith another 6 different target ranges being used for the remaining 8 patients The ranges usedhad a breadth of 3 microgramsl in 2 cases the rest had a breadth of 2 microgramslPatients had a median of 12 (range 3-72) tacrolimus levels over the preceding year Results werewithin specified target ranges for 54 +- 22 (Medan +- SD) of results checked
Conclusion We currently use a large number of different target ranges The majority of the ranges used had a breadth of just 2 microgramsl These factors help to account for the low proportion of test results which were within the specified target ranges This is important to bear in mind when interpreting whether tacrolimus levels are within target ranges after switching to Adoport We should consider aligning our target ranges and widening them
P8 Eculizumab use in Scottish paediatric dense deposit disease Stewart D1 David Hughes1 Lynne Riach2 Craig Oxley2 Athavale D1
1Royal Hospital for Children Glasgow 2Royal Aberdeen Childrenrsquos Hospital Aberdeen
Introduction The revised MPGN classification and increasing recognition of Dense Deposit Disease (DDD) a C3 glomerulopathy as an alternative complement pathway disorder suggests Eculizumab an anti-C5 monoclonal antibody may be beneficial in treatment However the experience of Eculizumab as an off-label and expensive treatment in children with DDD is limited with variable clinical response reported in the literature
Method We present the outcomes of the only 2 paediatric patients in Scotland who have received Eculizumab for the management of DDD
Results Case 1 A 10 year old male presented with proteinuria and haematuria resistant to steroid treatment with preserved renal function Initial biopsy confirmed DDD Conservative management with an angiotensin converting enzyme inhibitor and diuretics for symptom control continued until 14 years Due to worsening symptoms (oedema lethargy poor growth) and renal function deterioration along with elevated terminal complement complex (TCC) Eculizumab was commenced A repeat biopsy whilst suggestive of chronic irreversible damage showed 25 glomerular architecture preservation Symptom improvement was noted There was a reduction in proteinuria and renal function stabilisation fall in TCC and discontinuation of diuretics Eculizumab was discontinued after 24 months Progression of renal function decline was seen in the final months of Eculizumab therapy With recurrence of symptoms and increasing proteinuria following discontinuation Eculizumab was recommenced after 6 months Symptomatic improvement has since been noted
Case 2 A 5 year old girl presented with painless frank haematuria and proteinuria Initial biopsy confirmed DDD Proteinuria was unresponsive to steroid therapy and 5 months following diagnosis she rapidly progressed towards end stage renal disease despite the introduction of Mycophenolate Mofetil and plasmapheresis Haemodialysis was subsequently commenced TCC level was elevated and Eculizumab treatment was started 7 months after diagnosis Renal biopsy prior to treatment demonstrated continued severe pathological changes in all visible glomeruli However due to lack of clinical response Eculizumab was discontinued after 2 months and the patient remained dialysis dependent
Conclusions Our experience with Eculizumab in Scotland has demonstrated variable results in our 2 patients with one patient showing a positive response whilst the other experienced no improvement Eculizumab was administered to both patients at varying points in their clinical journey with differing progressive features on biopsy To date the outcomes of 9 paediatric patients with DDD treated with Eculizumab have been described in the literature with 8 experiencing some positive response to treatment including 2 patients who were able to stop renal replacement therapy within 12 weeks of treatment A role for Eculizumab in DDD may be guided by clinical and pathological features Well designed clinical trials will be necessary to define the role of complement inhibition therapy in DDD
No conflict of interest and no funding requested
P9 Examining markers of safety in the use of non-tunnelled central venous catheters
James WT Millar (Speciality Registrar) Scott W Oliver (Speciality Registrar) Peter C Thomson (Consultant Nephrologist) Glasgow Renal and Transplant Unit Queen Elizabeth University Hospital Glasgow
Background Non-tunnelled central venous catheters (NTCVC) remain an essential means of vascular access for incident haemodialysis Associated morbidity is well recognised for example in the form of Staphylococcus aureus bloodstream infections (SAB)[1]
Previous quality improvement initiatives in our unit have sought to both improve traditional markers of quality (such as SAB) and to identify additional areas of clinical risk In 2014 Oliver et al [2] suggested several additional quality measures including peri-procedure haemoglobin drop the need for a further NTCVC during the same clinical episode and the NTCVC insertion site This study further evaluated NTCVC related clinical practice within our unit
Methods The potential markers of clinical quality identified in a previous project were examined using prospectively collected data stored in the electronic patient record Identified cases of SAB significant peri-procedure haemoglobin drop and multiple NTCVC insertion were investigated by case note review
Results Between March 2016 and March 2017 a total of 222 patients received 346 NTCVC 54 patients (243) had more than one NTCVC inserted in a 21-day period (range 2-5) When considering NTCVC insertion site there were 159 (459) femoral vein catheters and 183 (541) internal jugular vein catheters No pneumothoraces were reported
15 SABrsquos were reported during this period equating to 43 of all NTCVC 5 arose in patients with femoral NTCVC (333) and 10 from internal jugular catheters (667) Mean time from line insertion to positive blood culture was 86 days 15 (67) patients had a drop in haemoglobin of greater than 20mgdl with no other source of blood loss identified on review of clinical notes
Discussion These data demonstrate that NTCVC-associated SAB rates remain low and significantly below Scottish government audit standards [3] Of interest is the continued trend towards the use of femoral catheters at 45 of lines compared with 38 in 2014 [2] Although traditionally thought of as having a higher incidence of infectious complications our data has shown fewer bacteraemia events associated with femoral catheters compared with internal jugular Our data also demonstrates a significant rate of peri-procedure haemorrhage arising in up to 1 in 20 cases Together these findings present opportunities to development practice and improve patient safety
References
[1] Murray E Deighan C Geddes CC Thomson PC Reducing haemodialysis bacteraemia rates Scottish Renal Association Glasgow November 2013 [2] Oliver SW Thomson PC Jardine AG defining safe effective and patient-centred dialysis catheter placement Scottish Renal Association Edinburgh September 2014 [3] The Staphylococcus aureus bacteraemia quarterly report of cumulative data from all NHS Boards in Scotland Health Protection Scotland January 2015
Sources of funding none Conflicts of interest none
P10 Prescribing of tolvaptan-The NHS Highland experience Lambie S1 McCulloch K2 Garrod J3
1Renal Consultant Renal unit Raigmore Hospital Inverness 2Renal Pharmacist Renal unit Raigmore Hospital Inverness 3Renal Pharmacist Renal unit Raigmore Hospital Inverness
Introduction Tolvaptan is a vasopressin antagonist It was accepted for use in Scotland by SMC in Jan 2016 to slow the progression of cyst development and renal insufficiency of autosomal dominant polycystic kidney disease in adults with chronic kidney disease (CKD) stage 1 to 3 at initiation of treatment with evidence of rapidly progressing disease1 Adverse effects related to aquaresis may affect patientsrsquo ability to achieve the optimum therapeutic dose and the risk of hepatic toxicity necessitates regular LFT monitoring The geography of NHS Highland required the implementation of novel methods of managing these patients and as a result a MDT approach with an emphasis on pharmacist input was adopted Consultant role Patient selection on the basis of evidence of rapidly progressing kidney disease declining
eGFR large volume kidneys on ultrasound and evidence of complications of PKD Side effects and potential benefits discussed Potential medication interactions reviewed Jinarc risk management prescriber training
Pharmacist role Undertook Jinarc risk management pharmacist training Prepares accurate drug history and reviews for potential drug interactions Carries out patient counselling and supplies patient education material sick day rules card
and lsquogot to gorsquo card Supplies GP education leaflet Provides advice on selection of new drug therapies eg for gout Manages stock and coordinates supply to patients
Results Prescribing commenced May 2016 patients currently prescribed tolvaptan 11 7 Female 4 male Number on target dose 73 n = 811 2 patients are still being titrated One patient did
not tolerate target dose due to aquaresis side effects and is being trialled on the middle dose
Withdrawals One patient has withdrawn due to agoraphobia and an inability to attend for monitoring and another is on hold due to having major surgery
Conclusion The MDT approach between the Renal Consultant and Pharmacist at Raigmore Hospital has enabled tolvaptan prescribing to be efficiently and safely implemented to patients living within a challenging geographical location
1 Scottish Medicines Consortium Detailed Advice Document tolvaptan 15mg 30mg 45mg 60mg and 90mg tablets (Jinarcreg) SMC No 111415 January 2016
NA1 Authors SCN Jacqueline Ross NHS Grampian
SCN Alan Somerville NHS Lanarkshire SCN Jane Humphrey NHS Lanarkshire
e- mail contact jacquelinerossnhsnet Alansommervillelanarkshirescotnhsuk
Janehumphreylanarkshirescotnhsuk
Phone contact 01224 552927 01236 712644
Title Sharing of Adverse Events in Renal Units across Scotland
Introduction Background The Scottish Renal Nurses Strategy Group (SRNSG) are a group of senior nurses from Renal
Units across Scotland who meet 3-4 times per year to discuss and implement best practice At the last meeting it was agreed that it would be good practice for each Health Board to share
their adverse events reported on the Datix System and deliver a presentation with an action plan to prevent incidents and improve patient safety across Scotland NHS Grampian and NHS Lanarkshire will be the first to deliver this presentation discussing adverse events from both Health Boards with an action plan
Top 5 adverse events over the past 12 months Renal Unit NHS Grampian 1 Violence and Aggression 2 Accidents including needlesticks slips trips and falls 3 Medication Errors 4 Infrastructure Staffing and Estates 5 Machines and Equipment
Top 5 adverse events over past 12 months Renal Unit NHS Lanarkshire
1 Slips Trips or Falls 2 Medicine errors 3 Treatment problems 4 Transfer problems 5 Breach of policy
The presentation will also focus on any serious adverse events which may not be in the top 5 categories
Aim Objective Each Health Board to share their adverse events with the aim to prevent them from occurring in other units to improve staff and patient safety and wellbeing across Scotland
Method Power Point Presentation
Outcome Results Sharing of adverse events resulting in the development of a national Action Plan to prevent these incidents improving safety and well being of staff and patients in Renal Units across Scotland
NA2
SRA Oct 2017 Abstract
BBV Never Event - The whats whys and hows
Staff Nurse Gillian Wilson Aberdeen Royal Infirmary
This presentation shares our experience of a never event that occurred and was not picked up for
a period of 18 months
Hepatitis C (HCV) positive antibodies were found in a previously negative patient
These results were a low positive with no biochemistry changes to suggest any liver damage
however steps were put immediately in place to isolate and investigate
Was it contamination from a dialysis machine was it related to a blood transfusion given prior to
first positive result was it faulty diagnostic tests in the laboratory
In Aberdeen we go over and above national guidelines and isolate all our BBV patients whether
they have positive blood results or are PCR negative
Further bloods tested at an external laboratory confirmed negative results
It highlighted that communication errors were to blame for the lack of speed in detecting this issue
Investigations concluded no real answers as to why this happened
NA3
Living Donation Scotland Changing attitudes towards living donor kidney transplantation
Jen Lumsdaine Julie Glen On behalf of the Living Donation Scotland Project Board
Background and aims
The rate of living donor transplantation has remained fairly static in Scotland over the past 10 years
Recent data has shown inequity of access to living donor transplantation throughout the UK so
there is potential to significantly increase this optimum form of treatment for patients with end-stage
renal failure in Scotland The Living Donation Project Board was formed in 2016 aiming to double
the number of living donor transplants by 2020
Method
The two key areas
1 Do recipients receive adequate and appropriate information at the right time about living
kidney donation
2 Informing the general public about altruistic donation
All patients active on the transplant list in Scotland were invited to an information event A follow-up
questionnaire was performed in the East of Scotland examining outcome or reasons for not
attending A scoping exercise looked at information provided by each unit was performed and link
nephrologists and low clearance nurses attended meeting to discuss strategies for early education
Outcome
An information pack containing both recipient and donor written information and short films on DVD
has been produced with the support of the Scottish Government for all recipients and potential
donors in Scotland A new website with comprehensive information both written and visual and
postcode finder to improve ease of access to local unit contact details has been developed
Two national media campaigns have been launched with a significant rise in the number of enquiries
from potential donors and actual increase in altruistic donor numbers
Nursing abstract ndash no conflict of interest
NA4Authors Susan Easson Charge Nurse Ward 4C QEUH Glasgow
e- mail contact SusanEassonggcscotnhsuk
Phone contact 0141 452 3300
Title A Conversational approach to find out ldquoWhat matters to yourdquo in a Renal Transplant ward
Introduction Background Finding out ldquo What Mattersrdquo to people using health and careservices is crucial to delivering safe effective and person centred care It is a simple yet profoundconcept and tries to get to the essence of person centred care by creating deeply personalengagements with patients and their families through a conversational approach However careexperience feedback all too often provides innumerable examples of where what really matters topatients and their family members is poorly understood or not addressed Using care experienceas the driver for change the nursing staff in Ward 4C used improvement approaches to explorehow to hold more meaningful ldquoWhat Matters to yourdquo conversations on a daily basis
Aim Objective To improve the patient experience by utilising a person centred approach
Method Using Care experience feedback What Matters to Me boards and the conversationalapproach
Outcome Results Improvements in patient experience will be shared using examples ofpractice and care experience feedback
There was no additional funding required for this project We worked in collaboration with theperson centred team whorsquos aim is to improve patient experience
NA5
The implementation of a renal education programme and its impact on clinical practice
The purpose was to implement a Renal Education Programme and to evaluate its impact on
clinical practise
It was identified that there was a need for an educational programme to be set up within Forth
Valley Royal Hospital There is no inpatient renal unit in FVRH on site for our renal patients they
attend Queen Elizabeth University Hospital We are an outpatient haemodialysis unit with
outpatient clinics on site Therefore it was identified that there was a need for nursing staff within
FVRH to be educated on all renal complexities for the benefit of our patients
This was done through a work-based learning approach which brought tangible benefits for our
patients However it did not come without pitfalls as educational programmes are often seen as
making very little difference to clinical practise
T
his study describes what methods were used and examines the advantages and disadvantages in
setting up an educational programme and evaluating its impact on clinical practise
NA6
Nursing Abstract ndash SRA Meeting ndash 26 October 2017
Chris McGee Tonya Broe Ken Weir
Renal Unit Forth Valley Royal Hospital
Use of the Therapy Monitor Haemodialysis Patient Record System Can we aim for a paper-
free dialysis unit
We are trialling a new haemodialysis patient monitoring system to work in conjunction with SERPR
and which is intended to supersede the Finesse system used previously
We are in the early stages of this process but with continuing staff education and regular tech
support we are hoping to gather sufficient evidence to evaluate whether the use of paper case
notes needs to continue
Is it a realistic goal to aim for a completely paper-free unit
NA7
THE CLINICAL USES OF APHERESIS WITHIN NHS TAYSIDE
Laura Thomson CN
Ninewells Hospital Dundee
NHS Tayside took over the apheresis service from BTS in 2012 The service has since expanded
with the benefits of carrying out this treatment has been widely recognised within NHS Tayside
and is now more commonly being offered to treat a wider range of conditions with the number of
treatments carried out each year rising
This presentation will highlight the progression of the apheresis service within NHS Tayside We
will identify the various conditions it is currently being used to treat and also identify the decision
making process involved in carrying out these treatments ie which replacement fluid will be used
anticoagulation medication administered
We will highlight the benefits and challenges we face in providing this expanding service within the
Renal Service
NA8Authors Linda McDougall Renal Physiotherapist NHS Highland
e- mail contact lindamcdougall1nhsnet
Phone contact 01463 706022
Title lsquoExercise on Haemodialysis- Keeping the Wheels in Motionrsquo
Introduction Background The impact of CKD on physical fitness functional ability independence amp ultimately quality of life cannot be underestimated Current national guidelines recommend that all individuals with CKD are encouraged to participate in regular exercise programmes between or during dialysis sessions if on HD Following a successful pilot study funding was approved to establish an lsquoExercise on Dialysisrsquo (EOD) programme across NHS Highland through the appointment of a dedicated renal physiotherapist in 2008 A successful programme was soon established but for several years post-vacancies and increasing in-patient demands limited the physiotherapy servicersquos ability to deliver the programme The need to improve the long-term sustainability of the service was recognised and in late 2016 funding was approved to develop a Band 4 PT HCSW role for this purpose
Aim ObjectiveTo optimise the sustainability and continuity of the lsquoExercise on Dialysisrsquo service across NHSHighland through development of a Band 4 PT HCSW role
Method The potential parameters of the role and limits of autonomy were scoped out using current NES resources and guidelines Service and task analysis was then carried out to establish which components of the EOD protocol could be undertaken by a Band 4 A series of competencies were developed in line with the clinical protocol and one-to-one training and supervision provided to the post-holder to ensure competency achieved in delivering the programme
Outcome Results A 10 WTE Band 4 PT HCSW was appointed in Jan 2017 with a dual role between the renal unit and acute medical wards Although training is not yet complete the post-holder is already running the day-to-day delivery and monthly audit of the EOD service with senior physiotherapist input only required for individual patient safety queries and general discussion around patientsrsquo progress and goals The benefit to the unit has been considerable as the band 4 is available to support patients and staff with EOD provision 5 days a week This allows for one-to-one supervision of patients who need more support to participate in EOD regular feedback on performance and reviews of outcome measures and goals to maintain motivation levels Feedback on the post has been very positive and its scope will only continue to expand as we look to further develop renal rehabilitation services across NHS Highland
NA9Authors Nadine Lyall and Kerry Guthrie
e- mail contact nadinelyallbordersscotnhsuk kerryguthriebordersscotnhsuk
Phone contact 01896 826637
Title The Developing Role of the NMP in a Satellite Dialysis Unit
Introduction Background
We have been practising as NMPrsquos for nearly 3 years working in the dialysis unit at the BGH The unit is a satellite unit of the ERI and we have expanded over the last 6 years The unit provides haemodialysis for 12 patients at any one time 3 sessions a day 6 days a week We are nurse-led and have 2 renal consultants who are based at the ERI
We saw an opportunity to use our knowledge and experience to develop our role By becoming NMPrsquos we have enhanced our professional development and we feel we meet the changing needs of the dialysis patient in a more holistic manner
Aim Objective
Our aim is to deliver effective care as we are better placed to deal with issues that often arise byacting swiftly this in turn is cost effective and convenient For example good anaemia and bonemanagement is important for their health wellbeing and lifespanTo help understand our role we will use a power point presentation highlighting issues we dealwith and the drugs we prescribe under the following headings Cardiovascular infection painanticoagulant disequilibrium diet renal bone disease and renal anaemia
Method Power point
Outcome Results
In the future we hope to further develop and have greater autonomy in our role We have great support from our renal consultants and have already built up a great relationship with our patients We hope to undertake the Clinical Decision Making course and this in turn will allow us to deal effectively with acute illness giving the dialysis patient better care We are keen to get feedback from other renal nurses in Scotland to enable us to develop our role further and in turn raise awareness of the NMP role in a dialysis unit We record all our prescribing decisions and keep the consultants up to date regularly Currently we are working on auditing our prescribing practice so that we can improve the service we can provide
NA10 Title Komunikacja w szkoleniu dializy ortzewnowej
Author Senior Charge Nurse Rhoda Bell
Address Raigmore Hospital Old Perth Road Inverness IV2 3UJ
Email rhodabellnhsnet Telephone 01463706023
Introduction Background Case study on lady with Polish as her first language she has some English but requires an interpreter to carry out Peritoneal Dialysis training and attend clinic She had some gynaecological issues that we were not aware of which impacted on the functionality of PD and therefore the success of treatment There were areas of concern in low clearance clinic with signs the patient had a reluctance to engage in decision making
AimObjective
Methods Discussion through the case study highlighted issues with communication between different PD staff and patients Areas of concern include different staffing techniques environment factors on training success Also language and communication issues the patient had were not fully apparent so training could not be individualised
Results We plan to trial training at home and have more individualised training schedule for patients The training step by step guides have been reviewed and practise standardised In collaboration with low clearance nurse we have developed a check list which will highlight concerns before the transition to PD ie language issues and need for training aids in another language gynaecological conditions
Conclusions Everyone learns differently and training methodsaids must be individualised for all It may not be apparent until training has commenced that there are concerns Having one to one training with the same nurse will consolidate training and build confidence in the patient Having a close working relationship with members of the MDT will help make a supportive PD journey
Would we do things differently if we knew about prolapse or lack of English both spoken and written
Key words - Peritoneal dialysis patient training communication
N11
Telehealth amp PDAudrey Jones
Advantages
Information on a daily basis about treatment weight and blood pressure
Change programme remotely via computer or mobile
Earlier intervention for machineprogramme issues
Reduction in home visits ie patient trained but still requires volume increases
No need to download cards to see what problems have been
Can have more detailed information available at clinics
Disadvantages
Relying on patient input data correctly
Machine is noisy especially first wave of machine
Still the same bag connection system and patient connection system (difficult for manual
dexterity problems)
Relying on patient having good signal
Modem problems
NA12Autosomal Dominant Polycystic Kidney Disease A cruel inheritance but new hopeAlistair Lawrie Renal Unit Victoria Hospital KirkcaldySadaf Arshad Corry Dunnigan Paul Phelan Neil Turner Renal Unit Royal Infirmary of Edinburgh
Background Autosomal Dominant Polycystic Kidney Disease (ADPKD) is the most prevalent single gene human genetic disorder and the most common of the inherited cystic and interstitial kidney diseases It is estimated to affect 1 in every 1000 individuals worldwide with over 50 of sufferers eventually developing end stage kidney disease and requiring dialysis or transplantation Symptoms include spasmodic severe pain hypertension haematuria infection and kidney failure There is currently no cure for ADPKD Management of the condition has traditionally involved lifestyle modification BP control and analgesia however a recent study (Torres et al 2012) demonstrated that treatment with V2-receptor antagonist drugs slowed increase in total kidney volume reduced the rate of functional decline and showed a reduced incidence of kidney pain
Aim Provision of a tolvaptan prescribing and monitoring service
Methods Experiential finding report of initial twelve months period of multidisciplinary ADPKDtolvaptan clinic
Results Early results are comparable with TEMPO study outcomes
Conclusion Due to the long term nature of this treatment results available at this time are showing only the earliest benefits of the intervention More quantifiable results such as increased time before the necessity for RRT will only be evident in coming years Torres VE et al (2012) Tolvaptan in Patients with Autosomal Dominant Polycystic Kidney Disease New England Journal of Medicine 367 pp 2407-2418 DOI 101056NEJMoa1205311
No funding requirement No conflict of interest
A12 Pneumocystis pneumonia prophylaxis post-renal transplant increased duration of co-trimoxazole is safe and effective FA Chapman JE Dickerson M Clancy C Daly C Geddes Renal amp Transplant Unit Queen Elizabeth University Hospital Glasgow
Introduction All renal transplant recipients receive Pneumocystis jirovecii prophylaxis usually with co-trimoxazole Guidelines suggest this should be continued for 3 to 6 months Our unit previously prescribed 3 months however following an outbreak of Pneumocystis pneumonia (PCP) infection this was increased to 6 months Given its constituents of sulfamethoxazole and trimethoprim co-trimoxazole prophylaxis may influence the frequency of urinary tract infection (UTI) We aimed to compare the frequency of UTI between patients on 3 months vs 6 months prophylaxis and assess rates of multi-drug resistant organisms We also sought to establish if the increased duration of co-trimoxazole was adversely affecting renal function potassium concentration white cell and platelet count and dosing of mycophenolate mofetil
Methods A retrospective search of the West of Scotland Electronic Renal Patient Record was conducted for all renal transplant recipients between 1st January 2012 and 31st May 2016 Patients were grouped according to the intended duration of co-trimoxazole Data were extracted for baseline characteristics co-trimoxazole prescription mycophenolate mofetil (MMF) prescription laboratory results (creatinine potassium white cell count platelets) at 3 6 9 and 12 months post-transplant and microbiology results for 6 months post-transplant Results were analysed on an intention to treat (ITT) basis with a second analysis according to actual duration of co-trimoxazole treatment (AT) Subjects with transplant failure had laboratory results censored from the time of transplant failure and all of their microbiology results were excluded
Results 609 renal transplants were performed over the study period On ITT analysis there were 418 patients in group 1 (ITT1 3 months co-trimoxazole) with 15 transplant failures and 191 patients in group 2 (ITT2 6 months co-trimoxazole) with 12 transplant failures There was a significant difference in the number of patients with at least one UTI with fewer in ITT2 (ITT1 133403 vs ITT2 42179 p = 001) However this was not present when comparing actual treatment duration (AT1 111345 vs AT2 36149 p=007) Overall there was a similar spectrum of organisms cultured There were significantly fewer cultures of multi-resistant organisms in both ITT and AT analyses with 6 months of co-trimoxazole (ITT1 28376 vs ITT2 0106 p= 0004 AT1 22313 vs AT2 198 p = 002) There was no difference in estimated Glomerular Filtration Rate serum potassium concentration platelet count or MMF dose On AT analysis there was a significant difference in the total white cell count (WCC) and lymphocyte count at 6 months post-transplant (WCC 78 x10^5L vs 71 x10^5L p =004 lymphocytes 13 x10^5L vs 12 x10^5L p=002) There were 18 cases of PCP with 7 deaths attributable All cases occurred after cessation of co-trimoxazole prophylaxis (81 ndash 913 days after stopping co-trimoxazole)
Conclusion Although there is a significant difference in UTI frequency on ITT analysis this is not present on AT analysis suggesting no real co-trimoxazole effect There was no increase in frequency of multi-drug resistant organisms with a longer course of co-trimoxazole Renal function and serum potassium were unaffected Our findings support continuing co-trimoxazole prophylaxis for at least 6 months
A13 Kidney transplantation in the over 60rsquos in Scotland 1996-2015 TJW Rennie1 P Phelan1 J Campbell2 JP Traynor2 L Henderson1 W Metcalfe2 On behalf of the Scottish Renal Registry 1Renal transplant unit Royal Infirmary Edinburgh 2NHS National Services Scotland Introduction The proportion of older kidney transplant recipients has increased in the UK but
long term outcome data are scarce We aimed to evaluate patient and graft survival in patients
ge60 years of age receiving a first kidney only transplant in the last 20 years in Scotland
Methods Retrospective analysis of Scottish Renal Registry data of incident Renal Replacement
Therapy (RRT) patients and those in receipt of a kidney only transplant performed 1996-2015
(follow up until 311216) Patients were stratified by age 60-69 ge70 (group 1 and 2 respectively)
and decade of transplantation 1996-2005 2006-2015 (decades 1 and 2 respectively)
Results 6743 patients aged ge60 started RRT from 1996-2016 Of those 108 were ever
transplant-listed 54 had received a transplant by 311216 26 listed and 11 transplanted
were aged ge70
535 patients aged ge60 received a kidney only transplant in 1996-2015 90 patients (168) were
aged ge70 no patients were aged ge80 Mean time from wait listing until transplantation was 33plusmn24
years (plusmnSD) and from starting RRT until transplantation was 38plusmn26 years (plusmnSD) One and five
year graft survival was 97 and 87 in decade 1 95 and 89 in decade 2 (p=NS) there was
no difference in graft survival between age groups 1 and 2 One and five year patient survival was
94 and 78 in age group 1 85 and 56 in group 2 (plt0001) there was no difference in one
and five year patient survival between the two decades
Conclusion One and five year graft and patient survival in renal transplant recipients aged ge60
have not changed significantly in the last 20 years Recipient age ge70 is not associated with
reduced graft survival but patient survival from time of transplant is lower in this age group
compared to recipients aged 60-69
No conflict of interest to be declared No funding received
A14 High Mortality In Older Patients With Primary Nephrotic Syndrome Sarah Beverstock Wendy Metcalfe amp Robert W Hunter Department of Renal Medicine Royal Infirmary of Edinburgh
Introduction
Nephrotic syndrome can develop at any age and may be due to a primary glomerular lesion or secondary to systemic disease The natural history of glomerular disease can be different in older patients For instance minimal change disease (MCD) in children almost always remits promptly with steroid therapy in adulthood it typically remits only after many weeks of steroids or with adjunctive immunosuppression However there are remarkably few published data on the mortality of primary nephrotic syndrome in adults We aimed to study this in our centre
Methods
We enrolled all adult patients who had a kidney biopsy in order to investigate nephrotic syndrome over 38 consecutive months (01 Jan 2014 ndash 28 Feb 2017) We defined nephrotic syndrome as heavy proteinuria (urinary proteincreatinine ratio UPCR gt350 mgmmol or albumincreatinine ratio gt220 mgmmol) and hypoalbuminaemia (serum albumin lt35 gL) In our analysis we included all patients in whom nephrotic syndrome was attributed to a primary glomerular disease We excluded kidney transplant recipients and patients in whom biopsies were performed to follow up a known glomerular disease We collected laboratory data at baseline (time of biopsy) and at 6 and 12 months We assessed patient survival by Kaplan-Meier analysis
Results
Of the 117 patients biopsied for nephrotic syndrome 71 patients (61 ) met the inclusion criteria and were followed up for a median of 469 days We compared outcomes in patients aged under 60 years old (n = 35) with those aged over 60 (n = 36) Mortality was higher in the older group (37 vs 4 mortality at one year p lt005 by logrank test) There were no significant differences between the two groups in serum creatinine or UPCR at any time Serum albumin was similar in both groups at baseline and at 12 months but was lower in the older group at 6 months (27 vs 32 gL p lt 005) Baseline haemoglobin was lower in the older group (114 vs 130 gL p lt005 by unpaired t-test) Primary diagnoses were MCD (n = 10 in younger group amp n = 5 in older group) membranous nephropathy (5 amp 10) IgA nephropathy (9 amp 8) FSGS (5 amp 5) membranoproliferative glomerulonephritis or C3GN (4 amp 7) and other (2 amp 1) Therefore unsurprisingly there were relatively fewer cases of MCD and more cases of membranous nephropathy in the older group otherwise the causative glomerular lesions were similar in both groups In those patients with MCD mortality was significantly higher in the older group none of the 10 patients with MCD diagnosed under 60 yrs old died during the follow-up period whereas 4 of the 5 older patients died 3 patients in the younger group and 1 in the older group were on renal replacement therapy (dialysis or transplant) by the end of follow-up
Conclusions
Primary nephrotic syndrome is associated with high mortality in the over 60s (37 at one year) Mortality was high even for MCD a disease that follows a benign course in childhood and early adulthood The higher mortality in older patients was not associated with greater severity of renal disease at presentation (as assessed by basic blood and urine parameters) This work was not funded we declare no conflicts of interest
A15 Renal biopsies in patients with diabetes mellitus in Scotland
Udana Ratnapala 1 Nicola Joss 2 Colin Geddes 3 Dana Kidder 1
1 Renal Unit Aberdeen Royal Infirmary Aberdeen 2 Renal Unit Raigmore Hospital Inverness 3 Glasgow Renal and Transplant Unit Glasgow
Introduction Diabetes mellitus is the leading cause of end-stage kidney disease (ESKD) requiring renal replacement therapy The utility of renal biopsy in patients with diabetes mellitus is controversial Broadly renal biopsy findings in patients with DM can be divided into diabetic nephropathy (DN) alone DN with non-diabetic renal disease (NDRD) or NDRD alone Timely identification of patients with NDRD is important to provide appropriate therapeutic measures Previously published guidelines on clinical predictors of NDRD have limited specificity and sensitivity The frequency of NDRD in renal biopsies of patients with DM is unclear in ScotlandThis study aimed at identifying the frequency and the pathology spectrum of NDRD in diabetic patients underwent kidney biopsy in 3 renal units
Methods A retrospective observational study was performed on clinical-pathologic findings in all patients with diabetes mellitus who underwent renal biopsy between 01012010 and 31122016 in 3 renal units (Aberdeen Inverness and Greater Glasgow) Data were gathered from electronic patient record systems Scottish Index of Multiple Deprivation (SIMD) 2012 was used to analyse correlation with patient outcomes
Results 247 patients were included 150 men (607) 217 type 2 DM (879) mean age 621 years and mean serum creatinine at the time of renal biopsy of 261 micromolL (+-190 std) On biopsy 92 patients (372) had DN while 127 (514) had NDRD and 28(114) had NDRD superimposed on DN The commonest NDRD aetiologies were IgA nephropathy (187) tubulointerstitial nephritis (168) and idiopathic membranous nephropathy (103) Predictors of NDRD were age (OR 1027 95 CI 1002-1052 p=003) duration of DM (OR 094 95 CI 0900-0987 p=001) and absence of AKI as indication for biopsy (OR 022 95 CI 0059-0826 p=0025) There was no significance difference in renal or patient survival in DN and NDRD Finally no significant correlation was depicted between SIMD quintiles and renal or patient survival in both groups
Conclusions The majority of renal biopsies carried out in patients with DM revealed a NDRD In this study age at the time of biopsy duration of DM and AKI were the main pointers towards NDRD Renal and patient survival were not significantly different between DN and NDRD groups
A16 The Impact of Withdrawal of Maintenance Immunosuppression and Graft Nephrectomy on HLA Sensitisation Ailish Nimmo1 Sophie McIntyre1 Lorna Henderson1 Richard Battle2
(1 Department of Renal Medicine Royal Infirmary of Edinburgh 2 Histocompatibility and Immunogenetics Royal Infirmary of Edinburgh)
Background The development of HLA antibodies towards a failing renal allograft is a barrier to re-transplantation We previously demonstrated an increase in HLA antibodies and calculated reaction frequency (cRF) following nephrectomy but results were confounded by immunosuppression changes occurring in close time proximity We examined the formation of HLA donor specific antibodies (DSA) in patients with failed grafts that remained in situ and compared results with patients undergoing graft nephrectomy to further assess the relative impact of nephrectomy and immunosuppression weaning on sensitisation and chance of transplant
Methods We carried out a single centre retrospective study of all patients with failed grafts in Lothian from 2005 to 2015 Samples were tested for DSA pre-immunosuppression (IS) wean post-IS wean and post-IS cessation Nephrectomy patients also had samples tested for DSA before and after nephrectomy Data on other sensitising events including blood transfusion and rejection were collected cRF was determined at each time point and entered into the ODT chance of transplant calculator with other demographics based on the average patient from the Edinburgh centre
Results 62 grafts failed over this time period Blood samples were available 41 patients (24 with nephrectomy 17 with failed graft left in situ) Patient demographics were similar between groups There was a higher rate of antibody mediated rejection in the nephrectomy group (46 vs 18) 76 of patients with nephrectomy group had received a blood transfusion The pattern of immunosuppression weaning was similar but median time from start of IS wean to cessation was longer in the nephrectomy group (350 vs 298 days) The changes in cRF and chance of transplant (COT) with immunosuppression weaning are shown in Table 1
Pre-IS Wean Post-IS Wean
Failed graft in situ (n=17)
Mean CRF COT at 5
years 15 62 38 59
Nephrectomy (n=24)
Mean cRF COT at 5
years 54 54 69 46
Post-IS Stop 55 53 89 42 Table 1 Mean cRF and Chance of Transplant (COT) at 5 years with IS alterations
Discussion A stepwise increase in cRF with reduced chance of transplant was observed in both groups as immunosuppression was withdrawn with a similar pattern of change irrespective of graft nephrectomy cRF was higher in the nephrectomy group despite a more gradual wean which may reflect a higher rate of antibody mediated rejection and increased number of patients receiving a blood transfusion The risks and benefits of stopping immunosuppression need to be carefully considered on an individual basis to maximise chance of future transplant
The authors have no conflicts of interest No funding was required for this study
A17 Obesity is not associated with progression to end stage renal disease in patients withbiopsy-proven glomerular diseases
Benjamin Elyan Jennifer S Lees Bruce Mackinnon Jonathan G Fox Colin C Geddes Emily PMcQuarrie
Glasgow Renal and Transplant Unit Queen Elizabeth University Hospital Glasgow
Introduction - Addressing risk factors for renal progression is a key aspect of managing chronic kidney disease (CKD) Body mass index (BMI) has been shown to impact on renal progression in unspecified CKD The aim of this study was to evaluate if there was an association between BMI and progression to renal endpoints in patients with biopsy-proven primary glomerular disease (GN)
Methods - We included all adult patients diagnosed with biopsy-proven primary GN (excluding minimal change nephropathy) in Greater Glasgow amp Clyde and Forth Valley between 01012000 and 31122015 Biochemical and anthropometric data were extracted from the electronic patient record at time of biopsy with follow-up data until 20062017 BMI was calculated from height and weight at time of biopsy and categorised into groups BMI le25 kgm2 (G1) gt25 to le30 kgm2 (G2) and gt30 kgm2 (G3 - obese) We assessed factors associated with reaching a combined renal endpoint of CKD5 or renal replacement therapy (RRT) with competing risk of death using the Fine and Gray subdistribution hazard model Analyses were conducted using cmprsk package for R statistical software package and SPSS version 24
Results - 560 patients with primary GN and available BMI data were included The average age was 532 years and 339 were female There were 132 patients in G1 210 in G2 and 207 patients in G3 Those in G2 and G3 were older (p=002) with slightly higher diastolic blood pressure (p=002) than those in G1 There was a greater proportion of focal segmental glomerulosclerosis in G3 but similar proportions of other GN diagnoses across groups There was no significant difference in baseline serum creatinine (sCr) (p=034) or log uPCR (p=045) between BMI groups On multivariate analysis age systolic blood pressure BMI or GN diagnosis were not predictive of renal outcome Higher baseline sCr (SHR 1003 per 1 umoll increase in sCr 1001-1004 plt0001) and log uPCR (SHR 130 per unit increase in log uPCR 95 CI 105-160 p=002) were associated with progression to the combined renal endpoint accounting for competing risk of death BMI was not associated with reaching combined renal endpoint on univariate analysis whether considered as a continuous variable (SHR=100 95 CI 098-102 p=096) or categorised by BMI group
Conclusion - Contrary to our expectations there was no association between BMI and progression to a combined renal endpoint of CKD5 or RRT in this cohort of patients with primary GN Efforts should be directed to managing other known risk factors for CKD progression
Sources of FundingConflicts of Interest - None
A18 Factors influencing long term renal function after living kidney donation
Matthew A Rutherford Norman J Galbraith Marc Clancy Colin C Geddes
Glasgow Renal and Transplant Unit Queen Elizabeth University Hospital Glasgow UK
Background Following live donor nephrectomy the remaining kidney undergoes an increase in filtration capacity known as compensatory hypertrophy Few cohorts with follow up of renal function beyond 5 years have been reported The impact on long term renal function of variability in donor factors such as age sex pre-donation blood pressure and glomerular filtration rate (GFR) is unknown Increasingly kidney donors have potential risk factors for future poor renal function such as hypertension older age and obesity The aim of this study was to analyse factors influencing long-term renal function in living kidney donors from our centre
Method Data were obtained from the electronic patient record Patients with a recorded procedure of lsquolive donor nephrectomyrsquo between 2005 and 2017 were identified GFR after donation (calcGFR) was calculated using the formula lsquocalcGFR = Pre-donation Isotope GFR x (Pre-donation Serum creatinine Serum Creatinine)rsquo which is accurate assuming muscle mass does not change Pre and post donation serum creatinines (two days two weeks three months and one to ten year) were recorded We analysed the influence of age sex pre-donation GFR and blood pressure on post donation GFR compensation
Results 355 live donor nephrectomies were performed between January 2005 and December 2016 The mean age was 469 (plusmn 116) years and 504 (n=179) were female Mean pre-donation isotope GFR was 937 plusmn 156 mlmin173m2 Median follow up was 2 years (IQR 1 to 6 years with range 2 weeks to 10 years) The calculated percentage of pre-donation GFR at 2 days 2 weeks 3 months 1 year 5 years and 10 years were 698 691 712 730 801 and 950 respectively (p lt 0001) Patients aged lt50 y had not only a higher calcGFR (858 plusmn 29 mlmin173m2 compared with 671 plusmn 28 mlmin173m2 p lt 0001) at 5 years following donation but achieved a higher degree of compensation than donors gt 50 y (836 plusmn 16 compared with 756 plusmn 19 (p = 0002) Patients with pre-donation hypertension achieved 774 plusmn 53 of pre-donation GFR compared with 804 plusmn 32 in normotensive patients (p = 0998) Females had equivalent degree of renal compensation achieving 819 plusmn 19 compared with 780 plusmn 16 in males (p = 0131) at 5 years following donation Patients with pre-donation GFR gt 100 mlmin173m2 achieved 844 plusmn 23 of pre-donation function by 5 years compared with 777 plusmn 14 in those with pre-donation GFR lt 100 mlmin173m2 (p = 001)
Conclusion Following live donor nephrectomy renal function has a nadir of 691 at 2 weeks Compensation in GFR occurs rapidly and appears to be maintained regardless of sex and pre-donation blood pressure Younger age and higher pre-donation GFR were associated with a greater degree of compensation
A19 The utility of high-sensitivity cardiac troponin to stratify cardiovascular risk in patients with renal impairment
Eve Miller-Hodges Atul Anand Anoop S V Shah Nicholas L Mills Neeraj Dhaun
Background Cardiovascular disease is the most common outcome of chronic kidney disease1
Declining glomerular filtration rate (GFR) and proteinuria predict increased cardiovascular risk over the long term2 However there are currently no methods to stratify cardiovascular risk in the short or medium term in patients with renal impairment We have already shown that high-sensitivity cardiac troponin I concentrations (hs-cTnI) lt5ngL in patients presenting with symptoms of acute coronary syndrome identifies those at low risk of cardiac events within 30 days and over the next year3 However uncertainty remains over the role of hs-cTnI testing in patients with renal impairment This study investigated whether hs-cTnI could also stratify future cardiovascular risk in patients with renal impairment
Methods In a prospective study of consecutive patients presenting with suspected acute coronary syndrome we evaluated the performance of hs-cTnI in patients with and without renal impairment (estimated glomerular filtration rate lt60mLmin173m2) using an early risk stratification threshold of 5ngL to ldquorule outrdquo acute myocardial infarction at presentation and within 30 days and sex-specific 99th centile diagnostic thresholds for index type 1 myocardial infarction Subsequent type 1 myocardial infarction and cardiac death were reported at one year
Results Of 4726 patients identified 904 (19) had renal impairment Index diagnosis of type 1 and type 2 myocardial infarction was almost twice as likely in patients with renal impairment (30 vs 15) Performance of the early risk stratification threshold of 5ngL to identify patients at low risk of major cardiac events was similar in patients with (NPV 984 95CI 960-997 sensitivity 989 95CI 975-999) and without renal impairment (NPV 997 95CI 994-999 sensitivity 984 95CI 972-994) These patients continued to remain at low risk over the next year The PPV and specificity at the 99th centile for diagnosis of myocardial infarction were lower in patients with renal impairment at 500 (95CI 452-548) and 709 (95CI 675-742) respectively compared to 624 (95CI 588-659) and 921 (95CI 912-930) At one year 24 of patients with renal impairment and troponin gt99th centile regardless of index diagnosis had experienced further myocardial infarction or cardiac death compared with 10 of patients without
Conclusion In suspected acute coronary syndrome hs-cTnI can stratify risk in patients with renal impairment Irrespective of diagnosis patients with renal impairment and elevated cardiac troponin concentrations had two-fold greater risk of a major cardiac event compared to those with normal renal function and should be considered for further investigation and treatment
Funders Wellcome Trust British Heart Foundation and Chest Heart amp Stroke Scotland
1 Gansevoort RT Lancet 2013
2 Chronic Kidney Disease Prognosis Consortium Lancet 2010
3 Shah AS Lancet 2015
A20 lsquoDOES IT DIALYSE OUTrsquo - THE EFFECT OF RENAL REPLACEMENT THERAPY ON THE BRAIN Mark Findlay Jesse Dawson David Dickie Deborah McGlynn Patrick Mark Institute of Cardiovascular and Medical Science University of Glasgow amp Queen Elizabeth University Hospital Glasgow
Introduction Cerebrovascular disease is common in end-stage renal disease (ESRD) on renal replacement therapy (RRT) We investigated the effect of RRT on cerebral structure and cognitive function over 12 months Methods Observational cohort study in ESRD patients receiving HD Prior cognitive impairment or cerebrovascular disease were exclusion criteria Multi-domain cognitive testing was performed at baseline and at follow-up Transcranial Doppler was used to assess intra-dialysis related alterations in mean flow velocity (MFV) ndash a marker of cerebral blood flow MR imaging was performed at 0 and 12 months We performed T1 T2 FLAIR and DWI sequences and used volumetric software to calculate white matter hyperintensity (WMH) burden markers of atrophy mean diffusivity and fractional anisotropy (FA) to describe structural changes at 1 year Results 97 patients median age 59 years 412 female At follow-up 15 patients were transplanted 6 died 4 withdrew and the remainder continued HD Those who were transplanted were younger (median age 51 vs 60 years p=0019) and had been on dialysis for a shorter period (median 06 vs 21 years p=0003) MFV declined during HD median 475cms to 405cms plt0001 and correlated with lower scores of executive and frontal lobe function during HD (Rho 045 p lt0001 and Rho -0313 p lt001 respectively) In all patients MR imaging demonstrated a significant decline in frontal parietal and temporal lobe volume at follow-up Median WMH volume increased in those who remained on HD but not in transplanted patients (median change 023 vs -012ml p=0018) WMH burden correlated with worsening scores of frontal lobe tests Rho 0585 p0005 and worse mood Rho -0485 p0026 FA improved following renal transplant (028 to 029 p=0016) and correlated with improved executive function testing at follow-up Rho 089 p0019 Conclusion Cerebral blood flow is reduced during haemodialysis and correlates with a reduction in intradialytic executive function There is an improvement in FA following transplantation WMH volume increases in those who remain on dialysis and the degree of increase correlates with executive and frontal lobe function This suggests that haemodialysis is associated with clinically significant changes in the brain and that these may be ameliorated by transplantation
Source of fundingconflicts MF is funded by a KRUK fellowship
A21 Pathological classification of IgA nephropathy to predict renal outcomes ndash is there a better way to score tubulointerstitial inflammation
Alastair Rankin David Kipgen Bruce Mackinnon Jonathan Fox Colin Geddes Emily McQuarrie Glasgow Renal and Transplant Unit On behalf of the Scottish Renal Biopsy Registry
Background The Oxford pathological classification of IgA nephropathy (IgAN MEST-C score) is limited by the fact that individual features of the score are not all predictive and its utility in assisting clinical decision-making is questioned The addition of tubulointerstitial inflammation to the existing scoring system is appealing but is not currently included due to reportedly wide inter-observer variability We report a novel method to score percentage of cortex containing tubulo-interstitial inflammation in non-atrophic renal cortex (ATIN) in patients with IgAN similar to that used in transplant biopsy reporting and assess its utility to predict clinical outcomes
Methods All adult patients with a native renal biopsy diagnosis of IgAN between 2010 and 2015 in a unit serving 15 million people were identified Baseline characteristics biopsy reports and outcome data were collected ATIN was calculated by subtracting the percentage of atrophic cortex from the percentage of total cortex with tubulo-interstitial inflammation withge10 representing significant tubulo-interstitial inflammation in non-atrophic cortex The primary outcome was a composite of requiring renal replacement therapy (RRT) or doubling of serum creatinine (sCr)
Results 153 new cases of IgAN were identified 33 were excluded (24 had lt8 glomeruli on biopsy 6 inadequate biopsy for MEST scoring and 3 on RRT at time of biopsy) In addition patients with a tubular atrophy (T) score of 2 were also excluded (n=9) Of the remaining 111 patients 76 (68) were male Mean age at biopsy was 52 years (+- 167) and 18 (16) had a co-existing clinical diagnosis of henoch-schonlein purpura (HSP) Median sCr was 156 micromoll (IQR 101-212) and 54 (49) had ATIN on biopsy During a median follow-up of 23 years 34 (31) reached the primary outcome 20 (18) received immunosuppression and 16 (14) died On univariate Cox regression survival analysis ATIN was associated with a four-fold increase in the primary outcome (HR 49 (21-113)) On multivariate analysis mesangial hypercellularity (M) T and ATIN independently predicted renal outcome while endocapillary proliferation (E) and segmental sclerosis (S) did not (plt002 for ATIN) Excluding patients with HSP or those who received immunosuppression did not change the result
Conclusion Within our centre ATIN predicts renal outcome for IgAN independently of established histological features Assessment of inter-observer reproducibility and validation in other cohorts is still required but these results suggest ATIN could be a worthwhile addition to current pathological scoring systems for IgAN
Source of funding none Conflicts of interest none
P1 Polypharmacy in Renal Replacement Therapy Patients
Jason McMinn Colin Geddes Glasgow Renal and Transplant Unit Queen Elizabeth University Hospital
Introduction
Prescribing is often led by evidence from studies containing participants with single health conditions and without multimorbidity Polypharmacy is becoming increasingly recognised in patients with multiple chronic health conditions Additional medications are more likely to result in diminishing returns in benefit with an increased risk of harm Patients with established renal failure (ERF) are likely to be susceptible to medication-related harm A high pill burden is also likely to contribute adversely to an already restricted quality of life and has been associated with poor medication adherence The aim of this study was to analyse polypharmacy in all patients with ERF attending our service
Methods
We extracted medication records for all prevalent ERF patients attending the Glasgow Renal and Transplant Unit from the West of Scotland Electronic Renal Patient Record (SERPR) as of 01012017 The records were analysed to calculate the number of regular medications and total pill burden of each patient These medications were categorised as being lsquopreventativersquo or lsquosymptomaticrsquo We also analysed the prescription of specific drug classes to examine the prevalence of these medications
Results
We identified 1091 transplant follow-up 529 hospital haemodialysis and 46 peritoneal dialysis patients who were on a mean of 94 13 and 129 different medications respectively Overall pill burden was 139 tablets a day in transplant follow-up patients 141 in haemodialysis patients and 162 in peritoneal dialysis patients There were similar rates of prescribing between the different dialysis units and clinics within our service
The proportions of medications deemed as preventative rather than symptomatic were 76 in transplant 69 in haemodialysis and 60 in peritoneal dialysis
In transplant patients decreasing renal function was associated with a higher pill burden but even patients with a transplant eGFR gt 60 were on a mean of 126 tablets per day including a mean of 14 antihypertensives
Rates of antidepressant prescribing were 15 in transplant patients and 20 in hospital haemodialysis patients 53 of haemodialysis patients were on a statin 39 on aspirin 61 on a proton pump inhibitor and 7 were on warfarin
Conclusion
Patients undergoing all forms of renal replacement therapy are likely to be on a considerable number of medications Whilst these drugs are inevitably prescribed for valid reasons this data demonstrates the need for clinicians to engage with patients to explore opportunities to reduce pill burden
Conflict of Interest None Sources of Funding None
P2 An audit of Acute Kidney Injury (AKI) on an acute stroke ward before and after plannedinterventions to review and maintain hydration
Clare Harris1 Simon Hart2 Fiona Duthie3 1 University of Edinburgh Medical School 2 Stroke Unit Royal Infirmary of Edinburgh 3 Renal Unit Royal Infirmary of Edinburgh
Background Dehydration is an important factor in the development of acute kidney injury which is associated with increased morbidity and mortality particularly in the elderly population Poor fluid intake is common post stroke (1) and dehydration is associated with poorer outcomes 3 months post stroke (2) In late 2014 there was no system of identifying patients with poor oral intake on the stroke ward at the Royal Infirmary of Edinburgh a hydration protocol and education programme were implemented aiming to improve fluid balance This included the use of prescribed water either orally or by nasogastric tube An audit pre and post intervention demonstrated that hydration as measured by ureacreatinine ratio significantly improved after the protocol introduction (3) We aimed to determine whether the incidence of AKI by KDIGO criteria was also reduced as this could have implications for reducing patient morbidity and mortality in this elderly comorbid patient cohort
Method 150 inpatients to the acute stroke ward during JulAug 2014 and JulAug 2015 were selected (n= 80 2014 n=70 2015) Patient data and creatinine values were collected from the electronic patient record and medical notes and retrospectively analysed Baseline creatinine values were calculated and cases of AKI were identified and staged using KDIGO criteria (4) Chi-Squared tests were performed to determine P values Individual patient notes were reviewed for both quantitative and qualitative data of patient management
Results Incidence of AKI (of any stage) was 263 pre-protocol and 200 post-protocol (P=03646) Incidence of AKI stages 23 was 100 pre-protocol and 715 post-protocol (P=05374) In hospital post stroke mortality was 338 pre-protocol and 1286 post protocol (P=00028) AKI was also associated with increased length of stay
Conclusions Despite a trend in benefit there was no significant difference in incidence of AKI pre and post hydration protocol nor in incidence of severe AKI (stage 23) AKI is influenced by many factors one of which is hydration status Further studies are needed to determine whether the trend of benefit exhibited in this sample is significant in a greater sample size if this were the case such a protocol could have great benefit to patient care on stroke units and elsewhere There was a significant difference in inpatient post stroke mortality following introduction of the hydration protocol Further investigations are needed to explain underlying reasons for this factors other than hydration may play an important role
References 1 Whelan K Inadequate fluid intakes in dysphagic acute stroke Clinical Nutrition (2001) 20(5)
423-428 2 Bhalla A Sankaralingam S Dundas R Swaminathan R Wolfe CDA Rudd AG The influence of
raised plasma osmolality on clinical outcome after acute stroke Stroke (2000) 312043ndash2048 3 Hart SR Craig R Berry E Lane N Gad A Farrugia M Burton L Paquay A What Happens to
Acute Stroke Patientsrsquo Fluid Balance Renal Status and Dehydration in the First Two Weeks How Can They Be Markedly Improved doi 101111ijs12634_13
4 KDIGO Clinical Practice Guideline for Acute Kidney InjuryKidney international supplements (2012) 2(1) 1-138
No funding or conflict of interest to declare
P3NHS Highland-Improving the management of hyperkalaemia using a kit Initial resultsCantley N1 Abedin T2 Lambie S3
1FY2 NHS Highland 2ST4 Renal Medicine NHS Grampian 3Renal Consultant Renal unitRaigmore Hospital Inverness
Introduction The incidence of hyperkalaemia in hospitalised in patients is between 1 and 10 Guidelines in Northern Ireland promote the use of a Hyperkalaemia Kit to improve management of hyperkalaemia We assessed the management of hyperkalaemia in Raigmore Hospital including post-treatment monitoring of serum potassium and blood glucose at baseline and after the introduction of a lsquoHyperkalaemia Kitrsquo which contains a pro forma for the management of hyperkalaemia and all the relevant equipment and drugs for treatment
Method Between July and September 2016 an automated algorithm identified 34 patients with a potassium result 65 mmoll or above on laboratory results 12 received no specific treatment of these 6 results were spurious 4 patients died before treatment could be started and 2 patients were chronic haemodialysis patients We introduced the Hyperkalaemia Kit to the Acute Medical Admissions Unit in Raigmore Hospital Since then 15 patients have been identified with serum potassium measurements above 65 and the pro forma and kit was used with eight of these patients One of these patients proceeded straight to acute renal replacement therapy
Results Prior to our intervention all 22 patients that were actively treated received at least one prescription of appropriate doses of Insulin with Dextrose However only 16 patients received intravenous calcium and only 7 received nebulised Salbutamol Potassium was measured at 4 hours in 5 cases and by 12 hours in 17 cases Monitoring of any capillary blood glucose was only documented in 8 cases Of the 22 treated 2 needed acute renal replacement therapy 3 required further doses of insulin and dextrose 2 were treated with Calcium Resonium
Eight cases of hyperkalaemia have been managed with the use of the kit and pro-forma so far An initial ECG was performed in all eight and four patients had continuous cardiac monitoring Intravenous calcium was given in seven and nebulised Salbutamol was given in five out of the eight cases Six out of eight patients had at least three blood sugar measurements One had two measurements documented and one patient was stopped from further monitoring following senior review and decision to palliate Seven patients had appropriate monitoring of their serum potassium by 4h and 12h again one patient was not monitored due to palliation
Conclusion Baseline results showed very low rates of prescription of nebulised Salbutamol low rates of Calcium Gluconate use and very low monitoring of blood sugars and potassium post treatment This has the potential for serious adverse outcomes particularly the potential for iatrogenic hypoglycaemia Our initial data shows the use of a Hyperkalaemia pro forma and kit improves the rate of prescription of intravenous calcium and nebulised Salbutamol and the post-treatment monitoring of serum potassium and blood sugar levels
P4Rituximab as maintenance therapy in ANCA associated vasculitisndash a single centre experience Rathnamalala NK Mcmenamin J Robertson S Almond A Kelly M Muniraju T M Renal Unit Dumfries and Galloway Royal Infirmary NHS Dumfries and Galloway Background The introduction of Cyclophosphamide and high dose steroids transformed ANCA associate vasculitis (AAV) from a disease of high mortality to a relapsing remitting disease Maintenance of remission however still remains a major challenge A two randomised clinical trials have looked at the use of Rituximab in remission induction in AAV and reported similar remission rates between Cyclophosphamide and Rituximab 12 Both these trials used Azathioprine as maintenance therapy and in the follow up showed similar remission rates with either agent for induction The role of Rituximab for maintenance therapy after cyclophosphamide induction was studied in the MAINRITSAN trial 3 Rituximab was compared with azathioprine and found that the relapse rate was significantly lower in the Rituximab group There have been several other retrospective studies that have suggested regular Rituximab infusions are successful in maintaining remission however has not been thoroughly evaluated 4 5678910 Here we share our centrersquos experience using Rituximab for maintenance of remission of AAV Materials and methods We conducted a retrospective review of electronic medical records of all patients who had received Rituximab as maintenance therapy for 12 months or longer between January 2014 to July 2016 Disease activity was assessed using Birmingham Vasculitis Activity Score ( BVAS) Version 3 and complete remission was defined as a score of 0 and partial remission as a score of lt50 of the value at diagnosis Due to uncertainties associated with sub classification we did not assign specific diagnosis but broadly classified as ANCA associated vasculitis Results 6 patients received Rituximab as maintenance therapy during the study period 3 (50) of them had eye ear nose and upper airway manifestations consistent with Granulomatosis with Polyangitis (GPA) All patients were PR3 ANCA positive except for one at initial diagnosis The mean BVAS score at the time of initiation of Rituximab was 4 All patients were initiated on Rituximab for relapses while on maintenance therapy with Azathioprine 4 patients received 6 monthly doses of Rituximab while two received annual doses All of them were also maintained on 5-10 mg of Prednisolone The mean BVAS score by 6 months was 0 and remained 0 at 12 months The mean PR3 titre was 562 at the initiation of treatment while at 12 months it had come down to 68 All patients remained in complete clinical remission at the end of 12 months after initiation of therapy Rituximab was well tolerated by all patients except one who developed pyrexia during an administration
Conclusions All patients had sustained remission at 6 months and 12 months after initiating Rituximab Rituximab has a potential role as maintenance therapy in AAV
P5 Chronic Myelo-Monocytic Leukaemia (CMML) as a contraindication to renal biopsy Alastair Rankin Emily McQuarrie Jennifer Lees Bruce MacKinnon Glasgow Renal and Transplant Unit On behalf of the Scottish Renal Biopsy Registry
Abstract Chronic Myelo-Monocytic Leukaemia (CMML) is a relatively rare mixed myelodysplastic myeloproliferative disorder that predominately affects patients over the age of 65 years Renal impairment in patients with CMML is well described with several different mechanisms reported including tumour infiltration lysozyme-induced injury amyloid deposition and tubulointerstitial nephritis From anecdotal evidence within our centre we are concerned that patients with CMML have an excessive risk of clinically significant bleeding following native renal biopsy This risk appears disproportionate to the degree of any co-existing thrombocytopenia or coagulopathy
We review the cases of 4 patients with an existing diagnosis of CMML who were referred to the renal clinic with proteinuria and excretory renal dysfunction Two of these patients underwent renal biopsy with subsequent major haemorrhage post-procedure despite normal bleeding parameters pre-procedure Patient 1 presented with flank pain 8 days post-biopsy A CT confirmed peri-nephric haematoma with retroperitoneal extension A total of 6 units of packed red cells (PRCs) were transfused prior to successful CT-guided emoblisation Histology from the biopsy revealed chronic tubulointerstitial nephritis Patient 2 experienced haemodynamic instability and haematuria one hour post-biopsy A total of 11 units of PRCs 7 units of fresh frozen plasma 2 pools of platelets intravenous tranexamic acid and 2 attempts at CT-guided embolization were required until haemostasis was achieved Histology later showed evidence of tumour infiltration with associated vasculitis Patient 3 presented with renal impairment and proteinuria on the background of known CMML Following discussion with haematology the risk of bleeding following renal biopsy was considered unjustifiable despite their platelets and coagulation screen being within normal range The patient was treated for presumed renal tumour infiltration with hydroxycarbamide Patient 4 was referred to the renal clinic with acute onset nephrotic syndrome Urinary proteincreatinine ratio was elevated over 800 mgmmol with serum albumin of 23 gL but normal excretory renal function The patient attends the haematology clinic with suspected CMML and chronic thrombocytopenia but previously declined bone marrow biopsy Following discussion with the patient there are no plans to proceed with renal biopsy given potential risks These cases highlight that while CMML is rare these patients are being referred to renal clinics with features that would commonly justify renal biopsy in other settings but in whom there may be an increased risk of bleeding post-procedure Our in-centre risk of major bleeding is 2 therefore to have such extreme amounts of bleeding in 2 patients with this underlying diagnosis is remarkable This creates a dilemma for the clinician as there is a wide range of potential renal pathology associated with CMML some of which will have disease specific but relatively toxic treatments available
Source of funding none Conflicts of interest none
P6 NHS Highland-Prograf to Adoport switch McCulloch K1 Peel R2 Lambie S3
1Renal Pharmacist Renal unit Raigmore Hospital Inverness 23Renal Consultant Renal unit Raigmore Hospital Inverness
Introduction NHS Highland (NHSH) is the first health board in Scotland to implement a switch from Prograf to Adoport for renal transplant patients This will provide considerable cost savings Adoport meets the bioequivalence criteria for drugs with a narrow therapeutic index set by the European Medicines agency and studies indicate therapeutic equivalence1 with the proviso that brands are non- interchangeable unless the switch is overseen by a Renal Consultant and post-conversion therapeutic drug monitoring is conducted23 The switch has been undertaken by a majority of transplant centres in England the main difference being that they have undergone repatriation NHSH Patients receive their transplant primarily at Royal Infirmary of Edinburgh and occasionally at Queen Elizabeth University Hospital Glasgow Care is transferred to NHS Highland on discharge NHS Highland cares for approximately 170 renal transplant patients 110 being prescribed Prograf These patients may live as far as 110 miles from Raigmore Hospital Given that prescribing is carried out by primary care clear communication with patients GPs and community pharmacy is essential to avoid inadvertent switching between brands
Method Clinically it was agreed a switch could be safely undertaken A business case was submitted and funding secured for pharmacist time laboratory costs and primary care time GPs have been informed via GP subgroup and local prescribing bulletin lsquoThe Pink Onersquo Community pharmacies are being informed by phone A protocol has been agreed Eligible patients selected by Renal Consultant and Renal Pharmacist Patients sent letter signed by Renal Consultant and Renal pharmacist Patients phoned prior to clinic to agree Adoport start date and address concerns Patient seen by Renal Consultant and pharmacist + given 1 month of Adoport Tacrolimus level and UampEs checked 5-7 days after commencing Adoport and patient
contacted by phone to check if tolerated If stable letter sent to GP and community pharmacy to continue supply
Results and Evaluation Letters have been sent to all eligible patients Seven patients have been reviewed One has received a one month supply of Adoport and 5 others are due to switch One patient was deemed non-eligible at present as they have a 6 month surplus of Prograf A database will be maintained and analysed at the end and primary care savings will be monitored Extra pharmacist input will give us the opportunity to review how immunosuppression is managed and to evaluate the benefit of having a renal transplant pharmacist Conclusion The switch is at an early stage Ultimately we hope to show that the switch from Prograf to Adoport can be managed safely with extra pharmacist input to a remote and rural population with prescribing being conducted by primary care
Fundingconflicts of interest none 1 McDevitt-Potter LM Sadaka B Tichy EM Rogers CC Gabardi S Transplantation 2011 A multicenter experience with
generic tacrolimus conversion 2 Medicines and Health Products Regulatory Agency Drug Safety Update 2012 Accessed online via
wwwmhragovukSafetyinformationDrugSafetyUpdateCON1557563 ESPRIT Guidance on management of repatriation and immunosuppressant switches in transplant patients 2015
Accessed online via httpwwwespritorgukwp-contentuploads201508Switch-guidance-document-final-Aug-31-2015pdf
P7 NHS Highland-Tacrolimus baseline dataMcCulloch K1 Peel R2 Lambie S3
1Renal Pharmacist Renal unit Raigmore Hospital Inverness 2Renal Consultant Renal unitRaigmore Hospital Inverness 3Renal Consultant Renal unit Raigmore Hospital Inverness
BackgroundAs part of planning a switch from using tacrolimus Prograf to Adoport we assessed baseline data for our transplant patients currently using Prograf After converting patients to Adoport we will compare their tacrolimus levels to their individual target range We assessed our use of appropriate target ranges and our current performance in achieving tacrolimus levels within target range on Prograf therapy
Method 107 renal transplant patients taking Prograf were identified a sample of 19 of these were analysed using electronic patient records and results Time from transplant ranged from 1 month to 18 years All tacrolimus levels for the preceding year were analysed and compared to the target range specified at the time of the level being done The assay used has a Coefficient of Variation of lt5 at the lower limit of the assay
Results All 19 patients had a target range for tacrolimus clearly identified and recorded in clinic letterswhich are routinely copied to the patients themselves A variety of target ranges were specifiedThe commonest used was 5-8 microgramsl in 7 patients followed by 5-7 in a further 4 patientswith another 6 different target ranges being used for the remaining 8 patients The ranges usedhad a breadth of 3 microgramsl in 2 cases the rest had a breadth of 2 microgramslPatients had a median of 12 (range 3-72) tacrolimus levels over the preceding year Results werewithin specified target ranges for 54 +- 22 (Medan +- SD) of results checked
Conclusion We currently use a large number of different target ranges The majority of the ranges used had a breadth of just 2 microgramsl These factors help to account for the low proportion of test results which were within the specified target ranges This is important to bear in mind when interpreting whether tacrolimus levels are within target ranges after switching to Adoport We should consider aligning our target ranges and widening them
P8 Eculizumab use in Scottish paediatric dense deposit disease Stewart D1 David Hughes1 Lynne Riach2 Craig Oxley2 Athavale D1
1Royal Hospital for Children Glasgow 2Royal Aberdeen Childrenrsquos Hospital Aberdeen
Introduction The revised MPGN classification and increasing recognition of Dense Deposit Disease (DDD) a C3 glomerulopathy as an alternative complement pathway disorder suggests Eculizumab an anti-C5 monoclonal antibody may be beneficial in treatment However the experience of Eculizumab as an off-label and expensive treatment in children with DDD is limited with variable clinical response reported in the literature
Method We present the outcomes of the only 2 paediatric patients in Scotland who have received Eculizumab for the management of DDD
Results Case 1 A 10 year old male presented with proteinuria and haematuria resistant to steroid treatment with preserved renal function Initial biopsy confirmed DDD Conservative management with an angiotensin converting enzyme inhibitor and diuretics for symptom control continued until 14 years Due to worsening symptoms (oedema lethargy poor growth) and renal function deterioration along with elevated terminal complement complex (TCC) Eculizumab was commenced A repeat biopsy whilst suggestive of chronic irreversible damage showed 25 glomerular architecture preservation Symptom improvement was noted There was a reduction in proteinuria and renal function stabilisation fall in TCC and discontinuation of diuretics Eculizumab was discontinued after 24 months Progression of renal function decline was seen in the final months of Eculizumab therapy With recurrence of symptoms and increasing proteinuria following discontinuation Eculizumab was recommenced after 6 months Symptomatic improvement has since been noted
Case 2 A 5 year old girl presented with painless frank haematuria and proteinuria Initial biopsy confirmed DDD Proteinuria was unresponsive to steroid therapy and 5 months following diagnosis she rapidly progressed towards end stage renal disease despite the introduction of Mycophenolate Mofetil and plasmapheresis Haemodialysis was subsequently commenced TCC level was elevated and Eculizumab treatment was started 7 months after diagnosis Renal biopsy prior to treatment demonstrated continued severe pathological changes in all visible glomeruli However due to lack of clinical response Eculizumab was discontinued after 2 months and the patient remained dialysis dependent
Conclusions Our experience with Eculizumab in Scotland has demonstrated variable results in our 2 patients with one patient showing a positive response whilst the other experienced no improvement Eculizumab was administered to both patients at varying points in their clinical journey with differing progressive features on biopsy To date the outcomes of 9 paediatric patients with DDD treated with Eculizumab have been described in the literature with 8 experiencing some positive response to treatment including 2 patients who were able to stop renal replacement therapy within 12 weeks of treatment A role for Eculizumab in DDD may be guided by clinical and pathological features Well designed clinical trials will be necessary to define the role of complement inhibition therapy in DDD
No conflict of interest and no funding requested
P9 Examining markers of safety in the use of non-tunnelled central venous catheters
James WT Millar (Speciality Registrar) Scott W Oliver (Speciality Registrar) Peter C Thomson (Consultant Nephrologist) Glasgow Renal and Transplant Unit Queen Elizabeth University Hospital Glasgow
Background Non-tunnelled central venous catheters (NTCVC) remain an essential means of vascular access for incident haemodialysis Associated morbidity is well recognised for example in the form of Staphylococcus aureus bloodstream infections (SAB)[1]
Previous quality improvement initiatives in our unit have sought to both improve traditional markers of quality (such as SAB) and to identify additional areas of clinical risk In 2014 Oliver et al [2] suggested several additional quality measures including peri-procedure haemoglobin drop the need for a further NTCVC during the same clinical episode and the NTCVC insertion site This study further evaluated NTCVC related clinical practice within our unit
Methods The potential markers of clinical quality identified in a previous project were examined using prospectively collected data stored in the electronic patient record Identified cases of SAB significant peri-procedure haemoglobin drop and multiple NTCVC insertion were investigated by case note review
Results Between March 2016 and March 2017 a total of 222 patients received 346 NTCVC 54 patients (243) had more than one NTCVC inserted in a 21-day period (range 2-5) When considering NTCVC insertion site there were 159 (459) femoral vein catheters and 183 (541) internal jugular vein catheters No pneumothoraces were reported
15 SABrsquos were reported during this period equating to 43 of all NTCVC 5 arose in patients with femoral NTCVC (333) and 10 from internal jugular catheters (667) Mean time from line insertion to positive blood culture was 86 days 15 (67) patients had a drop in haemoglobin of greater than 20mgdl with no other source of blood loss identified on review of clinical notes
Discussion These data demonstrate that NTCVC-associated SAB rates remain low and significantly below Scottish government audit standards [3] Of interest is the continued trend towards the use of femoral catheters at 45 of lines compared with 38 in 2014 [2] Although traditionally thought of as having a higher incidence of infectious complications our data has shown fewer bacteraemia events associated with femoral catheters compared with internal jugular Our data also demonstrates a significant rate of peri-procedure haemorrhage arising in up to 1 in 20 cases Together these findings present opportunities to development practice and improve patient safety
References
[1] Murray E Deighan C Geddes CC Thomson PC Reducing haemodialysis bacteraemia rates Scottish Renal Association Glasgow November 2013 [2] Oliver SW Thomson PC Jardine AG defining safe effective and patient-centred dialysis catheter placement Scottish Renal Association Edinburgh September 2014 [3] The Staphylococcus aureus bacteraemia quarterly report of cumulative data from all NHS Boards in Scotland Health Protection Scotland January 2015
Sources of funding none Conflicts of interest none
P10 Prescribing of tolvaptan-The NHS Highland experience Lambie S1 McCulloch K2 Garrod J3
1Renal Consultant Renal unit Raigmore Hospital Inverness 2Renal Pharmacist Renal unit Raigmore Hospital Inverness 3Renal Pharmacist Renal unit Raigmore Hospital Inverness
Introduction Tolvaptan is a vasopressin antagonist It was accepted for use in Scotland by SMC in Jan 2016 to slow the progression of cyst development and renal insufficiency of autosomal dominant polycystic kidney disease in adults with chronic kidney disease (CKD) stage 1 to 3 at initiation of treatment with evidence of rapidly progressing disease1 Adverse effects related to aquaresis may affect patientsrsquo ability to achieve the optimum therapeutic dose and the risk of hepatic toxicity necessitates regular LFT monitoring The geography of NHS Highland required the implementation of novel methods of managing these patients and as a result a MDT approach with an emphasis on pharmacist input was adopted Consultant role Patient selection on the basis of evidence of rapidly progressing kidney disease declining
eGFR large volume kidneys on ultrasound and evidence of complications of PKD Side effects and potential benefits discussed Potential medication interactions reviewed Jinarc risk management prescriber training
Pharmacist role Undertook Jinarc risk management pharmacist training Prepares accurate drug history and reviews for potential drug interactions Carries out patient counselling and supplies patient education material sick day rules card
and lsquogot to gorsquo card Supplies GP education leaflet Provides advice on selection of new drug therapies eg for gout Manages stock and coordinates supply to patients
Results Prescribing commenced May 2016 patients currently prescribed tolvaptan 11 7 Female 4 male Number on target dose 73 n = 811 2 patients are still being titrated One patient did
not tolerate target dose due to aquaresis side effects and is being trialled on the middle dose
Withdrawals One patient has withdrawn due to agoraphobia and an inability to attend for monitoring and another is on hold due to having major surgery
Conclusion The MDT approach between the Renal Consultant and Pharmacist at Raigmore Hospital has enabled tolvaptan prescribing to be efficiently and safely implemented to patients living within a challenging geographical location
1 Scottish Medicines Consortium Detailed Advice Document tolvaptan 15mg 30mg 45mg 60mg and 90mg tablets (Jinarcreg) SMC No 111415 January 2016
NA1 Authors SCN Jacqueline Ross NHS Grampian
SCN Alan Somerville NHS Lanarkshire SCN Jane Humphrey NHS Lanarkshire
e- mail contact jacquelinerossnhsnet Alansommervillelanarkshirescotnhsuk
Janehumphreylanarkshirescotnhsuk
Phone contact 01224 552927 01236 712644
Title Sharing of Adverse Events in Renal Units across Scotland
Introduction Background The Scottish Renal Nurses Strategy Group (SRNSG) are a group of senior nurses from Renal
Units across Scotland who meet 3-4 times per year to discuss and implement best practice At the last meeting it was agreed that it would be good practice for each Health Board to share
their adverse events reported on the Datix System and deliver a presentation with an action plan to prevent incidents and improve patient safety across Scotland NHS Grampian and NHS Lanarkshire will be the first to deliver this presentation discussing adverse events from both Health Boards with an action plan
Top 5 adverse events over the past 12 months Renal Unit NHS Grampian 1 Violence and Aggression 2 Accidents including needlesticks slips trips and falls 3 Medication Errors 4 Infrastructure Staffing and Estates 5 Machines and Equipment
Top 5 adverse events over past 12 months Renal Unit NHS Lanarkshire
1 Slips Trips or Falls 2 Medicine errors 3 Treatment problems 4 Transfer problems 5 Breach of policy
The presentation will also focus on any serious adverse events which may not be in the top 5 categories
Aim Objective Each Health Board to share their adverse events with the aim to prevent them from occurring in other units to improve staff and patient safety and wellbeing across Scotland
Method Power Point Presentation
Outcome Results Sharing of adverse events resulting in the development of a national Action Plan to prevent these incidents improving safety and well being of staff and patients in Renal Units across Scotland
NA2
SRA Oct 2017 Abstract
BBV Never Event - The whats whys and hows
Staff Nurse Gillian Wilson Aberdeen Royal Infirmary
This presentation shares our experience of a never event that occurred and was not picked up for
a period of 18 months
Hepatitis C (HCV) positive antibodies were found in a previously negative patient
These results were a low positive with no biochemistry changes to suggest any liver damage
however steps were put immediately in place to isolate and investigate
Was it contamination from a dialysis machine was it related to a blood transfusion given prior to
first positive result was it faulty diagnostic tests in the laboratory
In Aberdeen we go over and above national guidelines and isolate all our BBV patients whether
they have positive blood results or are PCR negative
Further bloods tested at an external laboratory confirmed negative results
It highlighted that communication errors were to blame for the lack of speed in detecting this issue
Investigations concluded no real answers as to why this happened
NA3
Living Donation Scotland Changing attitudes towards living donor kidney transplantation
Jen Lumsdaine Julie Glen On behalf of the Living Donation Scotland Project Board
Background and aims
The rate of living donor transplantation has remained fairly static in Scotland over the past 10 years
Recent data has shown inequity of access to living donor transplantation throughout the UK so
there is potential to significantly increase this optimum form of treatment for patients with end-stage
renal failure in Scotland The Living Donation Project Board was formed in 2016 aiming to double
the number of living donor transplants by 2020
Method
The two key areas
1 Do recipients receive adequate and appropriate information at the right time about living
kidney donation
2 Informing the general public about altruistic donation
All patients active on the transplant list in Scotland were invited to an information event A follow-up
questionnaire was performed in the East of Scotland examining outcome or reasons for not
attending A scoping exercise looked at information provided by each unit was performed and link
nephrologists and low clearance nurses attended meeting to discuss strategies for early education
Outcome
An information pack containing both recipient and donor written information and short films on DVD
has been produced with the support of the Scottish Government for all recipients and potential
donors in Scotland A new website with comprehensive information both written and visual and
postcode finder to improve ease of access to local unit contact details has been developed
Two national media campaigns have been launched with a significant rise in the number of enquiries
from potential donors and actual increase in altruistic donor numbers
Nursing abstract ndash no conflict of interest
NA4Authors Susan Easson Charge Nurse Ward 4C QEUH Glasgow
e- mail contact SusanEassonggcscotnhsuk
Phone contact 0141 452 3300
Title A Conversational approach to find out ldquoWhat matters to yourdquo in a Renal Transplant ward
Introduction Background Finding out ldquo What Mattersrdquo to people using health and careservices is crucial to delivering safe effective and person centred care It is a simple yet profoundconcept and tries to get to the essence of person centred care by creating deeply personalengagements with patients and their families through a conversational approach However careexperience feedback all too often provides innumerable examples of where what really matters topatients and their family members is poorly understood or not addressed Using care experienceas the driver for change the nursing staff in Ward 4C used improvement approaches to explorehow to hold more meaningful ldquoWhat Matters to yourdquo conversations on a daily basis
Aim Objective To improve the patient experience by utilising a person centred approach
Method Using Care experience feedback What Matters to Me boards and the conversationalapproach
Outcome Results Improvements in patient experience will be shared using examples ofpractice and care experience feedback
There was no additional funding required for this project We worked in collaboration with theperson centred team whorsquos aim is to improve patient experience
NA5
The implementation of a renal education programme and its impact on clinical practice
The purpose was to implement a Renal Education Programme and to evaluate its impact on
clinical practise
It was identified that there was a need for an educational programme to be set up within Forth
Valley Royal Hospital There is no inpatient renal unit in FVRH on site for our renal patients they
attend Queen Elizabeth University Hospital We are an outpatient haemodialysis unit with
outpatient clinics on site Therefore it was identified that there was a need for nursing staff within
FVRH to be educated on all renal complexities for the benefit of our patients
This was done through a work-based learning approach which brought tangible benefits for our
patients However it did not come without pitfalls as educational programmes are often seen as
making very little difference to clinical practise
T
his study describes what methods were used and examines the advantages and disadvantages in
setting up an educational programme and evaluating its impact on clinical practise
NA6
Nursing Abstract ndash SRA Meeting ndash 26 October 2017
Chris McGee Tonya Broe Ken Weir
Renal Unit Forth Valley Royal Hospital
Use of the Therapy Monitor Haemodialysis Patient Record System Can we aim for a paper-
free dialysis unit
We are trialling a new haemodialysis patient monitoring system to work in conjunction with SERPR
and which is intended to supersede the Finesse system used previously
We are in the early stages of this process but with continuing staff education and regular tech
support we are hoping to gather sufficient evidence to evaluate whether the use of paper case
notes needs to continue
Is it a realistic goal to aim for a completely paper-free unit
NA7
THE CLINICAL USES OF APHERESIS WITHIN NHS TAYSIDE
Laura Thomson CN
Ninewells Hospital Dundee
NHS Tayside took over the apheresis service from BTS in 2012 The service has since expanded
with the benefits of carrying out this treatment has been widely recognised within NHS Tayside
and is now more commonly being offered to treat a wider range of conditions with the number of
treatments carried out each year rising
This presentation will highlight the progression of the apheresis service within NHS Tayside We
will identify the various conditions it is currently being used to treat and also identify the decision
making process involved in carrying out these treatments ie which replacement fluid will be used
anticoagulation medication administered
We will highlight the benefits and challenges we face in providing this expanding service within the
Renal Service
NA8Authors Linda McDougall Renal Physiotherapist NHS Highland
e- mail contact lindamcdougall1nhsnet
Phone contact 01463 706022
Title lsquoExercise on Haemodialysis- Keeping the Wheels in Motionrsquo
Introduction Background The impact of CKD on physical fitness functional ability independence amp ultimately quality of life cannot be underestimated Current national guidelines recommend that all individuals with CKD are encouraged to participate in regular exercise programmes between or during dialysis sessions if on HD Following a successful pilot study funding was approved to establish an lsquoExercise on Dialysisrsquo (EOD) programme across NHS Highland through the appointment of a dedicated renal physiotherapist in 2008 A successful programme was soon established but for several years post-vacancies and increasing in-patient demands limited the physiotherapy servicersquos ability to deliver the programme The need to improve the long-term sustainability of the service was recognised and in late 2016 funding was approved to develop a Band 4 PT HCSW role for this purpose
Aim ObjectiveTo optimise the sustainability and continuity of the lsquoExercise on Dialysisrsquo service across NHSHighland through development of a Band 4 PT HCSW role
Method The potential parameters of the role and limits of autonomy were scoped out using current NES resources and guidelines Service and task analysis was then carried out to establish which components of the EOD protocol could be undertaken by a Band 4 A series of competencies were developed in line with the clinical protocol and one-to-one training and supervision provided to the post-holder to ensure competency achieved in delivering the programme
Outcome Results A 10 WTE Band 4 PT HCSW was appointed in Jan 2017 with a dual role between the renal unit and acute medical wards Although training is not yet complete the post-holder is already running the day-to-day delivery and monthly audit of the EOD service with senior physiotherapist input only required for individual patient safety queries and general discussion around patientsrsquo progress and goals The benefit to the unit has been considerable as the band 4 is available to support patients and staff with EOD provision 5 days a week This allows for one-to-one supervision of patients who need more support to participate in EOD regular feedback on performance and reviews of outcome measures and goals to maintain motivation levels Feedback on the post has been very positive and its scope will only continue to expand as we look to further develop renal rehabilitation services across NHS Highland
NA9Authors Nadine Lyall and Kerry Guthrie
e- mail contact nadinelyallbordersscotnhsuk kerryguthriebordersscotnhsuk
Phone contact 01896 826637
Title The Developing Role of the NMP in a Satellite Dialysis Unit
Introduction Background
We have been practising as NMPrsquos for nearly 3 years working in the dialysis unit at the BGH The unit is a satellite unit of the ERI and we have expanded over the last 6 years The unit provides haemodialysis for 12 patients at any one time 3 sessions a day 6 days a week We are nurse-led and have 2 renal consultants who are based at the ERI
We saw an opportunity to use our knowledge and experience to develop our role By becoming NMPrsquos we have enhanced our professional development and we feel we meet the changing needs of the dialysis patient in a more holistic manner
Aim Objective
Our aim is to deliver effective care as we are better placed to deal with issues that often arise byacting swiftly this in turn is cost effective and convenient For example good anaemia and bonemanagement is important for their health wellbeing and lifespanTo help understand our role we will use a power point presentation highlighting issues we dealwith and the drugs we prescribe under the following headings Cardiovascular infection painanticoagulant disequilibrium diet renal bone disease and renal anaemia
Method Power point
Outcome Results
In the future we hope to further develop and have greater autonomy in our role We have great support from our renal consultants and have already built up a great relationship with our patients We hope to undertake the Clinical Decision Making course and this in turn will allow us to deal effectively with acute illness giving the dialysis patient better care We are keen to get feedback from other renal nurses in Scotland to enable us to develop our role further and in turn raise awareness of the NMP role in a dialysis unit We record all our prescribing decisions and keep the consultants up to date regularly Currently we are working on auditing our prescribing practice so that we can improve the service we can provide
NA10 Title Komunikacja w szkoleniu dializy ortzewnowej
Author Senior Charge Nurse Rhoda Bell
Address Raigmore Hospital Old Perth Road Inverness IV2 3UJ
Email rhodabellnhsnet Telephone 01463706023
Introduction Background Case study on lady with Polish as her first language she has some English but requires an interpreter to carry out Peritoneal Dialysis training and attend clinic She had some gynaecological issues that we were not aware of which impacted on the functionality of PD and therefore the success of treatment There were areas of concern in low clearance clinic with signs the patient had a reluctance to engage in decision making
AimObjective
Methods Discussion through the case study highlighted issues with communication between different PD staff and patients Areas of concern include different staffing techniques environment factors on training success Also language and communication issues the patient had were not fully apparent so training could not be individualised
Results We plan to trial training at home and have more individualised training schedule for patients The training step by step guides have been reviewed and practise standardised In collaboration with low clearance nurse we have developed a check list which will highlight concerns before the transition to PD ie language issues and need for training aids in another language gynaecological conditions
Conclusions Everyone learns differently and training methodsaids must be individualised for all It may not be apparent until training has commenced that there are concerns Having one to one training with the same nurse will consolidate training and build confidence in the patient Having a close working relationship with members of the MDT will help make a supportive PD journey
Would we do things differently if we knew about prolapse or lack of English both spoken and written
Key words - Peritoneal dialysis patient training communication
N11
Telehealth amp PDAudrey Jones
Advantages
Information on a daily basis about treatment weight and blood pressure
Change programme remotely via computer or mobile
Earlier intervention for machineprogramme issues
Reduction in home visits ie patient trained but still requires volume increases
No need to download cards to see what problems have been
Can have more detailed information available at clinics
Disadvantages
Relying on patient input data correctly
Machine is noisy especially first wave of machine
Still the same bag connection system and patient connection system (difficult for manual
dexterity problems)
Relying on patient having good signal
Modem problems
NA12Autosomal Dominant Polycystic Kidney Disease A cruel inheritance but new hopeAlistair Lawrie Renal Unit Victoria Hospital KirkcaldySadaf Arshad Corry Dunnigan Paul Phelan Neil Turner Renal Unit Royal Infirmary of Edinburgh
Background Autosomal Dominant Polycystic Kidney Disease (ADPKD) is the most prevalent single gene human genetic disorder and the most common of the inherited cystic and interstitial kidney diseases It is estimated to affect 1 in every 1000 individuals worldwide with over 50 of sufferers eventually developing end stage kidney disease and requiring dialysis or transplantation Symptoms include spasmodic severe pain hypertension haematuria infection and kidney failure There is currently no cure for ADPKD Management of the condition has traditionally involved lifestyle modification BP control and analgesia however a recent study (Torres et al 2012) demonstrated that treatment with V2-receptor antagonist drugs slowed increase in total kidney volume reduced the rate of functional decline and showed a reduced incidence of kidney pain
Aim Provision of a tolvaptan prescribing and monitoring service
Methods Experiential finding report of initial twelve months period of multidisciplinary ADPKDtolvaptan clinic
Results Early results are comparable with TEMPO study outcomes
Conclusion Due to the long term nature of this treatment results available at this time are showing only the earliest benefits of the intervention More quantifiable results such as increased time before the necessity for RRT will only be evident in coming years Torres VE et al (2012) Tolvaptan in Patients with Autosomal Dominant Polycystic Kidney Disease New England Journal of Medicine 367 pp 2407-2418 DOI 101056NEJMoa1205311
No funding requirement No conflict of interest
A13 Kidney transplantation in the over 60rsquos in Scotland 1996-2015 TJW Rennie1 P Phelan1 J Campbell2 JP Traynor2 L Henderson1 W Metcalfe2 On behalf of the Scottish Renal Registry 1Renal transplant unit Royal Infirmary Edinburgh 2NHS National Services Scotland Introduction The proportion of older kidney transplant recipients has increased in the UK but
long term outcome data are scarce We aimed to evaluate patient and graft survival in patients
ge60 years of age receiving a first kidney only transplant in the last 20 years in Scotland
Methods Retrospective analysis of Scottish Renal Registry data of incident Renal Replacement
Therapy (RRT) patients and those in receipt of a kidney only transplant performed 1996-2015
(follow up until 311216) Patients were stratified by age 60-69 ge70 (group 1 and 2 respectively)
and decade of transplantation 1996-2005 2006-2015 (decades 1 and 2 respectively)
Results 6743 patients aged ge60 started RRT from 1996-2016 Of those 108 were ever
transplant-listed 54 had received a transplant by 311216 26 listed and 11 transplanted
were aged ge70
535 patients aged ge60 received a kidney only transplant in 1996-2015 90 patients (168) were
aged ge70 no patients were aged ge80 Mean time from wait listing until transplantation was 33plusmn24
years (plusmnSD) and from starting RRT until transplantation was 38plusmn26 years (plusmnSD) One and five
year graft survival was 97 and 87 in decade 1 95 and 89 in decade 2 (p=NS) there was
no difference in graft survival between age groups 1 and 2 One and five year patient survival was
94 and 78 in age group 1 85 and 56 in group 2 (plt0001) there was no difference in one
and five year patient survival between the two decades
Conclusion One and five year graft and patient survival in renal transplant recipients aged ge60
have not changed significantly in the last 20 years Recipient age ge70 is not associated with
reduced graft survival but patient survival from time of transplant is lower in this age group
compared to recipients aged 60-69
No conflict of interest to be declared No funding received
A14 High Mortality In Older Patients With Primary Nephrotic Syndrome Sarah Beverstock Wendy Metcalfe amp Robert W Hunter Department of Renal Medicine Royal Infirmary of Edinburgh
Introduction
Nephrotic syndrome can develop at any age and may be due to a primary glomerular lesion or secondary to systemic disease The natural history of glomerular disease can be different in older patients For instance minimal change disease (MCD) in children almost always remits promptly with steroid therapy in adulthood it typically remits only after many weeks of steroids or with adjunctive immunosuppression However there are remarkably few published data on the mortality of primary nephrotic syndrome in adults We aimed to study this in our centre
Methods
We enrolled all adult patients who had a kidney biopsy in order to investigate nephrotic syndrome over 38 consecutive months (01 Jan 2014 ndash 28 Feb 2017) We defined nephrotic syndrome as heavy proteinuria (urinary proteincreatinine ratio UPCR gt350 mgmmol or albumincreatinine ratio gt220 mgmmol) and hypoalbuminaemia (serum albumin lt35 gL) In our analysis we included all patients in whom nephrotic syndrome was attributed to a primary glomerular disease We excluded kidney transplant recipients and patients in whom biopsies were performed to follow up a known glomerular disease We collected laboratory data at baseline (time of biopsy) and at 6 and 12 months We assessed patient survival by Kaplan-Meier analysis
Results
Of the 117 patients biopsied for nephrotic syndrome 71 patients (61 ) met the inclusion criteria and were followed up for a median of 469 days We compared outcomes in patients aged under 60 years old (n = 35) with those aged over 60 (n = 36) Mortality was higher in the older group (37 vs 4 mortality at one year p lt005 by logrank test) There were no significant differences between the two groups in serum creatinine or UPCR at any time Serum albumin was similar in both groups at baseline and at 12 months but was lower in the older group at 6 months (27 vs 32 gL p lt 005) Baseline haemoglobin was lower in the older group (114 vs 130 gL p lt005 by unpaired t-test) Primary diagnoses were MCD (n = 10 in younger group amp n = 5 in older group) membranous nephropathy (5 amp 10) IgA nephropathy (9 amp 8) FSGS (5 amp 5) membranoproliferative glomerulonephritis or C3GN (4 amp 7) and other (2 amp 1) Therefore unsurprisingly there were relatively fewer cases of MCD and more cases of membranous nephropathy in the older group otherwise the causative glomerular lesions were similar in both groups In those patients with MCD mortality was significantly higher in the older group none of the 10 patients with MCD diagnosed under 60 yrs old died during the follow-up period whereas 4 of the 5 older patients died 3 patients in the younger group and 1 in the older group were on renal replacement therapy (dialysis or transplant) by the end of follow-up
Conclusions
Primary nephrotic syndrome is associated with high mortality in the over 60s (37 at one year) Mortality was high even for MCD a disease that follows a benign course in childhood and early adulthood The higher mortality in older patients was not associated with greater severity of renal disease at presentation (as assessed by basic blood and urine parameters) This work was not funded we declare no conflicts of interest
A15 Renal biopsies in patients with diabetes mellitus in Scotland
Udana Ratnapala 1 Nicola Joss 2 Colin Geddes 3 Dana Kidder 1
1 Renal Unit Aberdeen Royal Infirmary Aberdeen 2 Renal Unit Raigmore Hospital Inverness 3 Glasgow Renal and Transplant Unit Glasgow
Introduction Diabetes mellitus is the leading cause of end-stage kidney disease (ESKD) requiring renal replacement therapy The utility of renal biopsy in patients with diabetes mellitus is controversial Broadly renal biopsy findings in patients with DM can be divided into diabetic nephropathy (DN) alone DN with non-diabetic renal disease (NDRD) or NDRD alone Timely identification of patients with NDRD is important to provide appropriate therapeutic measures Previously published guidelines on clinical predictors of NDRD have limited specificity and sensitivity The frequency of NDRD in renal biopsies of patients with DM is unclear in ScotlandThis study aimed at identifying the frequency and the pathology spectrum of NDRD in diabetic patients underwent kidney biopsy in 3 renal units
Methods A retrospective observational study was performed on clinical-pathologic findings in all patients with diabetes mellitus who underwent renal biopsy between 01012010 and 31122016 in 3 renal units (Aberdeen Inverness and Greater Glasgow) Data were gathered from electronic patient record systems Scottish Index of Multiple Deprivation (SIMD) 2012 was used to analyse correlation with patient outcomes
Results 247 patients were included 150 men (607) 217 type 2 DM (879) mean age 621 years and mean serum creatinine at the time of renal biopsy of 261 micromolL (+-190 std) On biopsy 92 patients (372) had DN while 127 (514) had NDRD and 28(114) had NDRD superimposed on DN The commonest NDRD aetiologies were IgA nephropathy (187) tubulointerstitial nephritis (168) and idiopathic membranous nephropathy (103) Predictors of NDRD were age (OR 1027 95 CI 1002-1052 p=003) duration of DM (OR 094 95 CI 0900-0987 p=001) and absence of AKI as indication for biopsy (OR 022 95 CI 0059-0826 p=0025) There was no significance difference in renal or patient survival in DN and NDRD Finally no significant correlation was depicted between SIMD quintiles and renal or patient survival in both groups
Conclusions The majority of renal biopsies carried out in patients with DM revealed a NDRD In this study age at the time of biopsy duration of DM and AKI were the main pointers towards NDRD Renal and patient survival were not significantly different between DN and NDRD groups
A16 The Impact of Withdrawal of Maintenance Immunosuppression and Graft Nephrectomy on HLA Sensitisation Ailish Nimmo1 Sophie McIntyre1 Lorna Henderson1 Richard Battle2
(1 Department of Renal Medicine Royal Infirmary of Edinburgh 2 Histocompatibility and Immunogenetics Royal Infirmary of Edinburgh)
Background The development of HLA antibodies towards a failing renal allograft is a barrier to re-transplantation We previously demonstrated an increase in HLA antibodies and calculated reaction frequency (cRF) following nephrectomy but results were confounded by immunosuppression changes occurring in close time proximity We examined the formation of HLA donor specific antibodies (DSA) in patients with failed grafts that remained in situ and compared results with patients undergoing graft nephrectomy to further assess the relative impact of nephrectomy and immunosuppression weaning on sensitisation and chance of transplant
Methods We carried out a single centre retrospective study of all patients with failed grafts in Lothian from 2005 to 2015 Samples were tested for DSA pre-immunosuppression (IS) wean post-IS wean and post-IS cessation Nephrectomy patients also had samples tested for DSA before and after nephrectomy Data on other sensitising events including blood transfusion and rejection were collected cRF was determined at each time point and entered into the ODT chance of transplant calculator with other demographics based on the average patient from the Edinburgh centre
Results 62 grafts failed over this time period Blood samples were available 41 patients (24 with nephrectomy 17 with failed graft left in situ) Patient demographics were similar between groups There was a higher rate of antibody mediated rejection in the nephrectomy group (46 vs 18) 76 of patients with nephrectomy group had received a blood transfusion The pattern of immunosuppression weaning was similar but median time from start of IS wean to cessation was longer in the nephrectomy group (350 vs 298 days) The changes in cRF and chance of transplant (COT) with immunosuppression weaning are shown in Table 1
Pre-IS Wean Post-IS Wean
Failed graft in situ (n=17)
Mean CRF COT at 5
years 15 62 38 59
Nephrectomy (n=24)
Mean cRF COT at 5
years 54 54 69 46
Post-IS Stop 55 53 89 42 Table 1 Mean cRF and Chance of Transplant (COT) at 5 years with IS alterations
Discussion A stepwise increase in cRF with reduced chance of transplant was observed in both groups as immunosuppression was withdrawn with a similar pattern of change irrespective of graft nephrectomy cRF was higher in the nephrectomy group despite a more gradual wean which may reflect a higher rate of antibody mediated rejection and increased number of patients receiving a blood transfusion The risks and benefits of stopping immunosuppression need to be carefully considered on an individual basis to maximise chance of future transplant
The authors have no conflicts of interest No funding was required for this study
A17 Obesity is not associated with progression to end stage renal disease in patients withbiopsy-proven glomerular diseases
Benjamin Elyan Jennifer S Lees Bruce Mackinnon Jonathan G Fox Colin C Geddes Emily PMcQuarrie
Glasgow Renal and Transplant Unit Queen Elizabeth University Hospital Glasgow
Introduction - Addressing risk factors for renal progression is a key aspect of managing chronic kidney disease (CKD) Body mass index (BMI) has been shown to impact on renal progression in unspecified CKD The aim of this study was to evaluate if there was an association between BMI and progression to renal endpoints in patients with biopsy-proven primary glomerular disease (GN)
Methods - We included all adult patients diagnosed with biopsy-proven primary GN (excluding minimal change nephropathy) in Greater Glasgow amp Clyde and Forth Valley between 01012000 and 31122015 Biochemical and anthropometric data were extracted from the electronic patient record at time of biopsy with follow-up data until 20062017 BMI was calculated from height and weight at time of biopsy and categorised into groups BMI le25 kgm2 (G1) gt25 to le30 kgm2 (G2) and gt30 kgm2 (G3 - obese) We assessed factors associated with reaching a combined renal endpoint of CKD5 or renal replacement therapy (RRT) with competing risk of death using the Fine and Gray subdistribution hazard model Analyses were conducted using cmprsk package for R statistical software package and SPSS version 24
Results - 560 patients with primary GN and available BMI data were included The average age was 532 years and 339 were female There were 132 patients in G1 210 in G2 and 207 patients in G3 Those in G2 and G3 were older (p=002) with slightly higher diastolic blood pressure (p=002) than those in G1 There was a greater proportion of focal segmental glomerulosclerosis in G3 but similar proportions of other GN diagnoses across groups There was no significant difference in baseline serum creatinine (sCr) (p=034) or log uPCR (p=045) between BMI groups On multivariate analysis age systolic blood pressure BMI or GN diagnosis were not predictive of renal outcome Higher baseline sCr (SHR 1003 per 1 umoll increase in sCr 1001-1004 plt0001) and log uPCR (SHR 130 per unit increase in log uPCR 95 CI 105-160 p=002) were associated with progression to the combined renal endpoint accounting for competing risk of death BMI was not associated with reaching combined renal endpoint on univariate analysis whether considered as a continuous variable (SHR=100 95 CI 098-102 p=096) or categorised by BMI group
Conclusion - Contrary to our expectations there was no association between BMI and progression to a combined renal endpoint of CKD5 or RRT in this cohort of patients with primary GN Efforts should be directed to managing other known risk factors for CKD progression
Sources of FundingConflicts of Interest - None
A18 Factors influencing long term renal function after living kidney donation
Matthew A Rutherford Norman J Galbraith Marc Clancy Colin C Geddes
Glasgow Renal and Transplant Unit Queen Elizabeth University Hospital Glasgow UK
Background Following live donor nephrectomy the remaining kidney undergoes an increase in filtration capacity known as compensatory hypertrophy Few cohorts with follow up of renal function beyond 5 years have been reported The impact on long term renal function of variability in donor factors such as age sex pre-donation blood pressure and glomerular filtration rate (GFR) is unknown Increasingly kidney donors have potential risk factors for future poor renal function such as hypertension older age and obesity The aim of this study was to analyse factors influencing long-term renal function in living kidney donors from our centre
Method Data were obtained from the electronic patient record Patients with a recorded procedure of lsquolive donor nephrectomyrsquo between 2005 and 2017 were identified GFR after donation (calcGFR) was calculated using the formula lsquocalcGFR = Pre-donation Isotope GFR x (Pre-donation Serum creatinine Serum Creatinine)rsquo which is accurate assuming muscle mass does not change Pre and post donation serum creatinines (two days two weeks three months and one to ten year) were recorded We analysed the influence of age sex pre-donation GFR and blood pressure on post donation GFR compensation
Results 355 live donor nephrectomies were performed between January 2005 and December 2016 The mean age was 469 (plusmn 116) years and 504 (n=179) were female Mean pre-donation isotope GFR was 937 plusmn 156 mlmin173m2 Median follow up was 2 years (IQR 1 to 6 years with range 2 weeks to 10 years) The calculated percentage of pre-donation GFR at 2 days 2 weeks 3 months 1 year 5 years and 10 years were 698 691 712 730 801 and 950 respectively (p lt 0001) Patients aged lt50 y had not only a higher calcGFR (858 plusmn 29 mlmin173m2 compared with 671 plusmn 28 mlmin173m2 p lt 0001) at 5 years following donation but achieved a higher degree of compensation than donors gt 50 y (836 plusmn 16 compared with 756 plusmn 19 (p = 0002) Patients with pre-donation hypertension achieved 774 plusmn 53 of pre-donation GFR compared with 804 plusmn 32 in normotensive patients (p = 0998) Females had equivalent degree of renal compensation achieving 819 plusmn 19 compared with 780 plusmn 16 in males (p = 0131) at 5 years following donation Patients with pre-donation GFR gt 100 mlmin173m2 achieved 844 plusmn 23 of pre-donation function by 5 years compared with 777 plusmn 14 in those with pre-donation GFR lt 100 mlmin173m2 (p = 001)
Conclusion Following live donor nephrectomy renal function has a nadir of 691 at 2 weeks Compensation in GFR occurs rapidly and appears to be maintained regardless of sex and pre-donation blood pressure Younger age and higher pre-donation GFR were associated with a greater degree of compensation
A19 The utility of high-sensitivity cardiac troponin to stratify cardiovascular risk in patients with renal impairment
Eve Miller-Hodges Atul Anand Anoop S V Shah Nicholas L Mills Neeraj Dhaun
Background Cardiovascular disease is the most common outcome of chronic kidney disease1
Declining glomerular filtration rate (GFR) and proteinuria predict increased cardiovascular risk over the long term2 However there are currently no methods to stratify cardiovascular risk in the short or medium term in patients with renal impairment We have already shown that high-sensitivity cardiac troponin I concentrations (hs-cTnI) lt5ngL in patients presenting with symptoms of acute coronary syndrome identifies those at low risk of cardiac events within 30 days and over the next year3 However uncertainty remains over the role of hs-cTnI testing in patients with renal impairment This study investigated whether hs-cTnI could also stratify future cardiovascular risk in patients with renal impairment
Methods In a prospective study of consecutive patients presenting with suspected acute coronary syndrome we evaluated the performance of hs-cTnI in patients with and without renal impairment (estimated glomerular filtration rate lt60mLmin173m2) using an early risk stratification threshold of 5ngL to ldquorule outrdquo acute myocardial infarction at presentation and within 30 days and sex-specific 99th centile diagnostic thresholds for index type 1 myocardial infarction Subsequent type 1 myocardial infarction and cardiac death were reported at one year
Results Of 4726 patients identified 904 (19) had renal impairment Index diagnosis of type 1 and type 2 myocardial infarction was almost twice as likely in patients with renal impairment (30 vs 15) Performance of the early risk stratification threshold of 5ngL to identify patients at low risk of major cardiac events was similar in patients with (NPV 984 95CI 960-997 sensitivity 989 95CI 975-999) and without renal impairment (NPV 997 95CI 994-999 sensitivity 984 95CI 972-994) These patients continued to remain at low risk over the next year The PPV and specificity at the 99th centile for diagnosis of myocardial infarction were lower in patients with renal impairment at 500 (95CI 452-548) and 709 (95CI 675-742) respectively compared to 624 (95CI 588-659) and 921 (95CI 912-930) At one year 24 of patients with renal impairment and troponin gt99th centile regardless of index diagnosis had experienced further myocardial infarction or cardiac death compared with 10 of patients without
Conclusion In suspected acute coronary syndrome hs-cTnI can stratify risk in patients with renal impairment Irrespective of diagnosis patients with renal impairment and elevated cardiac troponin concentrations had two-fold greater risk of a major cardiac event compared to those with normal renal function and should be considered for further investigation and treatment
Funders Wellcome Trust British Heart Foundation and Chest Heart amp Stroke Scotland
1 Gansevoort RT Lancet 2013
2 Chronic Kidney Disease Prognosis Consortium Lancet 2010
3 Shah AS Lancet 2015
A20 lsquoDOES IT DIALYSE OUTrsquo - THE EFFECT OF RENAL REPLACEMENT THERAPY ON THE BRAIN Mark Findlay Jesse Dawson David Dickie Deborah McGlynn Patrick Mark Institute of Cardiovascular and Medical Science University of Glasgow amp Queen Elizabeth University Hospital Glasgow
Introduction Cerebrovascular disease is common in end-stage renal disease (ESRD) on renal replacement therapy (RRT) We investigated the effect of RRT on cerebral structure and cognitive function over 12 months Methods Observational cohort study in ESRD patients receiving HD Prior cognitive impairment or cerebrovascular disease were exclusion criteria Multi-domain cognitive testing was performed at baseline and at follow-up Transcranial Doppler was used to assess intra-dialysis related alterations in mean flow velocity (MFV) ndash a marker of cerebral blood flow MR imaging was performed at 0 and 12 months We performed T1 T2 FLAIR and DWI sequences and used volumetric software to calculate white matter hyperintensity (WMH) burden markers of atrophy mean diffusivity and fractional anisotropy (FA) to describe structural changes at 1 year Results 97 patients median age 59 years 412 female At follow-up 15 patients were transplanted 6 died 4 withdrew and the remainder continued HD Those who were transplanted were younger (median age 51 vs 60 years p=0019) and had been on dialysis for a shorter period (median 06 vs 21 years p=0003) MFV declined during HD median 475cms to 405cms plt0001 and correlated with lower scores of executive and frontal lobe function during HD (Rho 045 p lt0001 and Rho -0313 p lt001 respectively) In all patients MR imaging demonstrated a significant decline in frontal parietal and temporal lobe volume at follow-up Median WMH volume increased in those who remained on HD but not in transplanted patients (median change 023 vs -012ml p=0018) WMH burden correlated with worsening scores of frontal lobe tests Rho 0585 p0005 and worse mood Rho -0485 p0026 FA improved following renal transplant (028 to 029 p=0016) and correlated with improved executive function testing at follow-up Rho 089 p0019 Conclusion Cerebral blood flow is reduced during haemodialysis and correlates with a reduction in intradialytic executive function There is an improvement in FA following transplantation WMH volume increases in those who remain on dialysis and the degree of increase correlates with executive and frontal lobe function This suggests that haemodialysis is associated with clinically significant changes in the brain and that these may be ameliorated by transplantation
Source of fundingconflicts MF is funded by a KRUK fellowship
A21 Pathological classification of IgA nephropathy to predict renal outcomes ndash is there a better way to score tubulointerstitial inflammation
Alastair Rankin David Kipgen Bruce Mackinnon Jonathan Fox Colin Geddes Emily McQuarrie Glasgow Renal and Transplant Unit On behalf of the Scottish Renal Biopsy Registry
Background The Oxford pathological classification of IgA nephropathy (IgAN MEST-C score) is limited by the fact that individual features of the score are not all predictive and its utility in assisting clinical decision-making is questioned The addition of tubulointerstitial inflammation to the existing scoring system is appealing but is not currently included due to reportedly wide inter-observer variability We report a novel method to score percentage of cortex containing tubulo-interstitial inflammation in non-atrophic renal cortex (ATIN) in patients with IgAN similar to that used in transplant biopsy reporting and assess its utility to predict clinical outcomes
Methods All adult patients with a native renal biopsy diagnosis of IgAN between 2010 and 2015 in a unit serving 15 million people were identified Baseline characteristics biopsy reports and outcome data were collected ATIN was calculated by subtracting the percentage of atrophic cortex from the percentage of total cortex with tubulo-interstitial inflammation withge10 representing significant tubulo-interstitial inflammation in non-atrophic cortex The primary outcome was a composite of requiring renal replacement therapy (RRT) or doubling of serum creatinine (sCr)
Results 153 new cases of IgAN were identified 33 were excluded (24 had lt8 glomeruli on biopsy 6 inadequate biopsy for MEST scoring and 3 on RRT at time of biopsy) In addition patients with a tubular atrophy (T) score of 2 were also excluded (n=9) Of the remaining 111 patients 76 (68) were male Mean age at biopsy was 52 years (+- 167) and 18 (16) had a co-existing clinical diagnosis of henoch-schonlein purpura (HSP) Median sCr was 156 micromoll (IQR 101-212) and 54 (49) had ATIN on biopsy During a median follow-up of 23 years 34 (31) reached the primary outcome 20 (18) received immunosuppression and 16 (14) died On univariate Cox regression survival analysis ATIN was associated with a four-fold increase in the primary outcome (HR 49 (21-113)) On multivariate analysis mesangial hypercellularity (M) T and ATIN independently predicted renal outcome while endocapillary proliferation (E) and segmental sclerosis (S) did not (plt002 for ATIN) Excluding patients with HSP or those who received immunosuppression did not change the result
Conclusion Within our centre ATIN predicts renal outcome for IgAN independently of established histological features Assessment of inter-observer reproducibility and validation in other cohorts is still required but these results suggest ATIN could be a worthwhile addition to current pathological scoring systems for IgAN
Source of funding none Conflicts of interest none
P1 Polypharmacy in Renal Replacement Therapy Patients
Jason McMinn Colin Geddes Glasgow Renal and Transplant Unit Queen Elizabeth University Hospital
Introduction
Prescribing is often led by evidence from studies containing participants with single health conditions and without multimorbidity Polypharmacy is becoming increasingly recognised in patients with multiple chronic health conditions Additional medications are more likely to result in diminishing returns in benefit with an increased risk of harm Patients with established renal failure (ERF) are likely to be susceptible to medication-related harm A high pill burden is also likely to contribute adversely to an already restricted quality of life and has been associated with poor medication adherence The aim of this study was to analyse polypharmacy in all patients with ERF attending our service
Methods
We extracted medication records for all prevalent ERF patients attending the Glasgow Renal and Transplant Unit from the West of Scotland Electronic Renal Patient Record (SERPR) as of 01012017 The records were analysed to calculate the number of regular medications and total pill burden of each patient These medications were categorised as being lsquopreventativersquo or lsquosymptomaticrsquo We also analysed the prescription of specific drug classes to examine the prevalence of these medications
Results
We identified 1091 transplant follow-up 529 hospital haemodialysis and 46 peritoneal dialysis patients who were on a mean of 94 13 and 129 different medications respectively Overall pill burden was 139 tablets a day in transplant follow-up patients 141 in haemodialysis patients and 162 in peritoneal dialysis patients There were similar rates of prescribing between the different dialysis units and clinics within our service
The proportions of medications deemed as preventative rather than symptomatic were 76 in transplant 69 in haemodialysis and 60 in peritoneal dialysis
In transplant patients decreasing renal function was associated with a higher pill burden but even patients with a transplant eGFR gt 60 were on a mean of 126 tablets per day including a mean of 14 antihypertensives
Rates of antidepressant prescribing were 15 in transplant patients and 20 in hospital haemodialysis patients 53 of haemodialysis patients were on a statin 39 on aspirin 61 on a proton pump inhibitor and 7 were on warfarin
Conclusion
Patients undergoing all forms of renal replacement therapy are likely to be on a considerable number of medications Whilst these drugs are inevitably prescribed for valid reasons this data demonstrates the need for clinicians to engage with patients to explore opportunities to reduce pill burden
Conflict of Interest None Sources of Funding None
P2 An audit of Acute Kidney Injury (AKI) on an acute stroke ward before and after plannedinterventions to review and maintain hydration
Clare Harris1 Simon Hart2 Fiona Duthie3 1 University of Edinburgh Medical School 2 Stroke Unit Royal Infirmary of Edinburgh 3 Renal Unit Royal Infirmary of Edinburgh
Background Dehydration is an important factor in the development of acute kidney injury which is associated with increased morbidity and mortality particularly in the elderly population Poor fluid intake is common post stroke (1) and dehydration is associated with poorer outcomes 3 months post stroke (2) In late 2014 there was no system of identifying patients with poor oral intake on the stroke ward at the Royal Infirmary of Edinburgh a hydration protocol and education programme were implemented aiming to improve fluid balance This included the use of prescribed water either orally or by nasogastric tube An audit pre and post intervention demonstrated that hydration as measured by ureacreatinine ratio significantly improved after the protocol introduction (3) We aimed to determine whether the incidence of AKI by KDIGO criteria was also reduced as this could have implications for reducing patient morbidity and mortality in this elderly comorbid patient cohort
Method 150 inpatients to the acute stroke ward during JulAug 2014 and JulAug 2015 were selected (n= 80 2014 n=70 2015) Patient data and creatinine values were collected from the electronic patient record and medical notes and retrospectively analysed Baseline creatinine values were calculated and cases of AKI were identified and staged using KDIGO criteria (4) Chi-Squared tests were performed to determine P values Individual patient notes were reviewed for both quantitative and qualitative data of patient management
Results Incidence of AKI (of any stage) was 263 pre-protocol and 200 post-protocol (P=03646) Incidence of AKI stages 23 was 100 pre-protocol and 715 post-protocol (P=05374) In hospital post stroke mortality was 338 pre-protocol and 1286 post protocol (P=00028) AKI was also associated with increased length of stay
Conclusions Despite a trend in benefit there was no significant difference in incidence of AKI pre and post hydration protocol nor in incidence of severe AKI (stage 23) AKI is influenced by many factors one of which is hydration status Further studies are needed to determine whether the trend of benefit exhibited in this sample is significant in a greater sample size if this were the case such a protocol could have great benefit to patient care on stroke units and elsewhere There was a significant difference in inpatient post stroke mortality following introduction of the hydration protocol Further investigations are needed to explain underlying reasons for this factors other than hydration may play an important role
References 1 Whelan K Inadequate fluid intakes in dysphagic acute stroke Clinical Nutrition (2001) 20(5)
423-428 2 Bhalla A Sankaralingam S Dundas R Swaminathan R Wolfe CDA Rudd AG The influence of
raised plasma osmolality on clinical outcome after acute stroke Stroke (2000) 312043ndash2048 3 Hart SR Craig R Berry E Lane N Gad A Farrugia M Burton L Paquay A What Happens to
Acute Stroke Patientsrsquo Fluid Balance Renal Status and Dehydration in the First Two Weeks How Can They Be Markedly Improved doi 101111ijs12634_13
4 KDIGO Clinical Practice Guideline for Acute Kidney InjuryKidney international supplements (2012) 2(1) 1-138
No funding or conflict of interest to declare
P3NHS Highland-Improving the management of hyperkalaemia using a kit Initial resultsCantley N1 Abedin T2 Lambie S3
1FY2 NHS Highland 2ST4 Renal Medicine NHS Grampian 3Renal Consultant Renal unitRaigmore Hospital Inverness
Introduction The incidence of hyperkalaemia in hospitalised in patients is between 1 and 10 Guidelines in Northern Ireland promote the use of a Hyperkalaemia Kit to improve management of hyperkalaemia We assessed the management of hyperkalaemia in Raigmore Hospital including post-treatment monitoring of serum potassium and blood glucose at baseline and after the introduction of a lsquoHyperkalaemia Kitrsquo which contains a pro forma for the management of hyperkalaemia and all the relevant equipment and drugs for treatment
Method Between July and September 2016 an automated algorithm identified 34 patients with a potassium result 65 mmoll or above on laboratory results 12 received no specific treatment of these 6 results were spurious 4 patients died before treatment could be started and 2 patients were chronic haemodialysis patients We introduced the Hyperkalaemia Kit to the Acute Medical Admissions Unit in Raigmore Hospital Since then 15 patients have been identified with serum potassium measurements above 65 and the pro forma and kit was used with eight of these patients One of these patients proceeded straight to acute renal replacement therapy
Results Prior to our intervention all 22 patients that were actively treated received at least one prescription of appropriate doses of Insulin with Dextrose However only 16 patients received intravenous calcium and only 7 received nebulised Salbutamol Potassium was measured at 4 hours in 5 cases and by 12 hours in 17 cases Monitoring of any capillary blood glucose was only documented in 8 cases Of the 22 treated 2 needed acute renal replacement therapy 3 required further doses of insulin and dextrose 2 were treated with Calcium Resonium
Eight cases of hyperkalaemia have been managed with the use of the kit and pro-forma so far An initial ECG was performed in all eight and four patients had continuous cardiac monitoring Intravenous calcium was given in seven and nebulised Salbutamol was given in five out of the eight cases Six out of eight patients had at least three blood sugar measurements One had two measurements documented and one patient was stopped from further monitoring following senior review and decision to palliate Seven patients had appropriate monitoring of their serum potassium by 4h and 12h again one patient was not monitored due to palliation
Conclusion Baseline results showed very low rates of prescription of nebulised Salbutamol low rates of Calcium Gluconate use and very low monitoring of blood sugars and potassium post treatment This has the potential for serious adverse outcomes particularly the potential for iatrogenic hypoglycaemia Our initial data shows the use of a Hyperkalaemia pro forma and kit improves the rate of prescription of intravenous calcium and nebulised Salbutamol and the post-treatment monitoring of serum potassium and blood sugar levels
P4Rituximab as maintenance therapy in ANCA associated vasculitisndash a single centre experience Rathnamalala NK Mcmenamin J Robertson S Almond A Kelly M Muniraju T M Renal Unit Dumfries and Galloway Royal Infirmary NHS Dumfries and Galloway Background The introduction of Cyclophosphamide and high dose steroids transformed ANCA associate vasculitis (AAV) from a disease of high mortality to a relapsing remitting disease Maintenance of remission however still remains a major challenge A two randomised clinical trials have looked at the use of Rituximab in remission induction in AAV and reported similar remission rates between Cyclophosphamide and Rituximab 12 Both these trials used Azathioprine as maintenance therapy and in the follow up showed similar remission rates with either agent for induction The role of Rituximab for maintenance therapy after cyclophosphamide induction was studied in the MAINRITSAN trial 3 Rituximab was compared with azathioprine and found that the relapse rate was significantly lower in the Rituximab group There have been several other retrospective studies that have suggested regular Rituximab infusions are successful in maintaining remission however has not been thoroughly evaluated 4 5678910 Here we share our centrersquos experience using Rituximab for maintenance of remission of AAV Materials and methods We conducted a retrospective review of electronic medical records of all patients who had received Rituximab as maintenance therapy for 12 months or longer between January 2014 to July 2016 Disease activity was assessed using Birmingham Vasculitis Activity Score ( BVAS) Version 3 and complete remission was defined as a score of 0 and partial remission as a score of lt50 of the value at diagnosis Due to uncertainties associated with sub classification we did not assign specific diagnosis but broadly classified as ANCA associated vasculitis Results 6 patients received Rituximab as maintenance therapy during the study period 3 (50) of them had eye ear nose and upper airway manifestations consistent with Granulomatosis with Polyangitis (GPA) All patients were PR3 ANCA positive except for one at initial diagnosis The mean BVAS score at the time of initiation of Rituximab was 4 All patients were initiated on Rituximab for relapses while on maintenance therapy with Azathioprine 4 patients received 6 monthly doses of Rituximab while two received annual doses All of them were also maintained on 5-10 mg of Prednisolone The mean BVAS score by 6 months was 0 and remained 0 at 12 months The mean PR3 titre was 562 at the initiation of treatment while at 12 months it had come down to 68 All patients remained in complete clinical remission at the end of 12 months after initiation of therapy Rituximab was well tolerated by all patients except one who developed pyrexia during an administration
Conclusions All patients had sustained remission at 6 months and 12 months after initiating Rituximab Rituximab has a potential role as maintenance therapy in AAV
P5 Chronic Myelo-Monocytic Leukaemia (CMML) as a contraindication to renal biopsy Alastair Rankin Emily McQuarrie Jennifer Lees Bruce MacKinnon Glasgow Renal and Transplant Unit On behalf of the Scottish Renal Biopsy Registry
Abstract Chronic Myelo-Monocytic Leukaemia (CMML) is a relatively rare mixed myelodysplastic myeloproliferative disorder that predominately affects patients over the age of 65 years Renal impairment in patients with CMML is well described with several different mechanisms reported including tumour infiltration lysozyme-induced injury amyloid deposition and tubulointerstitial nephritis From anecdotal evidence within our centre we are concerned that patients with CMML have an excessive risk of clinically significant bleeding following native renal biopsy This risk appears disproportionate to the degree of any co-existing thrombocytopenia or coagulopathy
We review the cases of 4 patients with an existing diagnosis of CMML who were referred to the renal clinic with proteinuria and excretory renal dysfunction Two of these patients underwent renal biopsy with subsequent major haemorrhage post-procedure despite normal bleeding parameters pre-procedure Patient 1 presented with flank pain 8 days post-biopsy A CT confirmed peri-nephric haematoma with retroperitoneal extension A total of 6 units of packed red cells (PRCs) were transfused prior to successful CT-guided emoblisation Histology from the biopsy revealed chronic tubulointerstitial nephritis Patient 2 experienced haemodynamic instability and haematuria one hour post-biopsy A total of 11 units of PRCs 7 units of fresh frozen plasma 2 pools of platelets intravenous tranexamic acid and 2 attempts at CT-guided embolization were required until haemostasis was achieved Histology later showed evidence of tumour infiltration with associated vasculitis Patient 3 presented with renal impairment and proteinuria on the background of known CMML Following discussion with haematology the risk of bleeding following renal biopsy was considered unjustifiable despite their platelets and coagulation screen being within normal range The patient was treated for presumed renal tumour infiltration with hydroxycarbamide Patient 4 was referred to the renal clinic with acute onset nephrotic syndrome Urinary proteincreatinine ratio was elevated over 800 mgmmol with serum albumin of 23 gL but normal excretory renal function The patient attends the haematology clinic with suspected CMML and chronic thrombocytopenia but previously declined bone marrow biopsy Following discussion with the patient there are no plans to proceed with renal biopsy given potential risks These cases highlight that while CMML is rare these patients are being referred to renal clinics with features that would commonly justify renal biopsy in other settings but in whom there may be an increased risk of bleeding post-procedure Our in-centre risk of major bleeding is 2 therefore to have such extreme amounts of bleeding in 2 patients with this underlying diagnosis is remarkable This creates a dilemma for the clinician as there is a wide range of potential renal pathology associated with CMML some of which will have disease specific but relatively toxic treatments available
Source of funding none Conflicts of interest none
P6 NHS Highland-Prograf to Adoport switch McCulloch K1 Peel R2 Lambie S3
1Renal Pharmacist Renal unit Raigmore Hospital Inverness 23Renal Consultant Renal unit Raigmore Hospital Inverness
Introduction NHS Highland (NHSH) is the first health board in Scotland to implement a switch from Prograf to Adoport for renal transplant patients This will provide considerable cost savings Adoport meets the bioequivalence criteria for drugs with a narrow therapeutic index set by the European Medicines agency and studies indicate therapeutic equivalence1 with the proviso that brands are non- interchangeable unless the switch is overseen by a Renal Consultant and post-conversion therapeutic drug monitoring is conducted23 The switch has been undertaken by a majority of transplant centres in England the main difference being that they have undergone repatriation NHSH Patients receive their transplant primarily at Royal Infirmary of Edinburgh and occasionally at Queen Elizabeth University Hospital Glasgow Care is transferred to NHS Highland on discharge NHS Highland cares for approximately 170 renal transplant patients 110 being prescribed Prograf These patients may live as far as 110 miles from Raigmore Hospital Given that prescribing is carried out by primary care clear communication with patients GPs and community pharmacy is essential to avoid inadvertent switching between brands
Method Clinically it was agreed a switch could be safely undertaken A business case was submitted and funding secured for pharmacist time laboratory costs and primary care time GPs have been informed via GP subgroup and local prescribing bulletin lsquoThe Pink Onersquo Community pharmacies are being informed by phone A protocol has been agreed Eligible patients selected by Renal Consultant and Renal Pharmacist Patients sent letter signed by Renal Consultant and Renal pharmacist Patients phoned prior to clinic to agree Adoport start date and address concerns Patient seen by Renal Consultant and pharmacist + given 1 month of Adoport Tacrolimus level and UampEs checked 5-7 days after commencing Adoport and patient
contacted by phone to check if tolerated If stable letter sent to GP and community pharmacy to continue supply
Results and Evaluation Letters have been sent to all eligible patients Seven patients have been reviewed One has received a one month supply of Adoport and 5 others are due to switch One patient was deemed non-eligible at present as they have a 6 month surplus of Prograf A database will be maintained and analysed at the end and primary care savings will be monitored Extra pharmacist input will give us the opportunity to review how immunosuppression is managed and to evaluate the benefit of having a renal transplant pharmacist Conclusion The switch is at an early stage Ultimately we hope to show that the switch from Prograf to Adoport can be managed safely with extra pharmacist input to a remote and rural population with prescribing being conducted by primary care
Fundingconflicts of interest none 1 McDevitt-Potter LM Sadaka B Tichy EM Rogers CC Gabardi S Transplantation 2011 A multicenter experience with
generic tacrolimus conversion 2 Medicines and Health Products Regulatory Agency Drug Safety Update 2012 Accessed online via
wwwmhragovukSafetyinformationDrugSafetyUpdateCON1557563 ESPRIT Guidance on management of repatriation and immunosuppressant switches in transplant patients 2015
Accessed online via httpwwwespritorgukwp-contentuploads201508Switch-guidance-document-final-Aug-31-2015pdf
P7 NHS Highland-Tacrolimus baseline dataMcCulloch K1 Peel R2 Lambie S3
1Renal Pharmacist Renal unit Raigmore Hospital Inverness 2Renal Consultant Renal unitRaigmore Hospital Inverness 3Renal Consultant Renal unit Raigmore Hospital Inverness
BackgroundAs part of planning a switch from using tacrolimus Prograf to Adoport we assessed baseline data for our transplant patients currently using Prograf After converting patients to Adoport we will compare their tacrolimus levels to their individual target range We assessed our use of appropriate target ranges and our current performance in achieving tacrolimus levels within target range on Prograf therapy
Method 107 renal transplant patients taking Prograf were identified a sample of 19 of these were analysed using electronic patient records and results Time from transplant ranged from 1 month to 18 years All tacrolimus levels for the preceding year were analysed and compared to the target range specified at the time of the level being done The assay used has a Coefficient of Variation of lt5 at the lower limit of the assay
Results All 19 patients had a target range for tacrolimus clearly identified and recorded in clinic letterswhich are routinely copied to the patients themselves A variety of target ranges were specifiedThe commonest used was 5-8 microgramsl in 7 patients followed by 5-7 in a further 4 patientswith another 6 different target ranges being used for the remaining 8 patients The ranges usedhad a breadth of 3 microgramsl in 2 cases the rest had a breadth of 2 microgramslPatients had a median of 12 (range 3-72) tacrolimus levels over the preceding year Results werewithin specified target ranges for 54 +- 22 (Medan +- SD) of results checked
Conclusion We currently use a large number of different target ranges The majority of the ranges used had a breadth of just 2 microgramsl These factors help to account for the low proportion of test results which were within the specified target ranges This is important to bear in mind when interpreting whether tacrolimus levels are within target ranges after switching to Adoport We should consider aligning our target ranges and widening them
P8 Eculizumab use in Scottish paediatric dense deposit disease Stewart D1 David Hughes1 Lynne Riach2 Craig Oxley2 Athavale D1
1Royal Hospital for Children Glasgow 2Royal Aberdeen Childrenrsquos Hospital Aberdeen
Introduction The revised MPGN classification and increasing recognition of Dense Deposit Disease (DDD) a C3 glomerulopathy as an alternative complement pathway disorder suggests Eculizumab an anti-C5 monoclonal antibody may be beneficial in treatment However the experience of Eculizumab as an off-label and expensive treatment in children with DDD is limited with variable clinical response reported in the literature
Method We present the outcomes of the only 2 paediatric patients in Scotland who have received Eculizumab for the management of DDD
Results Case 1 A 10 year old male presented with proteinuria and haematuria resistant to steroid treatment with preserved renal function Initial biopsy confirmed DDD Conservative management with an angiotensin converting enzyme inhibitor and diuretics for symptom control continued until 14 years Due to worsening symptoms (oedema lethargy poor growth) and renal function deterioration along with elevated terminal complement complex (TCC) Eculizumab was commenced A repeat biopsy whilst suggestive of chronic irreversible damage showed 25 glomerular architecture preservation Symptom improvement was noted There was a reduction in proteinuria and renal function stabilisation fall in TCC and discontinuation of diuretics Eculizumab was discontinued after 24 months Progression of renal function decline was seen in the final months of Eculizumab therapy With recurrence of symptoms and increasing proteinuria following discontinuation Eculizumab was recommenced after 6 months Symptomatic improvement has since been noted
Case 2 A 5 year old girl presented with painless frank haematuria and proteinuria Initial biopsy confirmed DDD Proteinuria was unresponsive to steroid therapy and 5 months following diagnosis she rapidly progressed towards end stage renal disease despite the introduction of Mycophenolate Mofetil and plasmapheresis Haemodialysis was subsequently commenced TCC level was elevated and Eculizumab treatment was started 7 months after diagnosis Renal biopsy prior to treatment demonstrated continued severe pathological changes in all visible glomeruli However due to lack of clinical response Eculizumab was discontinued after 2 months and the patient remained dialysis dependent
Conclusions Our experience with Eculizumab in Scotland has demonstrated variable results in our 2 patients with one patient showing a positive response whilst the other experienced no improvement Eculizumab was administered to both patients at varying points in their clinical journey with differing progressive features on biopsy To date the outcomes of 9 paediatric patients with DDD treated with Eculizumab have been described in the literature with 8 experiencing some positive response to treatment including 2 patients who were able to stop renal replacement therapy within 12 weeks of treatment A role for Eculizumab in DDD may be guided by clinical and pathological features Well designed clinical trials will be necessary to define the role of complement inhibition therapy in DDD
No conflict of interest and no funding requested
P9 Examining markers of safety in the use of non-tunnelled central venous catheters
James WT Millar (Speciality Registrar) Scott W Oliver (Speciality Registrar) Peter C Thomson (Consultant Nephrologist) Glasgow Renal and Transplant Unit Queen Elizabeth University Hospital Glasgow
Background Non-tunnelled central venous catheters (NTCVC) remain an essential means of vascular access for incident haemodialysis Associated morbidity is well recognised for example in the form of Staphylococcus aureus bloodstream infections (SAB)[1]
Previous quality improvement initiatives in our unit have sought to both improve traditional markers of quality (such as SAB) and to identify additional areas of clinical risk In 2014 Oliver et al [2] suggested several additional quality measures including peri-procedure haemoglobin drop the need for a further NTCVC during the same clinical episode and the NTCVC insertion site This study further evaluated NTCVC related clinical practice within our unit
Methods The potential markers of clinical quality identified in a previous project were examined using prospectively collected data stored in the electronic patient record Identified cases of SAB significant peri-procedure haemoglobin drop and multiple NTCVC insertion were investigated by case note review
Results Between March 2016 and March 2017 a total of 222 patients received 346 NTCVC 54 patients (243) had more than one NTCVC inserted in a 21-day period (range 2-5) When considering NTCVC insertion site there were 159 (459) femoral vein catheters and 183 (541) internal jugular vein catheters No pneumothoraces were reported
15 SABrsquos were reported during this period equating to 43 of all NTCVC 5 arose in patients with femoral NTCVC (333) and 10 from internal jugular catheters (667) Mean time from line insertion to positive blood culture was 86 days 15 (67) patients had a drop in haemoglobin of greater than 20mgdl with no other source of blood loss identified on review of clinical notes
Discussion These data demonstrate that NTCVC-associated SAB rates remain low and significantly below Scottish government audit standards [3] Of interest is the continued trend towards the use of femoral catheters at 45 of lines compared with 38 in 2014 [2] Although traditionally thought of as having a higher incidence of infectious complications our data has shown fewer bacteraemia events associated with femoral catheters compared with internal jugular Our data also demonstrates a significant rate of peri-procedure haemorrhage arising in up to 1 in 20 cases Together these findings present opportunities to development practice and improve patient safety
References
[1] Murray E Deighan C Geddes CC Thomson PC Reducing haemodialysis bacteraemia rates Scottish Renal Association Glasgow November 2013 [2] Oliver SW Thomson PC Jardine AG defining safe effective and patient-centred dialysis catheter placement Scottish Renal Association Edinburgh September 2014 [3] The Staphylococcus aureus bacteraemia quarterly report of cumulative data from all NHS Boards in Scotland Health Protection Scotland January 2015
Sources of funding none Conflicts of interest none
P10 Prescribing of tolvaptan-The NHS Highland experience Lambie S1 McCulloch K2 Garrod J3
1Renal Consultant Renal unit Raigmore Hospital Inverness 2Renal Pharmacist Renal unit Raigmore Hospital Inverness 3Renal Pharmacist Renal unit Raigmore Hospital Inverness
Introduction Tolvaptan is a vasopressin antagonist It was accepted for use in Scotland by SMC in Jan 2016 to slow the progression of cyst development and renal insufficiency of autosomal dominant polycystic kidney disease in adults with chronic kidney disease (CKD) stage 1 to 3 at initiation of treatment with evidence of rapidly progressing disease1 Adverse effects related to aquaresis may affect patientsrsquo ability to achieve the optimum therapeutic dose and the risk of hepatic toxicity necessitates regular LFT monitoring The geography of NHS Highland required the implementation of novel methods of managing these patients and as a result a MDT approach with an emphasis on pharmacist input was adopted Consultant role Patient selection on the basis of evidence of rapidly progressing kidney disease declining
eGFR large volume kidneys on ultrasound and evidence of complications of PKD Side effects and potential benefits discussed Potential medication interactions reviewed Jinarc risk management prescriber training
Pharmacist role Undertook Jinarc risk management pharmacist training Prepares accurate drug history and reviews for potential drug interactions Carries out patient counselling and supplies patient education material sick day rules card
and lsquogot to gorsquo card Supplies GP education leaflet Provides advice on selection of new drug therapies eg for gout Manages stock and coordinates supply to patients
Results Prescribing commenced May 2016 patients currently prescribed tolvaptan 11 7 Female 4 male Number on target dose 73 n = 811 2 patients are still being titrated One patient did
not tolerate target dose due to aquaresis side effects and is being trialled on the middle dose
Withdrawals One patient has withdrawn due to agoraphobia and an inability to attend for monitoring and another is on hold due to having major surgery
Conclusion The MDT approach between the Renal Consultant and Pharmacist at Raigmore Hospital has enabled tolvaptan prescribing to be efficiently and safely implemented to patients living within a challenging geographical location
1 Scottish Medicines Consortium Detailed Advice Document tolvaptan 15mg 30mg 45mg 60mg and 90mg tablets (Jinarcreg) SMC No 111415 January 2016
NA1 Authors SCN Jacqueline Ross NHS Grampian
SCN Alan Somerville NHS Lanarkshire SCN Jane Humphrey NHS Lanarkshire
e- mail contact jacquelinerossnhsnet Alansommervillelanarkshirescotnhsuk
Janehumphreylanarkshirescotnhsuk
Phone contact 01224 552927 01236 712644
Title Sharing of Adverse Events in Renal Units across Scotland
Introduction Background The Scottish Renal Nurses Strategy Group (SRNSG) are a group of senior nurses from Renal
Units across Scotland who meet 3-4 times per year to discuss and implement best practice At the last meeting it was agreed that it would be good practice for each Health Board to share
their adverse events reported on the Datix System and deliver a presentation with an action plan to prevent incidents and improve patient safety across Scotland NHS Grampian and NHS Lanarkshire will be the first to deliver this presentation discussing adverse events from both Health Boards with an action plan
Top 5 adverse events over the past 12 months Renal Unit NHS Grampian 1 Violence and Aggression 2 Accidents including needlesticks slips trips and falls 3 Medication Errors 4 Infrastructure Staffing and Estates 5 Machines and Equipment
Top 5 adverse events over past 12 months Renal Unit NHS Lanarkshire
1 Slips Trips or Falls 2 Medicine errors 3 Treatment problems 4 Transfer problems 5 Breach of policy
The presentation will also focus on any serious adverse events which may not be in the top 5 categories
Aim Objective Each Health Board to share their adverse events with the aim to prevent them from occurring in other units to improve staff and patient safety and wellbeing across Scotland
Method Power Point Presentation
Outcome Results Sharing of adverse events resulting in the development of a national Action Plan to prevent these incidents improving safety and well being of staff and patients in Renal Units across Scotland
NA2
SRA Oct 2017 Abstract
BBV Never Event - The whats whys and hows
Staff Nurse Gillian Wilson Aberdeen Royal Infirmary
This presentation shares our experience of a never event that occurred and was not picked up for
a period of 18 months
Hepatitis C (HCV) positive antibodies were found in a previously negative patient
These results were a low positive with no biochemistry changes to suggest any liver damage
however steps were put immediately in place to isolate and investigate
Was it contamination from a dialysis machine was it related to a blood transfusion given prior to
first positive result was it faulty diagnostic tests in the laboratory
In Aberdeen we go over and above national guidelines and isolate all our BBV patients whether
they have positive blood results or are PCR negative
Further bloods tested at an external laboratory confirmed negative results
It highlighted that communication errors were to blame for the lack of speed in detecting this issue
Investigations concluded no real answers as to why this happened
NA3
Living Donation Scotland Changing attitudes towards living donor kidney transplantation
Jen Lumsdaine Julie Glen On behalf of the Living Donation Scotland Project Board
Background and aims
The rate of living donor transplantation has remained fairly static in Scotland over the past 10 years
Recent data has shown inequity of access to living donor transplantation throughout the UK so
there is potential to significantly increase this optimum form of treatment for patients with end-stage
renal failure in Scotland The Living Donation Project Board was formed in 2016 aiming to double
the number of living donor transplants by 2020
Method
The two key areas
1 Do recipients receive adequate and appropriate information at the right time about living
kidney donation
2 Informing the general public about altruistic donation
All patients active on the transplant list in Scotland were invited to an information event A follow-up
questionnaire was performed in the East of Scotland examining outcome or reasons for not
attending A scoping exercise looked at information provided by each unit was performed and link
nephrologists and low clearance nurses attended meeting to discuss strategies for early education
Outcome
An information pack containing both recipient and donor written information and short films on DVD
has been produced with the support of the Scottish Government for all recipients and potential
donors in Scotland A new website with comprehensive information both written and visual and
postcode finder to improve ease of access to local unit contact details has been developed
Two national media campaigns have been launched with a significant rise in the number of enquiries
from potential donors and actual increase in altruistic donor numbers
Nursing abstract ndash no conflict of interest
NA4Authors Susan Easson Charge Nurse Ward 4C QEUH Glasgow
e- mail contact SusanEassonggcscotnhsuk
Phone contact 0141 452 3300
Title A Conversational approach to find out ldquoWhat matters to yourdquo in a Renal Transplant ward
Introduction Background Finding out ldquo What Mattersrdquo to people using health and careservices is crucial to delivering safe effective and person centred care It is a simple yet profoundconcept and tries to get to the essence of person centred care by creating deeply personalengagements with patients and their families through a conversational approach However careexperience feedback all too often provides innumerable examples of where what really matters topatients and their family members is poorly understood or not addressed Using care experienceas the driver for change the nursing staff in Ward 4C used improvement approaches to explorehow to hold more meaningful ldquoWhat Matters to yourdquo conversations on a daily basis
Aim Objective To improve the patient experience by utilising a person centred approach
Method Using Care experience feedback What Matters to Me boards and the conversationalapproach
Outcome Results Improvements in patient experience will be shared using examples ofpractice and care experience feedback
There was no additional funding required for this project We worked in collaboration with theperson centred team whorsquos aim is to improve patient experience
NA5
The implementation of a renal education programme and its impact on clinical practice
The purpose was to implement a Renal Education Programme and to evaluate its impact on
clinical practise
It was identified that there was a need for an educational programme to be set up within Forth
Valley Royal Hospital There is no inpatient renal unit in FVRH on site for our renal patients they
attend Queen Elizabeth University Hospital We are an outpatient haemodialysis unit with
outpatient clinics on site Therefore it was identified that there was a need for nursing staff within
FVRH to be educated on all renal complexities for the benefit of our patients
This was done through a work-based learning approach which brought tangible benefits for our
patients However it did not come without pitfalls as educational programmes are often seen as
making very little difference to clinical practise
T
his study describes what methods were used and examines the advantages and disadvantages in
setting up an educational programme and evaluating its impact on clinical practise
NA6
Nursing Abstract ndash SRA Meeting ndash 26 October 2017
Chris McGee Tonya Broe Ken Weir
Renal Unit Forth Valley Royal Hospital
Use of the Therapy Monitor Haemodialysis Patient Record System Can we aim for a paper-
free dialysis unit
We are trialling a new haemodialysis patient monitoring system to work in conjunction with SERPR
and which is intended to supersede the Finesse system used previously
We are in the early stages of this process but with continuing staff education and regular tech
support we are hoping to gather sufficient evidence to evaluate whether the use of paper case
notes needs to continue
Is it a realistic goal to aim for a completely paper-free unit
NA7
THE CLINICAL USES OF APHERESIS WITHIN NHS TAYSIDE
Laura Thomson CN
Ninewells Hospital Dundee
NHS Tayside took over the apheresis service from BTS in 2012 The service has since expanded
with the benefits of carrying out this treatment has been widely recognised within NHS Tayside
and is now more commonly being offered to treat a wider range of conditions with the number of
treatments carried out each year rising
This presentation will highlight the progression of the apheresis service within NHS Tayside We
will identify the various conditions it is currently being used to treat and also identify the decision
making process involved in carrying out these treatments ie which replacement fluid will be used
anticoagulation medication administered
We will highlight the benefits and challenges we face in providing this expanding service within the
Renal Service
NA8Authors Linda McDougall Renal Physiotherapist NHS Highland
e- mail contact lindamcdougall1nhsnet
Phone contact 01463 706022
Title lsquoExercise on Haemodialysis- Keeping the Wheels in Motionrsquo
Introduction Background The impact of CKD on physical fitness functional ability independence amp ultimately quality of life cannot be underestimated Current national guidelines recommend that all individuals with CKD are encouraged to participate in regular exercise programmes between or during dialysis sessions if on HD Following a successful pilot study funding was approved to establish an lsquoExercise on Dialysisrsquo (EOD) programme across NHS Highland through the appointment of a dedicated renal physiotherapist in 2008 A successful programme was soon established but for several years post-vacancies and increasing in-patient demands limited the physiotherapy servicersquos ability to deliver the programme The need to improve the long-term sustainability of the service was recognised and in late 2016 funding was approved to develop a Band 4 PT HCSW role for this purpose
Aim ObjectiveTo optimise the sustainability and continuity of the lsquoExercise on Dialysisrsquo service across NHSHighland through development of a Band 4 PT HCSW role
Method The potential parameters of the role and limits of autonomy were scoped out using current NES resources and guidelines Service and task analysis was then carried out to establish which components of the EOD protocol could be undertaken by a Band 4 A series of competencies were developed in line with the clinical protocol and one-to-one training and supervision provided to the post-holder to ensure competency achieved in delivering the programme
Outcome Results A 10 WTE Band 4 PT HCSW was appointed in Jan 2017 with a dual role between the renal unit and acute medical wards Although training is not yet complete the post-holder is already running the day-to-day delivery and monthly audit of the EOD service with senior physiotherapist input only required for individual patient safety queries and general discussion around patientsrsquo progress and goals The benefit to the unit has been considerable as the band 4 is available to support patients and staff with EOD provision 5 days a week This allows for one-to-one supervision of patients who need more support to participate in EOD regular feedback on performance and reviews of outcome measures and goals to maintain motivation levels Feedback on the post has been very positive and its scope will only continue to expand as we look to further develop renal rehabilitation services across NHS Highland
NA9Authors Nadine Lyall and Kerry Guthrie
e- mail contact nadinelyallbordersscotnhsuk kerryguthriebordersscotnhsuk
Phone contact 01896 826637
Title The Developing Role of the NMP in a Satellite Dialysis Unit
Introduction Background
We have been practising as NMPrsquos for nearly 3 years working in the dialysis unit at the BGH The unit is a satellite unit of the ERI and we have expanded over the last 6 years The unit provides haemodialysis for 12 patients at any one time 3 sessions a day 6 days a week We are nurse-led and have 2 renal consultants who are based at the ERI
We saw an opportunity to use our knowledge and experience to develop our role By becoming NMPrsquos we have enhanced our professional development and we feel we meet the changing needs of the dialysis patient in a more holistic manner
Aim Objective
Our aim is to deliver effective care as we are better placed to deal with issues that often arise byacting swiftly this in turn is cost effective and convenient For example good anaemia and bonemanagement is important for their health wellbeing and lifespanTo help understand our role we will use a power point presentation highlighting issues we dealwith and the drugs we prescribe under the following headings Cardiovascular infection painanticoagulant disequilibrium diet renal bone disease and renal anaemia
Method Power point
Outcome Results
In the future we hope to further develop and have greater autonomy in our role We have great support from our renal consultants and have already built up a great relationship with our patients We hope to undertake the Clinical Decision Making course and this in turn will allow us to deal effectively with acute illness giving the dialysis patient better care We are keen to get feedback from other renal nurses in Scotland to enable us to develop our role further and in turn raise awareness of the NMP role in a dialysis unit We record all our prescribing decisions and keep the consultants up to date regularly Currently we are working on auditing our prescribing practice so that we can improve the service we can provide
NA10 Title Komunikacja w szkoleniu dializy ortzewnowej
Author Senior Charge Nurse Rhoda Bell
Address Raigmore Hospital Old Perth Road Inverness IV2 3UJ
Email rhodabellnhsnet Telephone 01463706023
Introduction Background Case study on lady with Polish as her first language she has some English but requires an interpreter to carry out Peritoneal Dialysis training and attend clinic She had some gynaecological issues that we were not aware of which impacted on the functionality of PD and therefore the success of treatment There were areas of concern in low clearance clinic with signs the patient had a reluctance to engage in decision making
AimObjective
Methods Discussion through the case study highlighted issues with communication between different PD staff and patients Areas of concern include different staffing techniques environment factors on training success Also language and communication issues the patient had were not fully apparent so training could not be individualised
Results We plan to trial training at home and have more individualised training schedule for patients The training step by step guides have been reviewed and practise standardised In collaboration with low clearance nurse we have developed a check list which will highlight concerns before the transition to PD ie language issues and need for training aids in another language gynaecological conditions
Conclusions Everyone learns differently and training methodsaids must be individualised for all It may not be apparent until training has commenced that there are concerns Having one to one training with the same nurse will consolidate training and build confidence in the patient Having a close working relationship with members of the MDT will help make a supportive PD journey
Would we do things differently if we knew about prolapse or lack of English both spoken and written
Key words - Peritoneal dialysis patient training communication
N11
Telehealth amp PDAudrey Jones
Advantages
Information on a daily basis about treatment weight and blood pressure
Change programme remotely via computer or mobile
Earlier intervention for machineprogramme issues
Reduction in home visits ie patient trained but still requires volume increases
No need to download cards to see what problems have been
Can have more detailed information available at clinics
Disadvantages
Relying on patient input data correctly
Machine is noisy especially first wave of machine
Still the same bag connection system and patient connection system (difficult for manual
dexterity problems)
Relying on patient having good signal
Modem problems
NA12Autosomal Dominant Polycystic Kidney Disease A cruel inheritance but new hopeAlistair Lawrie Renal Unit Victoria Hospital KirkcaldySadaf Arshad Corry Dunnigan Paul Phelan Neil Turner Renal Unit Royal Infirmary of Edinburgh
Background Autosomal Dominant Polycystic Kidney Disease (ADPKD) is the most prevalent single gene human genetic disorder and the most common of the inherited cystic and interstitial kidney diseases It is estimated to affect 1 in every 1000 individuals worldwide with over 50 of sufferers eventually developing end stage kidney disease and requiring dialysis or transplantation Symptoms include spasmodic severe pain hypertension haematuria infection and kidney failure There is currently no cure for ADPKD Management of the condition has traditionally involved lifestyle modification BP control and analgesia however a recent study (Torres et al 2012) demonstrated that treatment with V2-receptor antagonist drugs slowed increase in total kidney volume reduced the rate of functional decline and showed a reduced incidence of kidney pain
Aim Provision of a tolvaptan prescribing and monitoring service
Methods Experiential finding report of initial twelve months period of multidisciplinary ADPKDtolvaptan clinic
Results Early results are comparable with TEMPO study outcomes
Conclusion Due to the long term nature of this treatment results available at this time are showing only the earliest benefits of the intervention More quantifiable results such as increased time before the necessity for RRT will only be evident in coming years Torres VE et al (2012) Tolvaptan in Patients with Autosomal Dominant Polycystic Kidney Disease New England Journal of Medicine 367 pp 2407-2418 DOI 101056NEJMoa1205311
No funding requirement No conflict of interest
A14 High Mortality In Older Patients With Primary Nephrotic Syndrome Sarah Beverstock Wendy Metcalfe amp Robert W Hunter Department of Renal Medicine Royal Infirmary of Edinburgh
Introduction
Nephrotic syndrome can develop at any age and may be due to a primary glomerular lesion or secondary to systemic disease The natural history of glomerular disease can be different in older patients For instance minimal change disease (MCD) in children almost always remits promptly with steroid therapy in adulthood it typically remits only after many weeks of steroids or with adjunctive immunosuppression However there are remarkably few published data on the mortality of primary nephrotic syndrome in adults We aimed to study this in our centre
Methods
We enrolled all adult patients who had a kidney biopsy in order to investigate nephrotic syndrome over 38 consecutive months (01 Jan 2014 ndash 28 Feb 2017) We defined nephrotic syndrome as heavy proteinuria (urinary proteincreatinine ratio UPCR gt350 mgmmol or albumincreatinine ratio gt220 mgmmol) and hypoalbuminaemia (serum albumin lt35 gL) In our analysis we included all patients in whom nephrotic syndrome was attributed to a primary glomerular disease We excluded kidney transplant recipients and patients in whom biopsies were performed to follow up a known glomerular disease We collected laboratory data at baseline (time of biopsy) and at 6 and 12 months We assessed patient survival by Kaplan-Meier analysis
Results
Of the 117 patients biopsied for nephrotic syndrome 71 patients (61 ) met the inclusion criteria and were followed up for a median of 469 days We compared outcomes in patients aged under 60 years old (n = 35) with those aged over 60 (n = 36) Mortality was higher in the older group (37 vs 4 mortality at one year p lt005 by logrank test) There were no significant differences between the two groups in serum creatinine or UPCR at any time Serum albumin was similar in both groups at baseline and at 12 months but was lower in the older group at 6 months (27 vs 32 gL p lt 005) Baseline haemoglobin was lower in the older group (114 vs 130 gL p lt005 by unpaired t-test) Primary diagnoses were MCD (n = 10 in younger group amp n = 5 in older group) membranous nephropathy (5 amp 10) IgA nephropathy (9 amp 8) FSGS (5 amp 5) membranoproliferative glomerulonephritis or C3GN (4 amp 7) and other (2 amp 1) Therefore unsurprisingly there were relatively fewer cases of MCD and more cases of membranous nephropathy in the older group otherwise the causative glomerular lesions were similar in both groups In those patients with MCD mortality was significantly higher in the older group none of the 10 patients with MCD diagnosed under 60 yrs old died during the follow-up period whereas 4 of the 5 older patients died 3 patients in the younger group and 1 in the older group were on renal replacement therapy (dialysis or transplant) by the end of follow-up
Conclusions
Primary nephrotic syndrome is associated with high mortality in the over 60s (37 at one year) Mortality was high even for MCD a disease that follows a benign course in childhood and early adulthood The higher mortality in older patients was not associated with greater severity of renal disease at presentation (as assessed by basic blood and urine parameters) This work was not funded we declare no conflicts of interest
A15 Renal biopsies in patients with diabetes mellitus in Scotland
Udana Ratnapala 1 Nicola Joss 2 Colin Geddes 3 Dana Kidder 1
1 Renal Unit Aberdeen Royal Infirmary Aberdeen 2 Renal Unit Raigmore Hospital Inverness 3 Glasgow Renal and Transplant Unit Glasgow
Introduction Diabetes mellitus is the leading cause of end-stage kidney disease (ESKD) requiring renal replacement therapy The utility of renal biopsy in patients with diabetes mellitus is controversial Broadly renal biopsy findings in patients with DM can be divided into diabetic nephropathy (DN) alone DN with non-diabetic renal disease (NDRD) or NDRD alone Timely identification of patients with NDRD is important to provide appropriate therapeutic measures Previously published guidelines on clinical predictors of NDRD have limited specificity and sensitivity The frequency of NDRD in renal biopsies of patients with DM is unclear in ScotlandThis study aimed at identifying the frequency and the pathology spectrum of NDRD in diabetic patients underwent kidney biopsy in 3 renal units
Methods A retrospective observational study was performed on clinical-pathologic findings in all patients with diabetes mellitus who underwent renal biopsy between 01012010 and 31122016 in 3 renal units (Aberdeen Inverness and Greater Glasgow) Data were gathered from electronic patient record systems Scottish Index of Multiple Deprivation (SIMD) 2012 was used to analyse correlation with patient outcomes
Results 247 patients were included 150 men (607) 217 type 2 DM (879) mean age 621 years and mean serum creatinine at the time of renal biopsy of 261 micromolL (+-190 std) On biopsy 92 patients (372) had DN while 127 (514) had NDRD and 28(114) had NDRD superimposed on DN The commonest NDRD aetiologies were IgA nephropathy (187) tubulointerstitial nephritis (168) and idiopathic membranous nephropathy (103) Predictors of NDRD were age (OR 1027 95 CI 1002-1052 p=003) duration of DM (OR 094 95 CI 0900-0987 p=001) and absence of AKI as indication for biopsy (OR 022 95 CI 0059-0826 p=0025) There was no significance difference in renal or patient survival in DN and NDRD Finally no significant correlation was depicted between SIMD quintiles and renal or patient survival in both groups
Conclusions The majority of renal biopsies carried out in patients with DM revealed a NDRD In this study age at the time of biopsy duration of DM and AKI were the main pointers towards NDRD Renal and patient survival were not significantly different between DN and NDRD groups
A16 The Impact of Withdrawal of Maintenance Immunosuppression and Graft Nephrectomy on HLA Sensitisation Ailish Nimmo1 Sophie McIntyre1 Lorna Henderson1 Richard Battle2
(1 Department of Renal Medicine Royal Infirmary of Edinburgh 2 Histocompatibility and Immunogenetics Royal Infirmary of Edinburgh)
Background The development of HLA antibodies towards a failing renal allograft is a barrier to re-transplantation We previously demonstrated an increase in HLA antibodies and calculated reaction frequency (cRF) following nephrectomy but results were confounded by immunosuppression changes occurring in close time proximity We examined the formation of HLA donor specific antibodies (DSA) in patients with failed grafts that remained in situ and compared results with patients undergoing graft nephrectomy to further assess the relative impact of nephrectomy and immunosuppression weaning on sensitisation and chance of transplant
Methods We carried out a single centre retrospective study of all patients with failed grafts in Lothian from 2005 to 2015 Samples were tested for DSA pre-immunosuppression (IS) wean post-IS wean and post-IS cessation Nephrectomy patients also had samples tested for DSA before and after nephrectomy Data on other sensitising events including blood transfusion and rejection were collected cRF was determined at each time point and entered into the ODT chance of transplant calculator with other demographics based on the average patient from the Edinburgh centre
Results 62 grafts failed over this time period Blood samples were available 41 patients (24 with nephrectomy 17 with failed graft left in situ) Patient demographics were similar between groups There was a higher rate of antibody mediated rejection in the nephrectomy group (46 vs 18) 76 of patients with nephrectomy group had received a blood transfusion The pattern of immunosuppression weaning was similar but median time from start of IS wean to cessation was longer in the nephrectomy group (350 vs 298 days) The changes in cRF and chance of transplant (COT) with immunosuppression weaning are shown in Table 1
Pre-IS Wean Post-IS Wean
Failed graft in situ (n=17)
Mean CRF COT at 5
years 15 62 38 59
Nephrectomy (n=24)
Mean cRF COT at 5
years 54 54 69 46
Post-IS Stop 55 53 89 42 Table 1 Mean cRF and Chance of Transplant (COT) at 5 years with IS alterations
Discussion A stepwise increase in cRF with reduced chance of transplant was observed in both groups as immunosuppression was withdrawn with a similar pattern of change irrespective of graft nephrectomy cRF was higher in the nephrectomy group despite a more gradual wean which may reflect a higher rate of antibody mediated rejection and increased number of patients receiving a blood transfusion The risks and benefits of stopping immunosuppression need to be carefully considered on an individual basis to maximise chance of future transplant
The authors have no conflicts of interest No funding was required for this study
A17 Obesity is not associated with progression to end stage renal disease in patients withbiopsy-proven glomerular diseases
Benjamin Elyan Jennifer S Lees Bruce Mackinnon Jonathan G Fox Colin C Geddes Emily PMcQuarrie
Glasgow Renal and Transplant Unit Queen Elizabeth University Hospital Glasgow
Introduction - Addressing risk factors for renal progression is a key aspect of managing chronic kidney disease (CKD) Body mass index (BMI) has been shown to impact on renal progression in unspecified CKD The aim of this study was to evaluate if there was an association between BMI and progression to renal endpoints in patients with biopsy-proven primary glomerular disease (GN)
Methods - We included all adult patients diagnosed with biopsy-proven primary GN (excluding minimal change nephropathy) in Greater Glasgow amp Clyde and Forth Valley between 01012000 and 31122015 Biochemical and anthropometric data were extracted from the electronic patient record at time of biopsy with follow-up data until 20062017 BMI was calculated from height and weight at time of biopsy and categorised into groups BMI le25 kgm2 (G1) gt25 to le30 kgm2 (G2) and gt30 kgm2 (G3 - obese) We assessed factors associated with reaching a combined renal endpoint of CKD5 or renal replacement therapy (RRT) with competing risk of death using the Fine and Gray subdistribution hazard model Analyses were conducted using cmprsk package for R statistical software package and SPSS version 24
Results - 560 patients with primary GN and available BMI data were included The average age was 532 years and 339 were female There were 132 patients in G1 210 in G2 and 207 patients in G3 Those in G2 and G3 were older (p=002) with slightly higher diastolic blood pressure (p=002) than those in G1 There was a greater proportion of focal segmental glomerulosclerosis in G3 but similar proportions of other GN diagnoses across groups There was no significant difference in baseline serum creatinine (sCr) (p=034) or log uPCR (p=045) between BMI groups On multivariate analysis age systolic blood pressure BMI or GN diagnosis were not predictive of renal outcome Higher baseline sCr (SHR 1003 per 1 umoll increase in sCr 1001-1004 plt0001) and log uPCR (SHR 130 per unit increase in log uPCR 95 CI 105-160 p=002) were associated with progression to the combined renal endpoint accounting for competing risk of death BMI was not associated with reaching combined renal endpoint on univariate analysis whether considered as a continuous variable (SHR=100 95 CI 098-102 p=096) or categorised by BMI group
Conclusion - Contrary to our expectations there was no association between BMI and progression to a combined renal endpoint of CKD5 or RRT in this cohort of patients with primary GN Efforts should be directed to managing other known risk factors for CKD progression
Sources of FundingConflicts of Interest - None
A18 Factors influencing long term renal function after living kidney donation
Matthew A Rutherford Norman J Galbraith Marc Clancy Colin C Geddes
Glasgow Renal and Transplant Unit Queen Elizabeth University Hospital Glasgow UK
Background Following live donor nephrectomy the remaining kidney undergoes an increase in filtration capacity known as compensatory hypertrophy Few cohorts with follow up of renal function beyond 5 years have been reported The impact on long term renal function of variability in donor factors such as age sex pre-donation blood pressure and glomerular filtration rate (GFR) is unknown Increasingly kidney donors have potential risk factors for future poor renal function such as hypertension older age and obesity The aim of this study was to analyse factors influencing long-term renal function in living kidney donors from our centre
Method Data were obtained from the electronic patient record Patients with a recorded procedure of lsquolive donor nephrectomyrsquo between 2005 and 2017 were identified GFR after donation (calcGFR) was calculated using the formula lsquocalcGFR = Pre-donation Isotope GFR x (Pre-donation Serum creatinine Serum Creatinine)rsquo which is accurate assuming muscle mass does not change Pre and post donation serum creatinines (two days two weeks three months and one to ten year) were recorded We analysed the influence of age sex pre-donation GFR and blood pressure on post donation GFR compensation
Results 355 live donor nephrectomies were performed between January 2005 and December 2016 The mean age was 469 (plusmn 116) years and 504 (n=179) were female Mean pre-donation isotope GFR was 937 plusmn 156 mlmin173m2 Median follow up was 2 years (IQR 1 to 6 years with range 2 weeks to 10 years) The calculated percentage of pre-donation GFR at 2 days 2 weeks 3 months 1 year 5 years and 10 years were 698 691 712 730 801 and 950 respectively (p lt 0001) Patients aged lt50 y had not only a higher calcGFR (858 plusmn 29 mlmin173m2 compared with 671 plusmn 28 mlmin173m2 p lt 0001) at 5 years following donation but achieved a higher degree of compensation than donors gt 50 y (836 plusmn 16 compared with 756 plusmn 19 (p = 0002) Patients with pre-donation hypertension achieved 774 plusmn 53 of pre-donation GFR compared with 804 plusmn 32 in normotensive patients (p = 0998) Females had equivalent degree of renal compensation achieving 819 plusmn 19 compared with 780 plusmn 16 in males (p = 0131) at 5 years following donation Patients with pre-donation GFR gt 100 mlmin173m2 achieved 844 plusmn 23 of pre-donation function by 5 years compared with 777 plusmn 14 in those with pre-donation GFR lt 100 mlmin173m2 (p = 001)
Conclusion Following live donor nephrectomy renal function has a nadir of 691 at 2 weeks Compensation in GFR occurs rapidly and appears to be maintained regardless of sex and pre-donation blood pressure Younger age and higher pre-donation GFR were associated with a greater degree of compensation
A19 The utility of high-sensitivity cardiac troponin to stratify cardiovascular risk in patients with renal impairment
Eve Miller-Hodges Atul Anand Anoop S V Shah Nicholas L Mills Neeraj Dhaun
Background Cardiovascular disease is the most common outcome of chronic kidney disease1
Declining glomerular filtration rate (GFR) and proteinuria predict increased cardiovascular risk over the long term2 However there are currently no methods to stratify cardiovascular risk in the short or medium term in patients with renal impairment We have already shown that high-sensitivity cardiac troponin I concentrations (hs-cTnI) lt5ngL in patients presenting with symptoms of acute coronary syndrome identifies those at low risk of cardiac events within 30 days and over the next year3 However uncertainty remains over the role of hs-cTnI testing in patients with renal impairment This study investigated whether hs-cTnI could also stratify future cardiovascular risk in patients with renal impairment
Methods In a prospective study of consecutive patients presenting with suspected acute coronary syndrome we evaluated the performance of hs-cTnI in patients with and without renal impairment (estimated glomerular filtration rate lt60mLmin173m2) using an early risk stratification threshold of 5ngL to ldquorule outrdquo acute myocardial infarction at presentation and within 30 days and sex-specific 99th centile diagnostic thresholds for index type 1 myocardial infarction Subsequent type 1 myocardial infarction and cardiac death were reported at one year
Results Of 4726 patients identified 904 (19) had renal impairment Index diagnosis of type 1 and type 2 myocardial infarction was almost twice as likely in patients with renal impairment (30 vs 15) Performance of the early risk stratification threshold of 5ngL to identify patients at low risk of major cardiac events was similar in patients with (NPV 984 95CI 960-997 sensitivity 989 95CI 975-999) and without renal impairment (NPV 997 95CI 994-999 sensitivity 984 95CI 972-994) These patients continued to remain at low risk over the next year The PPV and specificity at the 99th centile for diagnosis of myocardial infarction were lower in patients with renal impairment at 500 (95CI 452-548) and 709 (95CI 675-742) respectively compared to 624 (95CI 588-659) and 921 (95CI 912-930) At one year 24 of patients with renal impairment and troponin gt99th centile regardless of index diagnosis had experienced further myocardial infarction or cardiac death compared with 10 of patients without
Conclusion In suspected acute coronary syndrome hs-cTnI can stratify risk in patients with renal impairment Irrespective of diagnosis patients with renal impairment and elevated cardiac troponin concentrations had two-fold greater risk of a major cardiac event compared to those with normal renal function and should be considered for further investigation and treatment
Funders Wellcome Trust British Heart Foundation and Chest Heart amp Stroke Scotland
1 Gansevoort RT Lancet 2013
2 Chronic Kidney Disease Prognosis Consortium Lancet 2010
3 Shah AS Lancet 2015
A20 lsquoDOES IT DIALYSE OUTrsquo - THE EFFECT OF RENAL REPLACEMENT THERAPY ON THE BRAIN Mark Findlay Jesse Dawson David Dickie Deborah McGlynn Patrick Mark Institute of Cardiovascular and Medical Science University of Glasgow amp Queen Elizabeth University Hospital Glasgow
Introduction Cerebrovascular disease is common in end-stage renal disease (ESRD) on renal replacement therapy (RRT) We investigated the effect of RRT on cerebral structure and cognitive function over 12 months Methods Observational cohort study in ESRD patients receiving HD Prior cognitive impairment or cerebrovascular disease were exclusion criteria Multi-domain cognitive testing was performed at baseline and at follow-up Transcranial Doppler was used to assess intra-dialysis related alterations in mean flow velocity (MFV) ndash a marker of cerebral blood flow MR imaging was performed at 0 and 12 months We performed T1 T2 FLAIR and DWI sequences and used volumetric software to calculate white matter hyperintensity (WMH) burden markers of atrophy mean diffusivity and fractional anisotropy (FA) to describe structural changes at 1 year Results 97 patients median age 59 years 412 female At follow-up 15 patients were transplanted 6 died 4 withdrew and the remainder continued HD Those who were transplanted were younger (median age 51 vs 60 years p=0019) and had been on dialysis for a shorter period (median 06 vs 21 years p=0003) MFV declined during HD median 475cms to 405cms plt0001 and correlated with lower scores of executive and frontal lobe function during HD (Rho 045 p lt0001 and Rho -0313 p lt001 respectively) In all patients MR imaging demonstrated a significant decline in frontal parietal and temporal lobe volume at follow-up Median WMH volume increased in those who remained on HD but not in transplanted patients (median change 023 vs -012ml p=0018) WMH burden correlated with worsening scores of frontal lobe tests Rho 0585 p0005 and worse mood Rho -0485 p0026 FA improved following renal transplant (028 to 029 p=0016) and correlated with improved executive function testing at follow-up Rho 089 p0019 Conclusion Cerebral blood flow is reduced during haemodialysis and correlates with a reduction in intradialytic executive function There is an improvement in FA following transplantation WMH volume increases in those who remain on dialysis and the degree of increase correlates with executive and frontal lobe function This suggests that haemodialysis is associated with clinically significant changes in the brain and that these may be ameliorated by transplantation
Source of fundingconflicts MF is funded by a KRUK fellowship
A21 Pathological classification of IgA nephropathy to predict renal outcomes ndash is there a better way to score tubulointerstitial inflammation
Alastair Rankin David Kipgen Bruce Mackinnon Jonathan Fox Colin Geddes Emily McQuarrie Glasgow Renal and Transplant Unit On behalf of the Scottish Renal Biopsy Registry
Background The Oxford pathological classification of IgA nephropathy (IgAN MEST-C score) is limited by the fact that individual features of the score are not all predictive and its utility in assisting clinical decision-making is questioned The addition of tubulointerstitial inflammation to the existing scoring system is appealing but is not currently included due to reportedly wide inter-observer variability We report a novel method to score percentage of cortex containing tubulo-interstitial inflammation in non-atrophic renal cortex (ATIN) in patients with IgAN similar to that used in transplant biopsy reporting and assess its utility to predict clinical outcomes
Methods All adult patients with a native renal biopsy diagnosis of IgAN between 2010 and 2015 in a unit serving 15 million people were identified Baseline characteristics biopsy reports and outcome data were collected ATIN was calculated by subtracting the percentage of atrophic cortex from the percentage of total cortex with tubulo-interstitial inflammation withge10 representing significant tubulo-interstitial inflammation in non-atrophic cortex The primary outcome was a composite of requiring renal replacement therapy (RRT) or doubling of serum creatinine (sCr)
Results 153 new cases of IgAN were identified 33 were excluded (24 had lt8 glomeruli on biopsy 6 inadequate biopsy for MEST scoring and 3 on RRT at time of biopsy) In addition patients with a tubular atrophy (T) score of 2 were also excluded (n=9) Of the remaining 111 patients 76 (68) were male Mean age at biopsy was 52 years (+- 167) and 18 (16) had a co-existing clinical diagnosis of henoch-schonlein purpura (HSP) Median sCr was 156 micromoll (IQR 101-212) and 54 (49) had ATIN on biopsy During a median follow-up of 23 years 34 (31) reached the primary outcome 20 (18) received immunosuppression and 16 (14) died On univariate Cox regression survival analysis ATIN was associated with a four-fold increase in the primary outcome (HR 49 (21-113)) On multivariate analysis mesangial hypercellularity (M) T and ATIN independently predicted renal outcome while endocapillary proliferation (E) and segmental sclerosis (S) did not (plt002 for ATIN) Excluding patients with HSP or those who received immunosuppression did not change the result
Conclusion Within our centre ATIN predicts renal outcome for IgAN independently of established histological features Assessment of inter-observer reproducibility and validation in other cohorts is still required but these results suggest ATIN could be a worthwhile addition to current pathological scoring systems for IgAN
Source of funding none Conflicts of interest none
P1 Polypharmacy in Renal Replacement Therapy Patients
Jason McMinn Colin Geddes Glasgow Renal and Transplant Unit Queen Elizabeth University Hospital
Introduction
Prescribing is often led by evidence from studies containing participants with single health conditions and without multimorbidity Polypharmacy is becoming increasingly recognised in patients with multiple chronic health conditions Additional medications are more likely to result in diminishing returns in benefit with an increased risk of harm Patients with established renal failure (ERF) are likely to be susceptible to medication-related harm A high pill burden is also likely to contribute adversely to an already restricted quality of life and has been associated with poor medication adherence The aim of this study was to analyse polypharmacy in all patients with ERF attending our service
Methods
We extracted medication records for all prevalent ERF patients attending the Glasgow Renal and Transplant Unit from the West of Scotland Electronic Renal Patient Record (SERPR) as of 01012017 The records were analysed to calculate the number of regular medications and total pill burden of each patient These medications were categorised as being lsquopreventativersquo or lsquosymptomaticrsquo We also analysed the prescription of specific drug classes to examine the prevalence of these medications
Results
We identified 1091 transplant follow-up 529 hospital haemodialysis and 46 peritoneal dialysis patients who were on a mean of 94 13 and 129 different medications respectively Overall pill burden was 139 tablets a day in transplant follow-up patients 141 in haemodialysis patients and 162 in peritoneal dialysis patients There were similar rates of prescribing between the different dialysis units and clinics within our service
The proportions of medications deemed as preventative rather than symptomatic were 76 in transplant 69 in haemodialysis and 60 in peritoneal dialysis
In transplant patients decreasing renal function was associated with a higher pill burden but even patients with a transplant eGFR gt 60 were on a mean of 126 tablets per day including a mean of 14 antihypertensives
Rates of antidepressant prescribing were 15 in transplant patients and 20 in hospital haemodialysis patients 53 of haemodialysis patients were on a statin 39 on aspirin 61 on a proton pump inhibitor and 7 were on warfarin
Conclusion
Patients undergoing all forms of renal replacement therapy are likely to be on a considerable number of medications Whilst these drugs are inevitably prescribed for valid reasons this data demonstrates the need for clinicians to engage with patients to explore opportunities to reduce pill burden
Conflict of Interest None Sources of Funding None
P2 An audit of Acute Kidney Injury (AKI) on an acute stroke ward before and after plannedinterventions to review and maintain hydration
Clare Harris1 Simon Hart2 Fiona Duthie3 1 University of Edinburgh Medical School 2 Stroke Unit Royal Infirmary of Edinburgh 3 Renal Unit Royal Infirmary of Edinburgh
Background Dehydration is an important factor in the development of acute kidney injury which is associated with increased morbidity and mortality particularly in the elderly population Poor fluid intake is common post stroke (1) and dehydration is associated with poorer outcomes 3 months post stroke (2) In late 2014 there was no system of identifying patients with poor oral intake on the stroke ward at the Royal Infirmary of Edinburgh a hydration protocol and education programme were implemented aiming to improve fluid balance This included the use of prescribed water either orally or by nasogastric tube An audit pre and post intervention demonstrated that hydration as measured by ureacreatinine ratio significantly improved after the protocol introduction (3) We aimed to determine whether the incidence of AKI by KDIGO criteria was also reduced as this could have implications for reducing patient morbidity and mortality in this elderly comorbid patient cohort
Method 150 inpatients to the acute stroke ward during JulAug 2014 and JulAug 2015 were selected (n= 80 2014 n=70 2015) Patient data and creatinine values were collected from the electronic patient record and medical notes and retrospectively analysed Baseline creatinine values were calculated and cases of AKI were identified and staged using KDIGO criteria (4) Chi-Squared tests were performed to determine P values Individual patient notes were reviewed for both quantitative and qualitative data of patient management
Results Incidence of AKI (of any stage) was 263 pre-protocol and 200 post-protocol (P=03646) Incidence of AKI stages 23 was 100 pre-protocol and 715 post-protocol (P=05374) In hospital post stroke mortality was 338 pre-protocol and 1286 post protocol (P=00028) AKI was also associated with increased length of stay
Conclusions Despite a trend in benefit there was no significant difference in incidence of AKI pre and post hydration protocol nor in incidence of severe AKI (stage 23) AKI is influenced by many factors one of which is hydration status Further studies are needed to determine whether the trend of benefit exhibited in this sample is significant in a greater sample size if this were the case such a protocol could have great benefit to patient care on stroke units and elsewhere There was a significant difference in inpatient post stroke mortality following introduction of the hydration protocol Further investigations are needed to explain underlying reasons for this factors other than hydration may play an important role
References 1 Whelan K Inadequate fluid intakes in dysphagic acute stroke Clinical Nutrition (2001) 20(5)
423-428 2 Bhalla A Sankaralingam S Dundas R Swaminathan R Wolfe CDA Rudd AG The influence of
raised plasma osmolality on clinical outcome after acute stroke Stroke (2000) 312043ndash2048 3 Hart SR Craig R Berry E Lane N Gad A Farrugia M Burton L Paquay A What Happens to
Acute Stroke Patientsrsquo Fluid Balance Renal Status and Dehydration in the First Two Weeks How Can They Be Markedly Improved doi 101111ijs12634_13
4 KDIGO Clinical Practice Guideline for Acute Kidney InjuryKidney international supplements (2012) 2(1) 1-138
No funding or conflict of interest to declare
P3NHS Highland-Improving the management of hyperkalaemia using a kit Initial resultsCantley N1 Abedin T2 Lambie S3
1FY2 NHS Highland 2ST4 Renal Medicine NHS Grampian 3Renal Consultant Renal unitRaigmore Hospital Inverness
Introduction The incidence of hyperkalaemia in hospitalised in patients is between 1 and 10 Guidelines in Northern Ireland promote the use of a Hyperkalaemia Kit to improve management of hyperkalaemia We assessed the management of hyperkalaemia in Raigmore Hospital including post-treatment monitoring of serum potassium and blood glucose at baseline and after the introduction of a lsquoHyperkalaemia Kitrsquo which contains a pro forma for the management of hyperkalaemia and all the relevant equipment and drugs for treatment
Method Between July and September 2016 an automated algorithm identified 34 patients with a potassium result 65 mmoll or above on laboratory results 12 received no specific treatment of these 6 results were spurious 4 patients died before treatment could be started and 2 patients were chronic haemodialysis patients We introduced the Hyperkalaemia Kit to the Acute Medical Admissions Unit in Raigmore Hospital Since then 15 patients have been identified with serum potassium measurements above 65 and the pro forma and kit was used with eight of these patients One of these patients proceeded straight to acute renal replacement therapy
Results Prior to our intervention all 22 patients that were actively treated received at least one prescription of appropriate doses of Insulin with Dextrose However only 16 patients received intravenous calcium and only 7 received nebulised Salbutamol Potassium was measured at 4 hours in 5 cases and by 12 hours in 17 cases Monitoring of any capillary blood glucose was only documented in 8 cases Of the 22 treated 2 needed acute renal replacement therapy 3 required further doses of insulin and dextrose 2 were treated with Calcium Resonium
Eight cases of hyperkalaemia have been managed with the use of the kit and pro-forma so far An initial ECG was performed in all eight and four patients had continuous cardiac monitoring Intravenous calcium was given in seven and nebulised Salbutamol was given in five out of the eight cases Six out of eight patients had at least three blood sugar measurements One had two measurements documented and one patient was stopped from further monitoring following senior review and decision to palliate Seven patients had appropriate monitoring of their serum potassium by 4h and 12h again one patient was not monitored due to palliation
Conclusion Baseline results showed very low rates of prescription of nebulised Salbutamol low rates of Calcium Gluconate use and very low monitoring of blood sugars and potassium post treatment This has the potential for serious adverse outcomes particularly the potential for iatrogenic hypoglycaemia Our initial data shows the use of a Hyperkalaemia pro forma and kit improves the rate of prescription of intravenous calcium and nebulised Salbutamol and the post-treatment monitoring of serum potassium and blood sugar levels
P4Rituximab as maintenance therapy in ANCA associated vasculitisndash a single centre experience Rathnamalala NK Mcmenamin J Robertson S Almond A Kelly M Muniraju T M Renal Unit Dumfries and Galloway Royal Infirmary NHS Dumfries and Galloway Background The introduction of Cyclophosphamide and high dose steroids transformed ANCA associate vasculitis (AAV) from a disease of high mortality to a relapsing remitting disease Maintenance of remission however still remains a major challenge A two randomised clinical trials have looked at the use of Rituximab in remission induction in AAV and reported similar remission rates between Cyclophosphamide and Rituximab 12 Both these trials used Azathioprine as maintenance therapy and in the follow up showed similar remission rates with either agent for induction The role of Rituximab for maintenance therapy after cyclophosphamide induction was studied in the MAINRITSAN trial 3 Rituximab was compared with azathioprine and found that the relapse rate was significantly lower in the Rituximab group There have been several other retrospective studies that have suggested regular Rituximab infusions are successful in maintaining remission however has not been thoroughly evaluated 4 5678910 Here we share our centrersquos experience using Rituximab for maintenance of remission of AAV Materials and methods We conducted a retrospective review of electronic medical records of all patients who had received Rituximab as maintenance therapy for 12 months or longer between January 2014 to July 2016 Disease activity was assessed using Birmingham Vasculitis Activity Score ( BVAS) Version 3 and complete remission was defined as a score of 0 and partial remission as a score of lt50 of the value at diagnosis Due to uncertainties associated with sub classification we did not assign specific diagnosis but broadly classified as ANCA associated vasculitis Results 6 patients received Rituximab as maintenance therapy during the study period 3 (50) of them had eye ear nose and upper airway manifestations consistent with Granulomatosis with Polyangitis (GPA) All patients were PR3 ANCA positive except for one at initial diagnosis The mean BVAS score at the time of initiation of Rituximab was 4 All patients were initiated on Rituximab for relapses while on maintenance therapy with Azathioprine 4 patients received 6 monthly doses of Rituximab while two received annual doses All of them were also maintained on 5-10 mg of Prednisolone The mean BVAS score by 6 months was 0 and remained 0 at 12 months The mean PR3 titre was 562 at the initiation of treatment while at 12 months it had come down to 68 All patients remained in complete clinical remission at the end of 12 months after initiation of therapy Rituximab was well tolerated by all patients except one who developed pyrexia during an administration
Conclusions All patients had sustained remission at 6 months and 12 months after initiating Rituximab Rituximab has a potential role as maintenance therapy in AAV
P5 Chronic Myelo-Monocytic Leukaemia (CMML) as a contraindication to renal biopsy Alastair Rankin Emily McQuarrie Jennifer Lees Bruce MacKinnon Glasgow Renal and Transplant Unit On behalf of the Scottish Renal Biopsy Registry
Abstract Chronic Myelo-Monocytic Leukaemia (CMML) is a relatively rare mixed myelodysplastic myeloproliferative disorder that predominately affects patients over the age of 65 years Renal impairment in patients with CMML is well described with several different mechanisms reported including tumour infiltration lysozyme-induced injury amyloid deposition and tubulointerstitial nephritis From anecdotal evidence within our centre we are concerned that patients with CMML have an excessive risk of clinically significant bleeding following native renal biopsy This risk appears disproportionate to the degree of any co-existing thrombocytopenia or coagulopathy
We review the cases of 4 patients with an existing diagnosis of CMML who were referred to the renal clinic with proteinuria and excretory renal dysfunction Two of these patients underwent renal biopsy with subsequent major haemorrhage post-procedure despite normal bleeding parameters pre-procedure Patient 1 presented with flank pain 8 days post-biopsy A CT confirmed peri-nephric haematoma with retroperitoneal extension A total of 6 units of packed red cells (PRCs) were transfused prior to successful CT-guided emoblisation Histology from the biopsy revealed chronic tubulointerstitial nephritis Patient 2 experienced haemodynamic instability and haematuria one hour post-biopsy A total of 11 units of PRCs 7 units of fresh frozen plasma 2 pools of platelets intravenous tranexamic acid and 2 attempts at CT-guided embolization were required until haemostasis was achieved Histology later showed evidence of tumour infiltration with associated vasculitis Patient 3 presented with renal impairment and proteinuria on the background of known CMML Following discussion with haematology the risk of bleeding following renal biopsy was considered unjustifiable despite their platelets and coagulation screen being within normal range The patient was treated for presumed renal tumour infiltration with hydroxycarbamide Patient 4 was referred to the renal clinic with acute onset nephrotic syndrome Urinary proteincreatinine ratio was elevated over 800 mgmmol with serum albumin of 23 gL but normal excretory renal function The patient attends the haematology clinic with suspected CMML and chronic thrombocytopenia but previously declined bone marrow biopsy Following discussion with the patient there are no plans to proceed with renal biopsy given potential risks These cases highlight that while CMML is rare these patients are being referred to renal clinics with features that would commonly justify renal biopsy in other settings but in whom there may be an increased risk of bleeding post-procedure Our in-centre risk of major bleeding is 2 therefore to have such extreme amounts of bleeding in 2 patients with this underlying diagnosis is remarkable This creates a dilemma for the clinician as there is a wide range of potential renal pathology associated with CMML some of which will have disease specific but relatively toxic treatments available
Source of funding none Conflicts of interest none
P6 NHS Highland-Prograf to Adoport switch McCulloch K1 Peel R2 Lambie S3
1Renal Pharmacist Renal unit Raigmore Hospital Inverness 23Renal Consultant Renal unit Raigmore Hospital Inverness
Introduction NHS Highland (NHSH) is the first health board in Scotland to implement a switch from Prograf to Adoport for renal transplant patients This will provide considerable cost savings Adoport meets the bioequivalence criteria for drugs with a narrow therapeutic index set by the European Medicines agency and studies indicate therapeutic equivalence1 with the proviso that brands are non- interchangeable unless the switch is overseen by a Renal Consultant and post-conversion therapeutic drug monitoring is conducted23 The switch has been undertaken by a majority of transplant centres in England the main difference being that they have undergone repatriation NHSH Patients receive their transplant primarily at Royal Infirmary of Edinburgh and occasionally at Queen Elizabeth University Hospital Glasgow Care is transferred to NHS Highland on discharge NHS Highland cares for approximately 170 renal transplant patients 110 being prescribed Prograf These patients may live as far as 110 miles from Raigmore Hospital Given that prescribing is carried out by primary care clear communication with patients GPs and community pharmacy is essential to avoid inadvertent switching between brands
Method Clinically it was agreed a switch could be safely undertaken A business case was submitted and funding secured for pharmacist time laboratory costs and primary care time GPs have been informed via GP subgroup and local prescribing bulletin lsquoThe Pink Onersquo Community pharmacies are being informed by phone A protocol has been agreed Eligible patients selected by Renal Consultant and Renal Pharmacist Patients sent letter signed by Renal Consultant and Renal pharmacist Patients phoned prior to clinic to agree Adoport start date and address concerns Patient seen by Renal Consultant and pharmacist + given 1 month of Adoport Tacrolimus level and UampEs checked 5-7 days after commencing Adoport and patient
contacted by phone to check if tolerated If stable letter sent to GP and community pharmacy to continue supply
Results and Evaluation Letters have been sent to all eligible patients Seven patients have been reviewed One has received a one month supply of Adoport and 5 others are due to switch One patient was deemed non-eligible at present as they have a 6 month surplus of Prograf A database will be maintained and analysed at the end and primary care savings will be monitored Extra pharmacist input will give us the opportunity to review how immunosuppression is managed and to evaluate the benefit of having a renal transplant pharmacist Conclusion The switch is at an early stage Ultimately we hope to show that the switch from Prograf to Adoport can be managed safely with extra pharmacist input to a remote and rural population with prescribing being conducted by primary care
Fundingconflicts of interest none 1 McDevitt-Potter LM Sadaka B Tichy EM Rogers CC Gabardi S Transplantation 2011 A multicenter experience with
generic tacrolimus conversion 2 Medicines and Health Products Regulatory Agency Drug Safety Update 2012 Accessed online via
wwwmhragovukSafetyinformationDrugSafetyUpdateCON1557563 ESPRIT Guidance on management of repatriation and immunosuppressant switches in transplant patients 2015
Accessed online via httpwwwespritorgukwp-contentuploads201508Switch-guidance-document-final-Aug-31-2015pdf
P7 NHS Highland-Tacrolimus baseline dataMcCulloch K1 Peel R2 Lambie S3
1Renal Pharmacist Renal unit Raigmore Hospital Inverness 2Renal Consultant Renal unitRaigmore Hospital Inverness 3Renal Consultant Renal unit Raigmore Hospital Inverness
BackgroundAs part of planning a switch from using tacrolimus Prograf to Adoport we assessed baseline data for our transplant patients currently using Prograf After converting patients to Adoport we will compare their tacrolimus levels to their individual target range We assessed our use of appropriate target ranges and our current performance in achieving tacrolimus levels within target range on Prograf therapy
Method 107 renal transplant patients taking Prograf were identified a sample of 19 of these were analysed using electronic patient records and results Time from transplant ranged from 1 month to 18 years All tacrolimus levels for the preceding year were analysed and compared to the target range specified at the time of the level being done The assay used has a Coefficient of Variation of lt5 at the lower limit of the assay
Results All 19 patients had a target range for tacrolimus clearly identified and recorded in clinic letterswhich are routinely copied to the patients themselves A variety of target ranges were specifiedThe commonest used was 5-8 microgramsl in 7 patients followed by 5-7 in a further 4 patientswith another 6 different target ranges being used for the remaining 8 patients The ranges usedhad a breadth of 3 microgramsl in 2 cases the rest had a breadth of 2 microgramslPatients had a median of 12 (range 3-72) tacrolimus levels over the preceding year Results werewithin specified target ranges for 54 +- 22 (Medan +- SD) of results checked
Conclusion We currently use a large number of different target ranges The majority of the ranges used had a breadth of just 2 microgramsl These factors help to account for the low proportion of test results which were within the specified target ranges This is important to bear in mind when interpreting whether tacrolimus levels are within target ranges after switching to Adoport We should consider aligning our target ranges and widening them
P8 Eculizumab use in Scottish paediatric dense deposit disease Stewart D1 David Hughes1 Lynne Riach2 Craig Oxley2 Athavale D1
1Royal Hospital for Children Glasgow 2Royal Aberdeen Childrenrsquos Hospital Aberdeen
Introduction The revised MPGN classification and increasing recognition of Dense Deposit Disease (DDD) a C3 glomerulopathy as an alternative complement pathway disorder suggests Eculizumab an anti-C5 monoclonal antibody may be beneficial in treatment However the experience of Eculizumab as an off-label and expensive treatment in children with DDD is limited with variable clinical response reported in the literature
Method We present the outcomes of the only 2 paediatric patients in Scotland who have received Eculizumab for the management of DDD
Results Case 1 A 10 year old male presented with proteinuria and haematuria resistant to steroid treatment with preserved renal function Initial biopsy confirmed DDD Conservative management with an angiotensin converting enzyme inhibitor and diuretics for symptom control continued until 14 years Due to worsening symptoms (oedema lethargy poor growth) and renal function deterioration along with elevated terminal complement complex (TCC) Eculizumab was commenced A repeat biopsy whilst suggestive of chronic irreversible damage showed 25 glomerular architecture preservation Symptom improvement was noted There was a reduction in proteinuria and renal function stabilisation fall in TCC and discontinuation of diuretics Eculizumab was discontinued after 24 months Progression of renal function decline was seen in the final months of Eculizumab therapy With recurrence of symptoms and increasing proteinuria following discontinuation Eculizumab was recommenced after 6 months Symptomatic improvement has since been noted
Case 2 A 5 year old girl presented with painless frank haematuria and proteinuria Initial biopsy confirmed DDD Proteinuria was unresponsive to steroid therapy and 5 months following diagnosis she rapidly progressed towards end stage renal disease despite the introduction of Mycophenolate Mofetil and plasmapheresis Haemodialysis was subsequently commenced TCC level was elevated and Eculizumab treatment was started 7 months after diagnosis Renal biopsy prior to treatment demonstrated continued severe pathological changes in all visible glomeruli However due to lack of clinical response Eculizumab was discontinued after 2 months and the patient remained dialysis dependent
Conclusions Our experience with Eculizumab in Scotland has demonstrated variable results in our 2 patients with one patient showing a positive response whilst the other experienced no improvement Eculizumab was administered to both patients at varying points in their clinical journey with differing progressive features on biopsy To date the outcomes of 9 paediatric patients with DDD treated with Eculizumab have been described in the literature with 8 experiencing some positive response to treatment including 2 patients who were able to stop renal replacement therapy within 12 weeks of treatment A role for Eculizumab in DDD may be guided by clinical and pathological features Well designed clinical trials will be necessary to define the role of complement inhibition therapy in DDD
No conflict of interest and no funding requested
P9 Examining markers of safety in the use of non-tunnelled central venous catheters
James WT Millar (Speciality Registrar) Scott W Oliver (Speciality Registrar) Peter C Thomson (Consultant Nephrologist) Glasgow Renal and Transplant Unit Queen Elizabeth University Hospital Glasgow
Background Non-tunnelled central venous catheters (NTCVC) remain an essential means of vascular access for incident haemodialysis Associated morbidity is well recognised for example in the form of Staphylococcus aureus bloodstream infections (SAB)[1]
Previous quality improvement initiatives in our unit have sought to both improve traditional markers of quality (such as SAB) and to identify additional areas of clinical risk In 2014 Oliver et al [2] suggested several additional quality measures including peri-procedure haemoglobin drop the need for a further NTCVC during the same clinical episode and the NTCVC insertion site This study further evaluated NTCVC related clinical practice within our unit
Methods The potential markers of clinical quality identified in a previous project were examined using prospectively collected data stored in the electronic patient record Identified cases of SAB significant peri-procedure haemoglobin drop and multiple NTCVC insertion were investigated by case note review
Results Between March 2016 and March 2017 a total of 222 patients received 346 NTCVC 54 patients (243) had more than one NTCVC inserted in a 21-day period (range 2-5) When considering NTCVC insertion site there were 159 (459) femoral vein catheters and 183 (541) internal jugular vein catheters No pneumothoraces were reported
15 SABrsquos were reported during this period equating to 43 of all NTCVC 5 arose in patients with femoral NTCVC (333) and 10 from internal jugular catheters (667) Mean time from line insertion to positive blood culture was 86 days 15 (67) patients had a drop in haemoglobin of greater than 20mgdl with no other source of blood loss identified on review of clinical notes
Discussion These data demonstrate that NTCVC-associated SAB rates remain low and significantly below Scottish government audit standards [3] Of interest is the continued trend towards the use of femoral catheters at 45 of lines compared with 38 in 2014 [2] Although traditionally thought of as having a higher incidence of infectious complications our data has shown fewer bacteraemia events associated with femoral catheters compared with internal jugular Our data also demonstrates a significant rate of peri-procedure haemorrhage arising in up to 1 in 20 cases Together these findings present opportunities to development practice and improve patient safety
References
[1] Murray E Deighan C Geddes CC Thomson PC Reducing haemodialysis bacteraemia rates Scottish Renal Association Glasgow November 2013 [2] Oliver SW Thomson PC Jardine AG defining safe effective and patient-centred dialysis catheter placement Scottish Renal Association Edinburgh September 2014 [3] The Staphylococcus aureus bacteraemia quarterly report of cumulative data from all NHS Boards in Scotland Health Protection Scotland January 2015
Sources of funding none Conflicts of interest none
P10 Prescribing of tolvaptan-The NHS Highland experience Lambie S1 McCulloch K2 Garrod J3
1Renal Consultant Renal unit Raigmore Hospital Inverness 2Renal Pharmacist Renal unit Raigmore Hospital Inverness 3Renal Pharmacist Renal unit Raigmore Hospital Inverness
Introduction Tolvaptan is a vasopressin antagonist It was accepted for use in Scotland by SMC in Jan 2016 to slow the progression of cyst development and renal insufficiency of autosomal dominant polycystic kidney disease in adults with chronic kidney disease (CKD) stage 1 to 3 at initiation of treatment with evidence of rapidly progressing disease1 Adverse effects related to aquaresis may affect patientsrsquo ability to achieve the optimum therapeutic dose and the risk of hepatic toxicity necessitates regular LFT monitoring The geography of NHS Highland required the implementation of novel methods of managing these patients and as a result a MDT approach with an emphasis on pharmacist input was adopted Consultant role Patient selection on the basis of evidence of rapidly progressing kidney disease declining
eGFR large volume kidneys on ultrasound and evidence of complications of PKD Side effects and potential benefits discussed Potential medication interactions reviewed Jinarc risk management prescriber training
Pharmacist role Undertook Jinarc risk management pharmacist training Prepares accurate drug history and reviews for potential drug interactions Carries out patient counselling and supplies patient education material sick day rules card
and lsquogot to gorsquo card Supplies GP education leaflet Provides advice on selection of new drug therapies eg for gout Manages stock and coordinates supply to patients
Results Prescribing commenced May 2016 patients currently prescribed tolvaptan 11 7 Female 4 male Number on target dose 73 n = 811 2 patients are still being titrated One patient did
not tolerate target dose due to aquaresis side effects and is being trialled on the middle dose
Withdrawals One patient has withdrawn due to agoraphobia and an inability to attend for monitoring and another is on hold due to having major surgery
Conclusion The MDT approach between the Renal Consultant and Pharmacist at Raigmore Hospital has enabled tolvaptan prescribing to be efficiently and safely implemented to patients living within a challenging geographical location
1 Scottish Medicines Consortium Detailed Advice Document tolvaptan 15mg 30mg 45mg 60mg and 90mg tablets (Jinarcreg) SMC No 111415 January 2016
NA1 Authors SCN Jacqueline Ross NHS Grampian
SCN Alan Somerville NHS Lanarkshire SCN Jane Humphrey NHS Lanarkshire
e- mail contact jacquelinerossnhsnet Alansommervillelanarkshirescotnhsuk
Janehumphreylanarkshirescotnhsuk
Phone contact 01224 552927 01236 712644
Title Sharing of Adverse Events in Renal Units across Scotland
Introduction Background The Scottish Renal Nurses Strategy Group (SRNSG) are a group of senior nurses from Renal
Units across Scotland who meet 3-4 times per year to discuss and implement best practice At the last meeting it was agreed that it would be good practice for each Health Board to share
their adverse events reported on the Datix System and deliver a presentation with an action plan to prevent incidents and improve patient safety across Scotland NHS Grampian and NHS Lanarkshire will be the first to deliver this presentation discussing adverse events from both Health Boards with an action plan
Top 5 adverse events over the past 12 months Renal Unit NHS Grampian 1 Violence and Aggression 2 Accidents including needlesticks slips trips and falls 3 Medication Errors 4 Infrastructure Staffing and Estates 5 Machines and Equipment
Top 5 adverse events over past 12 months Renal Unit NHS Lanarkshire
1 Slips Trips or Falls 2 Medicine errors 3 Treatment problems 4 Transfer problems 5 Breach of policy
The presentation will also focus on any serious adverse events which may not be in the top 5 categories
Aim Objective Each Health Board to share their adverse events with the aim to prevent them from occurring in other units to improve staff and patient safety and wellbeing across Scotland
Method Power Point Presentation
Outcome Results Sharing of adverse events resulting in the development of a national Action Plan to prevent these incidents improving safety and well being of staff and patients in Renal Units across Scotland
NA2
SRA Oct 2017 Abstract
BBV Never Event - The whats whys and hows
Staff Nurse Gillian Wilson Aberdeen Royal Infirmary
This presentation shares our experience of a never event that occurred and was not picked up for
a period of 18 months
Hepatitis C (HCV) positive antibodies were found in a previously negative patient
These results were a low positive with no biochemistry changes to suggest any liver damage
however steps were put immediately in place to isolate and investigate
Was it contamination from a dialysis machine was it related to a blood transfusion given prior to
first positive result was it faulty diagnostic tests in the laboratory
In Aberdeen we go over and above national guidelines and isolate all our BBV patients whether
they have positive blood results or are PCR negative
Further bloods tested at an external laboratory confirmed negative results
It highlighted that communication errors were to blame for the lack of speed in detecting this issue
Investigations concluded no real answers as to why this happened
NA3
Living Donation Scotland Changing attitudes towards living donor kidney transplantation
Jen Lumsdaine Julie Glen On behalf of the Living Donation Scotland Project Board
Background and aims
The rate of living donor transplantation has remained fairly static in Scotland over the past 10 years
Recent data has shown inequity of access to living donor transplantation throughout the UK so
there is potential to significantly increase this optimum form of treatment for patients with end-stage
renal failure in Scotland The Living Donation Project Board was formed in 2016 aiming to double
the number of living donor transplants by 2020
Method
The two key areas
1 Do recipients receive adequate and appropriate information at the right time about living
kidney donation
2 Informing the general public about altruistic donation
All patients active on the transplant list in Scotland were invited to an information event A follow-up
questionnaire was performed in the East of Scotland examining outcome or reasons for not
attending A scoping exercise looked at information provided by each unit was performed and link
nephrologists and low clearance nurses attended meeting to discuss strategies for early education
Outcome
An information pack containing both recipient and donor written information and short films on DVD
has been produced with the support of the Scottish Government for all recipients and potential
donors in Scotland A new website with comprehensive information both written and visual and
postcode finder to improve ease of access to local unit contact details has been developed
Two national media campaigns have been launched with a significant rise in the number of enquiries
from potential donors and actual increase in altruistic donor numbers
Nursing abstract ndash no conflict of interest
NA4Authors Susan Easson Charge Nurse Ward 4C QEUH Glasgow
e- mail contact SusanEassonggcscotnhsuk
Phone contact 0141 452 3300
Title A Conversational approach to find out ldquoWhat matters to yourdquo in a Renal Transplant ward
Introduction Background Finding out ldquo What Mattersrdquo to people using health and careservices is crucial to delivering safe effective and person centred care It is a simple yet profoundconcept and tries to get to the essence of person centred care by creating deeply personalengagements with patients and their families through a conversational approach However careexperience feedback all too often provides innumerable examples of where what really matters topatients and their family members is poorly understood or not addressed Using care experienceas the driver for change the nursing staff in Ward 4C used improvement approaches to explorehow to hold more meaningful ldquoWhat Matters to yourdquo conversations on a daily basis
Aim Objective To improve the patient experience by utilising a person centred approach
Method Using Care experience feedback What Matters to Me boards and the conversationalapproach
Outcome Results Improvements in patient experience will be shared using examples ofpractice and care experience feedback
There was no additional funding required for this project We worked in collaboration with theperson centred team whorsquos aim is to improve patient experience
NA5
The implementation of a renal education programme and its impact on clinical practice
The purpose was to implement a Renal Education Programme and to evaluate its impact on
clinical practise
It was identified that there was a need for an educational programme to be set up within Forth
Valley Royal Hospital There is no inpatient renal unit in FVRH on site for our renal patients they
attend Queen Elizabeth University Hospital We are an outpatient haemodialysis unit with
outpatient clinics on site Therefore it was identified that there was a need for nursing staff within
FVRH to be educated on all renal complexities for the benefit of our patients
This was done through a work-based learning approach which brought tangible benefits for our
patients However it did not come without pitfalls as educational programmes are often seen as
making very little difference to clinical practise
T
his study describes what methods were used and examines the advantages and disadvantages in
setting up an educational programme and evaluating its impact on clinical practise
NA6
Nursing Abstract ndash SRA Meeting ndash 26 October 2017
Chris McGee Tonya Broe Ken Weir
Renal Unit Forth Valley Royal Hospital
Use of the Therapy Monitor Haemodialysis Patient Record System Can we aim for a paper-
free dialysis unit
We are trialling a new haemodialysis patient monitoring system to work in conjunction with SERPR
and which is intended to supersede the Finesse system used previously
We are in the early stages of this process but with continuing staff education and regular tech
support we are hoping to gather sufficient evidence to evaluate whether the use of paper case
notes needs to continue
Is it a realistic goal to aim for a completely paper-free unit
NA7
THE CLINICAL USES OF APHERESIS WITHIN NHS TAYSIDE
Laura Thomson CN
Ninewells Hospital Dundee
NHS Tayside took over the apheresis service from BTS in 2012 The service has since expanded
with the benefits of carrying out this treatment has been widely recognised within NHS Tayside
and is now more commonly being offered to treat a wider range of conditions with the number of
treatments carried out each year rising
This presentation will highlight the progression of the apheresis service within NHS Tayside We
will identify the various conditions it is currently being used to treat and also identify the decision
making process involved in carrying out these treatments ie which replacement fluid will be used
anticoagulation medication administered
We will highlight the benefits and challenges we face in providing this expanding service within the
Renal Service
NA8Authors Linda McDougall Renal Physiotherapist NHS Highland
e- mail contact lindamcdougall1nhsnet
Phone contact 01463 706022
Title lsquoExercise on Haemodialysis- Keeping the Wheels in Motionrsquo
Introduction Background The impact of CKD on physical fitness functional ability independence amp ultimately quality of life cannot be underestimated Current national guidelines recommend that all individuals with CKD are encouraged to participate in regular exercise programmes between or during dialysis sessions if on HD Following a successful pilot study funding was approved to establish an lsquoExercise on Dialysisrsquo (EOD) programme across NHS Highland through the appointment of a dedicated renal physiotherapist in 2008 A successful programme was soon established but for several years post-vacancies and increasing in-patient demands limited the physiotherapy servicersquos ability to deliver the programme The need to improve the long-term sustainability of the service was recognised and in late 2016 funding was approved to develop a Band 4 PT HCSW role for this purpose
Aim ObjectiveTo optimise the sustainability and continuity of the lsquoExercise on Dialysisrsquo service across NHSHighland through development of a Band 4 PT HCSW role
Method The potential parameters of the role and limits of autonomy were scoped out using current NES resources and guidelines Service and task analysis was then carried out to establish which components of the EOD protocol could be undertaken by a Band 4 A series of competencies were developed in line with the clinical protocol and one-to-one training and supervision provided to the post-holder to ensure competency achieved in delivering the programme
Outcome Results A 10 WTE Band 4 PT HCSW was appointed in Jan 2017 with a dual role between the renal unit and acute medical wards Although training is not yet complete the post-holder is already running the day-to-day delivery and monthly audit of the EOD service with senior physiotherapist input only required for individual patient safety queries and general discussion around patientsrsquo progress and goals The benefit to the unit has been considerable as the band 4 is available to support patients and staff with EOD provision 5 days a week This allows for one-to-one supervision of patients who need more support to participate in EOD regular feedback on performance and reviews of outcome measures and goals to maintain motivation levels Feedback on the post has been very positive and its scope will only continue to expand as we look to further develop renal rehabilitation services across NHS Highland
NA9Authors Nadine Lyall and Kerry Guthrie
e- mail contact nadinelyallbordersscotnhsuk kerryguthriebordersscotnhsuk
Phone contact 01896 826637
Title The Developing Role of the NMP in a Satellite Dialysis Unit
Introduction Background
We have been practising as NMPrsquos for nearly 3 years working in the dialysis unit at the BGH The unit is a satellite unit of the ERI and we have expanded over the last 6 years The unit provides haemodialysis for 12 patients at any one time 3 sessions a day 6 days a week We are nurse-led and have 2 renal consultants who are based at the ERI
We saw an opportunity to use our knowledge and experience to develop our role By becoming NMPrsquos we have enhanced our professional development and we feel we meet the changing needs of the dialysis patient in a more holistic manner
Aim Objective
Our aim is to deliver effective care as we are better placed to deal with issues that often arise byacting swiftly this in turn is cost effective and convenient For example good anaemia and bonemanagement is important for their health wellbeing and lifespanTo help understand our role we will use a power point presentation highlighting issues we dealwith and the drugs we prescribe under the following headings Cardiovascular infection painanticoagulant disequilibrium diet renal bone disease and renal anaemia
Method Power point
Outcome Results
In the future we hope to further develop and have greater autonomy in our role We have great support from our renal consultants and have already built up a great relationship with our patients We hope to undertake the Clinical Decision Making course and this in turn will allow us to deal effectively with acute illness giving the dialysis patient better care We are keen to get feedback from other renal nurses in Scotland to enable us to develop our role further and in turn raise awareness of the NMP role in a dialysis unit We record all our prescribing decisions and keep the consultants up to date regularly Currently we are working on auditing our prescribing practice so that we can improve the service we can provide
NA10 Title Komunikacja w szkoleniu dializy ortzewnowej
Author Senior Charge Nurse Rhoda Bell
Address Raigmore Hospital Old Perth Road Inverness IV2 3UJ
Email rhodabellnhsnet Telephone 01463706023
Introduction Background Case study on lady with Polish as her first language she has some English but requires an interpreter to carry out Peritoneal Dialysis training and attend clinic She had some gynaecological issues that we were not aware of which impacted on the functionality of PD and therefore the success of treatment There were areas of concern in low clearance clinic with signs the patient had a reluctance to engage in decision making
AimObjective
Methods Discussion through the case study highlighted issues with communication between different PD staff and patients Areas of concern include different staffing techniques environment factors on training success Also language and communication issues the patient had were not fully apparent so training could not be individualised
Results We plan to trial training at home and have more individualised training schedule for patients The training step by step guides have been reviewed and practise standardised In collaboration with low clearance nurse we have developed a check list which will highlight concerns before the transition to PD ie language issues and need for training aids in another language gynaecological conditions
Conclusions Everyone learns differently and training methodsaids must be individualised for all It may not be apparent until training has commenced that there are concerns Having one to one training with the same nurse will consolidate training and build confidence in the patient Having a close working relationship with members of the MDT will help make a supportive PD journey
Would we do things differently if we knew about prolapse or lack of English both spoken and written
Key words - Peritoneal dialysis patient training communication
N11
Telehealth amp PDAudrey Jones
Advantages
Information on a daily basis about treatment weight and blood pressure
Change programme remotely via computer or mobile
Earlier intervention for machineprogramme issues
Reduction in home visits ie patient trained but still requires volume increases
No need to download cards to see what problems have been
Can have more detailed information available at clinics
Disadvantages
Relying on patient input data correctly
Machine is noisy especially first wave of machine
Still the same bag connection system and patient connection system (difficult for manual
dexterity problems)
Relying on patient having good signal
Modem problems
NA12Autosomal Dominant Polycystic Kidney Disease A cruel inheritance but new hopeAlistair Lawrie Renal Unit Victoria Hospital KirkcaldySadaf Arshad Corry Dunnigan Paul Phelan Neil Turner Renal Unit Royal Infirmary of Edinburgh
Background Autosomal Dominant Polycystic Kidney Disease (ADPKD) is the most prevalent single gene human genetic disorder and the most common of the inherited cystic and interstitial kidney diseases It is estimated to affect 1 in every 1000 individuals worldwide with over 50 of sufferers eventually developing end stage kidney disease and requiring dialysis or transplantation Symptoms include spasmodic severe pain hypertension haematuria infection and kidney failure There is currently no cure for ADPKD Management of the condition has traditionally involved lifestyle modification BP control and analgesia however a recent study (Torres et al 2012) demonstrated that treatment with V2-receptor antagonist drugs slowed increase in total kidney volume reduced the rate of functional decline and showed a reduced incidence of kidney pain
Aim Provision of a tolvaptan prescribing and monitoring service
Methods Experiential finding report of initial twelve months period of multidisciplinary ADPKDtolvaptan clinic
Results Early results are comparable with TEMPO study outcomes
Conclusion Due to the long term nature of this treatment results available at this time are showing only the earliest benefits of the intervention More quantifiable results such as increased time before the necessity for RRT will only be evident in coming years Torres VE et al (2012) Tolvaptan in Patients with Autosomal Dominant Polycystic Kidney Disease New England Journal of Medicine 367 pp 2407-2418 DOI 101056NEJMoa1205311
No funding requirement No conflict of interest
A15 Renal biopsies in patients with diabetes mellitus in Scotland
Udana Ratnapala 1 Nicola Joss 2 Colin Geddes 3 Dana Kidder 1
1 Renal Unit Aberdeen Royal Infirmary Aberdeen 2 Renal Unit Raigmore Hospital Inverness 3 Glasgow Renal and Transplant Unit Glasgow
Introduction Diabetes mellitus is the leading cause of end-stage kidney disease (ESKD) requiring renal replacement therapy The utility of renal biopsy in patients with diabetes mellitus is controversial Broadly renal biopsy findings in patients with DM can be divided into diabetic nephropathy (DN) alone DN with non-diabetic renal disease (NDRD) or NDRD alone Timely identification of patients with NDRD is important to provide appropriate therapeutic measures Previously published guidelines on clinical predictors of NDRD have limited specificity and sensitivity The frequency of NDRD in renal biopsies of patients with DM is unclear in ScotlandThis study aimed at identifying the frequency and the pathology spectrum of NDRD in diabetic patients underwent kidney biopsy in 3 renal units
Methods A retrospective observational study was performed on clinical-pathologic findings in all patients with diabetes mellitus who underwent renal biopsy between 01012010 and 31122016 in 3 renal units (Aberdeen Inverness and Greater Glasgow) Data were gathered from electronic patient record systems Scottish Index of Multiple Deprivation (SIMD) 2012 was used to analyse correlation with patient outcomes
Results 247 patients were included 150 men (607) 217 type 2 DM (879) mean age 621 years and mean serum creatinine at the time of renal biopsy of 261 micromolL (+-190 std) On biopsy 92 patients (372) had DN while 127 (514) had NDRD and 28(114) had NDRD superimposed on DN The commonest NDRD aetiologies were IgA nephropathy (187) tubulointerstitial nephritis (168) and idiopathic membranous nephropathy (103) Predictors of NDRD were age (OR 1027 95 CI 1002-1052 p=003) duration of DM (OR 094 95 CI 0900-0987 p=001) and absence of AKI as indication for biopsy (OR 022 95 CI 0059-0826 p=0025) There was no significance difference in renal or patient survival in DN and NDRD Finally no significant correlation was depicted between SIMD quintiles and renal or patient survival in both groups
Conclusions The majority of renal biopsies carried out in patients with DM revealed a NDRD In this study age at the time of biopsy duration of DM and AKI were the main pointers towards NDRD Renal and patient survival were not significantly different between DN and NDRD groups
A16 The Impact of Withdrawal of Maintenance Immunosuppression and Graft Nephrectomy on HLA Sensitisation Ailish Nimmo1 Sophie McIntyre1 Lorna Henderson1 Richard Battle2
(1 Department of Renal Medicine Royal Infirmary of Edinburgh 2 Histocompatibility and Immunogenetics Royal Infirmary of Edinburgh)
Background The development of HLA antibodies towards a failing renal allograft is a barrier to re-transplantation We previously demonstrated an increase in HLA antibodies and calculated reaction frequency (cRF) following nephrectomy but results were confounded by immunosuppression changes occurring in close time proximity We examined the formation of HLA donor specific antibodies (DSA) in patients with failed grafts that remained in situ and compared results with patients undergoing graft nephrectomy to further assess the relative impact of nephrectomy and immunosuppression weaning on sensitisation and chance of transplant
Methods We carried out a single centre retrospective study of all patients with failed grafts in Lothian from 2005 to 2015 Samples were tested for DSA pre-immunosuppression (IS) wean post-IS wean and post-IS cessation Nephrectomy patients also had samples tested for DSA before and after nephrectomy Data on other sensitising events including blood transfusion and rejection were collected cRF was determined at each time point and entered into the ODT chance of transplant calculator with other demographics based on the average patient from the Edinburgh centre
Results 62 grafts failed over this time period Blood samples were available 41 patients (24 with nephrectomy 17 with failed graft left in situ) Patient demographics were similar between groups There was a higher rate of antibody mediated rejection in the nephrectomy group (46 vs 18) 76 of patients with nephrectomy group had received a blood transfusion The pattern of immunosuppression weaning was similar but median time from start of IS wean to cessation was longer in the nephrectomy group (350 vs 298 days) The changes in cRF and chance of transplant (COT) with immunosuppression weaning are shown in Table 1
Pre-IS Wean Post-IS Wean
Failed graft in situ (n=17)
Mean CRF COT at 5
years 15 62 38 59
Nephrectomy (n=24)
Mean cRF COT at 5
years 54 54 69 46
Post-IS Stop 55 53 89 42 Table 1 Mean cRF and Chance of Transplant (COT) at 5 years with IS alterations
Discussion A stepwise increase in cRF with reduced chance of transplant was observed in both groups as immunosuppression was withdrawn with a similar pattern of change irrespective of graft nephrectomy cRF was higher in the nephrectomy group despite a more gradual wean which may reflect a higher rate of antibody mediated rejection and increased number of patients receiving a blood transfusion The risks and benefits of stopping immunosuppression need to be carefully considered on an individual basis to maximise chance of future transplant
The authors have no conflicts of interest No funding was required for this study
A17 Obesity is not associated with progression to end stage renal disease in patients withbiopsy-proven glomerular diseases
Benjamin Elyan Jennifer S Lees Bruce Mackinnon Jonathan G Fox Colin C Geddes Emily PMcQuarrie
Glasgow Renal and Transplant Unit Queen Elizabeth University Hospital Glasgow
Introduction - Addressing risk factors for renal progression is a key aspect of managing chronic kidney disease (CKD) Body mass index (BMI) has been shown to impact on renal progression in unspecified CKD The aim of this study was to evaluate if there was an association between BMI and progression to renal endpoints in patients with biopsy-proven primary glomerular disease (GN)
Methods - We included all adult patients diagnosed with biopsy-proven primary GN (excluding minimal change nephropathy) in Greater Glasgow amp Clyde and Forth Valley between 01012000 and 31122015 Biochemical and anthropometric data were extracted from the electronic patient record at time of biopsy with follow-up data until 20062017 BMI was calculated from height and weight at time of biopsy and categorised into groups BMI le25 kgm2 (G1) gt25 to le30 kgm2 (G2) and gt30 kgm2 (G3 - obese) We assessed factors associated with reaching a combined renal endpoint of CKD5 or renal replacement therapy (RRT) with competing risk of death using the Fine and Gray subdistribution hazard model Analyses were conducted using cmprsk package for R statistical software package and SPSS version 24
Results - 560 patients with primary GN and available BMI data were included The average age was 532 years and 339 were female There were 132 patients in G1 210 in G2 and 207 patients in G3 Those in G2 and G3 were older (p=002) with slightly higher diastolic blood pressure (p=002) than those in G1 There was a greater proportion of focal segmental glomerulosclerosis in G3 but similar proportions of other GN diagnoses across groups There was no significant difference in baseline serum creatinine (sCr) (p=034) or log uPCR (p=045) between BMI groups On multivariate analysis age systolic blood pressure BMI or GN diagnosis were not predictive of renal outcome Higher baseline sCr (SHR 1003 per 1 umoll increase in sCr 1001-1004 plt0001) and log uPCR (SHR 130 per unit increase in log uPCR 95 CI 105-160 p=002) were associated with progression to the combined renal endpoint accounting for competing risk of death BMI was not associated with reaching combined renal endpoint on univariate analysis whether considered as a continuous variable (SHR=100 95 CI 098-102 p=096) or categorised by BMI group
Conclusion - Contrary to our expectations there was no association between BMI and progression to a combined renal endpoint of CKD5 or RRT in this cohort of patients with primary GN Efforts should be directed to managing other known risk factors for CKD progression
Sources of FundingConflicts of Interest - None
A18 Factors influencing long term renal function after living kidney donation
Matthew A Rutherford Norman J Galbraith Marc Clancy Colin C Geddes
Glasgow Renal and Transplant Unit Queen Elizabeth University Hospital Glasgow UK
Background Following live donor nephrectomy the remaining kidney undergoes an increase in filtration capacity known as compensatory hypertrophy Few cohorts with follow up of renal function beyond 5 years have been reported The impact on long term renal function of variability in donor factors such as age sex pre-donation blood pressure and glomerular filtration rate (GFR) is unknown Increasingly kidney donors have potential risk factors for future poor renal function such as hypertension older age and obesity The aim of this study was to analyse factors influencing long-term renal function in living kidney donors from our centre
Method Data were obtained from the electronic patient record Patients with a recorded procedure of lsquolive donor nephrectomyrsquo between 2005 and 2017 were identified GFR after donation (calcGFR) was calculated using the formula lsquocalcGFR = Pre-donation Isotope GFR x (Pre-donation Serum creatinine Serum Creatinine)rsquo which is accurate assuming muscle mass does not change Pre and post donation serum creatinines (two days two weeks three months and one to ten year) were recorded We analysed the influence of age sex pre-donation GFR and blood pressure on post donation GFR compensation
Results 355 live donor nephrectomies were performed between January 2005 and December 2016 The mean age was 469 (plusmn 116) years and 504 (n=179) were female Mean pre-donation isotope GFR was 937 plusmn 156 mlmin173m2 Median follow up was 2 years (IQR 1 to 6 years with range 2 weeks to 10 years) The calculated percentage of pre-donation GFR at 2 days 2 weeks 3 months 1 year 5 years and 10 years were 698 691 712 730 801 and 950 respectively (p lt 0001) Patients aged lt50 y had not only a higher calcGFR (858 plusmn 29 mlmin173m2 compared with 671 plusmn 28 mlmin173m2 p lt 0001) at 5 years following donation but achieved a higher degree of compensation than donors gt 50 y (836 plusmn 16 compared with 756 plusmn 19 (p = 0002) Patients with pre-donation hypertension achieved 774 plusmn 53 of pre-donation GFR compared with 804 plusmn 32 in normotensive patients (p = 0998) Females had equivalent degree of renal compensation achieving 819 plusmn 19 compared with 780 plusmn 16 in males (p = 0131) at 5 years following donation Patients with pre-donation GFR gt 100 mlmin173m2 achieved 844 plusmn 23 of pre-donation function by 5 years compared with 777 plusmn 14 in those with pre-donation GFR lt 100 mlmin173m2 (p = 001)
Conclusion Following live donor nephrectomy renal function has a nadir of 691 at 2 weeks Compensation in GFR occurs rapidly and appears to be maintained regardless of sex and pre-donation blood pressure Younger age and higher pre-donation GFR were associated with a greater degree of compensation
A19 The utility of high-sensitivity cardiac troponin to stratify cardiovascular risk in patients with renal impairment
Eve Miller-Hodges Atul Anand Anoop S V Shah Nicholas L Mills Neeraj Dhaun
Background Cardiovascular disease is the most common outcome of chronic kidney disease1
Declining glomerular filtration rate (GFR) and proteinuria predict increased cardiovascular risk over the long term2 However there are currently no methods to stratify cardiovascular risk in the short or medium term in patients with renal impairment We have already shown that high-sensitivity cardiac troponin I concentrations (hs-cTnI) lt5ngL in patients presenting with symptoms of acute coronary syndrome identifies those at low risk of cardiac events within 30 days and over the next year3 However uncertainty remains over the role of hs-cTnI testing in patients with renal impairment This study investigated whether hs-cTnI could also stratify future cardiovascular risk in patients with renal impairment
Methods In a prospective study of consecutive patients presenting with suspected acute coronary syndrome we evaluated the performance of hs-cTnI in patients with and without renal impairment (estimated glomerular filtration rate lt60mLmin173m2) using an early risk stratification threshold of 5ngL to ldquorule outrdquo acute myocardial infarction at presentation and within 30 days and sex-specific 99th centile diagnostic thresholds for index type 1 myocardial infarction Subsequent type 1 myocardial infarction and cardiac death were reported at one year
Results Of 4726 patients identified 904 (19) had renal impairment Index diagnosis of type 1 and type 2 myocardial infarction was almost twice as likely in patients with renal impairment (30 vs 15) Performance of the early risk stratification threshold of 5ngL to identify patients at low risk of major cardiac events was similar in patients with (NPV 984 95CI 960-997 sensitivity 989 95CI 975-999) and without renal impairment (NPV 997 95CI 994-999 sensitivity 984 95CI 972-994) These patients continued to remain at low risk over the next year The PPV and specificity at the 99th centile for diagnosis of myocardial infarction were lower in patients with renal impairment at 500 (95CI 452-548) and 709 (95CI 675-742) respectively compared to 624 (95CI 588-659) and 921 (95CI 912-930) At one year 24 of patients with renal impairment and troponin gt99th centile regardless of index diagnosis had experienced further myocardial infarction or cardiac death compared with 10 of patients without
Conclusion In suspected acute coronary syndrome hs-cTnI can stratify risk in patients with renal impairment Irrespective of diagnosis patients with renal impairment and elevated cardiac troponin concentrations had two-fold greater risk of a major cardiac event compared to those with normal renal function and should be considered for further investigation and treatment
Funders Wellcome Trust British Heart Foundation and Chest Heart amp Stroke Scotland
1 Gansevoort RT Lancet 2013
2 Chronic Kidney Disease Prognosis Consortium Lancet 2010
3 Shah AS Lancet 2015
A20 lsquoDOES IT DIALYSE OUTrsquo - THE EFFECT OF RENAL REPLACEMENT THERAPY ON THE BRAIN Mark Findlay Jesse Dawson David Dickie Deborah McGlynn Patrick Mark Institute of Cardiovascular and Medical Science University of Glasgow amp Queen Elizabeth University Hospital Glasgow
Introduction Cerebrovascular disease is common in end-stage renal disease (ESRD) on renal replacement therapy (RRT) We investigated the effect of RRT on cerebral structure and cognitive function over 12 months Methods Observational cohort study in ESRD patients receiving HD Prior cognitive impairment or cerebrovascular disease were exclusion criteria Multi-domain cognitive testing was performed at baseline and at follow-up Transcranial Doppler was used to assess intra-dialysis related alterations in mean flow velocity (MFV) ndash a marker of cerebral blood flow MR imaging was performed at 0 and 12 months We performed T1 T2 FLAIR and DWI sequences and used volumetric software to calculate white matter hyperintensity (WMH) burden markers of atrophy mean diffusivity and fractional anisotropy (FA) to describe structural changes at 1 year Results 97 patients median age 59 years 412 female At follow-up 15 patients were transplanted 6 died 4 withdrew and the remainder continued HD Those who were transplanted were younger (median age 51 vs 60 years p=0019) and had been on dialysis for a shorter period (median 06 vs 21 years p=0003) MFV declined during HD median 475cms to 405cms plt0001 and correlated with lower scores of executive and frontal lobe function during HD (Rho 045 p lt0001 and Rho -0313 p lt001 respectively) In all patients MR imaging demonstrated a significant decline in frontal parietal and temporal lobe volume at follow-up Median WMH volume increased in those who remained on HD but not in transplanted patients (median change 023 vs -012ml p=0018) WMH burden correlated with worsening scores of frontal lobe tests Rho 0585 p0005 and worse mood Rho -0485 p0026 FA improved following renal transplant (028 to 029 p=0016) and correlated with improved executive function testing at follow-up Rho 089 p0019 Conclusion Cerebral blood flow is reduced during haemodialysis and correlates with a reduction in intradialytic executive function There is an improvement in FA following transplantation WMH volume increases in those who remain on dialysis and the degree of increase correlates with executive and frontal lobe function This suggests that haemodialysis is associated with clinically significant changes in the brain and that these may be ameliorated by transplantation
Source of fundingconflicts MF is funded by a KRUK fellowship
A21 Pathological classification of IgA nephropathy to predict renal outcomes ndash is there a better way to score tubulointerstitial inflammation
Alastair Rankin David Kipgen Bruce Mackinnon Jonathan Fox Colin Geddes Emily McQuarrie Glasgow Renal and Transplant Unit On behalf of the Scottish Renal Biopsy Registry
Background The Oxford pathological classification of IgA nephropathy (IgAN MEST-C score) is limited by the fact that individual features of the score are not all predictive and its utility in assisting clinical decision-making is questioned The addition of tubulointerstitial inflammation to the existing scoring system is appealing but is not currently included due to reportedly wide inter-observer variability We report a novel method to score percentage of cortex containing tubulo-interstitial inflammation in non-atrophic renal cortex (ATIN) in patients with IgAN similar to that used in transplant biopsy reporting and assess its utility to predict clinical outcomes
Methods All adult patients with a native renal biopsy diagnosis of IgAN between 2010 and 2015 in a unit serving 15 million people were identified Baseline characteristics biopsy reports and outcome data were collected ATIN was calculated by subtracting the percentage of atrophic cortex from the percentage of total cortex with tubulo-interstitial inflammation withge10 representing significant tubulo-interstitial inflammation in non-atrophic cortex The primary outcome was a composite of requiring renal replacement therapy (RRT) or doubling of serum creatinine (sCr)
Results 153 new cases of IgAN were identified 33 were excluded (24 had lt8 glomeruli on biopsy 6 inadequate biopsy for MEST scoring and 3 on RRT at time of biopsy) In addition patients with a tubular atrophy (T) score of 2 were also excluded (n=9) Of the remaining 111 patients 76 (68) were male Mean age at biopsy was 52 years (+- 167) and 18 (16) had a co-existing clinical diagnosis of henoch-schonlein purpura (HSP) Median sCr was 156 micromoll (IQR 101-212) and 54 (49) had ATIN on biopsy During a median follow-up of 23 years 34 (31) reached the primary outcome 20 (18) received immunosuppression and 16 (14) died On univariate Cox regression survival analysis ATIN was associated with a four-fold increase in the primary outcome (HR 49 (21-113)) On multivariate analysis mesangial hypercellularity (M) T and ATIN independently predicted renal outcome while endocapillary proliferation (E) and segmental sclerosis (S) did not (plt002 for ATIN) Excluding patients with HSP or those who received immunosuppression did not change the result
Conclusion Within our centre ATIN predicts renal outcome for IgAN independently of established histological features Assessment of inter-observer reproducibility and validation in other cohorts is still required but these results suggest ATIN could be a worthwhile addition to current pathological scoring systems for IgAN
Source of funding none Conflicts of interest none
P1 Polypharmacy in Renal Replacement Therapy Patients
Jason McMinn Colin Geddes Glasgow Renal and Transplant Unit Queen Elizabeth University Hospital
Introduction
Prescribing is often led by evidence from studies containing participants with single health conditions and without multimorbidity Polypharmacy is becoming increasingly recognised in patients with multiple chronic health conditions Additional medications are more likely to result in diminishing returns in benefit with an increased risk of harm Patients with established renal failure (ERF) are likely to be susceptible to medication-related harm A high pill burden is also likely to contribute adversely to an already restricted quality of life and has been associated with poor medication adherence The aim of this study was to analyse polypharmacy in all patients with ERF attending our service
Methods
We extracted medication records for all prevalent ERF patients attending the Glasgow Renal and Transplant Unit from the West of Scotland Electronic Renal Patient Record (SERPR) as of 01012017 The records were analysed to calculate the number of regular medications and total pill burden of each patient These medications were categorised as being lsquopreventativersquo or lsquosymptomaticrsquo We also analysed the prescription of specific drug classes to examine the prevalence of these medications
Results
We identified 1091 transplant follow-up 529 hospital haemodialysis and 46 peritoneal dialysis patients who were on a mean of 94 13 and 129 different medications respectively Overall pill burden was 139 tablets a day in transplant follow-up patients 141 in haemodialysis patients and 162 in peritoneal dialysis patients There were similar rates of prescribing between the different dialysis units and clinics within our service
The proportions of medications deemed as preventative rather than symptomatic were 76 in transplant 69 in haemodialysis and 60 in peritoneal dialysis
In transplant patients decreasing renal function was associated with a higher pill burden but even patients with a transplant eGFR gt 60 were on a mean of 126 tablets per day including a mean of 14 antihypertensives
Rates of antidepressant prescribing were 15 in transplant patients and 20 in hospital haemodialysis patients 53 of haemodialysis patients were on a statin 39 on aspirin 61 on a proton pump inhibitor and 7 were on warfarin
Conclusion
Patients undergoing all forms of renal replacement therapy are likely to be on a considerable number of medications Whilst these drugs are inevitably prescribed for valid reasons this data demonstrates the need for clinicians to engage with patients to explore opportunities to reduce pill burden
Conflict of Interest None Sources of Funding None
P2 An audit of Acute Kidney Injury (AKI) on an acute stroke ward before and after plannedinterventions to review and maintain hydration
Clare Harris1 Simon Hart2 Fiona Duthie3 1 University of Edinburgh Medical School 2 Stroke Unit Royal Infirmary of Edinburgh 3 Renal Unit Royal Infirmary of Edinburgh
Background Dehydration is an important factor in the development of acute kidney injury which is associated with increased morbidity and mortality particularly in the elderly population Poor fluid intake is common post stroke (1) and dehydration is associated with poorer outcomes 3 months post stroke (2) In late 2014 there was no system of identifying patients with poor oral intake on the stroke ward at the Royal Infirmary of Edinburgh a hydration protocol and education programme were implemented aiming to improve fluid balance This included the use of prescribed water either orally or by nasogastric tube An audit pre and post intervention demonstrated that hydration as measured by ureacreatinine ratio significantly improved after the protocol introduction (3) We aimed to determine whether the incidence of AKI by KDIGO criteria was also reduced as this could have implications for reducing patient morbidity and mortality in this elderly comorbid patient cohort
Method 150 inpatients to the acute stroke ward during JulAug 2014 and JulAug 2015 were selected (n= 80 2014 n=70 2015) Patient data and creatinine values were collected from the electronic patient record and medical notes and retrospectively analysed Baseline creatinine values were calculated and cases of AKI were identified and staged using KDIGO criteria (4) Chi-Squared tests were performed to determine P values Individual patient notes were reviewed for both quantitative and qualitative data of patient management
Results Incidence of AKI (of any stage) was 263 pre-protocol and 200 post-protocol (P=03646) Incidence of AKI stages 23 was 100 pre-protocol and 715 post-protocol (P=05374) In hospital post stroke mortality was 338 pre-protocol and 1286 post protocol (P=00028) AKI was also associated with increased length of stay
Conclusions Despite a trend in benefit there was no significant difference in incidence of AKI pre and post hydration protocol nor in incidence of severe AKI (stage 23) AKI is influenced by many factors one of which is hydration status Further studies are needed to determine whether the trend of benefit exhibited in this sample is significant in a greater sample size if this were the case such a protocol could have great benefit to patient care on stroke units and elsewhere There was a significant difference in inpatient post stroke mortality following introduction of the hydration protocol Further investigations are needed to explain underlying reasons for this factors other than hydration may play an important role
References 1 Whelan K Inadequate fluid intakes in dysphagic acute stroke Clinical Nutrition (2001) 20(5)
423-428 2 Bhalla A Sankaralingam S Dundas R Swaminathan R Wolfe CDA Rudd AG The influence of
raised plasma osmolality on clinical outcome after acute stroke Stroke (2000) 312043ndash2048 3 Hart SR Craig R Berry E Lane N Gad A Farrugia M Burton L Paquay A What Happens to
Acute Stroke Patientsrsquo Fluid Balance Renal Status and Dehydration in the First Two Weeks How Can They Be Markedly Improved doi 101111ijs12634_13
4 KDIGO Clinical Practice Guideline for Acute Kidney InjuryKidney international supplements (2012) 2(1) 1-138
No funding or conflict of interest to declare
P3NHS Highland-Improving the management of hyperkalaemia using a kit Initial resultsCantley N1 Abedin T2 Lambie S3
1FY2 NHS Highland 2ST4 Renal Medicine NHS Grampian 3Renal Consultant Renal unitRaigmore Hospital Inverness
Introduction The incidence of hyperkalaemia in hospitalised in patients is between 1 and 10 Guidelines in Northern Ireland promote the use of a Hyperkalaemia Kit to improve management of hyperkalaemia We assessed the management of hyperkalaemia in Raigmore Hospital including post-treatment monitoring of serum potassium and blood glucose at baseline and after the introduction of a lsquoHyperkalaemia Kitrsquo which contains a pro forma for the management of hyperkalaemia and all the relevant equipment and drugs for treatment
Method Between July and September 2016 an automated algorithm identified 34 patients with a potassium result 65 mmoll or above on laboratory results 12 received no specific treatment of these 6 results were spurious 4 patients died before treatment could be started and 2 patients were chronic haemodialysis patients We introduced the Hyperkalaemia Kit to the Acute Medical Admissions Unit in Raigmore Hospital Since then 15 patients have been identified with serum potassium measurements above 65 and the pro forma and kit was used with eight of these patients One of these patients proceeded straight to acute renal replacement therapy
Results Prior to our intervention all 22 patients that were actively treated received at least one prescription of appropriate doses of Insulin with Dextrose However only 16 patients received intravenous calcium and only 7 received nebulised Salbutamol Potassium was measured at 4 hours in 5 cases and by 12 hours in 17 cases Monitoring of any capillary blood glucose was only documented in 8 cases Of the 22 treated 2 needed acute renal replacement therapy 3 required further doses of insulin and dextrose 2 were treated with Calcium Resonium
Eight cases of hyperkalaemia have been managed with the use of the kit and pro-forma so far An initial ECG was performed in all eight and four patients had continuous cardiac monitoring Intravenous calcium was given in seven and nebulised Salbutamol was given in five out of the eight cases Six out of eight patients had at least three blood sugar measurements One had two measurements documented and one patient was stopped from further monitoring following senior review and decision to palliate Seven patients had appropriate monitoring of their serum potassium by 4h and 12h again one patient was not monitored due to palliation
Conclusion Baseline results showed very low rates of prescription of nebulised Salbutamol low rates of Calcium Gluconate use and very low monitoring of blood sugars and potassium post treatment This has the potential for serious adverse outcomes particularly the potential for iatrogenic hypoglycaemia Our initial data shows the use of a Hyperkalaemia pro forma and kit improves the rate of prescription of intravenous calcium and nebulised Salbutamol and the post-treatment monitoring of serum potassium and blood sugar levels
P4Rituximab as maintenance therapy in ANCA associated vasculitisndash a single centre experience Rathnamalala NK Mcmenamin J Robertson S Almond A Kelly M Muniraju T M Renal Unit Dumfries and Galloway Royal Infirmary NHS Dumfries and Galloway Background The introduction of Cyclophosphamide and high dose steroids transformed ANCA associate vasculitis (AAV) from a disease of high mortality to a relapsing remitting disease Maintenance of remission however still remains a major challenge A two randomised clinical trials have looked at the use of Rituximab in remission induction in AAV and reported similar remission rates between Cyclophosphamide and Rituximab 12 Both these trials used Azathioprine as maintenance therapy and in the follow up showed similar remission rates with either agent for induction The role of Rituximab for maintenance therapy after cyclophosphamide induction was studied in the MAINRITSAN trial 3 Rituximab was compared with azathioprine and found that the relapse rate was significantly lower in the Rituximab group There have been several other retrospective studies that have suggested regular Rituximab infusions are successful in maintaining remission however has not been thoroughly evaluated 4 5678910 Here we share our centrersquos experience using Rituximab for maintenance of remission of AAV Materials and methods We conducted a retrospective review of electronic medical records of all patients who had received Rituximab as maintenance therapy for 12 months or longer between January 2014 to July 2016 Disease activity was assessed using Birmingham Vasculitis Activity Score ( BVAS) Version 3 and complete remission was defined as a score of 0 and partial remission as a score of lt50 of the value at diagnosis Due to uncertainties associated with sub classification we did not assign specific diagnosis but broadly classified as ANCA associated vasculitis Results 6 patients received Rituximab as maintenance therapy during the study period 3 (50) of them had eye ear nose and upper airway manifestations consistent with Granulomatosis with Polyangitis (GPA) All patients were PR3 ANCA positive except for one at initial diagnosis The mean BVAS score at the time of initiation of Rituximab was 4 All patients were initiated on Rituximab for relapses while on maintenance therapy with Azathioprine 4 patients received 6 monthly doses of Rituximab while two received annual doses All of them were also maintained on 5-10 mg of Prednisolone The mean BVAS score by 6 months was 0 and remained 0 at 12 months The mean PR3 titre was 562 at the initiation of treatment while at 12 months it had come down to 68 All patients remained in complete clinical remission at the end of 12 months after initiation of therapy Rituximab was well tolerated by all patients except one who developed pyrexia during an administration
Conclusions All patients had sustained remission at 6 months and 12 months after initiating Rituximab Rituximab has a potential role as maintenance therapy in AAV
P5 Chronic Myelo-Monocytic Leukaemia (CMML) as a contraindication to renal biopsy Alastair Rankin Emily McQuarrie Jennifer Lees Bruce MacKinnon Glasgow Renal and Transplant Unit On behalf of the Scottish Renal Biopsy Registry
Abstract Chronic Myelo-Monocytic Leukaemia (CMML) is a relatively rare mixed myelodysplastic myeloproliferative disorder that predominately affects patients over the age of 65 years Renal impairment in patients with CMML is well described with several different mechanisms reported including tumour infiltration lysozyme-induced injury amyloid deposition and tubulointerstitial nephritis From anecdotal evidence within our centre we are concerned that patients with CMML have an excessive risk of clinically significant bleeding following native renal biopsy This risk appears disproportionate to the degree of any co-existing thrombocytopenia or coagulopathy
We review the cases of 4 patients with an existing diagnosis of CMML who were referred to the renal clinic with proteinuria and excretory renal dysfunction Two of these patients underwent renal biopsy with subsequent major haemorrhage post-procedure despite normal bleeding parameters pre-procedure Patient 1 presented with flank pain 8 days post-biopsy A CT confirmed peri-nephric haematoma with retroperitoneal extension A total of 6 units of packed red cells (PRCs) were transfused prior to successful CT-guided emoblisation Histology from the biopsy revealed chronic tubulointerstitial nephritis Patient 2 experienced haemodynamic instability and haematuria one hour post-biopsy A total of 11 units of PRCs 7 units of fresh frozen plasma 2 pools of platelets intravenous tranexamic acid and 2 attempts at CT-guided embolization were required until haemostasis was achieved Histology later showed evidence of tumour infiltration with associated vasculitis Patient 3 presented with renal impairment and proteinuria on the background of known CMML Following discussion with haematology the risk of bleeding following renal biopsy was considered unjustifiable despite their platelets and coagulation screen being within normal range The patient was treated for presumed renal tumour infiltration with hydroxycarbamide Patient 4 was referred to the renal clinic with acute onset nephrotic syndrome Urinary proteincreatinine ratio was elevated over 800 mgmmol with serum albumin of 23 gL but normal excretory renal function The patient attends the haematology clinic with suspected CMML and chronic thrombocytopenia but previously declined bone marrow biopsy Following discussion with the patient there are no plans to proceed with renal biopsy given potential risks These cases highlight that while CMML is rare these patients are being referred to renal clinics with features that would commonly justify renal biopsy in other settings but in whom there may be an increased risk of bleeding post-procedure Our in-centre risk of major bleeding is 2 therefore to have such extreme amounts of bleeding in 2 patients with this underlying diagnosis is remarkable This creates a dilemma for the clinician as there is a wide range of potential renal pathology associated with CMML some of which will have disease specific but relatively toxic treatments available
Source of funding none Conflicts of interest none
P6 NHS Highland-Prograf to Adoport switch McCulloch K1 Peel R2 Lambie S3
1Renal Pharmacist Renal unit Raigmore Hospital Inverness 23Renal Consultant Renal unit Raigmore Hospital Inverness
Introduction NHS Highland (NHSH) is the first health board in Scotland to implement a switch from Prograf to Adoport for renal transplant patients This will provide considerable cost savings Adoport meets the bioequivalence criteria for drugs with a narrow therapeutic index set by the European Medicines agency and studies indicate therapeutic equivalence1 with the proviso that brands are non- interchangeable unless the switch is overseen by a Renal Consultant and post-conversion therapeutic drug monitoring is conducted23 The switch has been undertaken by a majority of transplant centres in England the main difference being that they have undergone repatriation NHSH Patients receive their transplant primarily at Royal Infirmary of Edinburgh and occasionally at Queen Elizabeth University Hospital Glasgow Care is transferred to NHS Highland on discharge NHS Highland cares for approximately 170 renal transplant patients 110 being prescribed Prograf These patients may live as far as 110 miles from Raigmore Hospital Given that prescribing is carried out by primary care clear communication with patients GPs and community pharmacy is essential to avoid inadvertent switching between brands
Method Clinically it was agreed a switch could be safely undertaken A business case was submitted and funding secured for pharmacist time laboratory costs and primary care time GPs have been informed via GP subgroup and local prescribing bulletin lsquoThe Pink Onersquo Community pharmacies are being informed by phone A protocol has been agreed Eligible patients selected by Renal Consultant and Renal Pharmacist Patients sent letter signed by Renal Consultant and Renal pharmacist Patients phoned prior to clinic to agree Adoport start date and address concerns Patient seen by Renal Consultant and pharmacist + given 1 month of Adoport Tacrolimus level and UampEs checked 5-7 days after commencing Adoport and patient
contacted by phone to check if tolerated If stable letter sent to GP and community pharmacy to continue supply
Results and Evaluation Letters have been sent to all eligible patients Seven patients have been reviewed One has received a one month supply of Adoport and 5 others are due to switch One patient was deemed non-eligible at present as they have a 6 month surplus of Prograf A database will be maintained and analysed at the end and primary care savings will be monitored Extra pharmacist input will give us the opportunity to review how immunosuppression is managed and to evaluate the benefit of having a renal transplant pharmacist Conclusion The switch is at an early stage Ultimately we hope to show that the switch from Prograf to Adoport can be managed safely with extra pharmacist input to a remote and rural population with prescribing being conducted by primary care
Fundingconflicts of interest none 1 McDevitt-Potter LM Sadaka B Tichy EM Rogers CC Gabardi S Transplantation 2011 A multicenter experience with
generic tacrolimus conversion 2 Medicines and Health Products Regulatory Agency Drug Safety Update 2012 Accessed online via
wwwmhragovukSafetyinformationDrugSafetyUpdateCON1557563 ESPRIT Guidance on management of repatriation and immunosuppressant switches in transplant patients 2015
Accessed online via httpwwwespritorgukwp-contentuploads201508Switch-guidance-document-final-Aug-31-2015pdf
P7 NHS Highland-Tacrolimus baseline dataMcCulloch K1 Peel R2 Lambie S3
1Renal Pharmacist Renal unit Raigmore Hospital Inverness 2Renal Consultant Renal unitRaigmore Hospital Inverness 3Renal Consultant Renal unit Raigmore Hospital Inverness
BackgroundAs part of planning a switch from using tacrolimus Prograf to Adoport we assessed baseline data for our transplant patients currently using Prograf After converting patients to Adoport we will compare their tacrolimus levels to their individual target range We assessed our use of appropriate target ranges and our current performance in achieving tacrolimus levels within target range on Prograf therapy
Method 107 renal transplant patients taking Prograf were identified a sample of 19 of these were analysed using electronic patient records and results Time from transplant ranged from 1 month to 18 years All tacrolimus levels for the preceding year were analysed and compared to the target range specified at the time of the level being done The assay used has a Coefficient of Variation of lt5 at the lower limit of the assay
Results All 19 patients had a target range for tacrolimus clearly identified and recorded in clinic letterswhich are routinely copied to the patients themselves A variety of target ranges were specifiedThe commonest used was 5-8 microgramsl in 7 patients followed by 5-7 in a further 4 patientswith another 6 different target ranges being used for the remaining 8 patients The ranges usedhad a breadth of 3 microgramsl in 2 cases the rest had a breadth of 2 microgramslPatients had a median of 12 (range 3-72) tacrolimus levels over the preceding year Results werewithin specified target ranges for 54 +- 22 (Medan +- SD) of results checked
Conclusion We currently use a large number of different target ranges The majority of the ranges used had a breadth of just 2 microgramsl These factors help to account for the low proportion of test results which were within the specified target ranges This is important to bear in mind when interpreting whether tacrolimus levels are within target ranges after switching to Adoport We should consider aligning our target ranges and widening them
P8 Eculizumab use in Scottish paediatric dense deposit disease Stewart D1 David Hughes1 Lynne Riach2 Craig Oxley2 Athavale D1
1Royal Hospital for Children Glasgow 2Royal Aberdeen Childrenrsquos Hospital Aberdeen
Introduction The revised MPGN classification and increasing recognition of Dense Deposit Disease (DDD) a C3 glomerulopathy as an alternative complement pathway disorder suggests Eculizumab an anti-C5 monoclonal antibody may be beneficial in treatment However the experience of Eculizumab as an off-label and expensive treatment in children with DDD is limited with variable clinical response reported in the literature
Method We present the outcomes of the only 2 paediatric patients in Scotland who have received Eculizumab for the management of DDD
Results Case 1 A 10 year old male presented with proteinuria and haematuria resistant to steroid treatment with preserved renal function Initial biopsy confirmed DDD Conservative management with an angiotensin converting enzyme inhibitor and diuretics for symptom control continued until 14 years Due to worsening symptoms (oedema lethargy poor growth) and renal function deterioration along with elevated terminal complement complex (TCC) Eculizumab was commenced A repeat biopsy whilst suggestive of chronic irreversible damage showed 25 glomerular architecture preservation Symptom improvement was noted There was a reduction in proteinuria and renal function stabilisation fall in TCC and discontinuation of diuretics Eculizumab was discontinued after 24 months Progression of renal function decline was seen in the final months of Eculizumab therapy With recurrence of symptoms and increasing proteinuria following discontinuation Eculizumab was recommenced after 6 months Symptomatic improvement has since been noted
Case 2 A 5 year old girl presented with painless frank haematuria and proteinuria Initial biopsy confirmed DDD Proteinuria was unresponsive to steroid therapy and 5 months following diagnosis she rapidly progressed towards end stage renal disease despite the introduction of Mycophenolate Mofetil and plasmapheresis Haemodialysis was subsequently commenced TCC level was elevated and Eculizumab treatment was started 7 months after diagnosis Renal biopsy prior to treatment demonstrated continued severe pathological changes in all visible glomeruli However due to lack of clinical response Eculizumab was discontinued after 2 months and the patient remained dialysis dependent
Conclusions Our experience with Eculizumab in Scotland has demonstrated variable results in our 2 patients with one patient showing a positive response whilst the other experienced no improvement Eculizumab was administered to both patients at varying points in their clinical journey with differing progressive features on biopsy To date the outcomes of 9 paediatric patients with DDD treated with Eculizumab have been described in the literature with 8 experiencing some positive response to treatment including 2 patients who were able to stop renal replacement therapy within 12 weeks of treatment A role for Eculizumab in DDD may be guided by clinical and pathological features Well designed clinical trials will be necessary to define the role of complement inhibition therapy in DDD
No conflict of interest and no funding requested
P9 Examining markers of safety in the use of non-tunnelled central venous catheters
James WT Millar (Speciality Registrar) Scott W Oliver (Speciality Registrar) Peter C Thomson (Consultant Nephrologist) Glasgow Renal and Transplant Unit Queen Elizabeth University Hospital Glasgow
Background Non-tunnelled central venous catheters (NTCVC) remain an essential means of vascular access for incident haemodialysis Associated morbidity is well recognised for example in the form of Staphylococcus aureus bloodstream infections (SAB)[1]
Previous quality improvement initiatives in our unit have sought to both improve traditional markers of quality (such as SAB) and to identify additional areas of clinical risk In 2014 Oliver et al [2] suggested several additional quality measures including peri-procedure haemoglobin drop the need for a further NTCVC during the same clinical episode and the NTCVC insertion site This study further evaluated NTCVC related clinical practice within our unit
Methods The potential markers of clinical quality identified in a previous project were examined using prospectively collected data stored in the electronic patient record Identified cases of SAB significant peri-procedure haemoglobin drop and multiple NTCVC insertion were investigated by case note review
Results Between March 2016 and March 2017 a total of 222 patients received 346 NTCVC 54 patients (243) had more than one NTCVC inserted in a 21-day period (range 2-5) When considering NTCVC insertion site there were 159 (459) femoral vein catheters and 183 (541) internal jugular vein catheters No pneumothoraces were reported
15 SABrsquos were reported during this period equating to 43 of all NTCVC 5 arose in patients with femoral NTCVC (333) and 10 from internal jugular catheters (667) Mean time from line insertion to positive blood culture was 86 days 15 (67) patients had a drop in haemoglobin of greater than 20mgdl with no other source of blood loss identified on review of clinical notes
Discussion These data demonstrate that NTCVC-associated SAB rates remain low and significantly below Scottish government audit standards [3] Of interest is the continued trend towards the use of femoral catheters at 45 of lines compared with 38 in 2014 [2] Although traditionally thought of as having a higher incidence of infectious complications our data has shown fewer bacteraemia events associated with femoral catheters compared with internal jugular Our data also demonstrates a significant rate of peri-procedure haemorrhage arising in up to 1 in 20 cases Together these findings present opportunities to development practice and improve patient safety
References
[1] Murray E Deighan C Geddes CC Thomson PC Reducing haemodialysis bacteraemia rates Scottish Renal Association Glasgow November 2013 [2] Oliver SW Thomson PC Jardine AG defining safe effective and patient-centred dialysis catheter placement Scottish Renal Association Edinburgh September 2014 [3] The Staphylococcus aureus bacteraemia quarterly report of cumulative data from all NHS Boards in Scotland Health Protection Scotland January 2015
Sources of funding none Conflicts of interest none
P10 Prescribing of tolvaptan-The NHS Highland experience Lambie S1 McCulloch K2 Garrod J3
1Renal Consultant Renal unit Raigmore Hospital Inverness 2Renal Pharmacist Renal unit Raigmore Hospital Inverness 3Renal Pharmacist Renal unit Raigmore Hospital Inverness
Introduction Tolvaptan is a vasopressin antagonist It was accepted for use in Scotland by SMC in Jan 2016 to slow the progression of cyst development and renal insufficiency of autosomal dominant polycystic kidney disease in adults with chronic kidney disease (CKD) stage 1 to 3 at initiation of treatment with evidence of rapidly progressing disease1 Adverse effects related to aquaresis may affect patientsrsquo ability to achieve the optimum therapeutic dose and the risk of hepatic toxicity necessitates regular LFT monitoring The geography of NHS Highland required the implementation of novel methods of managing these patients and as a result a MDT approach with an emphasis on pharmacist input was adopted Consultant role Patient selection on the basis of evidence of rapidly progressing kidney disease declining
eGFR large volume kidneys on ultrasound and evidence of complications of PKD Side effects and potential benefits discussed Potential medication interactions reviewed Jinarc risk management prescriber training
Pharmacist role Undertook Jinarc risk management pharmacist training Prepares accurate drug history and reviews for potential drug interactions Carries out patient counselling and supplies patient education material sick day rules card
and lsquogot to gorsquo card Supplies GP education leaflet Provides advice on selection of new drug therapies eg for gout Manages stock and coordinates supply to patients
Results Prescribing commenced May 2016 patients currently prescribed tolvaptan 11 7 Female 4 male Number on target dose 73 n = 811 2 patients are still being titrated One patient did
not tolerate target dose due to aquaresis side effects and is being trialled on the middle dose
Withdrawals One patient has withdrawn due to agoraphobia and an inability to attend for monitoring and another is on hold due to having major surgery
Conclusion The MDT approach between the Renal Consultant and Pharmacist at Raigmore Hospital has enabled tolvaptan prescribing to be efficiently and safely implemented to patients living within a challenging geographical location
1 Scottish Medicines Consortium Detailed Advice Document tolvaptan 15mg 30mg 45mg 60mg and 90mg tablets (Jinarcreg) SMC No 111415 January 2016
NA1 Authors SCN Jacqueline Ross NHS Grampian
SCN Alan Somerville NHS Lanarkshire SCN Jane Humphrey NHS Lanarkshire
e- mail contact jacquelinerossnhsnet Alansommervillelanarkshirescotnhsuk
Janehumphreylanarkshirescotnhsuk
Phone contact 01224 552927 01236 712644
Title Sharing of Adverse Events in Renal Units across Scotland
Introduction Background The Scottish Renal Nurses Strategy Group (SRNSG) are a group of senior nurses from Renal
Units across Scotland who meet 3-4 times per year to discuss and implement best practice At the last meeting it was agreed that it would be good practice for each Health Board to share
their adverse events reported on the Datix System and deliver a presentation with an action plan to prevent incidents and improve patient safety across Scotland NHS Grampian and NHS Lanarkshire will be the first to deliver this presentation discussing adverse events from both Health Boards with an action plan
Top 5 adverse events over the past 12 months Renal Unit NHS Grampian 1 Violence and Aggression 2 Accidents including needlesticks slips trips and falls 3 Medication Errors 4 Infrastructure Staffing and Estates 5 Machines and Equipment
Top 5 adverse events over past 12 months Renal Unit NHS Lanarkshire
1 Slips Trips or Falls 2 Medicine errors 3 Treatment problems 4 Transfer problems 5 Breach of policy
The presentation will also focus on any serious adverse events which may not be in the top 5 categories
Aim Objective Each Health Board to share their adverse events with the aim to prevent them from occurring in other units to improve staff and patient safety and wellbeing across Scotland
Method Power Point Presentation
Outcome Results Sharing of adverse events resulting in the development of a national Action Plan to prevent these incidents improving safety and well being of staff and patients in Renal Units across Scotland
NA2
SRA Oct 2017 Abstract
BBV Never Event - The whats whys and hows
Staff Nurse Gillian Wilson Aberdeen Royal Infirmary
This presentation shares our experience of a never event that occurred and was not picked up for
a period of 18 months
Hepatitis C (HCV) positive antibodies were found in a previously negative patient
These results were a low positive with no biochemistry changes to suggest any liver damage
however steps were put immediately in place to isolate and investigate
Was it contamination from a dialysis machine was it related to a blood transfusion given prior to
first positive result was it faulty diagnostic tests in the laboratory
In Aberdeen we go over and above national guidelines and isolate all our BBV patients whether
they have positive blood results or are PCR negative
Further bloods tested at an external laboratory confirmed negative results
It highlighted that communication errors were to blame for the lack of speed in detecting this issue
Investigations concluded no real answers as to why this happened
NA3
Living Donation Scotland Changing attitudes towards living donor kidney transplantation
Jen Lumsdaine Julie Glen On behalf of the Living Donation Scotland Project Board
Background and aims
The rate of living donor transplantation has remained fairly static in Scotland over the past 10 years
Recent data has shown inequity of access to living donor transplantation throughout the UK so
there is potential to significantly increase this optimum form of treatment for patients with end-stage
renal failure in Scotland The Living Donation Project Board was formed in 2016 aiming to double
the number of living donor transplants by 2020
Method
The two key areas
1 Do recipients receive adequate and appropriate information at the right time about living
kidney donation
2 Informing the general public about altruistic donation
All patients active on the transplant list in Scotland were invited to an information event A follow-up
questionnaire was performed in the East of Scotland examining outcome or reasons for not
attending A scoping exercise looked at information provided by each unit was performed and link
nephrologists and low clearance nurses attended meeting to discuss strategies for early education
Outcome
An information pack containing both recipient and donor written information and short films on DVD
has been produced with the support of the Scottish Government for all recipients and potential
donors in Scotland A new website with comprehensive information both written and visual and
postcode finder to improve ease of access to local unit contact details has been developed
Two national media campaigns have been launched with a significant rise in the number of enquiries
from potential donors and actual increase in altruistic donor numbers
Nursing abstract ndash no conflict of interest
NA4Authors Susan Easson Charge Nurse Ward 4C QEUH Glasgow
e- mail contact SusanEassonggcscotnhsuk
Phone contact 0141 452 3300
Title A Conversational approach to find out ldquoWhat matters to yourdquo in a Renal Transplant ward
Introduction Background Finding out ldquo What Mattersrdquo to people using health and careservices is crucial to delivering safe effective and person centred care It is a simple yet profoundconcept and tries to get to the essence of person centred care by creating deeply personalengagements with patients and their families through a conversational approach However careexperience feedback all too often provides innumerable examples of where what really matters topatients and their family members is poorly understood or not addressed Using care experienceas the driver for change the nursing staff in Ward 4C used improvement approaches to explorehow to hold more meaningful ldquoWhat Matters to yourdquo conversations on a daily basis
Aim Objective To improve the patient experience by utilising a person centred approach
Method Using Care experience feedback What Matters to Me boards and the conversationalapproach
Outcome Results Improvements in patient experience will be shared using examples ofpractice and care experience feedback
There was no additional funding required for this project We worked in collaboration with theperson centred team whorsquos aim is to improve patient experience
NA5
The implementation of a renal education programme and its impact on clinical practice
The purpose was to implement a Renal Education Programme and to evaluate its impact on
clinical practise
It was identified that there was a need for an educational programme to be set up within Forth
Valley Royal Hospital There is no inpatient renal unit in FVRH on site for our renal patients they
attend Queen Elizabeth University Hospital We are an outpatient haemodialysis unit with
outpatient clinics on site Therefore it was identified that there was a need for nursing staff within
FVRH to be educated on all renal complexities for the benefit of our patients
This was done through a work-based learning approach which brought tangible benefits for our
patients However it did not come without pitfalls as educational programmes are often seen as
making very little difference to clinical practise
T
his study describes what methods were used and examines the advantages and disadvantages in
setting up an educational programme and evaluating its impact on clinical practise
NA6
Nursing Abstract ndash SRA Meeting ndash 26 October 2017
Chris McGee Tonya Broe Ken Weir
Renal Unit Forth Valley Royal Hospital
Use of the Therapy Monitor Haemodialysis Patient Record System Can we aim for a paper-
free dialysis unit
We are trialling a new haemodialysis patient monitoring system to work in conjunction with SERPR
and which is intended to supersede the Finesse system used previously
We are in the early stages of this process but with continuing staff education and regular tech
support we are hoping to gather sufficient evidence to evaluate whether the use of paper case
notes needs to continue
Is it a realistic goal to aim for a completely paper-free unit
NA7
THE CLINICAL USES OF APHERESIS WITHIN NHS TAYSIDE
Laura Thomson CN
Ninewells Hospital Dundee
NHS Tayside took over the apheresis service from BTS in 2012 The service has since expanded
with the benefits of carrying out this treatment has been widely recognised within NHS Tayside
and is now more commonly being offered to treat a wider range of conditions with the number of
treatments carried out each year rising
This presentation will highlight the progression of the apheresis service within NHS Tayside We
will identify the various conditions it is currently being used to treat and also identify the decision
making process involved in carrying out these treatments ie which replacement fluid will be used
anticoagulation medication administered
We will highlight the benefits and challenges we face in providing this expanding service within the
Renal Service
NA8Authors Linda McDougall Renal Physiotherapist NHS Highland
e- mail contact lindamcdougall1nhsnet
Phone contact 01463 706022
Title lsquoExercise on Haemodialysis- Keeping the Wheels in Motionrsquo
Introduction Background The impact of CKD on physical fitness functional ability independence amp ultimately quality of life cannot be underestimated Current national guidelines recommend that all individuals with CKD are encouraged to participate in regular exercise programmes between or during dialysis sessions if on HD Following a successful pilot study funding was approved to establish an lsquoExercise on Dialysisrsquo (EOD) programme across NHS Highland through the appointment of a dedicated renal physiotherapist in 2008 A successful programme was soon established but for several years post-vacancies and increasing in-patient demands limited the physiotherapy servicersquos ability to deliver the programme The need to improve the long-term sustainability of the service was recognised and in late 2016 funding was approved to develop a Band 4 PT HCSW role for this purpose
Aim ObjectiveTo optimise the sustainability and continuity of the lsquoExercise on Dialysisrsquo service across NHSHighland through development of a Band 4 PT HCSW role
Method The potential parameters of the role and limits of autonomy were scoped out using current NES resources and guidelines Service and task analysis was then carried out to establish which components of the EOD protocol could be undertaken by a Band 4 A series of competencies were developed in line with the clinical protocol and one-to-one training and supervision provided to the post-holder to ensure competency achieved in delivering the programme
Outcome Results A 10 WTE Band 4 PT HCSW was appointed in Jan 2017 with a dual role between the renal unit and acute medical wards Although training is not yet complete the post-holder is already running the day-to-day delivery and monthly audit of the EOD service with senior physiotherapist input only required for individual patient safety queries and general discussion around patientsrsquo progress and goals The benefit to the unit has been considerable as the band 4 is available to support patients and staff with EOD provision 5 days a week This allows for one-to-one supervision of patients who need more support to participate in EOD regular feedback on performance and reviews of outcome measures and goals to maintain motivation levels Feedback on the post has been very positive and its scope will only continue to expand as we look to further develop renal rehabilitation services across NHS Highland
NA9Authors Nadine Lyall and Kerry Guthrie
e- mail contact nadinelyallbordersscotnhsuk kerryguthriebordersscotnhsuk
Phone contact 01896 826637
Title The Developing Role of the NMP in a Satellite Dialysis Unit
Introduction Background
We have been practising as NMPrsquos for nearly 3 years working in the dialysis unit at the BGH The unit is a satellite unit of the ERI and we have expanded over the last 6 years The unit provides haemodialysis for 12 patients at any one time 3 sessions a day 6 days a week We are nurse-led and have 2 renal consultants who are based at the ERI
We saw an opportunity to use our knowledge and experience to develop our role By becoming NMPrsquos we have enhanced our professional development and we feel we meet the changing needs of the dialysis patient in a more holistic manner
Aim Objective
Our aim is to deliver effective care as we are better placed to deal with issues that often arise byacting swiftly this in turn is cost effective and convenient For example good anaemia and bonemanagement is important for their health wellbeing and lifespanTo help understand our role we will use a power point presentation highlighting issues we dealwith and the drugs we prescribe under the following headings Cardiovascular infection painanticoagulant disequilibrium diet renal bone disease and renal anaemia
Method Power point
Outcome Results
In the future we hope to further develop and have greater autonomy in our role We have great support from our renal consultants and have already built up a great relationship with our patients We hope to undertake the Clinical Decision Making course and this in turn will allow us to deal effectively with acute illness giving the dialysis patient better care We are keen to get feedback from other renal nurses in Scotland to enable us to develop our role further and in turn raise awareness of the NMP role in a dialysis unit We record all our prescribing decisions and keep the consultants up to date regularly Currently we are working on auditing our prescribing practice so that we can improve the service we can provide
NA10 Title Komunikacja w szkoleniu dializy ortzewnowej
Author Senior Charge Nurse Rhoda Bell
Address Raigmore Hospital Old Perth Road Inverness IV2 3UJ
Email rhodabellnhsnet Telephone 01463706023
Introduction Background Case study on lady with Polish as her first language she has some English but requires an interpreter to carry out Peritoneal Dialysis training and attend clinic She had some gynaecological issues that we were not aware of which impacted on the functionality of PD and therefore the success of treatment There were areas of concern in low clearance clinic with signs the patient had a reluctance to engage in decision making
AimObjective
Methods Discussion through the case study highlighted issues with communication between different PD staff and patients Areas of concern include different staffing techniques environment factors on training success Also language and communication issues the patient had were not fully apparent so training could not be individualised
Results We plan to trial training at home and have more individualised training schedule for patients The training step by step guides have been reviewed and practise standardised In collaboration with low clearance nurse we have developed a check list which will highlight concerns before the transition to PD ie language issues and need for training aids in another language gynaecological conditions
Conclusions Everyone learns differently and training methodsaids must be individualised for all It may not be apparent until training has commenced that there are concerns Having one to one training with the same nurse will consolidate training and build confidence in the patient Having a close working relationship with members of the MDT will help make a supportive PD journey
Would we do things differently if we knew about prolapse or lack of English both spoken and written
Key words - Peritoneal dialysis patient training communication
N11
Telehealth amp PDAudrey Jones
Advantages
Information on a daily basis about treatment weight and blood pressure
Change programme remotely via computer or mobile
Earlier intervention for machineprogramme issues
Reduction in home visits ie patient trained but still requires volume increases
No need to download cards to see what problems have been
Can have more detailed information available at clinics
Disadvantages
Relying on patient input data correctly
Machine is noisy especially first wave of machine
Still the same bag connection system and patient connection system (difficult for manual
dexterity problems)
Relying on patient having good signal
Modem problems
NA12Autosomal Dominant Polycystic Kidney Disease A cruel inheritance but new hopeAlistair Lawrie Renal Unit Victoria Hospital KirkcaldySadaf Arshad Corry Dunnigan Paul Phelan Neil Turner Renal Unit Royal Infirmary of Edinburgh
Background Autosomal Dominant Polycystic Kidney Disease (ADPKD) is the most prevalent single gene human genetic disorder and the most common of the inherited cystic and interstitial kidney diseases It is estimated to affect 1 in every 1000 individuals worldwide with over 50 of sufferers eventually developing end stage kidney disease and requiring dialysis or transplantation Symptoms include spasmodic severe pain hypertension haematuria infection and kidney failure There is currently no cure for ADPKD Management of the condition has traditionally involved lifestyle modification BP control and analgesia however a recent study (Torres et al 2012) demonstrated that treatment with V2-receptor antagonist drugs slowed increase in total kidney volume reduced the rate of functional decline and showed a reduced incidence of kidney pain
Aim Provision of a tolvaptan prescribing and monitoring service
Methods Experiential finding report of initial twelve months period of multidisciplinary ADPKDtolvaptan clinic
Results Early results are comparable with TEMPO study outcomes
Conclusion Due to the long term nature of this treatment results available at this time are showing only the earliest benefits of the intervention More quantifiable results such as increased time before the necessity for RRT will only be evident in coming years Torres VE et al (2012) Tolvaptan in Patients with Autosomal Dominant Polycystic Kidney Disease New England Journal of Medicine 367 pp 2407-2418 DOI 101056NEJMoa1205311
No funding requirement No conflict of interest
A16 The Impact of Withdrawal of Maintenance Immunosuppression and Graft Nephrectomy on HLA Sensitisation Ailish Nimmo1 Sophie McIntyre1 Lorna Henderson1 Richard Battle2
(1 Department of Renal Medicine Royal Infirmary of Edinburgh 2 Histocompatibility and Immunogenetics Royal Infirmary of Edinburgh)
Background The development of HLA antibodies towards a failing renal allograft is a barrier to re-transplantation We previously demonstrated an increase in HLA antibodies and calculated reaction frequency (cRF) following nephrectomy but results were confounded by immunosuppression changes occurring in close time proximity We examined the formation of HLA donor specific antibodies (DSA) in patients with failed grafts that remained in situ and compared results with patients undergoing graft nephrectomy to further assess the relative impact of nephrectomy and immunosuppression weaning on sensitisation and chance of transplant
Methods We carried out a single centre retrospective study of all patients with failed grafts in Lothian from 2005 to 2015 Samples were tested for DSA pre-immunosuppression (IS) wean post-IS wean and post-IS cessation Nephrectomy patients also had samples tested for DSA before and after nephrectomy Data on other sensitising events including blood transfusion and rejection were collected cRF was determined at each time point and entered into the ODT chance of transplant calculator with other demographics based on the average patient from the Edinburgh centre
Results 62 grafts failed over this time period Blood samples were available 41 patients (24 with nephrectomy 17 with failed graft left in situ) Patient demographics were similar between groups There was a higher rate of antibody mediated rejection in the nephrectomy group (46 vs 18) 76 of patients with nephrectomy group had received a blood transfusion The pattern of immunosuppression weaning was similar but median time from start of IS wean to cessation was longer in the nephrectomy group (350 vs 298 days) The changes in cRF and chance of transplant (COT) with immunosuppression weaning are shown in Table 1
Pre-IS Wean Post-IS Wean
Failed graft in situ (n=17)
Mean CRF COT at 5
years 15 62 38 59
Nephrectomy (n=24)
Mean cRF COT at 5
years 54 54 69 46
Post-IS Stop 55 53 89 42 Table 1 Mean cRF and Chance of Transplant (COT) at 5 years with IS alterations
Discussion A stepwise increase in cRF with reduced chance of transplant was observed in both groups as immunosuppression was withdrawn with a similar pattern of change irrespective of graft nephrectomy cRF was higher in the nephrectomy group despite a more gradual wean which may reflect a higher rate of antibody mediated rejection and increased number of patients receiving a blood transfusion The risks and benefits of stopping immunosuppression need to be carefully considered on an individual basis to maximise chance of future transplant
The authors have no conflicts of interest No funding was required for this study
A17 Obesity is not associated with progression to end stage renal disease in patients withbiopsy-proven glomerular diseases
Benjamin Elyan Jennifer S Lees Bruce Mackinnon Jonathan G Fox Colin C Geddes Emily PMcQuarrie
Glasgow Renal and Transplant Unit Queen Elizabeth University Hospital Glasgow
Introduction - Addressing risk factors for renal progression is a key aspect of managing chronic kidney disease (CKD) Body mass index (BMI) has been shown to impact on renal progression in unspecified CKD The aim of this study was to evaluate if there was an association between BMI and progression to renal endpoints in patients with biopsy-proven primary glomerular disease (GN)
Methods - We included all adult patients diagnosed with biopsy-proven primary GN (excluding minimal change nephropathy) in Greater Glasgow amp Clyde and Forth Valley between 01012000 and 31122015 Biochemical and anthropometric data were extracted from the electronic patient record at time of biopsy with follow-up data until 20062017 BMI was calculated from height and weight at time of biopsy and categorised into groups BMI le25 kgm2 (G1) gt25 to le30 kgm2 (G2) and gt30 kgm2 (G3 - obese) We assessed factors associated with reaching a combined renal endpoint of CKD5 or renal replacement therapy (RRT) with competing risk of death using the Fine and Gray subdistribution hazard model Analyses were conducted using cmprsk package for R statistical software package and SPSS version 24
Results - 560 patients with primary GN and available BMI data were included The average age was 532 years and 339 were female There were 132 patients in G1 210 in G2 and 207 patients in G3 Those in G2 and G3 were older (p=002) with slightly higher diastolic blood pressure (p=002) than those in G1 There was a greater proportion of focal segmental glomerulosclerosis in G3 but similar proportions of other GN diagnoses across groups There was no significant difference in baseline serum creatinine (sCr) (p=034) or log uPCR (p=045) between BMI groups On multivariate analysis age systolic blood pressure BMI or GN diagnosis were not predictive of renal outcome Higher baseline sCr (SHR 1003 per 1 umoll increase in sCr 1001-1004 plt0001) and log uPCR (SHR 130 per unit increase in log uPCR 95 CI 105-160 p=002) were associated with progression to the combined renal endpoint accounting for competing risk of death BMI was not associated with reaching combined renal endpoint on univariate analysis whether considered as a continuous variable (SHR=100 95 CI 098-102 p=096) or categorised by BMI group
Conclusion - Contrary to our expectations there was no association between BMI and progression to a combined renal endpoint of CKD5 or RRT in this cohort of patients with primary GN Efforts should be directed to managing other known risk factors for CKD progression
Sources of FundingConflicts of Interest - None
A18 Factors influencing long term renal function after living kidney donation
Matthew A Rutherford Norman J Galbraith Marc Clancy Colin C Geddes
Glasgow Renal and Transplant Unit Queen Elizabeth University Hospital Glasgow UK
Background Following live donor nephrectomy the remaining kidney undergoes an increase in filtration capacity known as compensatory hypertrophy Few cohorts with follow up of renal function beyond 5 years have been reported The impact on long term renal function of variability in donor factors such as age sex pre-donation blood pressure and glomerular filtration rate (GFR) is unknown Increasingly kidney donors have potential risk factors for future poor renal function such as hypertension older age and obesity The aim of this study was to analyse factors influencing long-term renal function in living kidney donors from our centre
Method Data were obtained from the electronic patient record Patients with a recorded procedure of lsquolive donor nephrectomyrsquo between 2005 and 2017 were identified GFR after donation (calcGFR) was calculated using the formula lsquocalcGFR = Pre-donation Isotope GFR x (Pre-donation Serum creatinine Serum Creatinine)rsquo which is accurate assuming muscle mass does not change Pre and post donation serum creatinines (two days two weeks three months and one to ten year) were recorded We analysed the influence of age sex pre-donation GFR and blood pressure on post donation GFR compensation
Results 355 live donor nephrectomies were performed between January 2005 and December 2016 The mean age was 469 (plusmn 116) years and 504 (n=179) were female Mean pre-donation isotope GFR was 937 plusmn 156 mlmin173m2 Median follow up was 2 years (IQR 1 to 6 years with range 2 weeks to 10 years) The calculated percentage of pre-donation GFR at 2 days 2 weeks 3 months 1 year 5 years and 10 years were 698 691 712 730 801 and 950 respectively (p lt 0001) Patients aged lt50 y had not only a higher calcGFR (858 plusmn 29 mlmin173m2 compared with 671 plusmn 28 mlmin173m2 p lt 0001) at 5 years following donation but achieved a higher degree of compensation than donors gt 50 y (836 plusmn 16 compared with 756 plusmn 19 (p = 0002) Patients with pre-donation hypertension achieved 774 plusmn 53 of pre-donation GFR compared with 804 plusmn 32 in normotensive patients (p = 0998) Females had equivalent degree of renal compensation achieving 819 plusmn 19 compared with 780 plusmn 16 in males (p = 0131) at 5 years following donation Patients with pre-donation GFR gt 100 mlmin173m2 achieved 844 plusmn 23 of pre-donation function by 5 years compared with 777 plusmn 14 in those with pre-donation GFR lt 100 mlmin173m2 (p = 001)
Conclusion Following live donor nephrectomy renal function has a nadir of 691 at 2 weeks Compensation in GFR occurs rapidly and appears to be maintained regardless of sex and pre-donation blood pressure Younger age and higher pre-donation GFR were associated with a greater degree of compensation
A19 The utility of high-sensitivity cardiac troponin to stratify cardiovascular risk in patients with renal impairment
Eve Miller-Hodges Atul Anand Anoop S V Shah Nicholas L Mills Neeraj Dhaun
Background Cardiovascular disease is the most common outcome of chronic kidney disease1
Declining glomerular filtration rate (GFR) and proteinuria predict increased cardiovascular risk over the long term2 However there are currently no methods to stratify cardiovascular risk in the short or medium term in patients with renal impairment We have already shown that high-sensitivity cardiac troponin I concentrations (hs-cTnI) lt5ngL in patients presenting with symptoms of acute coronary syndrome identifies those at low risk of cardiac events within 30 days and over the next year3 However uncertainty remains over the role of hs-cTnI testing in patients with renal impairment This study investigated whether hs-cTnI could also stratify future cardiovascular risk in patients with renal impairment
Methods In a prospective study of consecutive patients presenting with suspected acute coronary syndrome we evaluated the performance of hs-cTnI in patients with and without renal impairment (estimated glomerular filtration rate lt60mLmin173m2) using an early risk stratification threshold of 5ngL to ldquorule outrdquo acute myocardial infarction at presentation and within 30 days and sex-specific 99th centile diagnostic thresholds for index type 1 myocardial infarction Subsequent type 1 myocardial infarction and cardiac death were reported at one year
Results Of 4726 patients identified 904 (19) had renal impairment Index diagnosis of type 1 and type 2 myocardial infarction was almost twice as likely in patients with renal impairment (30 vs 15) Performance of the early risk stratification threshold of 5ngL to identify patients at low risk of major cardiac events was similar in patients with (NPV 984 95CI 960-997 sensitivity 989 95CI 975-999) and without renal impairment (NPV 997 95CI 994-999 sensitivity 984 95CI 972-994) These patients continued to remain at low risk over the next year The PPV and specificity at the 99th centile for diagnosis of myocardial infarction were lower in patients with renal impairment at 500 (95CI 452-548) and 709 (95CI 675-742) respectively compared to 624 (95CI 588-659) and 921 (95CI 912-930) At one year 24 of patients with renal impairment and troponin gt99th centile regardless of index diagnosis had experienced further myocardial infarction or cardiac death compared with 10 of patients without
Conclusion In suspected acute coronary syndrome hs-cTnI can stratify risk in patients with renal impairment Irrespective of diagnosis patients with renal impairment and elevated cardiac troponin concentrations had two-fold greater risk of a major cardiac event compared to those with normal renal function and should be considered for further investigation and treatment
Funders Wellcome Trust British Heart Foundation and Chest Heart amp Stroke Scotland
1 Gansevoort RT Lancet 2013
2 Chronic Kidney Disease Prognosis Consortium Lancet 2010
3 Shah AS Lancet 2015
A20 lsquoDOES IT DIALYSE OUTrsquo - THE EFFECT OF RENAL REPLACEMENT THERAPY ON THE BRAIN Mark Findlay Jesse Dawson David Dickie Deborah McGlynn Patrick Mark Institute of Cardiovascular and Medical Science University of Glasgow amp Queen Elizabeth University Hospital Glasgow
Introduction Cerebrovascular disease is common in end-stage renal disease (ESRD) on renal replacement therapy (RRT) We investigated the effect of RRT on cerebral structure and cognitive function over 12 months Methods Observational cohort study in ESRD patients receiving HD Prior cognitive impairment or cerebrovascular disease were exclusion criteria Multi-domain cognitive testing was performed at baseline and at follow-up Transcranial Doppler was used to assess intra-dialysis related alterations in mean flow velocity (MFV) ndash a marker of cerebral blood flow MR imaging was performed at 0 and 12 months We performed T1 T2 FLAIR and DWI sequences and used volumetric software to calculate white matter hyperintensity (WMH) burden markers of atrophy mean diffusivity and fractional anisotropy (FA) to describe structural changes at 1 year Results 97 patients median age 59 years 412 female At follow-up 15 patients were transplanted 6 died 4 withdrew and the remainder continued HD Those who were transplanted were younger (median age 51 vs 60 years p=0019) and had been on dialysis for a shorter period (median 06 vs 21 years p=0003) MFV declined during HD median 475cms to 405cms plt0001 and correlated with lower scores of executive and frontal lobe function during HD (Rho 045 p lt0001 and Rho -0313 p lt001 respectively) In all patients MR imaging demonstrated a significant decline in frontal parietal and temporal lobe volume at follow-up Median WMH volume increased in those who remained on HD but not in transplanted patients (median change 023 vs -012ml p=0018) WMH burden correlated with worsening scores of frontal lobe tests Rho 0585 p0005 and worse mood Rho -0485 p0026 FA improved following renal transplant (028 to 029 p=0016) and correlated with improved executive function testing at follow-up Rho 089 p0019 Conclusion Cerebral blood flow is reduced during haemodialysis and correlates with a reduction in intradialytic executive function There is an improvement in FA following transplantation WMH volume increases in those who remain on dialysis and the degree of increase correlates with executive and frontal lobe function This suggests that haemodialysis is associated with clinically significant changes in the brain and that these may be ameliorated by transplantation
Source of fundingconflicts MF is funded by a KRUK fellowship
A21 Pathological classification of IgA nephropathy to predict renal outcomes ndash is there a better way to score tubulointerstitial inflammation
Alastair Rankin David Kipgen Bruce Mackinnon Jonathan Fox Colin Geddes Emily McQuarrie Glasgow Renal and Transplant Unit On behalf of the Scottish Renal Biopsy Registry
Background The Oxford pathological classification of IgA nephropathy (IgAN MEST-C score) is limited by the fact that individual features of the score are not all predictive and its utility in assisting clinical decision-making is questioned The addition of tubulointerstitial inflammation to the existing scoring system is appealing but is not currently included due to reportedly wide inter-observer variability We report a novel method to score percentage of cortex containing tubulo-interstitial inflammation in non-atrophic renal cortex (ATIN) in patients with IgAN similar to that used in transplant biopsy reporting and assess its utility to predict clinical outcomes
Methods All adult patients with a native renal biopsy diagnosis of IgAN between 2010 and 2015 in a unit serving 15 million people were identified Baseline characteristics biopsy reports and outcome data were collected ATIN was calculated by subtracting the percentage of atrophic cortex from the percentage of total cortex with tubulo-interstitial inflammation withge10 representing significant tubulo-interstitial inflammation in non-atrophic cortex The primary outcome was a composite of requiring renal replacement therapy (RRT) or doubling of serum creatinine (sCr)
Results 153 new cases of IgAN were identified 33 were excluded (24 had lt8 glomeruli on biopsy 6 inadequate biopsy for MEST scoring and 3 on RRT at time of biopsy) In addition patients with a tubular atrophy (T) score of 2 were also excluded (n=9) Of the remaining 111 patients 76 (68) were male Mean age at biopsy was 52 years (+- 167) and 18 (16) had a co-existing clinical diagnosis of henoch-schonlein purpura (HSP) Median sCr was 156 micromoll (IQR 101-212) and 54 (49) had ATIN on biopsy During a median follow-up of 23 years 34 (31) reached the primary outcome 20 (18) received immunosuppression and 16 (14) died On univariate Cox regression survival analysis ATIN was associated with a four-fold increase in the primary outcome (HR 49 (21-113)) On multivariate analysis mesangial hypercellularity (M) T and ATIN independently predicted renal outcome while endocapillary proliferation (E) and segmental sclerosis (S) did not (plt002 for ATIN) Excluding patients with HSP or those who received immunosuppression did not change the result
Conclusion Within our centre ATIN predicts renal outcome for IgAN independently of established histological features Assessment of inter-observer reproducibility and validation in other cohorts is still required but these results suggest ATIN could be a worthwhile addition to current pathological scoring systems for IgAN
Source of funding none Conflicts of interest none
P1 Polypharmacy in Renal Replacement Therapy Patients
Jason McMinn Colin Geddes Glasgow Renal and Transplant Unit Queen Elizabeth University Hospital
Introduction
Prescribing is often led by evidence from studies containing participants with single health conditions and without multimorbidity Polypharmacy is becoming increasingly recognised in patients with multiple chronic health conditions Additional medications are more likely to result in diminishing returns in benefit with an increased risk of harm Patients with established renal failure (ERF) are likely to be susceptible to medication-related harm A high pill burden is also likely to contribute adversely to an already restricted quality of life and has been associated with poor medication adherence The aim of this study was to analyse polypharmacy in all patients with ERF attending our service
Methods
We extracted medication records for all prevalent ERF patients attending the Glasgow Renal and Transplant Unit from the West of Scotland Electronic Renal Patient Record (SERPR) as of 01012017 The records were analysed to calculate the number of regular medications and total pill burden of each patient These medications were categorised as being lsquopreventativersquo or lsquosymptomaticrsquo We also analysed the prescription of specific drug classes to examine the prevalence of these medications
Results
We identified 1091 transplant follow-up 529 hospital haemodialysis and 46 peritoneal dialysis patients who were on a mean of 94 13 and 129 different medications respectively Overall pill burden was 139 tablets a day in transplant follow-up patients 141 in haemodialysis patients and 162 in peritoneal dialysis patients There were similar rates of prescribing between the different dialysis units and clinics within our service
The proportions of medications deemed as preventative rather than symptomatic were 76 in transplant 69 in haemodialysis and 60 in peritoneal dialysis
In transplant patients decreasing renal function was associated with a higher pill burden but even patients with a transplant eGFR gt 60 were on a mean of 126 tablets per day including a mean of 14 antihypertensives
Rates of antidepressant prescribing were 15 in transplant patients and 20 in hospital haemodialysis patients 53 of haemodialysis patients were on a statin 39 on aspirin 61 on a proton pump inhibitor and 7 were on warfarin
Conclusion
Patients undergoing all forms of renal replacement therapy are likely to be on a considerable number of medications Whilst these drugs are inevitably prescribed for valid reasons this data demonstrates the need for clinicians to engage with patients to explore opportunities to reduce pill burden
Conflict of Interest None Sources of Funding None
P2 An audit of Acute Kidney Injury (AKI) on an acute stroke ward before and after plannedinterventions to review and maintain hydration
Clare Harris1 Simon Hart2 Fiona Duthie3 1 University of Edinburgh Medical School 2 Stroke Unit Royal Infirmary of Edinburgh 3 Renal Unit Royal Infirmary of Edinburgh
Background Dehydration is an important factor in the development of acute kidney injury which is associated with increased morbidity and mortality particularly in the elderly population Poor fluid intake is common post stroke (1) and dehydration is associated with poorer outcomes 3 months post stroke (2) In late 2014 there was no system of identifying patients with poor oral intake on the stroke ward at the Royal Infirmary of Edinburgh a hydration protocol and education programme were implemented aiming to improve fluid balance This included the use of prescribed water either orally or by nasogastric tube An audit pre and post intervention demonstrated that hydration as measured by ureacreatinine ratio significantly improved after the protocol introduction (3) We aimed to determine whether the incidence of AKI by KDIGO criteria was also reduced as this could have implications for reducing patient morbidity and mortality in this elderly comorbid patient cohort
Method 150 inpatients to the acute stroke ward during JulAug 2014 and JulAug 2015 were selected (n= 80 2014 n=70 2015) Patient data and creatinine values were collected from the electronic patient record and medical notes and retrospectively analysed Baseline creatinine values were calculated and cases of AKI were identified and staged using KDIGO criteria (4) Chi-Squared tests were performed to determine P values Individual patient notes were reviewed for both quantitative and qualitative data of patient management
Results Incidence of AKI (of any stage) was 263 pre-protocol and 200 post-protocol (P=03646) Incidence of AKI stages 23 was 100 pre-protocol and 715 post-protocol (P=05374) In hospital post stroke mortality was 338 pre-protocol and 1286 post protocol (P=00028) AKI was also associated with increased length of stay
Conclusions Despite a trend in benefit there was no significant difference in incidence of AKI pre and post hydration protocol nor in incidence of severe AKI (stage 23) AKI is influenced by many factors one of which is hydration status Further studies are needed to determine whether the trend of benefit exhibited in this sample is significant in a greater sample size if this were the case such a protocol could have great benefit to patient care on stroke units and elsewhere There was a significant difference in inpatient post stroke mortality following introduction of the hydration protocol Further investigations are needed to explain underlying reasons for this factors other than hydration may play an important role
References 1 Whelan K Inadequate fluid intakes in dysphagic acute stroke Clinical Nutrition (2001) 20(5)
423-428 2 Bhalla A Sankaralingam S Dundas R Swaminathan R Wolfe CDA Rudd AG The influence of
raised plasma osmolality on clinical outcome after acute stroke Stroke (2000) 312043ndash2048 3 Hart SR Craig R Berry E Lane N Gad A Farrugia M Burton L Paquay A What Happens to
Acute Stroke Patientsrsquo Fluid Balance Renal Status and Dehydration in the First Two Weeks How Can They Be Markedly Improved doi 101111ijs12634_13
4 KDIGO Clinical Practice Guideline for Acute Kidney InjuryKidney international supplements (2012) 2(1) 1-138
No funding or conflict of interest to declare
P3NHS Highland-Improving the management of hyperkalaemia using a kit Initial resultsCantley N1 Abedin T2 Lambie S3
1FY2 NHS Highland 2ST4 Renal Medicine NHS Grampian 3Renal Consultant Renal unitRaigmore Hospital Inverness
Introduction The incidence of hyperkalaemia in hospitalised in patients is between 1 and 10 Guidelines in Northern Ireland promote the use of a Hyperkalaemia Kit to improve management of hyperkalaemia We assessed the management of hyperkalaemia in Raigmore Hospital including post-treatment monitoring of serum potassium and blood glucose at baseline and after the introduction of a lsquoHyperkalaemia Kitrsquo which contains a pro forma for the management of hyperkalaemia and all the relevant equipment and drugs for treatment
Method Between July and September 2016 an automated algorithm identified 34 patients with a potassium result 65 mmoll or above on laboratory results 12 received no specific treatment of these 6 results were spurious 4 patients died before treatment could be started and 2 patients were chronic haemodialysis patients We introduced the Hyperkalaemia Kit to the Acute Medical Admissions Unit in Raigmore Hospital Since then 15 patients have been identified with serum potassium measurements above 65 and the pro forma and kit was used with eight of these patients One of these patients proceeded straight to acute renal replacement therapy
Results Prior to our intervention all 22 patients that were actively treated received at least one prescription of appropriate doses of Insulin with Dextrose However only 16 patients received intravenous calcium and only 7 received nebulised Salbutamol Potassium was measured at 4 hours in 5 cases and by 12 hours in 17 cases Monitoring of any capillary blood glucose was only documented in 8 cases Of the 22 treated 2 needed acute renal replacement therapy 3 required further doses of insulin and dextrose 2 were treated with Calcium Resonium
Eight cases of hyperkalaemia have been managed with the use of the kit and pro-forma so far An initial ECG was performed in all eight and four patients had continuous cardiac monitoring Intravenous calcium was given in seven and nebulised Salbutamol was given in five out of the eight cases Six out of eight patients had at least three blood sugar measurements One had two measurements documented and one patient was stopped from further monitoring following senior review and decision to palliate Seven patients had appropriate monitoring of their serum potassium by 4h and 12h again one patient was not monitored due to palliation
Conclusion Baseline results showed very low rates of prescription of nebulised Salbutamol low rates of Calcium Gluconate use and very low monitoring of blood sugars and potassium post treatment This has the potential for serious adverse outcomes particularly the potential for iatrogenic hypoglycaemia Our initial data shows the use of a Hyperkalaemia pro forma and kit improves the rate of prescription of intravenous calcium and nebulised Salbutamol and the post-treatment monitoring of serum potassium and blood sugar levels
P4Rituximab as maintenance therapy in ANCA associated vasculitisndash a single centre experience Rathnamalala NK Mcmenamin J Robertson S Almond A Kelly M Muniraju T M Renal Unit Dumfries and Galloway Royal Infirmary NHS Dumfries and Galloway Background The introduction of Cyclophosphamide and high dose steroids transformed ANCA associate vasculitis (AAV) from a disease of high mortality to a relapsing remitting disease Maintenance of remission however still remains a major challenge A two randomised clinical trials have looked at the use of Rituximab in remission induction in AAV and reported similar remission rates between Cyclophosphamide and Rituximab 12 Both these trials used Azathioprine as maintenance therapy and in the follow up showed similar remission rates with either agent for induction The role of Rituximab for maintenance therapy after cyclophosphamide induction was studied in the MAINRITSAN trial 3 Rituximab was compared with azathioprine and found that the relapse rate was significantly lower in the Rituximab group There have been several other retrospective studies that have suggested regular Rituximab infusions are successful in maintaining remission however has not been thoroughly evaluated 4 5678910 Here we share our centrersquos experience using Rituximab for maintenance of remission of AAV Materials and methods We conducted a retrospective review of electronic medical records of all patients who had received Rituximab as maintenance therapy for 12 months or longer between January 2014 to July 2016 Disease activity was assessed using Birmingham Vasculitis Activity Score ( BVAS) Version 3 and complete remission was defined as a score of 0 and partial remission as a score of lt50 of the value at diagnosis Due to uncertainties associated with sub classification we did not assign specific diagnosis but broadly classified as ANCA associated vasculitis Results 6 patients received Rituximab as maintenance therapy during the study period 3 (50) of them had eye ear nose and upper airway manifestations consistent with Granulomatosis with Polyangitis (GPA) All patients were PR3 ANCA positive except for one at initial diagnosis The mean BVAS score at the time of initiation of Rituximab was 4 All patients were initiated on Rituximab for relapses while on maintenance therapy with Azathioprine 4 patients received 6 monthly doses of Rituximab while two received annual doses All of them were also maintained on 5-10 mg of Prednisolone The mean BVAS score by 6 months was 0 and remained 0 at 12 months The mean PR3 titre was 562 at the initiation of treatment while at 12 months it had come down to 68 All patients remained in complete clinical remission at the end of 12 months after initiation of therapy Rituximab was well tolerated by all patients except one who developed pyrexia during an administration
Conclusions All patients had sustained remission at 6 months and 12 months after initiating Rituximab Rituximab has a potential role as maintenance therapy in AAV
P5 Chronic Myelo-Monocytic Leukaemia (CMML) as a contraindication to renal biopsy Alastair Rankin Emily McQuarrie Jennifer Lees Bruce MacKinnon Glasgow Renal and Transplant Unit On behalf of the Scottish Renal Biopsy Registry
Abstract Chronic Myelo-Monocytic Leukaemia (CMML) is a relatively rare mixed myelodysplastic myeloproliferative disorder that predominately affects patients over the age of 65 years Renal impairment in patients with CMML is well described with several different mechanisms reported including tumour infiltration lysozyme-induced injury amyloid deposition and tubulointerstitial nephritis From anecdotal evidence within our centre we are concerned that patients with CMML have an excessive risk of clinically significant bleeding following native renal biopsy This risk appears disproportionate to the degree of any co-existing thrombocytopenia or coagulopathy
We review the cases of 4 patients with an existing diagnosis of CMML who were referred to the renal clinic with proteinuria and excretory renal dysfunction Two of these patients underwent renal biopsy with subsequent major haemorrhage post-procedure despite normal bleeding parameters pre-procedure Patient 1 presented with flank pain 8 days post-biopsy A CT confirmed peri-nephric haematoma with retroperitoneal extension A total of 6 units of packed red cells (PRCs) were transfused prior to successful CT-guided emoblisation Histology from the biopsy revealed chronic tubulointerstitial nephritis Patient 2 experienced haemodynamic instability and haematuria one hour post-biopsy A total of 11 units of PRCs 7 units of fresh frozen plasma 2 pools of platelets intravenous tranexamic acid and 2 attempts at CT-guided embolization were required until haemostasis was achieved Histology later showed evidence of tumour infiltration with associated vasculitis Patient 3 presented with renal impairment and proteinuria on the background of known CMML Following discussion with haematology the risk of bleeding following renal biopsy was considered unjustifiable despite their platelets and coagulation screen being within normal range The patient was treated for presumed renal tumour infiltration with hydroxycarbamide Patient 4 was referred to the renal clinic with acute onset nephrotic syndrome Urinary proteincreatinine ratio was elevated over 800 mgmmol with serum albumin of 23 gL but normal excretory renal function The patient attends the haematology clinic with suspected CMML and chronic thrombocytopenia but previously declined bone marrow biopsy Following discussion with the patient there are no plans to proceed with renal biopsy given potential risks These cases highlight that while CMML is rare these patients are being referred to renal clinics with features that would commonly justify renal biopsy in other settings but in whom there may be an increased risk of bleeding post-procedure Our in-centre risk of major bleeding is 2 therefore to have such extreme amounts of bleeding in 2 patients with this underlying diagnosis is remarkable This creates a dilemma for the clinician as there is a wide range of potential renal pathology associated with CMML some of which will have disease specific but relatively toxic treatments available
Source of funding none Conflicts of interest none
P6 NHS Highland-Prograf to Adoport switch McCulloch K1 Peel R2 Lambie S3
1Renal Pharmacist Renal unit Raigmore Hospital Inverness 23Renal Consultant Renal unit Raigmore Hospital Inverness
Introduction NHS Highland (NHSH) is the first health board in Scotland to implement a switch from Prograf to Adoport for renal transplant patients This will provide considerable cost savings Adoport meets the bioequivalence criteria for drugs with a narrow therapeutic index set by the European Medicines agency and studies indicate therapeutic equivalence1 with the proviso that brands are non- interchangeable unless the switch is overseen by a Renal Consultant and post-conversion therapeutic drug monitoring is conducted23 The switch has been undertaken by a majority of transplant centres in England the main difference being that they have undergone repatriation NHSH Patients receive their transplant primarily at Royal Infirmary of Edinburgh and occasionally at Queen Elizabeth University Hospital Glasgow Care is transferred to NHS Highland on discharge NHS Highland cares for approximately 170 renal transplant patients 110 being prescribed Prograf These patients may live as far as 110 miles from Raigmore Hospital Given that prescribing is carried out by primary care clear communication with patients GPs and community pharmacy is essential to avoid inadvertent switching between brands
Method Clinically it was agreed a switch could be safely undertaken A business case was submitted and funding secured for pharmacist time laboratory costs and primary care time GPs have been informed via GP subgroup and local prescribing bulletin lsquoThe Pink Onersquo Community pharmacies are being informed by phone A protocol has been agreed Eligible patients selected by Renal Consultant and Renal Pharmacist Patients sent letter signed by Renal Consultant and Renal pharmacist Patients phoned prior to clinic to agree Adoport start date and address concerns Patient seen by Renal Consultant and pharmacist + given 1 month of Adoport Tacrolimus level and UampEs checked 5-7 days after commencing Adoport and patient
contacted by phone to check if tolerated If stable letter sent to GP and community pharmacy to continue supply
Results and Evaluation Letters have been sent to all eligible patients Seven patients have been reviewed One has received a one month supply of Adoport and 5 others are due to switch One patient was deemed non-eligible at present as they have a 6 month surplus of Prograf A database will be maintained and analysed at the end and primary care savings will be monitored Extra pharmacist input will give us the opportunity to review how immunosuppression is managed and to evaluate the benefit of having a renal transplant pharmacist Conclusion The switch is at an early stage Ultimately we hope to show that the switch from Prograf to Adoport can be managed safely with extra pharmacist input to a remote and rural population with prescribing being conducted by primary care
Fundingconflicts of interest none 1 McDevitt-Potter LM Sadaka B Tichy EM Rogers CC Gabardi S Transplantation 2011 A multicenter experience with
generic tacrolimus conversion 2 Medicines and Health Products Regulatory Agency Drug Safety Update 2012 Accessed online via
wwwmhragovukSafetyinformationDrugSafetyUpdateCON1557563 ESPRIT Guidance on management of repatriation and immunosuppressant switches in transplant patients 2015
Accessed online via httpwwwespritorgukwp-contentuploads201508Switch-guidance-document-final-Aug-31-2015pdf
P7 NHS Highland-Tacrolimus baseline dataMcCulloch K1 Peel R2 Lambie S3
1Renal Pharmacist Renal unit Raigmore Hospital Inverness 2Renal Consultant Renal unitRaigmore Hospital Inverness 3Renal Consultant Renal unit Raigmore Hospital Inverness
BackgroundAs part of planning a switch from using tacrolimus Prograf to Adoport we assessed baseline data for our transplant patients currently using Prograf After converting patients to Adoport we will compare their tacrolimus levels to their individual target range We assessed our use of appropriate target ranges and our current performance in achieving tacrolimus levels within target range on Prograf therapy
Method 107 renal transplant patients taking Prograf were identified a sample of 19 of these were analysed using electronic patient records and results Time from transplant ranged from 1 month to 18 years All tacrolimus levels for the preceding year were analysed and compared to the target range specified at the time of the level being done The assay used has a Coefficient of Variation of lt5 at the lower limit of the assay
Results All 19 patients had a target range for tacrolimus clearly identified and recorded in clinic letterswhich are routinely copied to the patients themselves A variety of target ranges were specifiedThe commonest used was 5-8 microgramsl in 7 patients followed by 5-7 in a further 4 patientswith another 6 different target ranges being used for the remaining 8 patients The ranges usedhad a breadth of 3 microgramsl in 2 cases the rest had a breadth of 2 microgramslPatients had a median of 12 (range 3-72) tacrolimus levels over the preceding year Results werewithin specified target ranges for 54 +- 22 (Medan +- SD) of results checked
Conclusion We currently use a large number of different target ranges The majority of the ranges used had a breadth of just 2 microgramsl These factors help to account for the low proportion of test results which were within the specified target ranges This is important to bear in mind when interpreting whether tacrolimus levels are within target ranges after switching to Adoport We should consider aligning our target ranges and widening them
P8 Eculizumab use in Scottish paediatric dense deposit disease Stewart D1 David Hughes1 Lynne Riach2 Craig Oxley2 Athavale D1
1Royal Hospital for Children Glasgow 2Royal Aberdeen Childrenrsquos Hospital Aberdeen
Introduction The revised MPGN classification and increasing recognition of Dense Deposit Disease (DDD) a C3 glomerulopathy as an alternative complement pathway disorder suggests Eculizumab an anti-C5 monoclonal antibody may be beneficial in treatment However the experience of Eculizumab as an off-label and expensive treatment in children with DDD is limited with variable clinical response reported in the literature
Method We present the outcomes of the only 2 paediatric patients in Scotland who have received Eculizumab for the management of DDD
Results Case 1 A 10 year old male presented with proteinuria and haematuria resistant to steroid treatment with preserved renal function Initial biopsy confirmed DDD Conservative management with an angiotensin converting enzyme inhibitor and diuretics for symptom control continued until 14 years Due to worsening symptoms (oedema lethargy poor growth) and renal function deterioration along with elevated terminal complement complex (TCC) Eculizumab was commenced A repeat biopsy whilst suggestive of chronic irreversible damage showed 25 glomerular architecture preservation Symptom improvement was noted There was a reduction in proteinuria and renal function stabilisation fall in TCC and discontinuation of diuretics Eculizumab was discontinued after 24 months Progression of renal function decline was seen in the final months of Eculizumab therapy With recurrence of symptoms and increasing proteinuria following discontinuation Eculizumab was recommenced after 6 months Symptomatic improvement has since been noted
Case 2 A 5 year old girl presented with painless frank haematuria and proteinuria Initial biopsy confirmed DDD Proteinuria was unresponsive to steroid therapy and 5 months following diagnosis she rapidly progressed towards end stage renal disease despite the introduction of Mycophenolate Mofetil and plasmapheresis Haemodialysis was subsequently commenced TCC level was elevated and Eculizumab treatment was started 7 months after diagnosis Renal biopsy prior to treatment demonstrated continued severe pathological changes in all visible glomeruli However due to lack of clinical response Eculizumab was discontinued after 2 months and the patient remained dialysis dependent
Conclusions Our experience with Eculizumab in Scotland has demonstrated variable results in our 2 patients with one patient showing a positive response whilst the other experienced no improvement Eculizumab was administered to both patients at varying points in their clinical journey with differing progressive features on biopsy To date the outcomes of 9 paediatric patients with DDD treated with Eculizumab have been described in the literature with 8 experiencing some positive response to treatment including 2 patients who were able to stop renal replacement therapy within 12 weeks of treatment A role for Eculizumab in DDD may be guided by clinical and pathological features Well designed clinical trials will be necessary to define the role of complement inhibition therapy in DDD
No conflict of interest and no funding requested
P9 Examining markers of safety in the use of non-tunnelled central venous catheters
James WT Millar (Speciality Registrar) Scott W Oliver (Speciality Registrar) Peter C Thomson (Consultant Nephrologist) Glasgow Renal and Transplant Unit Queen Elizabeth University Hospital Glasgow
Background Non-tunnelled central venous catheters (NTCVC) remain an essential means of vascular access for incident haemodialysis Associated morbidity is well recognised for example in the form of Staphylococcus aureus bloodstream infections (SAB)[1]
Previous quality improvement initiatives in our unit have sought to both improve traditional markers of quality (such as SAB) and to identify additional areas of clinical risk In 2014 Oliver et al [2] suggested several additional quality measures including peri-procedure haemoglobin drop the need for a further NTCVC during the same clinical episode and the NTCVC insertion site This study further evaluated NTCVC related clinical practice within our unit
Methods The potential markers of clinical quality identified in a previous project were examined using prospectively collected data stored in the electronic patient record Identified cases of SAB significant peri-procedure haemoglobin drop and multiple NTCVC insertion were investigated by case note review
Results Between March 2016 and March 2017 a total of 222 patients received 346 NTCVC 54 patients (243) had more than one NTCVC inserted in a 21-day period (range 2-5) When considering NTCVC insertion site there were 159 (459) femoral vein catheters and 183 (541) internal jugular vein catheters No pneumothoraces were reported
15 SABrsquos were reported during this period equating to 43 of all NTCVC 5 arose in patients with femoral NTCVC (333) and 10 from internal jugular catheters (667) Mean time from line insertion to positive blood culture was 86 days 15 (67) patients had a drop in haemoglobin of greater than 20mgdl with no other source of blood loss identified on review of clinical notes
Discussion These data demonstrate that NTCVC-associated SAB rates remain low and significantly below Scottish government audit standards [3] Of interest is the continued trend towards the use of femoral catheters at 45 of lines compared with 38 in 2014 [2] Although traditionally thought of as having a higher incidence of infectious complications our data has shown fewer bacteraemia events associated with femoral catheters compared with internal jugular Our data also demonstrates a significant rate of peri-procedure haemorrhage arising in up to 1 in 20 cases Together these findings present opportunities to development practice and improve patient safety
References
[1] Murray E Deighan C Geddes CC Thomson PC Reducing haemodialysis bacteraemia rates Scottish Renal Association Glasgow November 2013 [2] Oliver SW Thomson PC Jardine AG defining safe effective and patient-centred dialysis catheter placement Scottish Renal Association Edinburgh September 2014 [3] The Staphylococcus aureus bacteraemia quarterly report of cumulative data from all NHS Boards in Scotland Health Protection Scotland January 2015
Sources of funding none Conflicts of interest none
P10 Prescribing of tolvaptan-The NHS Highland experience Lambie S1 McCulloch K2 Garrod J3
1Renal Consultant Renal unit Raigmore Hospital Inverness 2Renal Pharmacist Renal unit Raigmore Hospital Inverness 3Renal Pharmacist Renal unit Raigmore Hospital Inverness
Introduction Tolvaptan is a vasopressin antagonist It was accepted for use in Scotland by SMC in Jan 2016 to slow the progression of cyst development and renal insufficiency of autosomal dominant polycystic kidney disease in adults with chronic kidney disease (CKD) stage 1 to 3 at initiation of treatment with evidence of rapidly progressing disease1 Adverse effects related to aquaresis may affect patientsrsquo ability to achieve the optimum therapeutic dose and the risk of hepatic toxicity necessitates regular LFT monitoring The geography of NHS Highland required the implementation of novel methods of managing these patients and as a result a MDT approach with an emphasis on pharmacist input was adopted Consultant role Patient selection on the basis of evidence of rapidly progressing kidney disease declining
eGFR large volume kidneys on ultrasound and evidence of complications of PKD Side effects and potential benefits discussed Potential medication interactions reviewed Jinarc risk management prescriber training
Pharmacist role Undertook Jinarc risk management pharmacist training Prepares accurate drug history and reviews for potential drug interactions Carries out patient counselling and supplies patient education material sick day rules card
and lsquogot to gorsquo card Supplies GP education leaflet Provides advice on selection of new drug therapies eg for gout Manages stock and coordinates supply to patients
Results Prescribing commenced May 2016 patients currently prescribed tolvaptan 11 7 Female 4 male Number on target dose 73 n = 811 2 patients are still being titrated One patient did
not tolerate target dose due to aquaresis side effects and is being trialled on the middle dose
Withdrawals One patient has withdrawn due to agoraphobia and an inability to attend for monitoring and another is on hold due to having major surgery
Conclusion The MDT approach between the Renal Consultant and Pharmacist at Raigmore Hospital has enabled tolvaptan prescribing to be efficiently and safely implemented to patients living within a challenging geographical location
1 Scottish Medicines Consortium Detailed Advice Document tolvaptan 15mg 30mg 45mg 60mg and 90mg tablets (Jinarcreg) SMC No 111415 January 2016
NA1 Authors SCN Jacqueline Ross NHS Grampian
SCN Alan Somerville NHS Lanarkshire SCN Jane Humphrey NHS Lanarkshire
e- mail contact jacquelinerossnhsnet Alansommervillelanarkshirescotnhsuk
Janehumphreylanarkshirescotnhsuk
Phone contact 01224 552927 01236 712644
Title Sharing of Adverse Events in Renal Units across Scotland
Introduction Background The Scottish Renal Nurses Strategy Group (SRNSG) are a group of senior nurses from Renal
Units across Scotland who meet 3-4 times per year to discuss and implement best practice At the last meeting it was agreed that it would be good practice for each Health Board to share
their adverse events reported on the Datix System and deliver a presentation with an action plan to prevent incidents and improve patient safety across Scotland NHS Grampian and NHS Lanarkshire will be the first to deliver this presentation discussing adverse events from both Health Boards with an action plan
Top 5 adverse events over the past 12 months Renal Unit NHS Grampian 1 Violence and Aggression 2 Accidents including needlesticks slips trips and falls 3 Medication Errors 4 Infrastructure Staffing and Estates 5 Machines and Equipment
Top 5 adverse events over past 12 months Renal Unit NHS Lanarkshire
1 Slips Trips or Falls 2 Medicine errors 3 Treatment problems 4 Transfer problems 5 Breach of policy
The presentation will also focus on any serious adverse events which may not be in the top 5 categories
Aim Objective Each Health Board to share their adverse events with the aim to prevent them from occurring in other units to improve staff and patient safety and wellbeing across Scotland
Method Power Point Presentation
Outcome Results Sharing of adverse events resulting in the development of a national Action Plan to prevent these incidents improving safety and well being of staff and patients in Renal Units across Scotland
NA2
SRA Oct 2017 Abstract
BBV Never Event - The whats whys and hows
Staff Nurse Gillian Wilson Aberdeen Royal Infirmary
This presentation shares our experience of a never event that occurred and was not picked up for
a period of 18 months
Hepatitis C (HCV) positive antibodies were found in a previously negative patient
These results were a low positive with no biochemistry changes to suggest any liver damage
however steps were put immediately in place to isolate and investigate
Was it contamination from a dialysis machine was it related to a blood transfusion given prior to
first positive result was it faulty diagnostic tests in the laboratory
In Aberdeen we go over and above national guidelines and isolate all our BBV patients whether
they have positive blood results or are PCR negative
Further bloods tested at an external laboratory confirmed negative results
It highlighted that communication errors were to blame for the lack of speed in detecting this issue
Investigations concluded no real answers as to why this happened
NA3
Living Donation Scotland Changing attitudes towards living donor kidney transplantation
Jen Lumsdaine Julie Glen On behalf of the Living Donation Scotland Project Board
Background and aims
The rate of living donor transplantation has remained fairly static in Scotland over the past 10 years
Recent data has shown inequity of access to living donor transplantation throughout the UK so
there is potential to significantly increase this optimum form of treatment for patients with end-stage
renal failure in Scotland The Living Donation Project Board was formed in 2016 aiming to double
the number of living donor transplants by 2020
Method
The two key areas
1 Do recipients receive adequate and appropriate information at the right time about living
kidney donation
2 Informing the general public about altruistic donation
All patients active on the transplant list in Scotland were invited to an information event A follow-up
questionnaire was performed in the East of Scotland examining outcome or reasons for not
attending A scoping exercise looked at information provided by each unit was performed and link
nephrologists and low clearance nurses attended meeting to discuss strategies for early education
Outcome
An information pack containing both recipient and donor written information and short films on DVD
has been produced with the support of the Scottish Government for all recipients and potential
donors in Scotland A new website with comprehensive information both written and visual and
postcode finder to improve ease of access to local unit contact details has been developed
Two national media campaigns have been launched with a significant rise in the number of enquiries
from potential donors and actual increase in altruistic donor numbers
Nursing abstract ndash no conflict of interest
NA4Authors Susan Easson Charge Nurse Ward 4C QEUH Glasgow
e- mail contact SusanEassonggcscotnhsuk
Phone contact 0141 452 3300
Title A Conversational approach to find out ldquoWhat matters to yourdquo in a Renal Transplant ward
Introduction Background Finding out ldquo What Mattersrdquo to people using health and careservices is crucial to delivering safe effective and person centred care It is a simple yet profoundconcept and tries to get to the essence of person centred care by creating deeply personalengagements with patients and their families through a conversational approach However careexperience feedback all too often provides innumerable examples of where what really matters topatients and their family members is poorly understood or not addressed Using care experienceas the driver for change the nursing staff in Ward 4C used improvement approaches to explorehow to hold more meaningful ldquoWhat Matters to yourdquo conversations on a daily basis
Aim Objective To improve the patient experience by utilising a person centred approach
Method Using Care experience feedback What Matters to Me boards and the conversationalapproach
Outcome Results Improvements in patient experience will be shared using examples ofpractice and care experience feedback
There was no additional funding required for this project We worked in collaboration with theperson centred team whorsquos aim is to improve patient experience
NA5
The implementation of a renal education programme and its impact on clinical practice
The purpose was to implement a Renal Education Programme and to evaluate its impact on
clinical practise
It was identified that there was a need for an educational programme to be set up within Forth
Valley Royal Hospital There is no inpatient renal unit in FVRH on site for our renal patients they
attend Queen Elizabeth University Hospital We are an outpatient haemodialysis unit with
outpatient clinics on site Therefore it was identified that there was a need for nursing staff within
FVRH to be educated on all renal complexities for the benefit of our patients
This was done through a work-based learning approach which brought tangible benefits for our
patients However it did not come without pitfalls as educational programmes are often seen as
making very little difference to clinical practise
T
his study describes what methods were used and examines the advantages and disadvantages in
setting up an educational programme and evaluating its impact on clinical practise
NA6
Nursing Abstract ndash SRA Meeting ndash 26 October 2017
Chris McGee Tonya Broe Ken Weir
Renal Unit Forth Valley Royal Hospital
Use of the Therapy Monitor Haemodialysis Patient Record System Can we aim for a paper-
free dialysis unit
We are trialling a new haemodialysis patient monitoring system to work in conjunction with SERPR
and which is intended to supersede the Finesse system used previously
We are in the early stages of this process but with continuing staff education and regular tech
support we are hoping to gather sufficient evidence to evaluate whether the use of paper case
notes needs to continue
Is it a realistic goal to aim for a completely paper-free unit
NA7
THE CLINICAL USES OF APHERESIS WITHIN NHS TAYSIDE
Laura Thomson CN
Ninewells Hospital Dundee
NHS Tayside took over the apheresis service from BTS in 2012 The service has since expanded
with the benefits of carrying out this treatment has been widely recognised within NHS Tayside
and is now more commonly being offered to treat a wider range of conditions with the number of
treatments carried out each year rising
This presentation will highlight the progression of the apheresis service within NHS Tayside We
will identify the various conditions it is currently being used to treat and also identify the decision
making process involved in carrying out these treatments ie which replacement fluid will be used
anticoagulation medication administered
We will highlight the benefits and challenges we face in providing this expanding service within the
Renal Service
NA8Authors Linda McDougall Renal Physiotherapist NHS Highland
e- mail contact lindamcdougall1nhsnet
Phone contact 01463 706022
Title lsquoExercise on Haemodialysis- Keeping the Wheels in Motionrsquo
Introduction Background The impact of CKD on physical fitness functional ability independence amp ultimately quality of life cannot be underestimated Current national guidelines recommend that all individuals with CKD are encouraged to participate in regular exercise programmes between or during dialysis sessions if on HD Following a successful pilot study funding was approved to establish an lsquoExercise on Dialysisrsquo (EOD) programme across NHS Highland through the appointment of a dedicated renal physiotherapist in 2008 A successful programme was soon established but for several years post-vacancies and increasing in-patient demands limited the physiotherapy servicersquos ability to deliver the programme The need to improve the long-term sustainability of the service was recognised and in late 2016 funding was approved to develop a Band 4 PT HCSW role for this purpose
Aim ObjectiveTo optimise the sustainability and continuity of the lsquoExercise on Dialysisrsquo service across NHSHighland through development of a Band 4 PT HCSW role
Method The potential parameters of the role and limits of autonomy were scoped out using current NES resources and guidelines Service and task analysis was then carried out to establish which components of the EOD protocol could be undertaken by a Band 4 A series of competencies were developed in line with the clinical protocol and one-to-one training and supervision provided to the post-holder to ensure competency achieved in delivering the programme
Outcome Results A 10 WTE Band 4 PT HCSW was appointed in Jan 2017 with a dual role between the renal unit and acute medical wards Although training is not yet complete the post-holder is already running the day-to-day delivery and monthly audit of the EOD service with senior physiotherapist input only required for individual patient safety queries and general discussion around patientsrsquo progress and goals The benefit to the unit has been considerable as the band 4 is available to support patients and staff with EOD provision 5 days a week This allows for one-to-one supervision of patients who need more support to participate in EOD regular feedback on performance and reviews of outcome measures and goals to maintain motivation levels Feedback on the post has been very positive and its scope will only continue to expand as we look to further develop renal rehabilitation services across NHS Highland
NA9Authors Nadine Lyall and Kerry Guthrie
e- mail contact nadinelyallbordersscotnhsuk kerryguthriebordersscotnhsuk
Phone contact 01896 826637
Title The Developing Role of the NMP in a Satellite Dialysis Unit
Introduction Background
We have been practising as NMPrsquos for nearly 3 years working in the dialysis unit at the BGH The unit is a satellite unit of the ERI and we have expanded over the last 6 years The unit provides haemodialysis for 12 patients at any one time 3 sessions a day 6 days a week We are nurse-led and have 2 renal consultants who are based at the ERI
We saw an opportunity to use our knowledge and experience to develop our role By becoming NMPrsquos we have enhanced our professional development and we feel we meet the changing needs of the dialysis patient in a more holistic manner
Aim Objective
Our aim is to deliver effective care as we are better placed to deal with issues that often arise byacting swiftly this in turn is cost effective and convenient For example good anaemia and bonemanagement is important for their health wellbeing and lifespanTo help understand our role we will use a power point presentation highlighting issues we dealwith and the drugs we prescribe under the following headings Cardiovascular infection painanticoagulant disequilibrium diet renal bone disease and renal anaemia
Method Power point
Outcome Results
In the future we hope to further develop and have greater autonomy in our role We have great support from our renal consultants and have already built up a great relationship with our patients We hope to undertake the Clinical Decision Making course and this in turn will allow us to deal effectively with acute illness giving the dialysis patient better care We are keen to get feedback from other renal nurses in Scotland to enable us to develop our role further and in turn raise awareness of the NMP role in a dialysis unit We record all our prescribing decisions and keep the consultants up to date regularly Currently we are working on auditing our prescribing practice so that we can improve the service we can provide
NA10 Title Komunikacja w szkoleniu dializy ortzewnowej
Author Senior Charge Nurse Rhoda Bell
Address Raigmore Hospital Old Perth Road Inverness IV2 3UJ
Email rhodabellnhsnet Telephone 01463706023
Introduction Background Case study on lady with Polish as her first language she has some English but requires an interpreter to carry out Peritoneal Dialysis training and attend clinic She had some gynaecological issues that we were not aware of which impacted on the functionality of PD and therefore the success of treatment There were areas of concern in low clearance clinic with signs the patient had a reluctance to engage in decision making
AimObjective
Methods Discussion through the case study highlighted issues with communication between different PD staff and patients Areas of concern include different staffing techniques environment factors on training success Also language and communication issues the patient had were not fully apparent so training could not be individualised
Results We plan to trial training at home and have more individualised training schedule for patients The training step by step guides have been reviewed and practise standardised In collaboration with low clearance nurse we have developed a check list which will highlight concerns before the transition to PD ie language issues and need for training aids in another language gynaecological conditions
Conclusions Everyone learns differently and training methodsaids must be individualised for all It may not be apparent until training has commenced that there are concerns Having one to one training with the same nurse will consolidate training and build confidence in the patient Having a close working relationship with members of the MDT will help make a supportive PD journey
Would we do things differently if we knew about prolapse or lack of English both spoken and written
Key words - Peritoneal dialysis patient training communication
N11
Telehealth amp PDAudrey Jones
Advantages
Information on a daily basis about treatment weight and blood pressure
Change programme remotely via computer or mobile
Earlier intervention for machineprogramme issues
Reduction in home visits ie patient trained but still requires volume increases
No need to download cards to see what problems have been
Can have more detailed information available at clinics
Disadvantages
Relying on patient input data correctly
Machine is noisy especially first wave of machine
Still the same bag connection system and patient connection system (difficult for manual
dexterity problems)
Relying on patient having good signal
Modem problems
NA12Autosomal Dominant Polycystic Kidney Disease A cruel inheritance but new hopeAlistair Lawrie Renal Unit Victoria Hospital KirkcaldySadaf Arshad Corry Dunnigan Paul Phelan Neil Turner Renal Unit Royal Infirmary of Edinburgh
Background Autosomal Dominant Polycystic Kidney Disease (ADPKD) is the most prevalent single gene human genetic disorder and the most common of the inherited cystic and interstitial kidney diseases It is estimated to affect 1 in every 1000 individuals worldwide with over 50 of sufferers eventually developing end stage kidney disease and requiring dialysis or transplantation Symptoms include spasmodic severe pain hypertension haematuria infection and kidney failure There is currently no cure for ADPKD Management of the condition has traditionally involved lifestyle modification BP control and analgesia however a recent study (Torres et al 2012) demonstrated that treatment with V2-receptor antagonist drugs slowed increase in total kidney volume reduced the rate of functional decline and showed a reduced incidence of kidney pain
Aim Provision of a tolvaptan prescribing and monitoring service
Methods Experiential finding report of initial twelve months period of multidisciplinary ADPKDtolvaptan clinic
Results Early results are comparable with TEMPO study outcomes
Conclusion Due to the long term nature of this treatment results available at this time are showing only the earliest benefits of the intervention More quantifiable results such as increased time before the necessity for RRT will only be evident in coming years Torres VE et al (2012) Tolvaptan in Patients with Autosomal Dominant Polycystic Kidney Disease New England Journal of Medicine 367 pp 2407-2418 DOI 101056NEJMoa1205311
No funding requirement No conflict of interest
A17 Obesity is not associated with progression to end stage renal disease in patients withbiopsy-proven glomerular diseases
Benjamin Elyan Jennifer S Lees Bruce Mackinnon Jonathan G Fox Colin C Geddes Emily PMcQuarrie
Glasgow Renal and Transplant Unit Queen Elizabeth University Hospital Glasgow
Introduction - Addressing risk factors for renal progression is a key aspect of managing chronic kidney disease (CKD) Body mass index (BMI) has been shown to impact on renal progression in unspecified CKD The aim of this study was to evaluate if there was an association between BMI and progression to renal endpoints in patients with biopsy-proven primary glomerular disease (GN)
Methods - We included all adult patients diagnosed with biopsy-proven primary GN (excluding minimal change nephropathy) in Greater Glasgow amp Clyde and Forth Valley between 01012000 and 31122015 Biochemical and anthropometric data were extracted from the electronic patient record at time of biopsy with follow-up data until 20062017 BMI was calculated from height and weight at time of biopsy and categorised into groups BMI le25 kgm2 (G1) gt25 to le30 kgm2 (G2) and gt30 kgm2 (G3 - obese) We assessed factors associated with reaching a combined renal endpoint of CKD5 or renal replacement therapy (RRT) with competing risk of death using the Fine and Gray subdistribution hazard model Analyses were conducted using cmprsk package for R statistical software package and SPSS version 24
Results - 560 patients with primary GN and available BMI data were included The average age was 532 years and 339 were female There were 132 patients in G1 210 in G2 and 207 patients in G3 Those in G2 and G3 were older (p=002) with slightly higher diastolic blood pressure (p=002) than those in G1 There was a greater proportion of focal segmental glomerulosclerosis in G3 but similar proportions of other GN diagnoses across groups There was no significant difference in baseline serum creatinine (sCr) (p=034) or log uPCR (p=045) between BMI groups On multivariate analysis age systolic blood pressure BMI or GN diagnosis were not predictive of renal outcome Higher baseline sCr (SHR 1003 per 1 umoll increase in sCr 1001-1004 plt0001) and log uPCR (SHR 130 per unit increase in log uPCR 95 CI 105-160 p=002) were associated with progression to the combined renal endpoint accounting for competing risk of death BMI was not associated with reaching combined renal endpoint on univariate analysis whether considered as a continuous variable (SHR=100 95 CI 098-102 p=096) or categorised by BMI group
Conclusion - Contrary to our expectations there was no association between BMI and progression to a combined renal endpoint of CKD5 or RRT in this cohort of patients with primary GN Efforts should be directed to managing other known risk factors for CKD progression
Sources of FundingConflicts of Interest - None
A18 Factors influencing long term renal function after living kidney donation
Matthew A Rutherford Norman J Galbraith Marc Clancy Colin C Geddes
Glasgow Renal and Transplant Unit Queen Elizabeth University Hospital Glasgow UK
Background Following live donor nephrectomy the remaining kidney undergoes an increase in filtration capacity known as compensatory hypertrophy Few cohorts with follow up of renal function beyond 5 years have been reported The impact on long term renal function of variability in donor factors such as age sex pre-donation blood pressure and glomerular filtration rate (GFR) is unknown Increasingly kidney donors have potential risk factors for future poor renal function such as hypertension older age and obesity The aim of this study was to analyse factors influencing long-term renal function in living kidney donors from our centre
Method Data were obtained from the electronic patient record Patients with a recorded procedure of lsquolive donor nephrectomyrsquo between 2005 and 2017 were identified GFR after donation (calcGFR) was calculated using the formula lsquocalcGFR = Pre-donation Isotope GFR x (Pre-donation Serum creatinine Serum Creatinine)rsquo which is accurate assuming muscle mass does not change Pre and post donation serum creatinines (two days two weeks three months and one to ten year) were recorded We analysed the influence of age sex pre-donation GFR and blood pressure on post donation GFR compensation
Results 355 live donor nephrectomies were performed between January 2005 and December 2016 The mean age was 469 (plusmn 116) years and 504 (n=179) were female Mean pre-donation isotope GFR was 937 plusmn 156 mlmin173m2 Median follow up was 2 years (IQR 1 to 6 years with range 2 weeks to 10 years) The calculated percentage of pre-donation GFR at 2 days 2 weeks 3 months 1 year 5 years and 10 years were 698 691 712 730 801 and 950 respectively (p lt 0001) Patients aged lt50 y had not only a higher calcGFR (858 plusmn 29 mlmin173m2 compared with 671 plusmn 28 mlmin173m2 p lt 0001) at 5 years following donation but achieved a higher degree of compensation than donors gt 50 y (836 plusmn 16 compared with 756 plusmn 19 (p = 0002) Patients with pre-donation hypertension achieved 774 plusmn 53 of pre-donation GFR compared with 804 plusmn 32 in normotensive patients (p = 0998) Females had equivalent degree of renal compensation achieving 819 plusmn 19 compared with 780 plusmn 16 in males (p = 0131) at 5 years following donation Patients with pre-donation GFR gt 100 mlmin173m2 achieved 844 plusmn 23 of pre-donation function by 5 years compared with 777 plusmn 14 in those with pre-donation GFR lt 100 mlmin173m2 (p = 001)
Conclusion Following live donor nephrectomy renal function has a nadir of 691 at 2 weeks Compensation in GFR occurs rapidly and appears to be maintained regardless of sex and pre-donation blood pressure Younger age and higher pre-donation GFR were associated with a greater degree of compensation
A19 The utility of high-sensitivity cardiac troponin to stratify cardiovascular risk in patients with renal impairment
Eve Miller-Hodges Atul Anand Anoop S V Shah Nicholas L Mills Neeraj Dhaun
Background Cardiovascular disease is the most common outcome of chronic kidney disease1
Declining glomerular filtration rate (GFR) and proteinuria predict increased cardiovascular risk over the long term2 However there are currently no methods to stratify cardiovascular risk in the short or medium term in patients with renal impairment We have already shown that high-sensitivity cardiac troponin I concentrations (hs-cTnI) lt5ngL in patients presenting with symptoms of acute coronary syndrome identifies those at low risk of cardiac events within 30 days and over the next year3 However uncertainty remains over the role of hs-cTnI testing in patients with renal impairment This study investigated whether hs-cTnI could also stratify future cardiovascular risk in patients with renal impairment
Methods In a prospective study of consecutive patients presenting with suspected acute coronary syndrome we evaluated the performance of hs-cTnI in patients with and without renal impairment (estimated glomerular filtration rate lt60mLmin173m2) using an early risk stratification threshold of 5ngL to ldquorule outrdquo acute myocardial infarction at presentation and within 30 days and sex-specific 99th centile diagnostic thresholds for index type 1 myocardial infarction Subsequent type 1 myocardial infarction and cardiac death were reported at one year
Results Of 4726 patients identified 904 (19) had renal impairment Index diagnosis of type 1 and type 2 myocardial infarction was almost twice as likely in patients with renal impairment (30 vs 15) Performance of the early risk stratification threshold of 5ngL to identify patients at low risk of major cardiac events was similar in patients with (NPV 984 95CI 960-997 sensitivity 989 95CI 975-999) and without renal impairment (NPV 997 95CI 994-999 sensitivity 984 95CI 972-994) These patients continued to remain at low risk over the next year The PPV and specificity at the 99th centile for diagnosis of myocardial infarction were lower in patients with renal impairment at 500 (95CI 452-548) and 709 (95CI 675-742) respectively compared to 624 (95CI 588-659) and 921 (95CI 912-930) At one year 24 of patients with renal impairment and troponin gt99th centile regardless of index diagnosis had experienced further myocardial infarction or cardiac death compared with 10 of patients without
Conclusion In suspected acute coronary syndrome hs-cTnI can stratify risk in patients with renal impairment Irrespective of diagnosis patients with renal impairment and elevated cardiac troponin concentrations had two-fold greater risk of a major cardiac event compared to those with normal renal function and should be considered for further investigation and treatment
Funders Wellcome Trust British Heart Foundation and Chest Heart amp Stroke Scotland
1 Gansevoort RT Lancet 2013
2 Chronic Kidney Disease Prognosis Consortium Lancet 2010
3 Shah AS Lancet 2015
A20 lsquoDOES IT DIALYSE OUTrsquo - THE EFFECT OF RENAL REPLACEMENT THERAPY ON THE BRAIN Mark Findlay Jesse Dawson David Dickie Deborah McGlynn Patrick Mark Institute of Cardiovascular and Medical Science University of Glasgow amp Queen Elizabeth University Hospital Glasgow
Introduction Cerebrovascular disease is common in end-stage renal disease (ESRD) on renal replacement therapy (RRT) We investigated the effect of RRT on cerebral structure and cognitive function over 12 months Methods Observational cohort study in ESRD patients receiving HD Prior cognitive impairment or cerebrovascular disease were exclusion criteria Multi-domain cognitive testing was performed at baseline and at follow-up Transcranial Doppler was used to assess intra-dialysis related alterations in mean flow velocity (MFV) ndash a marker of cerebral blood flow MR imaging was performed at 0 and 12 months We performed T1 T2 FLAIR and DWI sequences and used volumetric software to calculate white matter hyperintensity (WMH) burden markers of atrophy mean diffusivity and fractional anisotropy (FA) to describe structural changes at 1 year Results 97 patients median age 59 years 412 female At follow-up 15 patients were transplanted 6 died 4 withdrew and the remainder continued HD Those who were transplanted were younger (median age 51 vs 60 years p=0019) and had been on dialysis for a shorter period (median 06 vs 21 years p=0003) MFV declined during HD median 475cms to 405cms plt0001 and correlated with lower scores of executive and frontal lobe function during HD (Rho 045 p lt0001 and Rho -0313 p lt001 respectively) In all patients MR imaging demonstrated a significant decline in frontal parietal and temporal lobe volume at follow-up Median WMH volume increased in those who remained on HD but not in transplanted patients (median change 023 vs -012ml p=0018) WMH burden correlated with worsening scores of frontal lobe tests Rho 0585 p0005 and worse mood Rho -0485 p0026 FA improved following renal transplant (028 to 029 p=0016) and correlated with improved executive function testing at follow-up Rho 089 p0019 Conclusion Cerebral blood flow is reduced during haemodialysis and correlates with a reduction in intradialytic executive function There is an improvement in FA following transplantation WMH volume increases in those who remain on dialysis and the degree of increase correlates with executive and frontal lobe function This suggests that haemodialysis is associated with clinically significant changes in the brain and that these may be ameliorated by transplantation
Source of fundingconflicts MF is funded by a KRUK fellowship
A21 Pathological classification of IgA nephropathy to predict renal outcomes ndash is there a better way to score tubulointerstitial inflammation
Alastair Rankin David Kipgen Bruce Mackinnon Jonathan Fox Colin Geddes Emily McQuarrie Glasgow Renal and Transplant Unit On behalf of the Scottish Renal Biopsy Registry
Background The Oxford pathological classification of IgA nephropathy (IgAN MEST-C score) is limited by the fact that individual features of the score are not all predictive and its utility in assisting clinical decision-making is questioned The addition of tubulointerstitial inflammation to the existing scoring system is appealing but is not currently included due to reportedly wide inter-observer variability We report a novel method to score percentage of cortex containing tubulo-interstitial inflammation in non-atrophic renal cortex (ATIN) in patients with IgAN similar to that used in transplant biopsy reporting and assess its utility to predict clinical outcomes
Methods All adult patients with a native renal biopsy diagnosis of IgAN between 2010 and 2015 in a unit serving 15 million people were identified Baseline characteristics biopsy reports and outcome data were collected ATIN was calculated by subtracting the percentage of atrophic cortex from the percentage of total cortex with tubulo-interstitial inflammation withge10 representing significant tubulo-interstitial inflammation in non-atrophic cortex The primary outcome was a composite of requiring renal replacement therapy (RRT) or doubling of serum creatinine (sCr)
Results 153 new cases of IgAN were identified 33 were excluded (24 had lt8 glomeruli on biopsy 6 inadequate biopsy for MEST scoring and 3 on RRT at time of biopsy) In addition patients with a tubular atrophy (T) score of 2 were also excluded (n=9) Of the remaining 111 patients 76 (68) were male Mean age at biopsy was 52 years (+- 167) and 18 (16) had a co-existing clinical diagnosis of henoch-schonlein purpura (HSP) Median sCr was 156 micromoll (IQR 101-212) and 54 (49) had ATIN on biopsy During a median follow-up of 23 years 34 (31) reached the primary outcome 20 (18) received immunosuppression and 16 (14) died On univariate Cox regression survival analysis ATIN was associated with a four-fold increase in the primary outcome (HR 49 (21-113)) On multivariate analysis mesangial hypercellularity (M) T and ATIN independently predicted renal outcome while endocapillary proliferation (E) and segmental sclerosis (S) did not (plt002 for ATIN) Excluding patients with HSP or those who received immunosuppression did not change the result
Conclusion Within our centre ATIN predicts renal outcome for IgAN independently of established histological features Assessment of inter-observer reproducibility and validation in other cohorts is still required but these results suggest ATIN could be a worthwhile addition to current pathological scoring systems for IgAN
Source of funding none Conflicts of interest none
P1 Polypharmacy in Renal Replacement Therapy Patients
Jason McMinn Colin Geddes Glasgow Renal and Transplant Unit Queen Elizabeth University Hospital
Introduction
Prescribing is often led by evidence from studies containing participants with single health conditions and without multimorbidity Polypharmacy is becoming increasingly recognised in patients with multiple chronic health conditions Additional medications are more likely to result in diminishing returns in benefit with an increased risk of harm Patients with established renal failure (ERF) are likely to be susceptible to medication-related harm A high pill burden is also likely to contribute adversely to an already restricted quality of life and has been associated with poor medication adherence The aim of this study was to analyse polypharmacy in all patients with ERF attending our service
Methods
We extracted medication records for all prevalent ERF patients attending the Glasgow Renal and Transplant Unit from the West of Scotland Electronic Renal Patient Record (SERPR) as of 01012017 The records were analysed to calculate the number of regular medications and total pill burden of each patient These medications were categorised as being lsquopreventativersquo or lsquosymptomaticrsquo We also analysed the prescription of specific drug classes to examine the prevalence of these medications
Results
We identified 1091 transplant follow-up 529 hospital haemodialysis and 46 peritoneal dialysis patients who were on a mean of 94 13 and 129 different medications respectively Overall pill burden was 139 tablets a day in transplant follow-up patients 141 in haemodialysis patients and 162 in peritoneal dialysis patients There were similar rates of prescribing between the different dialysis units and clinics within our service
The proportions of medications deemed as preventative rather than symptomatic were 76 in transplant 69 in haemodialysis and 60 in peritoneal dialysis
In transplant patients decreasing renal function was associated with a higher pill burden but even patients with a transplant eGFR gt 60 were on a mean of 126 tablets per day including a mean of 14 antihypertensives
Rates of antidepressant prescribing were 15 in transplant patients and 20 in hospital haemodialysis patients 53 of haemodialysis patients were on a statin 39 on aspirin 61 on a proton pump inhibitor and 7 were on warfarin
Conclusion
Patients undergoing all forms of renal replacement therapy are likely to be on a considerable number of medications Whilst these drugs are inevitably prescribed for valid reasons this data demonstrates the need for clinicians to engage with patients to explore opportunities to reduce pill burden
Conflict of Interest None Sources of Funding None
P2 An audit of Acute Kidney Injury (AKI) on an acute stroke ward before and after plannedinterventions to review and maintain hydration
Clare Harris1 Simon Hart2 Fiona Duthie3 1 University of Edinburgh Medical School 2 Stroke Unit Royal Infirmary of Edinburgh 3 Renal Unit Royal Infirmary of Edinburgh
Background Dehydration is an important factor in the development of acute kidney injury which is associated with increased morbidity and mortality particularly in the elderly population Poor fluid intake is common post stroke (1) and dehydration is associated with poorer outcomes 3 months post stroke (2) In late 2014 there was no system of identifying patients with poor oral intake on the stroke ward at the Royal Infirmary of Edinburgh a hydration protocol and education programme were implemented aiming to improve fluid balance This included the use of prescribed water either orally or by nasogastric tube An audit pre and post intervention demonstrated that hydration as measured by ureacreatinine ratio significantly improved after the protocol introduction (3) We aimed to determine whether the incidence of AKI by KDIGO criteria was also reduced as this could have implications for reducing patient morbidity and mortality in this elderly comorbid patient cohort
Method 150 inpatients to the acute stroke ward during JulAug 2014 and JulAug 2015 were selected (n= 80 2014 n=70 2015) Patient data and creatinine values were collected from the electronic patient record and medical notes and retrospectively analysed Baseline creatinine values were calculated and cases of AKI were identified and staged using KDIGO criteria (4) Chi-Squared tests were performed to determine P values Individual patient notes were reviewed for both quantitative and qualitative data of patient management
Results Incidence of AKI (of any stage) was 263 pre-protocol and 200 post-protocol (P=03646) Incidence of AKI stages 23 was 100 pre-protocol and 715 post-protocol (P=05374) In hospital post stroke mortality was 338 pre-protocol and 1286 post protocol (P=00028) AKI was also associated with increased length of stay
Conclusions Despite a trend in benefit there was no significant difference in incidence of AKI pre and post hydration protocol nor in incidence of severe AKI (stage 23) AKI is influenced by many factors one of which is hydration status Further studies are needed to determine whether the trend of benefit exhibited in this sample is significant in a greater sample size if this were the case such a protocol could have great benefit to patient care on stroke units and elsewhere There was a significant difference in inpatient post stroke mortality following introduction of the hydration protocol Further investigations are needed to explain underlying reasons for this factors other than hydration may play an important role
References 1 Whelan K Inadequate fluid intakes in dysphagic acute stroke Clinical Nutrition (2001) 20(5)
423-428 2 Bhalla A Sankaralingam S Dundas R Swaminathan R Wolfe CDA Rudd AG The influence of
raised plasma osmolality on clinical outcome after acute stroke Stroke (2000) 312043ndash2048 3 Hart SR Craig R Berry E Lane N Gad A Farrugia M Burton L Paquay A What Happens to
Acute Stroke Patientsrsquo Fluid Balance Renal Status and Dehydration in the First Two Weeks How Can They Be Markedly Improved doi 101111ijs12634_13
4 KDIGO Clinical Practice Guideline for Acute Kidney InjuryKidney international supplements (2012) 2(1) 1-138
No funding or conflict of interest to declare
P3NHS Highland-Improving the management of hyperkalaemia using a kit Initial resultsCantley N1 Abedin T2 Lambie S3
1FY2 NHS Highland 2ST4 Renal Medicine NHS Grampian 3Renal Consultant Renal unitRaigmore Hospital Inverness
Introduction The incidence of hyperkalaemia in hospitalised in patients is between 1 and 10 Guidelines in Northern Ireland promote the use of a Hyperkalaemia Kit to improve management of hyperkalaemia We assessed the management of hyperkalaemia in Raigmore Hospital including post-treatment monitoring of serum potassium and blood glucose at baseline and after the introduction of a lsquoHyperkalaemia Kitrsquo which contains a pro forma for the management of hyperkalaemia and all the relevant equipment and drugs for treatment
Method Between July and September 2016 an automated algorithm identified 34 patients with a potassium result 65 mmoll or above on laboratory results 12 received no specific treatment of these 6 results were spurious 4 patients died before treatment could be started and 2 patients were chronic haemodialysis patients We introduced the Hyperkalaemia Kit to the Acute Medical Admissions Unit in Raigmore Hospital Since then 15 patients have been identified with serum potassium measurements above 65 and the pro forma and kit was used with eight of these patients One of these patients proceeded straight to acute renal replacement therapy
Results Prior to our intervention all 22 patients that were actively treated received at least one prescription of appropriate doses of Insulin with Dextrose However only 16 patients received intravenous calcium and only 7 received nebulised Salbutamol Potassium was measured at 4 hours in 5 cases and by 12 hours in 17 cases Monitoring of any capillary blood glucose was only documented in 8 cases Of the 22 treated 2 needed acute renal replacement therapy 3 required further doses of insulin and dextrose 2 were treated with Calcium Resonium
Eight cases of hyperkalaemia have been managed with the use of the kit and pro-forma so far An initial ECG was performed in all eight and four patients had continuous cardiac monitoring Intravenous calcium was given in seven and nebulised Salbutamol was given in five out of the eight cases Six out of eight patients had at least three blood sugar measurements One had two measurements documented and one patient was stopped from further monitoring following senior review and decision to palliate Seven patients had appropriate monitoring of their serum potassium by 4h and 12h again one patient was not monitored due to palliation
Conclusion Baseline results showed very low rates of prescription of nebulised Salbutamol low rates of Calcium Gluconate use and very low monitoring of blood sugars and potassium post treatment This has the potential for serious adverse outcomes particularly the potential for iatrogenic hypoglycaemia Our initial data shows the use of a Hyperkalaemia pro forma and kit improves the rate of prescription of intravenous calcium and nebulised Salbutamol and the post-treatment monitoring of serum potassium and blood sugar levels
P4Rituximab as maintenance therapy in ANCA associated vasculitisndash a single centre experience Rathnamalala NK Mcmenamin J Robertson S Almond A Kelly M Muniraju T M Renal Unit Dumfries and Galloway Royal Infirmary NHS Dumfries and Galloway Background The introduction of Cyclophosphamide and high dose steroids transformed ANCA associate vasculitis (AAV) from a disease of high mortality to a relapsing remitting disease Maintenance of remission however still remains a major challenge A two randomised clinical trials have looked at the use of Rituximab in remission induction in AAV and reported similar remission rates between Cyclophosphamide and Rituximab 12 Both these trials used Azathioprine as maintenance therapy and in the follow up showed similar remission rates with either agent for induction The role of Rituximab for maintenance therapy after cyclophosphamide induction was studied in the MAINRITSAN trial 3 Rituximab was compared with azathioprine and found that the relapse rate was significantly lower in the Rituximab group There have been several other retrospective studies that have suggested regular Rituximab infusions are successful in maintaining remission however has not been thoroughly evaluated 4 5678910 Here we share our centrersquos experience using Rituximab for maintenance of remission of AAV Materials and methods We conducted a retrospective review of electronic medical records of all patients who had received Rituximab as maintenance therapy for 12 months or longer between January 2014 to July 2016 Disease activity was assessed using Birmingham Vasculitis Activity Score ( BVAS) Version 3 and complete remission was defined as a score of 0 and partial remission as a score of lt50 of the value at diagnosis Due to uncertainties associated with sub classification we did not assign specific diagnosis but broadly classified as ANCA associated vasculitis Results 6 patients received Rituximab as maintenance therapy during the study period 3 (50) of them had eye ear nose and upper airway manifestations consistent with Granulomatosis with Polyangitis (GPA) All patients were PR3 ANCA positive except for one at initial diagnosis The mean BVAS score at the time of initiation of Rituximab was 4 All patients were initiated on Rituximab for relapses while on maintenance therapy with Azathioprine 4 patients received 6 monthly doses of Rituximab while two received annual doses All of them were also maintained on 5-10 mg of Prednisolone The mean BVAS score by 6 months was 0 and remained 0 at 12 months The mean PR3 titre was 562 at the initiation of treatment while at 12 months it had come down to 68 All patients remained in complete clinical remission at the end of 12 months after initiation of therapy Rituximab was well tolerated by all patients except one who developed pyrexia during an administration
Conclusions All patients had sustained remission at 6 months and 12 months after initiating Rituximab Rituximab has a potential role as maintenance therapy in AAV
P5 Chronic Myelo-Monocytic Leukaemia (CMML) as a contraindication to renal biopsy Alastair Rankin Emily McQuarrie Jennifer Lees Bruce MacKinnon Glasgow Renal and Transplant Unit On behalf of the Scottish Renal Biopsy Registry
Abstract Chronic Myelo-Monocytic Leukaemia (CMML) is a relatively rare mixed myelodysplastic myeloproliferative disorder that predominately affects patients over the age of 65 years Renal impairment in patients with CMML is well described with several different mechanisms reported including tumour infiltration lysozyme-induced injury amyloid deposition and tubulointerstitial nephritis From anecdotal evidence within our centre we are concerned that patients with CMML have an excessive risk of clinically significant bleeding following native renal biopsy This risk appears disproportionate to the degree of any co-existing thrombocytopenia or coagulopathy
We review the cases of 4 patients with an existing diagnosis of CMML who were referred to the renal clinic with proteinuria and excretory renal dysfunction Two of these patients underwent renal biopsy with subsequent major haemorrhage post-procedure despite normal bleeding parameters pre-procedure Patient 1 presented with flank pain 8 days post-biopsy A CT confirmed peri-nephric haematoma with retroperitoneal extension A total of 6 units of packed red cells (PRCs) were transfused prior to successful CT-guided emoblisation Histology from the biopsy revealed chronic tubulointerstitial nephritis Patient 2 experienced haemodynamic instability and haematuria one hour post-biopsy A total of 11 units of PRCs 7 units of fresh frozen plasma 2 pools of platelets intravenous tranexamic acid and 2 attempts at CT-guided embolization were required until haemostasis was achieved Histology later showed evidence of tumour infiltration with associated vasculitis Patient 3 presented with renal impairment and proteinuria on the background of known CMML Following discussion with haematology the risk of bleeding following renal biopsy was considered unjustifiable despite their platelets and coagulation screen being within normal range The patient was treated for presumed renal tumour infiltration with hydroxycarbamide Patient 4 was referred to the renal clinic with acute onset nephrotic syndrome Urinary proteincreatinine ratio was elevated over 800 mgmmol with serum albumin of 23 gL but normal excretory renal function The patient attends the haematology clinic with suspected CMML and chronic thrombocytopenia but previously declined bone marrow biopsy Following discussion with the patient there are no plans to proceed with renal biopsy given potential risks These cases highlight that while CMML is rare these patients are being referred to renal clinics with features that would commonly justify renal biopsy in other settings but in whom there may be an increased risk of bleeding post-procedure Our in-centre risk of major bleeding is 2 therefore to have such extreme amounts of bleeding in 2 patients with this underlying diagnosis is remarkable This creates a dilemma for the clinician as there is a wide range of potential renal pathology associated with CMML some of which will have disease specific but relatively toxic treatments available
Source of funding none Conflicts of interest none
P6 NHS Highland-Prograf to Adoport switch McCulloch K1 Peel R2 Lambie S3
1Renal Pharmacist Renal unit Raigmore Hospital Inverness 23Renal Consultant Renal unit Raigmore Hospital Inverness
Introduction NHS Highland (NHSH) is the first health board in Scotland to implement a switch from Prograf to Adoport for renal transplant patients This will provide considerable cost savings Adoport meets the bioequivalence criteria for drugs with a narrow therapeutic index set by the European Medicines agency and studies indicate therapeutic equivalence1 with the proviso that brands are non- interchangeable unless the switch is overseen by a Renal Consultant and post-conversion therapeutic drug monitoring is conducted23 The switch has been undertaken by a majority of transplant centres in England the main difference being that they have undergone repatriation NHSH Patients receive their transplant primarily at Royal Infirmary of Edinburgh and occasionally at Queen Elizabeth University Hospital Glasgow Care is transferred to NHS Highland on discharge NHS Highland cares for approximately 170 renal transplant patients 110 being prescribed Prograf These patients may live as far as 110 miles from Raigmore Hospital Given that prescribing is carried out by primary care clear communication with patients GPs and community pharmacy is essential to avoid inadvertent switching between brands
Method Clinically it was agreed a switch could be safely undertaken A business case was submitted and funding secured for pharmacist time laboratory costs and primary care time GPs have been informed via GP subgroup and local prescribing bulletin lsquoThe Pink Onersquo Community pharmacies are being informed by phone A protocol has been agreed Eligible patients selected by Renal Consultant and Renal Pharmacist Patients sent letter signed by Renal Consultant and Renal pharmacist Patients phoned prior to clinic to agree Adoport start date and address concerns Patient seen by Renal Consultant and pharmacist + given 1 month of Adoport Tacrolimus level and UampEs checked 5-7 days after commencing Adoport and patient
contacted by phone to check if tolerated If stable letter sent to GP and community pharmacy to continue supply
Results and Evaluation Letters have been sent to all eligible patients Seven patients have been reviewed One has received a one month supply of Adoport and 5 others are due to switch One patient was deemed non-eligible at present as they have a 6 month surplus of Prograf A database will be maintained and analysed at the end and primary care savings will be monitored Extra pharmacist input will give us the opportunity to review how immunosuppression is managed and to evaluate the benefit of having a renal transplant pharmacist Conclusion The switch is at an early stage Ultimately we hope to show that the switch from Prograf to Adoport can be managed safely with extra pharmacist input to a remote and rural population with prescribing being conducted by primary care
Fundingconflicts of interest none 1 McDevitt-Potter LM Sadaka B Tichy EM Rogers CC Gabardi S Transplantation 2011 A multicenter experience with
generic tacrolimus conversion 2 Medicines and Health Products Regulatory Agency Drug Safety Update 2012 Accessed online via
wwwmhragovukSafetyinformationDrugSafetyUpdateCON1557563 ESPRIT Guidance on management of repatriation and immunosuppressant switches in transplant patients 2015
Accessed online via httpwwwespritorgukwp-contentuploads201508Switch-guidance-document-final-Aug-31-2015pdf
P7 NHS Highland-Tacrolimus baseline dataMcCulloch K1 Peel R2 Lambie S3
1Renal Pharmacist Renal unit Raigmore Hospital Inverness 2Renal Consultant Renal unitRaigmore Hospital Inverness 3Renal Consultant Renal unit Raigmore Hospital Inverness
BackgroundAs part of planning a switch from using tacrolimus Prograf to Adoport we assessed baseline data for our transplant patients currently using Prograf After converting patients to Adoport we will compare their tacrolimus levels to their individual target range We assessed our use of appropriate target ranges and our current performance in achieving tacrolimus levels within target range on Prograf therapy
Method 107 renal transplant patients taking Prograf were identified a sample of 19 of these were analysed using electronic patient records and results Time from transplant ranged from 1 month to 18 years All tacrolimus levels for the preceding year were analysed and compared to the target range specified at the time of the level being done The assay used has a Coefficient of Variation of lt5 at the lower limit of the assay
Results All 19 patients had a target range for tacrolimus clearly identified and recorded in clinic letterswhich are routinely copied to the patients themselves A variety of target ranges were specifiedThe commonest used was 5-8 microgramsl in 7 patients followed by 5-7 in a further 4 patientswith another 6 different target ranges being used for the remaining 8 patients The ranges usedhad a breadth of 3 microgramsl in 2 cases the rest had a breadth of 2 microgramslPatients had a median of 12 (range 3-72) tacrolimus levels over the preceding year Results werewithin specified target ranges for 54 +- 22 (Medan +- SD) of results checked
Conclusion We currently use a large number of different target ranges The majority of the ranges used had a breadth of just 2 microgramsl These factors help to account for the low proportion of test results which were within the specified target ranges This is important to bear in mind when interpreting whether tacrolimus levels are within target ranges after switching to Adoport We should consider aligning our target ranges and widening them
P8 Eculizumab use in Scottish paediatric dense deposit disease Stewart D1 David Hughes1 Lynne Riach2 Craig Oxley2 Athavale D1
1Royal Hospital for Children Glasgow 2Royal Aberdeen Childrenrsquos Hospital Aberdeen
Introduction The revised MPGN classification and increasing recognition of Dense Deposit Disease (DDD) a C3 glomerulopathy as an alternative complement pathway disorder suggests Eculizumab an anti-C5 monoclonal antibody may be beneficial in treatment However the experience of Eculizumab as an off-label and expensive treatment in children with DDD is limited with variable clinical response reported in the literature
Method We present the outcomes of the only 2 paediatric patients in Scotland who have received Eculizumab for the management of DDD
Results Case 1 A 10 year old male presented with proteinuria and haematuria resistant to steroid treatment with preserved renal function Initial biopsy confirmed DDD Conservative management with an angiotensin converting enzyme inhibitor and diuretics for symptom control continued until 14 years Due to worsening symptoms (oedema lethargy poor growth) and renal function deterioration along with elevated terminal complement complex (TCC) Eculizumab was commenced A repeat biopsy whilst suggestive of chronic irreversible damage showed 25 glomerular architecture preservation Symptom improvement was noted There was a reduction in proteinuria and renal function stabilisation fall in TCC and discontinuation of diuretics Eculizumab was discontinued after 24 months Progression of renal function decline was seen in the final months of Eculizumab therapy With recurrence of symptoms and increasing proteinuria following discontinuation Eculizumab was recommenced after 6 months Symptomatic improvement has since been noted
Case 2 A 5 year old girl presented with painless frank haematuria and proteinuria Initial biopsy confirmed DDD Proteinuria was unresponsive to steroid therapy and 5 months following diagnosis she rapidly progressed towards end stage renal disease despite the introduction of Mycophenolate Mofetil and plasmapheresis Haemodialysis was subsequently commenced TCC level was elevated and Eculizumab treatment was started 7 months after diagnosis Renal biopsy prior to treatment demonstrated continued severe pathological changes in all visible glomeruli However due to lack of clinical response Eculizumab was discontinued after 2 months and the patient remained dialysis dependent
Conclusions Our experience with Eculizumab in Scotland has demonstrated variable results in our 2 patients with one patient showing a positive response whilst the other experienced no improvement Eculizumab was administered to both patients at varying points in their clinical journey with differing progressive features on biopsy To date the outcomes of 9 paediatric patients with DDD treated with Eculizumab have been described in the literature with 8 experiencing some positive response to treatment including 2 patients who were able to stop renal replacement therapy within 12 weeks of treatment A role for Eculizumab in DDD may be guided by clinical and pathological features Well designed clinical trials will be necessary to define the role of complement inhibition therapy in DDD
No conflict of interest and no funding requested
P9 Examining markers of safety in the use of non-tunnelled central venous catheters
James WT Millar (Speciality Registrar) Scott W Oliver (Speciality Registrar) Peter C Thomson (Consultant Nephrologist) Glasgow Renal and Transplant Unit Queen Elizabeth University Hospital Glasgow
Background Non-tunnelled central venous catheters (NTCVC) remain an essential means of vascular access for incident haemodialysis Associated morbidity is well recognised for example in the form of Staphylococcus aureus bloodstream infections (SAB)[1]
Previous quality improvement initiatives in our unit have sought to both improve traditional markers of quality (such as SAB) and to identify additional areas of clinical risk In 2014 Oliver et al [2] suggested several additional quality measures including peri-procedure haemoglobin drop the need for a further NTCVC during the same clinical episode and the NTCVC insertion site This study further evaluated NTCVC related clinical practice within our unit
Methods The potential markers of clinical quality identified in a previous project were examined using prospectively collected data stored in the electronic patient record Identified cases of SAB significant peri-procedure haemoglobin drop and multiple NTCVC insertion were investigated by case note review
Results Between March 2016 and March 2017 a total of 222 patients received 346 NTCVC 54 patients (243) had more than one NTCVC inserted in a 21-day period (range 2-5) When considering NTCVC insertion site there were 159 (459) femoral vein catheters and 183 (541) internal jugular vein catheters No pneumothoraces were reported
15 SABrsquos were reported during this period equating to 43 of all NTCVC 5 arose in patients with femoral NTCVC (333) and 10 from internal jugular catheters (667) Mean time from line insertion to positive blood culture was 86 days 15 (67) patients had a drop in haemoglobin of greater than 20mgdl with no other source of blood loss identified on review of clinical notes
Discussion These data demonstrate that NTCVC-associated SAB rates remain low and significantly below Scottish government audit standards [3] Of interest is the continued trend towards the use of femoral catheters at 45 of lines compared with 38 in 2014 [2] Although traditionally thought of as having a higher incidence of infectious complications our data has shown fewer bacteraemia events associated with femoral catheters compared with internal jugular Our data also demonstrates a significant rate of peri-procedure haemorrhage arising in up to 1 in 20 cases Together these findings present opportunities to development practice and improve patient safety
References
[1] Murray E Deighan C Geddes CC Thomson PC Reducing haemodialysis bacteraemia rates Scottish Renal Association Glasgow November 2013 [2] Oliver SW Thomson PC Jardine AG defining safe effective and patient-centred dialysis catheter placement Scottish Renal Association Edinburgh September 2014 [3] The Staphylococcus aureus bacteraemia quarterly report of cumulative data from all NHS Boards in Scotland Health Protection Scotland January 2015
Sources of funding none Conflicts of interest none
P10 Prescribing of tolvaptan-The NHS Highland experience Lambie S1 McCulloch K2 Garrod J3
1Renal Consultant Renal unit Raigmore Hospital Inverness 2Renal Pharmacist Renal unit Raigmore Hospital Inverness 3Renal Pharmacist Renal unit Raigmore Hospital Inverness
Introduction Tolvaptan is a vasopressin antagonist It was accepted for use in Scotland by SMC in Jan 2016 to slow the progression of cyst development and renal insufficiency of autosomal dominant polycystic kidney disease in adults with chronic kidney disease (CKD) stage 1 to 3 at initiation of treatment with evidence of rapidly progressing disease1 Adverse effects related to aquaresis may affect patientsrsquo ability to achieve the optimum therapeutic dose and the risk of hepatic toxicity necessitates regular LFT monitoring The geography of NHS Highland required the implementation of novel methods of managing these patients and as a result a MDT approach with an emphasis on pharmacist input was adopted Consultant role Patient selection on the basis of evidence of rapidly progressing kidney disease declining
eGFR large volume kidneys on ultrasound and evidence of complications of PKD Side effects and potential benefits discussed Potential medication interactions reviewed Jinarc risk management prescriber training
Pharmacist role Undertook Jinarc risk management pharmacist training Prepares accurate drug history and reviews for potential drug interactions Carries out patient counselling and supplies patient education material sick day rules card
and lsquogot to gorsquo card Supplies GP education leaflet Provides advice on selection of new drug therapies eg for gout Manages stock and coordinates supply to patients
Results Prescribing commenced May 2016 patients currently prescribed tolvaptan 11 7 Female 4 male Number on target dose 73 n = 811 2 patients are still being titrated One patient did
not tolerate target dose due to aquaresis side effects and is being trialled on the middle dose
Withdrawals One patient has withdrawn due to agoraphobia and an inability to attend for monitoring and another is on hold due to having major surgery
Conclusion The MDT approach between the Renal Consultant and Pharmacist at Raigmore Hospital has enabled tolvaptan prescribing to be efficiently and safely implemented to patients living within a challenging geographical location
1 Scottish Medicines Consortium Detailed Advice Document tolvaptan 15mg 30mg 45mg 60mg and 90mg tablets (Jinarcreg) SMC No 111415 January 2016
NA1 Authors SCN Jacqueline Ross NHS Grampian
SCN Alan Somerville NHS Lanarkshire SCN Jane Humphrey NHS Lanarkshire
e- mail contact jacquelinerossnhsnet Alansommervillelanarkshirescotnhsuk
Janehumphreylanarkshirescotnhsuk
Phone contact 01224 552927 01236 712644
Title Sharing of Adverse Events in Renal Units across Scotland
Introduction Background The Scottish Renal Nurses Strategy Group (SRNSG) are a group of senior nurses from Renal
Units across Scotland who meet 3-4 times per year to discuss and implement best practice At the last meeting it was agreed that it would be good practice for each Health Board to share
their adverse events reported on the Datix System and deliver a presentation with an action plan to prevent incidents and improve patient safety across Scotland NHS Grampian and NHS Lanarkshire will be the first to deliver this presentation discussing adverse events from both Health Boards with an action plan
Top 5 adverse events over the past 12 months Renal Unit NHS Grampian 1 Violence and Aggression 2 Accidents including needlesticks slips trips and falls 3 Medication Errors 4 Infrastructure Staffing and Estates 5 Machines and Equipment
Top 5 adverse events over past 12 months Renal Unit NHS Lanarkshire
1 Slips Trips or Falls 2 Medicine errors 3 Treatment problems 4 Transfer problems 5 Breach of policy
The presentation will also focus on any serious adverse events which may not be in the top 5 categories
Aim Objective Each Health Board to share their adverse events with the aim to prevent them from occurring in other units to improve staff and patient safety and wellbeing across Scotland
Method Power Point Presentation
Outcome Results Sharing of adverse events resulting in the development of a national Action Plan to prevent these incidents improving safety and well being of staff and patients in Renal Units across Scotland
NA2
SRA Oct 2017 Abstract
BBV Never Event - The whats whys and hows
Staff Nurse Gillian Wilson Aberdeen Royal Infirmary
This presentation shares our experience of a never event that occurred and was not picked up for
a period of 18 months
Hepatitis C (HCV) positive antibodies were found in a previously negative patient
These results were a low positive with no biochemistry changes to suggest any liver damage
however steps were put immediately in place to isolate and investigate
Was it contamination from a dialysis machine was it related to a blood transfusion given prior to
first positive result was it faulty diagnostic tests in the laboratory
In Aberdeen we go over and above national guidelines and isolate all our BBV patients whether
they have positive blood results or are PCR negative
Further bloods tested at an external laboratory confirmed negative results
It highlighted that communication errors were to blame for the lack of speed in detecting this issue
Investigations concluded no real answers as to why this happened
NA3
Living Donation Scotland Changing attitudes towards living donor kidney transplantation
Jen Lumsdaine Julie Glen On behalf of the Living Donation Scotland Project Board
Background and aims
The rate of living donor transplantation has remained fairly static in Scotland over the past 10 years
Recent data has shown inequity of access to living donor transplantation throughout the UK so
there is potential to significantly increase this optimum form of treatment for patients with end-stage
renal failure in Scotland The Living Donation Project Board was formed in 2016 aiming to double
the number of living donor transplants by 2020
Method
The two key areas
1 Do recipients receive adequate and appropriate information at the right time about living
kidney donation
2 Informing the general public about altruistic donation
All patients active on the transplant list in Scotland were invited to an information event A follow-up
questionnaire was performed in the East of Scotland examining outcome or reasons for not
attending A scoping exercise looked at information provided by each unit was performed and link
nephrologists and low clearance nurses attended meeting to discuss strategies for early education
Outcome
An information pack containing both recipient and donor written information and short films on DVD
has been produced with the support of the Scottish Government for all recipients and potential
donors in Scotland A new website with comprehensive information both written and visual and
postcode finder to improve ease of access to local unit contact details has been developed
Two national media campaigns have been launched with a significant rise in the number of enquiries
from potential donors and actual increase in altruistic donor numbers
Nursing abstract ndash no conflict of interest
NA4Authors Susan Easson Charge Nurse Ward 4C QEUH Glasgow
e- mail contact SusanEassonggcscotnhsuk
Phone contact 0141 452 3300
Title A Conversational approach to find out ldquoWhat matters to yourdquo in a Renal Transplant ward
Introduction Background Finding out ldquo What Mattersrdquo to people using health and careservices is crucial to delivering safe effective and person centred care It is a simple yet profoundconcept and tries to get to the essence of person centred care by creating deeply personalengagements with patients and their families through a conversational approach However careexperience feedback all too often provides innumerable examples of where what really matters topatients and their family members is poorly understood or not addressed Using care experienceas the driver for change the nursing staff in Ward 4C used improvement approaches to explorehow to hold more meaningful ldquoWhat Matters to yourdquo conversations on a daily basis
Aim Objective To improve the patient experience by utilising a person centred approach
Method Using Care experience feedback What Matters to Me boards and the conversationalapproach
Outcome Results Improvements in patient experience will be shared using examples ofpractice and care experience feedback
There was no additional funding required for this project We worked in collaboration with theperson centred team whorsquos aim is to improve patient experience
NA5
The implementation of a renal education programme and its impact on clinical practice
The purpose was to implement a Renal Education Programme and to evaluate its impact on
clinical practise
It was identified that there was a need for an educational programme to be set up within Forth
Valley Royal Hospital There is no inpatient renal unit in FVRH on site for our renal patients they
attend Queen Elizabeth University Hospital We are an outpatient haemodialysis unit with
outpatient clinics on site Therefore it was identified that there was a need for nursing staff within
FVRH to be educated on all renal complexities for the benefit of our patients
This was done through a work-based learning approach which brought tangible benefits for our
patients However it did not come without pitfalls as educational programmes are often seen as
making very little difference to clinical practise
T
his study describes what methods were used and examines the advantages and disadvantages in
setting up an educational programme and evaluating its impact on clinical practise
NA6
Nursing Abstract ndash SRA Meeting ndash 26 October 2017
Chris McGee Tonya Broe Ken Weir
Renal Unit Forth Valley Royal Hospital
Use of the Therapy Monitor Haemodialysis Patient Record System Can we aim for a paper-
free dialysis unit
We are trialling a new haemodialysis patient monitoring system to work in conjunction with SERPR
and which is intended to supersede the Finesse system used previously
We are in the early stages of this process but with continuing staff education and regular tech
support we are hoping to gather sufficient evidence to evaluate whether the use of paper case
notes needs to continue
Is it a realistic goal to aim for a completely paper-free unit
NA7
THE CLINICAL USES OF APHERESIS WITHIN NHS TAYSIDE
Laura Thomson CN
Ninewells Hospital Dundee
NHS Tayside took over the apheresis service from BTS in 2012 The service has since expanded
with the benefits of carrying out this treatment has been widely recognised within NHS Tayside
and is now more commonly being offered to treat a wider range of conditions with the number of
treatments carried out each year rising
This presentation will highlight the progression of the apheresis service within NHS Tayside We
will identify the various conditions it is currently being used to treat and also identify the decision
making process involved in carrying out these treatments ie which replacement fluid will be used
anticoagulation medication administered
We will highlight the benefits and challenges we face in providing this expanding service within the
Renal Service
NA8Authors Linda McDougall Renal Physiotherapist NHS Highland
e- mail contact lindamcdougall1nhsnet
Phone contact 01463 706022
Title lsquoExercise on Haemodialysis- Keeping the Wheels in Motionrsquo
Introduction Background The impact of CKD on physical fitness functional ability independence amp ultimately quality of life cannot be underestimated Current national guidelines recommend that all individuals with CKD are encouraged to participate in regular exercise programmes between or during dialysis sessions if on HD Following a successful pilot study funding was approved to establish an lsquoExercise on Dialysisrsquo (EOD) programme across NHS Highland through the appointment of a dedicated renal physiotherapist in 2008 A successful programme was soon established but for several years post-vacancies and increasing in-patient demands limited the physiotherapy servicersquos ability to deliver the programme The need to improve the long-term sustainability of the service was recognised and in late 2016 funding was approved to develop a Band 4 PT HCSW role for this purpose
Aim ObjectiveTo optimise the sustainability and continuity of the lsquoExercise on Dialysisrsquo service across NHSHighland through development of a Band 4 PT HCSW role
Method The potential parameters of the role and limits of autonomy were scoped out using current NES resources and guidelines Service and task analysis was then carried out to establish which components of the EOD protocol could be undertaken by a Band 4 A series of competencies were developed in line with the clinical protocol and one-to-one training and supervision provided to the post-holder to ensure competency achieved in delivering the programme
Outcome Results A 10 WTE Band 4 PT HCSW was appointed in Jan 2017 with a dual role between the renal unit and acute medical wards Although training is not yet complete the post-holder is already running the day-to-day delivery and monthly audit of the EOD service with senior physiotherapist input only required for individual patient safety queries and general discussion around patientsrsquo progress and goals The benefit to the unit has been considerable as the band 4 is available to support patients and staff with EOD provision 5 days a week This allows for one-to-one supervision of patients who need more support to participate in EOD regular feedback on performance and reviews of outcome measures and goals to maintain motivation levels Feedback on the post has been very positive and its scope will only continue to expand as we look to further develop renal rehabilitation services across NHS Highland
NA9Authors Nadine Lyall and Kerry Guthrie
e- mail contact nadinelyallbordersscotnhsuk kerryguthriebordersscotnhsuk
Phone contact 01896 826637
Title The Developing Role of the NMP in a Satellite Dialysis Unit
Introduction Background
We have been practising as NMPrsquos for nearly 3 years working in the dialysis unit at the BGH The unit is a satellite unit of the ERI and we have expanded over the last 6 years The unit provides haemodialysis for 12 patients at any one time 3 sessions a day 6 days a week We are nurse-led and have 2 renal consultants who are based at the ERI
We saw an opportunity to use our knowledge and experience to develop our role By becoming NMPrsquos we have enhanced our professional development and we feel we meet the changing needs of the dialysis patient in a more holistic manner
Aim Objective
Our aim is to deliver effective care as we are better placed to deal with issues that often arise byacting swiftly this in turn is cost effective and convenient For example good anaemia and bonemanagement is important for their health wellbeing and lifespanTo help understand our role we will use a power point presentation highlighting issues we dealwith and the drugs we prescribe under the following headings Cardiovascular infection painanticoagulant disequilibrium diet renal bone disease and renal anaemia
Method Power point
Outcome Results
In the future we hope to further develop and have greater autonomy in our role We have great support from our renal consultants and have already built up a great relationship with our patients We hope to undertake the Clinical Decision Making course and this in turn will allow us to deal effectively with acute illness giving the dialysis patient better care We are keen to get feedback from other renal nurses in Scotland to enable us to develop our role further and in turn raise awareness of the NMP role in a dialysis unit We record all our prescribing decisions and keep the consultants up to date regularly Currently we are working on auditing our prescribing practice so that we can improve the service we can provide
NA10 Title Komunikacja w szkoleniu dializy ortzewnowej
Author Senior Charge Nurse Rhoda Bell
Address Raigmore Hospital Old Perth Road Inverness IV2 3UJ
Email rhodabellnhsnet Telephone 01463706023
Introduction Background Case study on lady with Polish as her first language she has some English but requires an interpreter to carry out Peritoneal Dialysis training and attend clinic She had some gynaecological issues that we were not aware of which impacted on the functionality of PD and therefore the success of treatment There were areas of concern in low clearance clinic with signs the patient had a reluctance to engage in decision making
AimObjective
Methods Discussion through the case study highlighted issues with communication between different PD staff and patients Areas of concern include different staffing techniques environment factors on training success Also language and communication issues the patient had were not fully apparent so training could not be individualised
Results We plan to trial training at home and have more individualised training schedule for patients The training step by step guides have been reviewed and practise standardised In collaboration with low clearance nurse we have developed a check list which will highlight concerns before the transition to PD ie language issues and need for training aids in another language gynaecological conditions
Conclusions Everyone learns differently and training methodsaids must be individualised for all It may not be apparent until training has commenced that there are concerns Having one to one training with the same nurse will consolidate training and build confidence in the patient Having a close working relationship with members of the MDT will help make a supportive PD journey
Would we do things differently if we knew about prolapse or lack of English both spoken and written
Key words - Peritoneal dialysis patient training communication
N11
Telehealth amp PDAudrey Jones
Advantages
Information on a daily basis about treatment weight and blood pressure
Change programme remotely via computer or mobile
Earlier intervention for machineprogramme issues
Reduction in home visits ie patient trained but still requires volume increases
No need to download cards to see what problems have been
Can have more detailed information available at clinics
Disadvantages
Relying on patient input data correctly
Machine is noisy especially first wave of machine
Still the same bag connection system and patient connection system (difficult for manual
dexterity problems)
Relying on patient having good signal
Modem problems
NA12Autosomal Dominant Polycystic Kidney Disease A cruel inheritance but new hopeAlistair Lawrie Renal Unit Victoria Hospital KirkcaldySadaf Arshad Corry Dunnigan Paul Phelan Neil Turner Renal Unit Royal Infirmary of Edinburgh
Background Autosomal Dominant Polycystic Kidney Disease (ADPKD) is the most prevalent single gene human genetic disorder and the most common of the inherited cystic and interstitial kidney diseases It is estimated to affect 1 in every 1000 individuals worldwide with over 50 of sufferers eventually developing end stage kidney disease and requiring dialysis or transplantation Symptoms include spasmodic severe pain hypertension haematuria infection and kidney failure There is currently no cure for ADPKD Management of the condition has traditionally involved lifestyle modification BP control and analgesia however a recent study (Torres et al 2012) demonstrated that treatment with V2-receptor antagonist drugs slowed increase in total kidney volume reduced the rate of functional decline and showed a reduced incidence of kidney pain
Aim Provision of a tolvaptan prescribing and monitoring service
Methods Experiential finding report of initial twelve months period of multidisciplinary ADPKDtolvaptan clinic
Results Early results are comparable with TEMPO study outcomes
Conclusion Due to the long term nature of this treatment results available at this time are showing only the earliest benefits of the intervention More quantifiable results such as increased time before the necessity for RRT will only be evident in coming years Torres VE et al (2012) Tolvaptan in Patients with Autosomal Dominant Polycystic Kidney Disease New England Journal of Medicine 367 pp 2407-2418 DOI 101056NEJMoa1205311
No funding requirement No conflict of interest
A18 Factors influencing long term renal function after living kidney donation
Matthew A Rutherford Norman J Galbraith Marc Clancy Colin C Geddes
Glasgow Renal and Transplant Unit Queen Elizabeth University Hospital Glasgow UK
Background Following live donor nephrectomy the remaining kidney undergoes an increase in filtration capacity known as compensatory hypertrophy Few cohorts with follow up of renal function beyond 5 years have been reported The impact on long term renal function of variability in donor factors such as age sex pre-donation blood pressure and glomerular filtration rate (GFR) is unknown Increasingly kidney donors have potential risk factors for future poor renal function such as hypertension older age and obesity The aim of this study was to analyse factors influencing long-term renal function in living kidney donors from our centre
Method Data were obtained from the electronic patient record Patients with a recorded procedure of lsquolive donor nephrectomyrsquo between 2005 and 2017 were identified GFR after donation (calcGFR) was calculated using the formula lsquocalcGFR = Pre-donation Isotope GFR x (Pre-donation Serum creatinine Serum Creatinine)rsquo which is accurate assuming muscle mass does not change Pre and post donation serum creatinines (two days two weeks three months and one to ten year) were recorded We analysed the influence of age sex pre-donation GFR and blood pressure on post donation GFR compensation
Results 355 live donor nephrectomies were performed between January 2005 and December 2016 The mean age was 469 (plusmn 116) years and 504 (n=179) were female Mean pre-donation isotope GFR was 937 plusmn 156 mlmin173m2 Median follow up was 2 years (IQR 1 to 6 years with range 2 weeks to 10 years) The calculated percentage of pre-donation GFR at 2 days 2 weeks 3 months 1 year 5 years and 10 years were 698 691 712 730 801 and 950 respectively (p lt 0001) Patients aged lt50 y had not only a higher calcGFR (858 plusmn 29 mlmin173m2 compared with 671 plusmn 28 mlmin173m2 p lt 0001) at 5 years following donation but achieved a higher degree of compensation than donors gt 50 y (836 plusmn 16 compared with 756 plusmn 19 (p = 0002) Patients with pre-donation hypertension achieved 774 plusmn 53 of pre-donation GFR compared with 804 plusmn 32 in normotensive patients (p = 0998) Females had equivalent degree of renal compensation achieving 819 plusmn 19 compared with 780 plusmn 16 in males (p = 0131) at 5 years following donation Patients with pre-donation GFR gt 100 mlmin173m2 achieved 844 plusmn 23 of pre-donation function by 5 years compared with 777 plusmn 14 in those with pre-donation GFR lt 100 mlmin173m2 (p = 001)
Conclusion Following live donor nephrectomy renal function has a nadir of 691 at 2 weeks Compensation in GFR occurs rapidly and appears to be maintained regardless of sex and pre-donation blood pressure Younger age and higher pre-donation GFR were associated with a greater degree of compensation
A19 The utility of high-sensitivity cardiac troponin to stratify cardiovascular risk in patients with renal impairment
Eve Miller-Hodges Atul Anand Anoop S V Shah Nicholas L Mills Neeraj Dhaun
Background Cardiovascular disease is the most common outcome of chronic kidney disease1
Declining glomerular filtration rate (GFR) and proteinuria predict increased cardiovascular risk over the long term2 However there are currently no methods to stratify cardiovascular risk in the short or medium term in patients with renal impairment We have already shown that high-sensitivity cardiac troponin I concentrations (hs-cTnI) lt5ngL in patients presenting with symptoms of acute coronary syndrome identifies those at low risk of cardiac events within 30 days and over the next year3 However uncertainty remains over the role of hs-cTnI testing in patients with renal impairment This study investigated whether hs-cTnI could also stratify future cardiovascular risk in patients with renal impairment
Methods In a prospective study of consecutive patients presenting with suspected acute coronary syndrome we evaluated the performance of hs-cTnI in patients with and without renal impairment (estimated glomerular filtration rate lt60mLmin173m2) using an early risk stratification threshold of 5ngL to ldquorule outrdquo acute myocardial infarction at presentation and within 30 days and sex-specific 99th centile diagnostic thresholds for index type 1 myocardial infarction Subsequent type 1 myocardial infarction and cardiac death were reported at one year
Results Of 4726 patients identified 904 (19) had renal impairment Index diagnosis of type 1 and type 2 myocardial infarction was almost twice as likely in patients with renal impairment (30 vs 15) Performance of the early risk stratification threshold of 5ngL to identify patients at low risk of major cardiac events was similar in patients with (NPV 984 95CI 960-997 sensitivity 989 95CI 975-999) and without renal impairment (NPV 997 95CI 994-999 sensitivity 984 95CI 972-994) These patients continued to remain at low risk over the next year The PPV and specificity at the 99th centile for diagnosis of myocardial infarction were lower in patients with renal impairment at 500 (95CI 452-548) and 709 (95CI 675-742) respectively compared to 624 (95CI 588-659) and 921 (95CI 912-930) At one year 24 of patients with renal impairment and troponin gt99th centile regardless of index diagnosis had experienced further myocardial infarction or cardiac death compared with 10 of patients without
Conclusion In suspected acute coronary syndrome hs-cTnI can stratify risk in patients with renal impairment Irrespective of diagnosis patients with renal impairment and elevated cardiac troponin concentrations had two-fold greater risk of a major cardiac event compared to those with normal renal function and should be considered for further investigation and treatment
Funders Wellcome Trust British Heart Foundation and Chest Heart amp Stroke Scotland
1 Gansevoort RT Lancet 2013
2 Chronic Kidney Disease Prognosis Consortium Lancet 2010
3 Shah AS Lancet 2015
A20 lsquoDOES IT DIALYSE OUTrsquo - THE EFFECT OF RENAL REPLACEMENT THERAPY ON THE BRAIN Mark Findlay Jesse Dawson David Dickie Deborah McGlynn Patrick Mark Institute of Cardiovascular and Medical Science University of Glasgow amp Queen Elizabeth University Hospital Glasgow
Introduction Cerebrovascular disease is common in end-stage renal disease (ESRD) on renal replacement therapy (RRT) We investigated the effect of RRT on cerebral structure and cognitive function over 12 months Methods Observational cohort study in ESRD patients receiving HD Prior cognitive impairment or cerebrovascular disease were exclusion criteria Multi-domain cognitive testing was performed at baseline and at follow-up Transcranial Doppler was used to assess intra-dialysis related alterations in mean flow velocity (MFV) ndash a marker of cerebral blood flow MR imaging was performed at 0 and 12 months We performed T1 T2 FLAIR and DWI sequences and used volumetric software to calculate white matter hyperintensity (WMH) burden markers of atrophy mean diffusivity and fractional anisotropy (FA) to describe structural changes at 1 year Results 97 patients median age 59 years 412 female At follow-up 15 patients were transplanted 6 died 4 withdrew and the remainder continued HD Those who were transplanted were younger (median age 51 vs 60 years p=0019) and had been on dialysis for a shorter period (median 06 vs 21 years p=0003) MFV declined during HD median 475cms to 405cms plt0001 and correlated with lower scores of executive and frontal lobe function during HD (Rho 045 p lt0001 and Rho -0313 p lt001 respectively) In all patients MR imaging demonstrated a significant decline in frontal parietal and temporal lobe volume at follow-up Median WMH volume increased in those who remained on HD but not in transplanted patients (median change 023 vs -012ml p=0018) WMH burden correlated with worsening scores of frontal lobe tests Rho 0585 p0005 and worse mood Rho -0485 p0026 FA improved following renal transplant (028 to 029 p=0016) and correlated with improved executive function testing at follow-up Rho 089 p0019 Conclusion Cerebral blood flow is reduced during haemodialysis and correlates with a reduction in intradialytic executive function There is an improvement in FA following transplantation WMH volume increases in those who remain on dialysis and the degree of increase correlates with executive and frontal lobe function This suggests that haemodialysis is associated with clinically significant changes in the brain and that these may be ameliorated by transplantation
Source of fundingconflicts MF is funded by a KRUK fellowship
A21 Pathological classification of IgA nephropathy to predict renal outcomes ndash is there a better way to score tubulointerstitial inflammation
Alastair Rankin David Kipgen Bruce Mackinnon Jonathan Fox Colin Geddes Emily McQuarrie Glasgow Renal and Transplant Unit On behalf of the Scottish Renal Biopsy Registry
Background The Oxford pathological classification of IgA nephropathy (IgAN MEST-C score) is limited by the fact that individual features of the score are not all predictive and its utility in assisting clinical decision-making is questioned The addition of tubulointerstitial inflammation to the existing scoring system is appealing but is not currently included due to reportedly wide inter-observer variability We report a novel method to score percentage of cortex containing tubulo-interstitial inflammation in non-atrophic renal cortex (ATIN) in patients with IgAN similar to that used in transplant biopsy reporting and assess its utility to predict clinical outcomes
Methods All adult patients with a native renal biopsy diagnosis of IgAN between 2010 and 2015 in a unit serving 15 million people were identified Baseline characteristics biopsy reports and outcome data were collected ATIN was calculated by subtracting the percentage of atrophic cortex from the percentage of total cortex with tubulo-interstitial inflammation withge10 representing significant tubulo-interstitial inflammation in non-atrophic cortex The primary outcome was a composite of requiring renal replacement therapy (RRT) or doubling of serum creatinine (sCr)
Results 153 new cases of IgAN were identified 33 were excluded (24 had lt8 glomeruli on biopsy 6 inadequate biopsy for MEST scoring and 3 on RRT at time of biopsy) In addition patients with a tubular atrophy (T) score of 2 were also excluded (n=9) Of the remaining 111 patients 76 (68) were male Mean age at biopsy was 52 years (+- 167) and 18 (16) had a co-existing clinical diagnosis of henoch-schonlein purpura (HSP) Median sCr was 156 micromoll (IQR 101-212) and 54 (49) had ATIN on biopsy During a median follow-up of 23 years 34 (31) reached the primary outcome 20 (18) received immunosuppression and 16 (14) died On univariate Cox regression survival analysis ATIN was associated with a four-fold increase in the primary outcome (HR 49 (21-113)) On multivariate analysis mesangial hypercellularity (M) T and ATIN independently predicted renal outcome while endocapillary proliferation (E) and segmental sclerosis (S) did not (plt002 for ATIN) Excluding patients with HSP or those who received immunosuppression did not change the result
Conclusion Within our centre ATIN predicts renal outcome for IgAN independently of established histological features Assessment of inter-observer reproducibility and validation in other cohorts is still required but these results suggest ATIN could be a worthwhile addition to current pathological scoring systems for IgAN
Source of funding none Conflicts of interest none
P1 Polypharmacy in Renal Replacement Therapy Patients
Jason McMinn Colin Geddes Glasgow Renal and Transplant Unit Queen Elizabeth University Hospital
Introduction
Prescribing is often led by evidence from studies containing participants with single health conditions and without multimorbidity Polypharmacy is becoming increasingly recognised in patients with multiple chronic health conditions Additional medications are more likely to result in diminishing returns in benefit with an increased risk of harm Patients with established renal failure (ERF) are likely to be susceptible to medication-related harm A high pill burden is also likely to contribute adversely to an already restricted quality of life and has been associated with poor medication adherence The aim of this study was to analyse polypharmacy in all patients with ERF attending our service
Methods
We extracted medication records for all prevalent ERF patients attending the Glasgow Renal and Transplant Unit from the West of Scotland Electronic Renal Patient Record (SERPR) as of 01012017 The records were analysed to calculate the number of regular medications and total pill burden of each patient These medications were categorised as being lsquopreventativersquo or lsquosymptomaticrsquo We also analysed the prescription of specific drug classes to examine the prevalence of these medications
Results
We identified 1091 transplant follow-up 529 hospital haemodialysis and 46 peritoneal dialysis patients who were on a mean of 94 13 and 129 different medications respectively Overall pill burden was 139 tablets a day in transplant follow-up patients 141 in haemodialysis patients and 162 in peritoneal dialysis patients There were similar rates of prescribing between the different dialysis units and clinics within our service
The proportions of medications deemed as preventative rather than symptomatic were 76 in transplant 69 in haemodialysis and 60 in peritoneal dialysis
In transplant patients decreasing renal function was associated with a higher pill burden but even patients with a transplant eGFR gt 60 were on a mean of 126 tablets per day including a mean of 14 antihypertensives
Rates of antidepressant prescribing were 15 in transplant patients and 20 in hospital haemodialysis patients 53 of haemodialysis patients were on a statin 39 on aspirin 61 on a proton pump inhibitor and 7 were on warfarin
Conclusion
Patients undergoing all forms of renal replacement therapy are likely to be on a considerable number of medications Whilst these drugs are inevitably prescribed for valid reasons this data demonstrates the need for clinicians to engage with patients to explore opportunities to reduce pill burden
Conflict of Interest None Sources of Funding None
P2 An audit of Acute Kidney Injury (AKI) on an acute stroke ward before and after plannedinterventions to review and maintain hydration
Clare Harris1 Simon Hart2 Fiona Duthie3 1 University of Edinburgh Medical School 2 Stroke Unit Royal Infirmary of Edinburgh 3 Renal Unit Royal Infirmary of Edinburgh
Background Dehydration is an important factor in the development of acute kidney injury which is associated with increased morbidity and mortality particularly in the elderly population Poor fluid intake is common post stroke (1) and dehydration is associated with poorer outcomes 3 months post stroke (2) In late 2014 there was no system of identifying patients with poor oral intake on the stroke ward at the Royal Infirmary of Edinburgh a hydration protocol and education programme were implemented aiming to improve fluid balance This included the use of prescribed water either orally or by nasogastric tube An audit pre and post intervention demonstrated that hydration as measured by ureacreatinine ratio significantly improved after the protocol introduction (3) We aimed to determine whether the incidence of AKI by KDIGO criteria was also reduced as this could have implications for reducing patient morbidity and mortality in this elderly comorbid patient cohort
Method 150 inpatients to the acute stroke ward during JulAug 2014 and JulAug 2015 were selected (n= 80 2014 n=70 2015) Patient data and creatinine values were collected from the electronic patient record and medical notes and retrospectively analysed Baseline creatinine values were calculated and cases of AKI were identified and staged using KDIGO criteria (4) Chi-Squared tests were performed to determine P values Individual patient notes were reviewed for both quantitative and qualitative data of patient management
Results Incidence of AKI (of any stage) was 263 pre-protocol and 200 post-protocol (P=03646) Incidence of AKI stages 23 was 100 pre-protocol and 715 post-protocol (P=05374) In hospital post stroke mortality was 338 pre-protocol and 1286 post protocol (P=00028) AKI was also associated with increased length of stay
Conclusions Despite a trend in benefit there was no significant difference in incidence of AKI pre and post hydration protocol nor in incidence of severe AKI (stage 23) AKI is influenced by many factors one of which is hydration status Further studies are needed to determine whether the trend of benefit exhibited in this sample is significant in a greater sample size if this were the case such a protocol could have great benefit to patient care on stroke units and elsewhere There was a significant difference in inpatient post stroke mortality following introduction of the hydration protocol Further investigations are needed to explain underlying reasons for this factors other than hydration may play an important role
References 1 Whelan K Inadequate fluid intakes in dysphagic acute stroke Clinical Nutrition (2001) 20(5)
423-428 2 Bhalla A Sankaralingam S Dundas R Swaminathan R Wolfe CDA Rudd AG The influence of
raised plasma osmolality on clinical outcome after acute stroke Stroke (2000) 312043ndash2048 3 Hart SR Craig R Berry E Lane N Gad A Farrugia M Burton L Paquay A What Happens to
Acute Stroke Patientsrsquo Fluid Balance Renal Status and Dehydration in the First Two Weeks How Can They Be Markedly Improved doi 101111ijs12634_13
4 KDIGO Clinical Practice Guideline for Acute Kidney InjuryKidney international supplements (2012) 2(1) 1-138
No funding or conflict of interest to declare
P3NHS Highland-Improving the management of hyperkalaemia using a kit Initial resultsCantley N1 Abedin T2 Lambie S3
1FY2 NHS Highland 2ST4 Renal Medicine NHS Grampian 3Renal Consultant Renal unitRaigmore Hospital Inverness
Introduction The incidence of hyperkalaemia in hospitalised in patients is between 1 and 10 Guidelines in Northern Ireland promote the use of a Hyperkalaemia Kit to improve management of hyperkalaemia We assessed the management of hyperkalaemia in Raigmore Hospital including post-treatment monitoring of serum potassium and blood glucose at baseline and after the introduction of a lsquoHyperkalaemia Kitrsquo which contains a pro forma for the management of hyperkalaemia and all the relevant equipment and drugs for treatment
Method Between July and September 2016 an automated algorithm identified 34 patients with a potassium result 65 mmoll or above on laboratory results 12 received no specific treatment of these 6 results were spurious 4 patients died before treatment could be started and 2 patients were chronic haemodialysis patients We introduced the Hyperkalaemia Kit to the Acute Medical Admissions Unit in Raigmore Hospital Since then 15 patients have been identified with serum potassium measurements above 65 and the pro forma and kit was used with eight of these patients One of these patients proceeded straight to acute renal replacement therapy
Results Prior to our intervention all 22 patients that were actively treated received at least one prescription of appropriate doses of Insulin with Dextrose However only 16 patients received intravenous calcium and only 7 received nebulised Salbutamol Potassium was measured at 4 hours in 5 cases and by 12 hours in 17 cases Monitoring of any capillary blood glucose was only documented in 8 cases Of the 22 treated 2 needed acute renal replacement therapy 3 required further doses of insulin and dextrose 2 were treated with Calcium Resonium
Eight cases of hyperkalaemia have been managed with the use of the kit and pro-forma so far An initial ECG was performed in all eight and four patients had continuous cardiac monitoring Intravenous calcium was given in seven and nebulised Salbutamol was given in five out of the eight cases Six out of eight patients had at least three blood sugar measurements One had two measurements documented and one patient was stopped from further monitoring following senior review and decision to palliate Seven patients had appropriate monitoring of their serum potassium by 4h and 12h again one patient was not monitored due to palliation
Conclusion Baseline results showed very low rates of prescription of nebulised Salbutamol low rates of Calcium Gluconate use and very low monitoring of blood sugars and potassium post treatment This has the potential for serious adverse outcomes particularly the potential for iatrogenic hypoglycaemia Our initial data shows the use of a Hyperkalaemia pro forma and kit improves the rate of prescription of intravenous calcium and nebulised Salbutamol and the post-treatment monitoring of serum potassium and blood sugar levels
P4Rituximab as maintenance therapy in ANCA associated vasculitisndash a single centre experience Rathnamalala NK Mcmenamin J Robertson S Almond A Kelly M Muniraju T M Renal Unit Dumfries and Galloway Royal Infirmary NHS Dumfries and Galloway Background The introduction of Cyclophosphamide and high dose steroids transformed ANCA associate vasculitis (AAV) from a disease of high mortality to a relapsing remitting disease Maintenance of remission however still remains a major challenge A two randomised clinical trials have looked at the use of Rituximab in remission induction in AAV and reported similar remission rates between Cyclophosphamide and Rituximab 12 Both these trials used Azathioprine as maintenance therapy and in the follow up showed similar remission rates with either agent for induction The role of Rituximab for maintenance therapy after cyclophosphamide induction was studied in the MAINRITSAN trial 3 Rituximab was compared with azathioprine and found that the relapse rate was significantly lower in the Rituximab group There have been several other retrospective studies that have suggested regular Rituximab infusions are successful in maintaining remission however has not been thoroughly evaluated 4 5678910 Here we share our centrersquos experience using Rituximab for maintenance of remission of AAV Materials and methods We conducted a retrospective review of electronic medical records of all patients who had received Rituximab as maintenance therapy for 12 months or longer between January 2014 to July 2016 Disease activity was assessed using Birmingham Vasculitis Activity Score ( BVAS) Version 3 and complete remission was defined as a score of 0 and partial remission as a score of lt50 of the value at diagnosis Due to uncertainties associated with sub classification we did not assign specific diagnosis but broadly classified as ANCA associated vasculitis Results 6 patients received Rituximab as maintenance therapy during the study period 3 (50) of them had eye ear nose and upper airway manifestations consistent with Granulomatosis with Polyangitis (GPA) All patients were PR3 ANCA positive except for one at initial diagnosis The mean BVAS score at the time of initiation of Rituximab was 4 All patients were initiated on Rituximab for relapses while on maintenance therapy with Azathioprine 4 patients received 6 monthly doses of Rituximab while two received annual doses All of them were also maintained on 5-10 mg of Prednisolone The mean BVAS score by 6 months was 0 and remained 0 at 12 months The mean PR3 titre was 562 at the initiation of treatment while at 12 months it had come down to 68 All patients remained in complete clinical remission at the end of 12 months after initiation of therapy Rituximab was well tolerated by all patients except one who developed pyrexia during an administration
Conclusions All patients had sustained remission at 6 months and 12 months after initiating Rituximab Rituximab has a potential role as maintenance therapy in AAV
P5 Chronic Myelo-Monocytic Leukaemia (CMML) as a contraindication to renal biopsy Alastair Rankin Emily McQuarrie Jennifer Lees Bruce MacKinnon Glasgow Renal and Transplant Unit On behalf of the Scottish Renal Biopsy Registry
Abstract Chronic Myelo-Monocytic Leukaemia (CMML) is a relatively rare mixed myelodysplastic myeloproliferative disorder that predominately affects patients over the age of 65 years Renal impairment in patients with CMML is well described with several different mechanisms reported including tumour infiltration lysozyme-induced injury amyloid deposition and tubulointerstitial nephritis From anecdotal evidence within our centre we are concerned that patients with CMML have an excessive risk of clinically significant bleeding following native renal biopsy This risk appears disproportionate to the degree of any co-existing thrombocytopenia or coagulopathy
We review the cases of 4 patients with an existing diagnosis of CMML who were referred to the renal clinic with proteinuria and excretory renal dysfunction Two of these patients underwent renal biopsy with subsequent major haemorrhage post-procedure despite normal bleeding parameters pre-procedure Patient 1 presented with flank pain 8 days post-biopsy A CT confirmed peri-nephric haematoma with retroperitoneal extension A total of 6 units of packed red cells (PRCs) were transfused prior to successful CT-guided emoblisation Histology from the biopsy revealed chronic tubulointerstitial nephritis Patient 2 experienced haemodynamic instability and haematuria one hour post-biopsy A total of 11 units of PRCs 7 units of fresh frozen plasma 2 pools of platelets intravenous tranexamic acid and 2 attempts at CT-guided embolization were required until haemostasis was achieved Histology later showed evidence of tumour infiltration with associated vasculitis Patient 3 presented with renal impairment and proteinuria on the background of known CMML Following discussion with haematology the risk of bleeding following renal biopsy was considered unjustifiable despite their platelets and coagulation screen being within normal range The patient was treated for presumed renal tumour infiltration with hydroxycarbamide Patient 4 was referred to the renal clinic with acute onset nephrotic syndrome Urinary proteincreatinine ratio was elevated over 800 mgmmol with serum albumin of 23 gL but normal excretory renal function The patient attends the haematology clinic with suspected CMML and chronic thrombocytopenia but previously declined bone marrow biopsy Following discussion with the patient there are no plans to proceed with renal biopsy given potential risks These cases highlight that while CMML is rare these patients are being referred to renal clinics with features that would commonly justify renal biopsy in other settings but in whom there may be an increased risk of bleeding post-procedure Our in-centre risk of major bleeding is 2 therefore to have such extreme amounts of bleeding in 2 patients with this underlying diagnosis is remarkable This creates a dilemma for the clinician as there is a wide range of potential renal pathology associated with CMML some of which will have disease specific but relatively toxic treatments available
Source of funding none Conflicts of interest none
P6 NHS Highland-Prograf to Adoport switch McCulloch K1 Peel R2 Lambie S3
1Renal Pharmacist Renal unit Raigmore Hospital Inverness 23Renal Consultant Renal unit Raigmore Hospital Inverness
Introduction NHS Highland (NHSH) is the first health board in Scotland to implement a switch from Prograf to Adoport for renal transplant patients This will provide considerable cost savings Adoport meets the bioequivalence criteria for drugs with a narrow therapeutic index set by the European Medicines agency and studies indicate therapeutic equivalence1 with the proviso that brands are non- interchangeable unless the switch is overseen by a Renal Consultant and post-conversion therapeutic drug monitoring is conducted23 The switch has been undertaken by a majority of transplant centres in England the main difference being that they have undergone repatriation NHSH Patients receive their transplant primarily at Royal Infirmary of Edinburgh and occasionally at Queen Elizabeth University Hospital Glasgow Care is transferred to NHS Highland on discharge NHS Highland cares for approximately 170 renal transplant patients 110 being prescribed Prograf These patients may live as far as 110 miles from Raigmore Hospital Given that prescribing is carried out by primary care clear communication with patients GPs and community pharmacy is essential to avoid inadvertent switching between brands
Method Clinically it was agreed a switch could be safely undertaken A business case was submitted and funding secured for pharmacist time laboratory costs and primary care time GPs have been informed via GP subgroup and local prescribing bulletin lsquoThe Pink Onersquo Community pharmacies are being informed by phone A protocol has been agreed Eligible patients selected by Renal Consultant and Renal Pharmacist Patients sent letter signed by Renal Consultant and Renal pharmacist Patients phoned prior to clinic to agree Adoport start date and address concerns Patient seen by Renal Consultant and pharmacist + given 1 month of Adoport Tacrolimus level and UampEs checked 5-7 days after commencing Adoport and patient
contacted by phone to check if tolerated If stable letter sent to GP and community pharmacy to continue supply
Results and Evaluation Letters have been sent to all eligible patients Seven patients have been reviewed One has received a one month supply of Adoport and 5 others are due to switch One patient was deemed non-eligible at present as they have a 6 month surplus of Prograf A database will be maintained and analysed at the end and primary care savings will be monitored Extra pharmacist input will give us the opportunity to review how immunosuppression is managed and to evaluate the benefit of having a renal transplant pharmacist Conclusion The switch is at an early stage Ultimately we hope to show that the switch from Prograf to Adoport can be managed safely with extra pharmacist input to a remote and rural population with prescribing being conducted by primary care
Fundingconflicts of interest none 1 McDevitt-Potter LM Sadaka B Tichy EM Rogers CC Gabardi S Transplantation 2011 A multicenter experience with
generic tacrolimus conversion 2 Medicines and Health Products Regulatory Agency Drug Safety Update 2012 Accessed online via
wwwmhragovukSafetyinformationDrugSafetyUpdateCON1557563 ESPRIT Guidance on management of repatriation and immunosuppressant switches in transplant patients 2015
Accessed online via httpwwwespritorgukwp-contentuploads201508Switch-guidance-document-final-Aug-31-2015pdf
P7 NHS Highland-Tacrolimus baseline dataMcCulloch K1 Peel R2 Lambie S3
1Renal Pharmacist Renal unit Raigmore Hospital Inverness 2Renal Consultant Renal unitRaigmore Hospital Inverness 3Renal Consultant Renal unit Raigmore Hospital Inverness
BackgroundAs part of planning a switch from using tacrolimus Prograf to Adoport we assessed baseline data for our transplant patients currently using Prograf After converting patients to Adoport we will compare their tacrolimus levels to their individual target range We assessed our use of appropriate target ranges and our current performance in achieving tacrolimus levels within target range on Prograf therapy
Method 107 renal transplant patients taking Prograf were identified a sample of 19 of these were analysed using electronic patient records and results Time from transplant ranged from 1 month to 18 years All tacrolimus levels for the preceding year were analysed and compared to the target range specified at the time of the level being done The assay used has a Coefficient of Variation of lt5 at the lower limit of the assay
Results All 19 patients had a target range for tacrolimus clearly identified and recorded in clinic letterswhich are routinely copied to the patients themselves A variety of target ranges were specifiedThe commonest used was 5-8 microgramsl in 7 patients followed by 5-7 in a further 4 patientswith another 6 different target ranges being used for the remaining 8 patients The ranges usedhad a breadth of 3 microgramsl in 2 cases the rest had a breadth of 2 microgramslPatients had a median of 12 (range 3-72) tacrolimus levels over the preceding year Results werewithin specified target ranges for 54 +- 22 (Medan +- SD) of results checked
Conclusion We currently use a large number of different target ranges The majority of the ranges used had a breadth of just 2 microgramsl These factors help to account for the low proportion of test results which were within the specified target ranges This is important to bear in mind when interpreting whether tacrolimus levels are within target ranges after switching to Adoport We should consider aligning our target ranges and widening them
P8 Eculizumab use in Scottish paediatric dense deposit disease Stewart D1 David Hughes1 Lynne Riach2 Craig Oxley2 Athavale D1
1Royal Hospital for Children Glasgow 2Royal Aberdeen Childrenrsquos Hospital Aberdeen
Introduction The revised MPGN classification and increasing recognition of Dense Deposit Disease (DDD) a C3 glomerulopathy as an alternative complement pathway disorder suggests Eculizumab an anti-C5 monoclonal antibody may be beneficial in treatment However the experience of Eculizumab as an off-label and expensive treatment in children with DDD is limited with variable clinical response reported in the literature
Method We present the outcomes of the only 2 paediatric patients in Scotland who have received Eculizumab for the management of DDD
Results Case 1 A 10 year old male presented with proteinuria and haematuria resistant to steroid treatment with preserved renal function Initial biopsy confirmed DDD Conservative management with an angiotensin converting enzyme inhibitor and diuretics for symptom control continued until 14 years Due to worsening symptoms (oedema lethargy poor growth) and renal function deterioration along with elevated terminal complement complex (TCC) Eculizumab was commenced A repeat biopsy whilst suggestive of chronic irreversible damage showed 25 glomerular architecture preservation Symptom improvement was noted There was a reduction in proteinuria and renal function stabilisation fall in TCC and discontinuation of diuretics Eculizumab was discontinued after 24 months Progression of renal function decline was seen in the final months of Eculizumab therapy With recurrence of symptoms and increasing proteinuria following discontinuation Eculizumab was recommenced after 6 months Symptomatic improvement has since been noted
Case 2 A 5 year old girl presented with painless frank haematuria and proteinuria Initial biopsy confirmed DDD Proteinuria was unresponsive to steroid therapy and 5 months following diagnosis she rapidly progressed towards end stage renal disease despite the introduction of Mycophenolate Mofetil and plasmapheresis Haemodialysis was subsequently commenced TCC level was elevated and Eculizumab treatment was started 7 months after diagnosis Renal biopsy prior to treatment demonstrated continued severe pathological changes in all visible glomeruli However due to lack of clinical response Eculizumab was discontinued after 2 months and the patient remained dialysis dependent
Conclusions Our experience with Eculizumab in Scotland has demonstrated variable results in our 2 patients with one patient showing a positive response whilst the other experienced no improvement Eculizumab was administered to both patients at varying points in their clinical journey with differing progressive features on biopsy To date the outcomes of 9 paediatric patients with DDD treated with Eculizumab have been described in the literature with 8 experiencing some positive response to treatment including 2 patients who were able to stop renal replacement therapy within 12 weeks of treatment A role for Eculizumab in DDD may be guided by clinical and pathological features Well designed clinical trials will be necessary to define the role of complement inhibition therapy in DDD
No conflict of interest and no funding requested
P9 Examining markers of safety in the use of non-tunnelled central venous catheters
James WT Millar (Speciality Registrar) Scott W Oliver (Speciality Registrar) Peter C Thomson (Consultant Nephrologist) Glasgow Renal and Transplant Unit Queen Elizabeth University Hospital Glasgow
Background Non-tunnelled central venous catheters (NTCVC) remain an essential means of vascular access for incident haemodialysis Associated morbidity is well recognised for example in the form of Staphylococcus aureus bloodstream infections (SAB)[1]
Previous quality improvement initiatives in our unit have sought to both improve traditional markers of quality (such as SAB) and to identify additional areas of clinical risk In 2014 Oliver et al [2] suggested several additional quality measures including peri-procedure haemoglobin drop the need for a further NTCVC during the same clinical episode and the NTCVC insertion site This study further evaluated NTCVC related clinical practice within our unit
Methods The potential markers of clinical quality identified in a previous project were examined using prospectively collected data stored in the electronic patient record Identified cases of SAB significant peri-procedure haemoglobin drop and multiple NTCVC insertion were investigated by case note review
Results Between March 2016 and March 2017 a total of 222 patients received 346 NTCVC 54 patients (243) had more than one NTCVC inserted in a 21-day period (range 2-5) When considering NTCVC insertion site there were 159 (459) femoral vein catheters and 183 (541) internal jugular vein catheters No pneumothoraces were reported
15 SABrsquos were reported during this period equating to 43 of all NTCVC 5 arose in patients with femoral NTCVC (333) and 10 from internal jugular catheters (667) Mean time from line insertion to positive blood culture was 86 days 15 (67) patients had a drop in haemoglobin of greater than 20mgdl with no other source of blood loss identified on review of clinical notes
Discussion These data demonstrate that NTCVC-associated SAB rates remain low and significantly below Scottish government audit standards [3] Of interest is the continued trend towards the use of femoral catheters at 45 of lines compared with 38 in 2014 [2] Although traditionally thought of as having a higher incidence of infectious complications our data has shown fewer bacteraemia events associated with femoral catheters compared with internal jugular Our data also demonstrates a significant rate of peri-procedure haemorrhage arising in up to 1 in 20 cases Together these findings present opportunities to development practice and improve patient safety
References
[1] Murray E Deighan C Geddes CC Thomson PC Reducing haemodialysis bacteraemia rates Scottish Renal Association Glasgow November 2013 [2] Oliver SW Thomson PC Jardine AG defining safe effective and patient-centred dialysis catheter placement Scottish Renal Association Edinburgh September 2014 [3] The Staphylococcus aureus bacteraemia quarterly report of cumulative data from all NHS Boards in Scotland Health Protection Scotland January 2015
Sources of funding none Conflicts of interest none
P10 Prescribing of tolvaptan-The NHS Highland experience Lambie S1 McCulloch K2 Garrod J3
1Renal Consultant Renal unit Raigmore Hospital Inverness 2Renal Pharmacist Renal unit Raigmore Hospital Inverness 3Renal Pharmacist Renal unit Raigmore Hospital Inverness
Introduction Tolvaptan is a vasopressin antagonist It was accepted for use in Scotland by SMC in Jan 2016 to slow the progression of cyst development and renal insufficiency of autosomal dominant polycystic kidney disease in adults with chronic kidney disease (CKD) stage 1 to 3 at initiation of treatment with evidence of rapidly progressing disease1 Adverse effects related to aquaresis may affect patientsrsquo ability to achieve the optimum therapeutic dose and the risk of hepatic toxicity necessitates regular LFT monitoring The geography of NHS Highland required the implementation of novel methods of managing these patients and as a result a MDT approach with an emphasis on pharmacist input was adopted Consultant role Patient selection on the basis of evidence of rapidly progressing kidney disease declining
eGFR large volume kidneys on ultrasound and evidence of complications of PKD Side effects and potential benefits discussed Potential medication interactions reviewed Jinarc risk management prescriber training
Pharmacist role Undertook Jinarc risk management pharmacist training Prepares accurate drug history and reviews for potential drug interactions Carries out patient counselling and supplies patient education material sick day rules card
and lsquogot to gorsquo card Supplies GP education leaflet Provides advice on selection of new drug therapies eg for gout Manages stock and coordinates supply to patients
Results Prescribing commenced May 2016 patients currently prescribed tolvaptan 11 7 Female 4 male Number on target dose 73 n = 811 2 patients are still being titrated One patient did
not tolerate target dose due to aquaresis side effects and is being trialled on the middle dose
Withdrawals One patient has withdrawn due to agoraphobia and an inability to attend for monitoring and another is on hold due to having major surgery
Conclusion The MDT approach between the Renal Consultant and Pharmacist at Raigmore Hospital has enabled tolvaptan prescribing to be efficiently and safely implemented to patients living within a challenging geographical location
1 Scottish Medicines Consortium Detailed Advice Document tolvaptan 15mg 30mg 45mg 60mg and 90mg tablets (Jinarcreg) SMC No 111415 January 2016
NA1 Authors SCN Jacqueline Ross NHS Grampian
SCN Alan Somerville NHS Lanarkshire SCN Jane Humphrey NHS Lanarkshire
e- mail contact jacquelinerossnhsnet Alansommervillelanarkshirescotnhsuk
Janehumphreylanarkshirescotnhsuk
Phone contact 01224 552927 01236 712644
Title Sharing of Adverse Events in Renal Units across Scotland
Introduction Background The Scottish Renal Nurses Strategy Group (SRNSG) are a group of senior nurses from Renal
Units across Scotland who meet 3-4 times per year to discuss and implement best practice At the last meeting it was agreed that it would be good practice for each Health Board to share
their adverse events reported on the Datix System and deliver a presentation with an action plan to prevent incidents and improve patient safety across Scotland NHS Grampian and NHS Lanarkshire will be the first to deliver this presentation discussing adverse events from both Health Boards with an action plan
Top 5 adverse events over the past 12 months Renal Unit NHS Grampian 1 Violence and Aggression 2 Accidents including needlesticks slips trips and falls 3 Medication Errors 4 Infrastructure Staffing and Estates 5 Machines and Equipment
Top 5 adverse events over past 12 months Renal Unit NHS Lanarkshire
1 Slips Trips or Falls 2 Medicine errors 3 Treatment problems 4 Transfer problems 5 Breach of policy
The presentation will also focus on any serious adverse events which may not be in the top 5 categories
Aim Objective Each Health Board to share their adverse events with the aim to prevent them from occurring in other units to improve staff and patient safety and wellbeing across Scotland
Method Power Point Presentation
Outcome Results Sharing of adverse events resulting in the development of a national Action Plan to prevent these incidents improving safety and well being of staff and patients in Renal Units across Scotland
NA2
SRA Oct 2017 Abstract
BBV Never Event - The whats whys and hows
Staff Nurse Gillian Wilson Aberdeen Royal Infirmary
This presentation shares our experience of a never event that occurred and was not picked up for
a period of 18 months
Hepatitis C (HCV) positive antibodies were found in a previously negative patient
These results were a low positive with no biochemistry changes to suggest any liver damage
however steps were put immediately in place to isolate and investigate
Was it contamination from a dialysis machine was it related to a blood transfusion given prior to
first positive result was it faulty diagnostic tests in the laboratory
In Aberdeen we go over and above national guidelines and isolate all our BBV patients whether
they have positive blood results or are PCR negative
Further bloods tested at an external laboratory confirmed negative results
It highlighted that communication errors were to blame for the lack of speed in detecting this issue
Investigations concluded no real answers as to why this happened
NA3
Living Donation Scotland Changing attitudes towards living donor kidney transplantation
Jen Lumsdaine Julie Glen On behalf of the Living Donation Scotland Project Board
Background and aims
The rate of living donor transplantation has remained fairly static in Scotland over the past 10 years
Recent data has shown inequity of access to living donor transplantation throughout the UK so
there is potential to significantly increase this optimum form of treatment for patients with end-stage
renal failure in Scotland The Living Donation Project Board was formed in 2016 aiming to double
the number of living donor transplants by 2020
Method
The two key areas
1 Do recipients receive adequate and appropriate information at the right time about living
kidney donation
2 Informing the general public about altruistic donation
All patients active on the transplant list in Scotland were invited to an information event A follow-up
questionnaire was performed in the East of Scotland examining outcome or reasons for not
attending A scoping exercise looked at information provided by each unit was performed and link
nephrologists and low clearance nurses attended meeting to discuss strategies for early education
Outcome
An information pack containing both recipient and donor written information and short films on DVD
has been produced with the support of the Scottish Government for all recipients and potential
donors in Scotland A new website with comprehensive information both written and visual and
postcode finder to improve ease of access to local unit contact details has been developed
Two national media campaigns have been launched with a significant rise in the number of enquiries
from potential donors and actual increase in altruistic donor numbers
Nursing abstract ndash no conflict of interest
NA4Authors Susan Easson Charge Nurse Ward 4C QEUH Glasgow
e- mail contact SusanEassonggcscotnhsuk
Phone contact 0141 452 3300
Title A Conversational approach to find out ldquoWhat matters to yourdquo in a Renal Transplant ward
Introduction Background Finding out ldquo What Mattersrdquo to people using health and careservices is crucial to delivering safe effective and person centred care It is a simple yet profoundconcept and tries to get to the essence of person centred care by creating deeply personalengagements with patients and their families through a conversational approach However careexperience feedback all too often provides innumerable examples of where what really matters topatients and their family members is poorly understood or not addressed Using care experienceas the driver for change the nursing staff in Ward 4C used improvement approaches to explorehow to hold more meaningful ldquoWhat Matters to yourdquo conversations on a daily basis
Aim Objective To improve the patient experience by utilising a person centred approach
Method Using Care experience feedback What Matters to Me boards and the conversationalapproach
Outcome Results Improvements in patient experience will be shared using examples ofpractice and care experience feedback
There was no additional funding required for this project We worked in collaboration with theperson centred team whorsquos aim is to improve patient experience
NA5
The implementation of a renal education programme and its impact on clinical practice
The purpose was to implement a Renal Education Programme and to evaluate its impact on
clinical practise
It was identified that there was a need for an educational programme to be set up within Forth
Valley Royal Hospital There is no inpatient renal unit in FVRH on site for our renal patients they
attend Queen Elizabeth University Hospital We are an outpatient haemodialysis unit with
outpatient clinics on site Therefore it was identified that there was a need for nursing staff within
FVRH to be educated on all renal complexities for the benefit of our patients
This was done through a work-based learning approach which brought tangible benefits for our
patients However it did not come without pitfalls as educational programmes are often seen as
making very little difference to clinical practise
T
his study describes what methods were used and examines the advantages and disadvantages in
setting up an educational programme and evaluating its impact on clinical practise
NA6
Nursing Abstract ndash SRA Meeting ndash 26 October 2017
Chris McGee Tonya Broe Ken Weir
Renal Unit Forth Valley Royal Hospital
Use of the Therapy Monitor Haemodialysis Patient Record System Can we aim for a paper-
free dialysis unit
We are trialling a new haemodialysis patient monitoring system to work in conjunction with SERPR
and which is intended to supersede the Finesse system used previously
We are in the early stages of this process but with continuing staff education and regular tech
support we are hoping to gather sufficient evidence to evaluate whether the use of paper case
notes needs to continue
Is it a realistic goal to aim for a completely paper-free unit
NA7
THE CLINICAL USES OF APHERESIS WITHIN NHS TAYSIDE
Laura Thomson CN
Ninewells Hospital Dundee
NHS Tayside took over the apheresis service from BTS in 2012 The service has since expanded
with the benefits of carrying out this treatment has been widely recognised within NHS Tayside
and is now more commonly being offered to treat a wider range of conditions with the number of
treatments carried out each year rising
This presentation will highlight the progression of the apheresis service within NHS Tayside We
will identify the various conditions it is currently being used to treat and also identify the decision
making process involved in carrying out these treatments ie which replacement fluid will be used
anticoagulation medication administered
We will highlight the benefits and challenges we face in providing this expanding service within the
Renal Service
NA8Authors Linda McDougall Renal Physiotherapist NHS Highland
e- mail contact lindamcdougall1nhsnet
Phone contact 01463 706022
Title lsquoExercise on Haemodialysis- Keeping the Wheels in Motionrsquo
Introduction Background The impact of CKD on physical fitness functional ability independence amp ultimately quality of life cannot be underestimated Current national guidelines recommend that all individuals with CKD are encouraged to participate in regular exercise programmes between or during dialysis sessions if on HD Following a successful pilot study funding was approved to establish an lsquoExercise on Dialysisrsquo (EOD) programme across NHS Highland through the appointment of a dedicated renal physiotherapist in 2008 A successful programme was soon established but for several years post-vacancies and increasing in-patient demands limited the physiotherapy servicersquos ability to deliver the programme The need to improve the long-term sustainability of the service was recognised and in late 2016 funding was approved to develop a Band 4 PT HCSW role for this purpose
Aim ObjectiveTo optimise the sustainability and continuity of the lsquoExercise on Dialysisrsquo service across NHSHighland through development of a Band 4 PT HCSW role
Method The potential parameters of the role and limits of autonomy were scoped out using current NES resources and guidelines Service and task analysis was then carried out to establish which components of the EOD protocol could be undertaken by a Band 4 A series of competencies were developed in line with the clinical protocol and one-to-one training and supervision provided to the post-holder to ensure competency achieved in delivering the programme
Outcome Results A 10 WTE Band 4 PT HCSW was appointed in Jan 2017 with a dual role between the renal unit and acute medical wards Although training is not yet complete the post-holder is already running the day-to-day delivery and monthly audit of the EOD service with senior physiotherapist input only required for individual patient safety queries and general discussion around patientsrsquo progress and goals The benefit to the unit has been considerable as the band 4 is available to support patients and staff with EOD provision 5 days a week This allows for one-to-one supervision of patients who need more support to participate in EOD regular feedback on performance and reviews of outcome measures and goals to maintain motivation levels Feedback on the post has been very positive and its scope will only continue to expand as we look to further develop renal rehabilitation services across NHS Highland
NA9Authors Nadine Lyall and Kerry Guthrie
e- mail contact nadinelyallbordersscotnhsuk kerryguthriebordersscotnhsuk
Phone contact 01896 826637
Title The Developing Role of the NMP in a Satellite Dialysis Unit
Introduction Background
We have been practising as NMPrsquos for nearly 3 years working in the dialysis unit at the BGH The unit is a satellite unit of the ERI and we have expanded over the last 6 years The unit provides haemodialysis for 12 patients at any one time 3 sessions a day 6 days a week We are nurse-led and have 2 renal consultants who are based at the ERI
We saw an opportunity to use our knowledge and experience to develop our role By becoming NMPrsquos we have enhanced our professional development and we feel we meet the changing needs of the dialysis patient in a more holistic manner
Aim Objective
Our aim is to deliver effective care as we are better placed to deal with issues that often arise byacting swiftly this in turn is cost effective and convenient For example good anaemia and bonemanagement is important for their health wellbeing and lifespanTo help understand our role we will use a power point presentation highlighting issues we dealwith and the drugs we prescribe under the following headings Cardiovascular infection painanticoagulant disequilibrium diet renal bone disease and renal anaemia
Method Power point
Outcome Results
In the future we hope to further develop and have greater autonomy in our role We have great support from our renal consultants and have already built up a great relationship with our patients We hope to undertake the Clinical Decision Making course and this in turn will allow us to deal effectively with acute illness giving the dialysis patient better care We are keen to get feedback from other renal nurses in Scotland to enable us to develop our role further and in turn raise awareness of the NMP role in a dialysis unit We record all our prescribing decisions and keep the consultants up to date regularly Currently we are working on auditing our prescribing practice so that we can improve the service we can provide
NA10 Title Komunikacja w szkoleniu dializy ortzewnowej
Author Senior Charge Nurse Rhoda Bell
Address Raigmore Hospital Old Perth Road Inverness IV2 3UJ
Email rhodabellnhsnet Telephone 01463706023
Introduction Background Case study on lady with Polish as her first language she has some English but requires an interpreter to carry out Peritoneal Dialysis training and attend clinic She had some gynaecological issues that we were not aware of which impacted on the functionality of PD and therefore the success of treatment There were areas of concern in low clearance clinic with signs the patient had a reluctance to engage in decision making
AimObjective
Methods Discussion through the case study highlighted issues with communication between different PD staff and patients Areas of concern include different staffing techniques environment factors on training success Also language and communication issues the patient had were not fully apparent so training could not be individualised
Results We plan to trial training at home and have more individualised training schedule for patients The training step by step guides have been reviewed and practise standardised In collaboration with low clearance nurse we have developed a check list which will highlight concerns before the transition to PD ie language issues and need for training aids in another language gynaecological conditions
Conclusions Everyone learns differently and training methodsaids must be individualised for all It may not be apparent until training has commenced that there are concerns Having one to one training with the same nurse will consolidate training and build confidence in the patient Having a close working relationship with members of the MDT will help make a supportive PD journey
Would we do things differently if we knew about prolapse or lack of English both spoken and written
Key words - Peritoneal dialysis patient training communication
N11
Telehealth amp PDAudrey Jones
Advantages
Information on a daily basis about treatment weight and blood pressure
Change programme remotely via computer or mobile
Earlier intervention for machineprogramme issues
Reduction in home visits ie patient trained but still requires volume increases
No need to download cards to see what problems have been
Can have more detailed information available at clinics
Disadvantages
Relying on patient input data correctly
Machine is noisy especially first wave of machine
Still the same bag connection system and patient connection system (difficult for manual
dexterity problems)
Relying on patient having good signal
Modem problems
NA12Autosomal Dominant Polycystic Kidney Disease A cruel inheritance but new hopeAlistair Lawrie Renal Unit Victoria Hospital KirkcaldySadaf Arshad Corry Dunnigan Paul Phelan Neil Turner Renal Unit Royal Infirmary of Edinburgh
Background Autosomal Dominant Polycystic Kidney Disease (ADPKD) is the most prevalent single gene human genetic disorder and the most common of the inherited cystic and interstitial kidney diseases It is estimated to affect 1 in every 1000 individuals worldwide with over 50 of sufferers eventually developing end stage kidney disease and requiring dialysis or transplantation Symptoms include spasmodic severe pain hypertension haematuria infection and kidney failure There is currently no cure for ADPKD Management of the condition has traditionally involved lifestyle modification BP control and analgesia however a recent study (Torres et al 2012) demonstrated that treatment with V2-receptor antagonist drugs slowed increase in total kidney volume reduced the rate of functional decline and showed a reduced incidence of kidney pain
Aim Provision of a tolvaptan prescribing and monitoring service
Methods Experiential finding report of initial twelve months period of multidisciplinary ADPKDtolvaptan clinic
Results Early results are comparable with TEMPO study outcomes
Conclusion Due to the long term nature of this treatment results available at this time are showing only the earliest benefits of the intervention More quantifiable results such as increased time before the necessity for RRT will only be evident in coming years Torres VE et al (2012) Tolvaptan in Patients with Autosomal Dominant Polycystic Kidney Disease New England Journal of Medicine 367 pp 2407-2418 DOI 101056NEJMoa1205311
No funding requirement No conflict of interest
A19 The utility of high-sensitivity cardiac troponin to stratify cardiovascular risk in patients with renal impairment
Eve Miller-Hodges Atul Anand Anoop S V Shah Nicholas L Mills Neeraj Dhaun
Background Cardiovascular disease is the most common outcome of chronic kidney disease1
Declining glomerular filtration rate (GFR) and proteinuria predict increased cardiovascular risk over the long term2 However there are currently no methods to stratify cardiovascular risk in the short or medium term in patients with renal impairment We have already shown that high-sensitivity cardiac troponin I concentrations (hs-cTnI) lt5ngL in patients presenting with symptoms of acute coronary syndrome identifies those at low risk of cardiac events within 30 days and over the next year3 However uncertainty remains over the role of hs-cTnI testing in patients with renal impairment This study investigated whether hs-cTnI could also stratify future cardiovascular risk in patients with renal impairment
Methods In a prospective study of consecutive patients presenting with suspected acute coronary syndrome we evaluated the performance of hs-cTnI in patients with and without renal impairment (estimated glomerular filtration rate lt60mLmin173m2) using an early risk stratification threshold of 5ngL to ldquorule outrdquo acute myocardial infarction at presentation and within 30 days and sex-specific 99th centile diagnostic thresholds for index type 1 myocardial infarction Subsequent type 1 myocardial infarction and cardiac death were reported at one year
Results Of 4726 patients identified 904 (19) had renal impairment Index diagnosis of type 1 and type 2 myocardial infarction was almost twice as likely in patients with renal impairment (30 vs 15) Performance of the early risk stratification threshold of 5ngL to identify patients at low risk of major cardiac events was similar in patients with (NPV 984 95CI 960-997 sensitivity 989 95CI 975-999) and without renal impairment (NPV 997 95CI 994-999 sensitivity 984 95CI 972-994) These patients continued to remain at low risk over the next year The PPV and specificity at the 99th centile for diagnosis of myocardial infarction were lower in patients with renal impairment at 500 (95CI 452-548) and 709 (95CI 675-742) respectively compared to 624 (95CI 588-659) and 921 (95CI 912-930) At one year 24 of patients with renal impairment and troponin gt99th centile regardless of index diagnosis had experienced further myocardial infarction or cardiac death compared with 10 of patients without
Conclusion In suspected acute coronary syndrome hs-cTnI can stratify risk in patients with renal impairment Irrespective of diagnosis patients with renal impairment and elevated cardiac troponin concentrations had two-fold greater risk of a major cardiac event compared to those with normal renal function and should be considered for further investigation and treatment
Funders Wellcome Trust British Heart Foundation and Chest Heart amp Stroke Scotland
1 Gansevoort RT Lancet 2013
2 Chronic Kidney Disease Prognosis Consortium Lancet 2010
3 Shah AS Lancet 2015
A20 lsquoDOES IT DIALYSE OUTrsquo - THE EFFECT OF RENAL REPLACEMENT THERAPY ON THE BRAIN Mark Findlay Jesse Dawson David Dickie Deborah McGlynn Patrick Mark Institute of Cardiovascular and Medical Science University of Glasgow amp Queen Elizabeth University Hospital Glasgow
Introduction Cerebrovascular disease is common in end-stage renal disease (ESRD) on renal replacement therapy (RRT) We investigated the effect of RRT on cerebral structure and cognitive function over 12 months Methods Observational cohort study in ESRD patients receiving HD Prior cognitive impairment or cerebrovascular disease were exclusion criteria Multi-domain cognitive testing was performed at baseline and at follow-up Transcranial Doppler was used to assess intra-dialysis related alterations in mean flow velocity (MFV) ndash a marker of cerebral blood flow MR imaging was performed at 0 and 12 months We performed T1 T2 FLAIR and DWI sequences and used volumetric software to calculate white matter hyperintensity (WMH) burden markers of atrophy mean diffusivity and fractional anisotropy (FA) to describe structural changes at 1 year Results 97 patients median age 59 years 412 female At follow-up 15 patients were transplanted 6 died 4 withdrew and the remainder continued HD Those who were transplanted were younger (median age 51 vs 60 years p=0019) and had been on dialysis for a shorter period (median 06 vs 21 years p=0003) MFV declined during HD median 475cms to 405cms plt0001 and correlated with lower scores of executive and frontal lobe function during HD (Rho 045 p lt0001 and Rho -0313 p lt001 respectively) In all patients MR imaging demonstrated a significant decline in frontal parietal and temporal lobe volume at follow-up Median WMH volume increased in those who remained on HD but not in transplanted patients (median change 023 vs -012ml p=0018) WMH burden correlated with worsening scores of frontal lobe tests Rho 0585 p0005 and worse mood Rho -0485 p0026 FA improved following renal transplant (028 to 029 p=0016) and correlated with improved executive function testing at follow-up Rho 089 p0019 Conclusion Cerebral blood flow is reduced during haemodialysis and correlates with a reduction in intradialytic executive function There is an improvement in FA following transplantation WMH volume increases in those who remain on dialysis and the degree of increase correlates with executive and frontal lobe function This suggests that haemodialysis is associated with clinically significant changes in the brain and that these may be ameliorated by transplantation
Source of fundingconflicts MF is funded by a KRUK fellowship
A21 Pathological classification of IgA nephropathy to predict renal outcomes ndash is there a better way to score tubulointerstitial inflammation
Alastair Rankin David Kipgen Bruce Mackinnon Jonathan Fox Colin Geddes Emily McQuarrie Glasgow Renal and Transplant Unit On behalf of the Scottish Renal Biopsy Registry
Background The Oxford pathological classification of IgA nephropathy (IgAN MEST-C score) is limited by the fact that individual features of the score are not all predictive and its utility in assisting clinical decision-making is questioned The addition of tubulointerstitial inflammation to the existing scoring system is appealing but is not currently included due to reportedly wide inter-observer variability We report a novel method to score percentage of cortex containing tubulo-interstitial inflammation in non-atrophic renal cortex (ATIN) in patients with IgAN similar to that used in transplant biopsy reporting and assess its utility to predict clinical outcomes
Methods All adult patients with a native renal biopsy diagnosis of IgAN between 2010 and 2015 in a unit serving 15 million people were identified Baseline characteristics biopsy reports and outcome data were collected ATIN was calculated by subtracting the percentage of atrophic cortex from the percentage of total cortex with tubulo-interstitial inflammation withge10 representing significant tubulo-interstitial inflammation in non-atrophic cortex The primary outcome was a composite of requiring renal replacement therapy (RRT) or doubling of serum creatinine (sCr)
Results 153 new cases of IgAN were identified 33 were excluded (24 had lt8 glomeruli on biopsy 6 inadequate biopsy for MEST scoring and 3 on RRT at time of biopsy) In addition patients with a tubular atrophy (T) score of 2 were also excluded (n=9) Of the remaining 111 patients 76 (68) were male Mean age at biopsy was 52 years (+- 167) and 18 (16) had a co-existing clinical diagnosis of henoch-schonlein purpura (HSP) Median sCr was 156 micromoll (IQR 101-212) and 54 (49) had ATIN on biopsy During a median follow-up of 23 years 34 (31) reached the primary outcome 20 (18) received immunosuppression and 16 (14) died On univariate Cox regression survival analysis ATIN was associated with a four-fold increase in the primary outcome (HR 49 (21-113)) On multivariate analysis mesangial hypercellularity (M) T and ATIN independently predicted renal outcome while endocapillary proliferation (E) and segmental sclerosis (S) did not (plt002 for ATIN) Excluding patients with HSP or those who received immunosuppression did not change the result
Conclusion Within our centre ATIN predicts renal outcome for IgAN independently of established histological features Assessment of inter-observer reproducibility and validation in other cohorts is still required but these results suggest ATIN could be a worthwhile addition to current pathological scoring systems for IgAN
Source of funding none Conflicts of interest none
P1 Polypharmacy in Renal Replacement Therapy Patients
Jason McMinn Colin Geddes Glasgow Renal and Transplant Unit Queen Elizabeth University Hospital
Introduction
Prescribing is often led by evidence from studies containing participants with single health conditions and without multimorbidity Polypharmacy is becoming increasingly recognised in patients with multiple chronic health conditions Additional medications are more likely to result in diminishing returns in benefit with an increased risk of harm Patients with established renal failure (ERF) are likely to be susceptible to medication-related harm A high pill burden is also likely to contribute adversely to an already restricted quality of life and has been associated with poor medication adherence The aim of this study was to analyse polypharmacy in all patients with ERF attending our service
Methods
We extracted medication records for all prevalent ERF patients attending the Glasgow Renal and Transplant Unit from the West of Scotland Electronic Renal Patient Record (SERPR) as of 01012017 The records were analysed to calculate the number of regular medications and total pill burden of each patient These medications were categorised as being lsquopreventativersquo or lsquosymptomaticrsquo We also analysed the prescription of specific drug classes to examine the prevalence of these medications
Results
We identified 1091 transplant follow-up 529 hospital haemodialysis and 46 peritoneal dialysis patients who were on a mean of 94 13 and 129 different medications respectively Overall pill burden was 139 tablets a day in transplant follow-up patients 141 in haemodialysis patients and 162 in peritoneal dialysis patients There were similar rates of prescribing between the different dialysis units and clinics within our service
The proportions of medications deemed as preventative rather than symptomatic were 76 in transplant 69 in haemodialysis and 60 in peritoneal dialysis
In transplant patients decreasing renal function was associated with a higher pill burden but even patients with a transplant eGFR gt 60 were on a mean of 126 tablets per day including a mean of 14 antihypertensives
Rates of antidepressant prescribing were 15 in transplant patients and 20 in hospital haemodialysis patients 53 of haemodialysis patients were on a statin 39 on aspirin 61 on a proton pump inhibitor and 7 were on warfarin
Conclusion
Patients undergoing all forms of renal replacement therapy are likely to be on a considerable number of medications Whilst these drugs are inevitably prescribed for valid reasons this data demonstrates the need for clinicians to engage with patients to explore opportunities to reduce pill burden
Conflict of Interest None Sources of Funding None
P2 An audit of Acute Kidney Injury (AKI) on an acute stroke ward before and after plannedinterventions to review and maintain hydration
Clare Harris1 Simon Hart2 Fiona Duthie3 1 University of Edinburgh Medical School 2 Stroke Unit Royal Infirmary of Edinburgh 3 Renal Unit Royal Infirmary of Edinburgh
Background Dehydration is an important factor in the development of acute kidney injury which is associated with increased morbidity and mortality particularly in the elderly population Poor fluid intake is common post stroke (1) and dehydration is associated with poorer outcomes 3 months post stroke (2) In late 2014 there was no system of identifying patients with poor oral intake on the stroke ward at the Royal Infirmary of Edinburgh a hydration protocol and education programme were implemented aiming to improve fluid balance This included the use of prescribed water either orally or by nasogastric tube An audit pre and post intervention demonstrated that hydration as measured by ureacreatinine ratio significantly improved after the protocol introduction (3) We aimed to determine whether the incidence of AKI by KDIGO criteria was also reduced as this could have implications for reducing patient morbidity and mortality in this elderly comorbid patient cohort
Method 150 inpatients to the acute stroke ward during JulAug 2014 and JulAug 2015 were selected (n= 80 2014 n=70 2015) Patient data and creatinine values were collected from the electronic patient record and medical notes and retrospectively analysed Baseline creatinine values were calculated and cases of AKI were identified and staged using KDIGO criteria (4) Chi-Squared tests were performed to determine P values Individual patient notes were reviewed for both quantitative and qualitative data of patient management
Results Incidence of AKI (of any stage) was 263 pre-protocol and 200 post-protocol (P=03646) Incidence of AKI stages 23 was 100 pre-protocol and 715 post-protocol (P=05374) In hospital post stroke mortality was 338 pre-protocol and 1286 post protocol (P=00028) AKI was also associated with increased length of stay
Conclusions Despite a trend in benefit there was no significant difference in incidence of AKI pre and post hydration protocol nor in incidence of severe AKI (stage 23) AKI is influenced by many factors one of which is hydration status Further studies are needed to determine whether the trend of benefit exhibited in this sample is significant in a greater sample size if this were the case such a protocol could have great benefit to patient care on stroke units and elsewhere There was a significant difference in inpatient post stroke mortality following introduction of the hydration protocol Further investigations are needed to explain underlying reasons for this factors other than hydration may play an important role
References 1 Whelan K Inadequate fluid intakes in dysphagic acute stroke Clinical Nutrition (2001) 20(5)
423-428 2 Bhalla A Sankaralingam S Dundas R Swaminathan R Wolfe CDA Rudd AG The influence of
raised plasma osmolality on clinical outcome after acute stroke Stroke (2000) 312043ndash2048 3 Hart SR Craig R Berry E Lane N Gad A Farrugia M Burton L Paquay A What Happens to
Acute Stroke Patientsrsquo Fluid Balance Renal Status and Dehydration in the First Two Weeks How Can They Be Markedly Improved doi 101111ijs12634_13
4 KDIGO Clinical Practice Guideline for Acute Kidney InjuryKidney international supplements (2012) 2(1) 1-138
No funding or conflict of interest to declare
P3NHS Highland-Improving the management of hyperkalaemia using a kit Initial resultsCantley N1 Abedin T2 Lambie S3
1FY2 NHS Highland 2ST4 Renal Medicine NHS Grampian 3Renal Consultant Renal unitRaigmore Hospital Inverness
Introduction The incidence of hyperkalaemia in hospitalised in patients is between 1 and 10 Guidelines in Northern Ireland promote the use of a Hyperkalaemia Kit to improve management of hyperkalaemia We assessed the management of hyperkalaemia in Raigmore Hospital including post-treatment monitoring of serum potassium and blood glucose at baseline and after the introduction of a lsquoHyperkalaemia Kitrsquo which contains a pro forma for the management of hyperkalaemia and all the relevant equipment and drugs for treatment
Method Between July and September 2016 an automated algorithm identified 34 patients with a potassium result 65 mmoll or above on laboratory results 12 received no specific treatment of these 6 results were spurious 4 patients died before treatment could be started and 2 patients were chronic haemodialysis patients We introduced the Hyperkalaemia Kit to the Acute Medical Admissions Unit in Raigmore Hospital Since then 15 patients have been identified with serum potassium measurements above 65 and the pro forma and kit was used with eight of these patients One of these patients proceeded straight to acute renal replacement therapy
Results Prior to our intervention all 22 patients that were actively treated received at least one prescription of appropriate doses of Insulin with Dextrose However only 16 patients received intravenous calcium and only 7 received nebulised Salbutamol Potassium was measured at 4 hours in 5 cases and by 12 hours in 17 cases Monitoring of any capillary blood glucose was only documented in 8 cases Of the 22 treated 2 needed acute renal replacement therapy 3 required further doses of insulin and dextrose 2 were treated with Calcium Resonium
Eight cases of hyperkalaemia have been managed with the use of the kit and pro-forma so far An initial ECG was performed in all eight and four patients had continuous cardiac monitoring Intravenous calcium was given in seven and nebulised Salbutamol was given in five out of the eight cases Six out of eight patients had at least three blood sugar measurements One had two measurements documented and one patient was stopped from further monitoring following senior review and decision to palliate Seven patients had appropriate monitoring of their serum potassium by 4h and 12h again one patient was not monitored due to palliation
Conclusion Baseline results showed very low rates of prescription of nebulised Salbutamol low rates of Calcium Gluconate use and very low monitoring of blood sugars and potassium post treatment This has the potential for serious adverse outcomes particularly the potential for iatrogenic hypoglycaemia Our initial data shows the use of a Hyperkalaemia pro forma and kit improves the rate of prescription of intravenous calcium and nebulised Salbutamol and the post-treatment monitoring of serum potassium and blood sugar levels
P4Rituximab as maintenance therapy in ANCA associated vasculitisndash a single centre experience Rathnamalala NK Mcmenamin J Robertson S Almond A Kelly M Muniraju T M Renal Unit Dumfries and Galloway Royal Infirmary NHS Dumfries and Galloway Background The introduction of Cyclophosphamide and high dose steroids transformed ANCA associate vasculitis (AAV) from a disease of high mortality to a relapsing remitting disease Maintenance of remission however still remains a major challenge A two randomised clinical trials have looked at the use of Rituximab in remission induction in AAV and reported similar remission rates between Cyclophosphamide and Rituximab 12 Both these trials used Azathioprine as maintenance therapy and in the follow up showed similar remission rates with either agent for induction The role of Rituximab for maintenance therapy after cyclophosphamide induction was studied in the MAINRITSAN trial 3 Rituximab was compared with azathioprine and found that the relapse rate was significantly lower in the Rituximab group There have been several other retrospective studies that have suggested regular Rituximab infusions are successful in maintaining remission however has not been thoroughly evaluated 4 5678910 Here we share our centrersquos experience using Rituximab for maintenance of remission of AAV Materials and methods We conducted a retrospective review of electronic medical records of all patients who had received Rituximab as maintenance therapy for 12 months or longer between January 2014 to July 2016 Disease activity was assessed using Birmingham Vasculitis Activity Score ( BVAS) Version 3 and complete remission was defined as a score of 0 and partial remission as a score of lt50 of the value at diagnosis Due to uncertainties associated with sub classification we did not assign specific diagnosis but broadly classified as ANCA associated vasculitis Results 6 patients received Rituximab as maintenance therapy during the study period 3 (50) of them had eye ear nose and upper airway manifestations consistent with Granulomatosis with Polyangitis (GPA) All patients were PR3 ANCA positive except for one at initial diagnosis The mean BVAS score at the time of initiation of Rituximab was 4 All patients were initiated on Rituximab for relapses while on maintenance therapy with Azathioprine 4 patients received 6 monthly doses of Rituximab while two received annual doses All of them were also maintained on 5-10 mg of Prednisolone The mean BVAS score by 6 months was 0 and remained 0 at 12 months The mean PR3 titre was 562 at the initiation of treatment while at 12 months it had come down to 68 All patients remained in complete clinical remission at the end of 12 months after initiation of therapy Rituximab was well tolerated by all patients except one who developed pyrexia during an administration
Conclusions All patients had sustained remission at 6 months and 12 months after initiating Rituximab Rituximab has a potential role as maintenance therapy in AAV
P5 Chronic Myelo-Monocytic Leukaemia (CMML) as a contraindication to renal biopsy Alastair Rankin Emily McQuarrie Jennifer Lees Bruce MacKinnon Glasgow Renal and Transplant Unit On behalf of the Scottish Renal Biopsy Registry
Abstract Chronic Myelo-Monocytic Leukaemia (CMML) is a relatively rare mixed myelodysplastic myeloproliferative disorder that predominately affects patients over the age of 65 years Renal impairment in patients with CMML is well described with several different mechanisms reported including tumour infiltration lysozyme-induced injury amyloid deposition and tubulointerstitial nephritis From anecdotal evidence within our centre we are concerned that patients with CMML have an excessive risk of clinically significant bleeding following native renal biopsy This risk appears disproportionate to the degree of any co-existing thrombocytopenia or coagulopathy
We review the cases of 4 patients with an existing diagnosis of CMML who were referred to the renal clinic with proteinuria and excretory renal dysfunction Two of these patients underwent renal biopsy with subsequent major haemorrhage post-procedure despite normal bleeding parameters pre-procedure Patient 1 presented with flank pain 8 days post-biopsy A CT confirmed peri-nephric haematoma with retroperitoneal extension A total of 6 units of packed red cells (PRCs) were transfused prior to successful CT-guided emoblisation Histology from the biopsy revealed chronic tubulointerstitial nephritis Patient 2 experienced haemodynamic instability and haematuria one hour post-biopsy A total of 11 units of PRCs 7 units of fresh frozen plasma 2 pools of platelets intravenous tranexamic acid and 2 attempts at CT-guided embolization were required until haemostasis was achieved Histology later showed evidence of tumour infiltration with associated vasculitis Patient 3 presented with renal impairment and proteinuria on the background of known CMML Following discussion with haematology the risk of bleeding following renal biopsy was considered unjustifiable despite their platelets and coagulation screen being within normal range The patient was treated for presumed renal tumour infiltration with hydroxycarbamide Patient 4 was referred to the renal clinic with acute onset nephrotic syndrome Urinary proteincreatinine ratio was elevated over 800 mgmmol with serum albumin of 23 gL but normal excretory renal function The patient attends the haematology clinic with suspected CMML and chronic thrombocytopenia but previously declined bone marrow biopsy Following discussion with the patient there are no plans to proceed with renal biopsy given potential risks These cases highlight that while CMML is rare these patients are being referred to renal clinics with features that would commonly justify renal biopsy in other settings but in whom there may be an increased risk of bleeding post-procedure Our in-centre risk of major bleeding is 2 therefore to have such extreme amounts of bleeding in 2 patients with this underlying diagnosis is remarkable This creates a dilemma for the clinician as there is a wide range of potential renal pathology associated with CMML some of which will have disease specific but relatively toxic treatments available
Source of funding none Conflicts of interest none
P6 NHS Highland-Prograf to Adoport switch McCulloch K1 Peel R2 Lambie S3
1Renal Pharmacist Renal unit Raigmore Hospital Inverness 23Renal Consultant Renal unit Raigmore Hospital Inverness
Introduction NHS Highland (NHSH) is the first health board in Scotland to implement a switch from Prograf to Adoport for renal transplant patients This will provide considerable cost savings Adoport meets the bioequivalence criteria for drugs with a narrow therapeutic index set by the European Medicines agency and studies indicate therapeutic equivalence1 with the proviso that brands are non- interchangeable unless the switch is overseen by a Renal Consultant and post-conversion therapeutic drug monitoring is conducted23 The switch has been undertaken by a majority of transplant centres in England the main difference being that they have undergone repatriation NHSH Patients receive their transplant primarily at Royal Infirmary of Edinburgh and occasionally at Queen Elizabeth University Hospital Glasgow Care is transferred to NHS Highland on discharge NHS Highland cares for approximately 170 renal transplant patients 110 being prescribed Prograf These patients may live as far as 110 miles from Raigmore Hospital Given that prescribing is carried out by primary care clear communication with patients GPs and community pharmacy is essential to avoid inadvertent switching between brands
Method Clinically it was agreed a switch could be safely undertaken A business case was submitted and funding secured for pharmacist time laboratory costs and primary care time GPs have been informed via GP subgroup and local prescribing bulletin lsquoThe Pink Onersquo Community pharmacies are being informed by phone A protocol has been agreed Eligible patients selected by Renal Consultant and Renal Pharmacist Patients sent letter signed by Renal Consultant and Renal pharmacist Patients phoned prior to clinic to agree Adoport start date and address concerns Patient seen by Renal Consultant and pharmacist + given 1 month of Adoport Tacrolimus level and UampEs checked 5-7 days after commencing Adoport and patient
contacted by phone to check if tolerated If stable letter sent to GP and community pharmacy to continue supply
Results and Evaluation Letters have been sent to all eligible patients Seven patients have been reviewed One has received a one month supply of Adoport and 5 others are due to switch One patient was deemed non-eligible at present as they have a 6 month surplus of Prograf A database will be maintained and analysed at the end and primary care savings will be monitored Extra pharmacist input will give us the opportunity to review how immunosuppression is managed and to evaluate the benefit of having a renal transplant pharmacist Conclusion The switch is at an early stage Ultimately we hope to show that the switch from Prograf to Adoport can be managed safely with extra pharmacist input to a remote and rural population with prescribing being conducted by primary care
Fundingconflicts of interest none 1 McDevitt-Potter LM Sadaka B Tichy EM Rogers CC Gabardi S Transplantation 2011 A multicenter experience with
generic tacrolimus conversion 2 Medicines and Health Products Regulatory Agency Drug Safety Update 2012 Accessed online via
wwwmhragovukSafetyinformationDrugSafetyUpdateCON1557563 ESPRIT Guidance on management of repatriation and immunosuppressant switches in transplant patients 2015
Accessed online via httpwwwespritorgukwp-contentuploads201508Switch-guidance-document-final-Aug-31-2015pdf
P7 NHS Highland-Tacrolimus baseline dataMcCulloch K1 Peel R2 Lambie S3
1Renal Pharmacist Renal unit Raigmore Hospital Inverness 2Renal Consultant Renal unitRaigmore Hospital Inverness 3Renal Consultant Renal unit Raigmore Hospital Inverness
BackgroundAs part of planning a switch from using tacrolimus Prograf to Adoport we assessed baseline data for our transplant patients currently using Prograf After converting patients to Adoport we will compare their tacrolimus levels to their individual target range We assessed our use of appropriate target ranges and our current performance in achieving tacrolimus levels within target range on Prograf therapy
Method 107 renal transplant patients taking Prograf were identified a sample of 19 of these were analysed using electronic patient records and results Time from transplant ranged from 1 month to 18 years All tacrolimus levels for the preceding year were analysed and compared to the target range specified at the time of the level being done The assay used has a Coefficient of Variation of lt5 at the lower limit of the assay
Results All 19 patients had a target range for tacrolimus clearly identified and recorded in clinic letterswhich are routinely copied to the patients themselves A variety of target ranges were specifiedThe commonest used was 5-8 microgramsl in 7 patients followed by 5-7 in a further 4 patientswith another 6 different target ranges being used for the remaining 8 patients The ranges usedhad a breadth of 3 microgramsl in 2 cases the rest had a breadth of 2 microgramslPatients had a median of 12 (range 3-72) tacrolimus levels over the preceding year Results werewithin specified target ranges for 54 +- 22 (Medan +- SD) of results checked
Conclusion We currently use a large number of different target ranges The majority of the ranges used had a breadth of just 2 microgramsl These factors help to account for the low proportion of test results which were within the specified target ranges This is important to bear in mind when interpreting whether tacrolimus levels are within target ranges after switching to Adoport We should consider aligning our target ranges and widening them
P8 Eculizumab use in Scottish paediatric dense deposit disease Stewart D1 David Hughes1 Lynne Riach2 Craig Oxley2 Athavale D1
1Royal Hospital for Children Glasgow 2Royal Aberdeen Childrenrsquos Hospital Aberdeen
Introduction The revised MPGN classification and increasing recognition of Dense Deposit Disease (DDD) a C3 glomerulopathy as an alternative complement pathway disorder suggests Eculizumab an anti-C5 monoclonal antibody may be beneficial in treatment However the experience of Eculizumab as an off-label and expensive treatment in children with DDD is limited with variable clinical response reported in the literature
Method We present the outcomes of the only 2 paediatric patients in Scotland who have received Eculizumab for the management of DDD
Results Case 1 A 10 year old male presented with proteinuria and haematuria resistant to steroid treatment with preserved renal function Initial biopsy confirmed DDD Conservative management with an angiotensin converting enzyme inhibitor and diuretics for symptom control continued until 14 years Due to worsening symptoms (oedema lethargy poor growth) and renal function deterioration along with elevated terminal complement complex (TCC) Eculizumab was commenced A repeat biopsy whilst suggestive of chronic irreversible damage showed 25 glomerular architecture preservation Symptom improvement was noted There was a reduction in proteinuria and renal function stabilisation fall in TCC and discontinuation of diuretics Eculizumab was discontinued after 24 months Progression of renal function decline was seen in the final months of Eculizumab therapy With recurrence of symptoms and increasing proteinuria following discontinuation Eculizumab was recommenced after 6 months Symptomatic improvement has since been noted
Case 2 A 5 year old girl presented with painless frank haematuria and proteinuria Initial biopsy confirmed DDD Proteinuria was unresponsive to steroid therapy and 5 months following diagnosis she rapidly progressed towards end stage renal disease despite the introduction of Mycophenolate Mofetil and plasmapheresis Haemodialysis was subsequently commenced TCC level was elevated and Eculizumab treatment was started 7 months after diagnosis Renal biopsy prior to treatment demonstrated continued severe pathological changes in all visible glomeruli However due to lack of clinical response Eculizumab was discontinued after 2 months and the patient remained dialysis dependent
Conclusions Our experience with Eculizumab in Scotland has demonstrated variable results in our 2 patients with one patient showing a positive response whilst the other experienced no improvement Eculizumab was administered to both patients at varying points in their clinical journey with differing progressive features on biopsy To date the outcomes of 9 paediatric patients with DDD treated with Eculizumab have been described in the literature with 8 experiencing some positive response to treatment including 2 patients who were able to stop renal replacement therapy within 12 weeks of treatment A role for Eculizumab in DDD may be guided by clinical and pathological features Well designed clinical trials will be necessary to define the role of complement inhibition therapy in DDD
No conflict of interest and no funding requested
P9 Examining markers of safety in the use of non-tunnelled central venous catheters
James WT Millar (Speciality Registrar) Scott W Oliver (Speciality Registrar) Peter C Thomson (Consultant Nephrologist) Glasgow Renal and Transplant Unit Queen Elizabeth University Hospital Glasgow
Background Non-tunnelled central venous catheters (NTCVC) remain an essential means of vascular access for incident haemodialysis Associated morbidity is well recognised for example in the form of Staphylococcus aureus bloodstream infections (SAB)[1]
Previous quality improvement initiatives in our unit have sought to both improve traditional markers of quality (such as SAB) and to identify additional areas of clinical risk In 2014 Oliver et al [2] suggested several additional quality measures including peri-procedure haemoglobin drop the need for a further NTCVC during the same clinical episode and the NTCVC insertion site This study further evaluated NTCVC related clinical practice within our unit
Methods The potential markers of clinical quality identified in a previous project were examined using prospectively collected data stored in the electronic patient record Identified cases of SAB significant peri-procedure haemoglobin drop and multiple NTCVC insertion were investigated by case note review
Results Between March 2016 and March 2017 a total of 222 patients received 346 NTCVC 54 patients (243) had more than one NTCVC inserted in a 21-day period (range 2-5) When considering NTCVC insertion site there were 159 (459) femoral vein catheters and 183 (541) internal jugular vein catheters No pneumothoraces were reported
15 SABrsquos were reported during this period equating to 43 of all NTCVC 5 arose in patients with femoral NTCVC (333) and 10 from internal jugular catheters (667) Mean time from line insertion to positive blood culture was 86 days 15 (67) patients had a drop in haemoglobin of greater than 20mgdl with no other source of blood loss identified on review of clinical notes
Discussion These data demonstrate that NTCVC-associated SAB rates remain low and significantly below Scottish government audit standards [3] Of interest is the continued trend towards the use of femoral catheters at 45 of lines compared with 38 in 2014 [2] Although traditionally thought of as having a higher incidence of infectious complications our data has shown fewer bacteraemia events associated with femoral catheters compared with internal jugular Our data also demonstrates a significant rate of peri-procedure haemorrhage arising in up to 1 in 20 cases Together these findings present opportunities to development practice and improve patient safety
References
[1] Murray E Deighan C Geddes CC Thomson PC Reducing haemodialysis bacteraemia rates Scottish Renal Association Glasgow November 2013 [2] Oliver SW Thomson PC Jardine AG defining safe effective and patient-centred dialysis catheter placement Scottish Renal Association Edinburgh September 2014 [3] The Staphylococcus aureus bacteraemia quarterly report of cumulative data from all NHS Boards in Scotland Health Protection Scotland January 2015
Sources of funding none Conflicts of interest none
P10 Prescribing of tolvaptan-The NHS Highland experience Lambie S1 McCulloch K2 Garrod J3
1Renal Consultant Renal unit Raigmore Hospital Inverness 2Renal Pharmacist Renal unit Raigmore Hospital Inverness 3Renal Pharmacist Renal unit Raigmore Hospital Inverness
Introduction Tolvaptan is a vasopressin antagonist It was accepted for use in Scotland by SMC in Jan 2016 to slow the progression of cyst development and renal insufficiency of autosomal dominant polycystic kidney disease in adults with chronic kidney disease (CKD) stage 1 to 3 at initiation of treatment with evidence of rapidly progressing disease1 Adverse effects related to aquaresis may affect patientsrsquo ability to achieve the optimum therapeutic dose and the risk of hepatic toxicity necessitates regular LFT monitoring The geography of NHS Highland required the implementation of novel methods of managing these patients and as a result a MDT approach with an emphasis on pharmacist input was adopted Consultant role Patient selection on the basis of evidence of rapidly progressing kidney disease declining
eGFR large volume kidneys on ultrasound and evidence of complications of PKD Side effects and potential benefits discussed Potential medication interactions reviewed Jinarc risk management prescriber training
Pharmacist role Undertook Jinarc risk management pharmacist training Prepares accurate drug history and reviews for potential drug interactions Carries out patient counselling and supplies patient education material sick day rules card
and lsquogot to gorsquo card Supplies GP education leaflet Provides advice on selection of new drug therapies eg for gout Manages stock and coordinates supply to patients
Results Prescribing commenced May 2016 patients currently prescribed tolvaptan 11 7 Female 4 male Number on target dose 73 n = 811 2 patients are still being titrated One patient did
not tolerate target dose due to aquaresis side effects and is being trialled on the middle dose
Withdrawals One patient has withdrawn due to agoraphobia and an inability to attend for monitoring and another is on hold due to having major surgery
Conclusion The MDT approach between the Renal Consultant and Pharmacist at Raigmore Hospital has enabled tolvaptan prescribing to be efficiently and safely implemented to patients living within a challenging geographical location
1 Scottish Medicines Consortium Detailed Advice Document tolvaptan 15mg 30mg 45mg 60mg and 90mg tablets (Jinarcreg) SMC No 111415 January 2016
NA1 Authors SCN Jacqueline Ross NHS Grampian
SCN Alan Somerville NHS Lanarkshire SCN Jane Humphrey NHS Lanarkshire
e- mail contact jacquelinerossnhsnet Alansommervillelanarkshirescotnhsuk
Janehumphreylanarkshirescotnhsuk
Phone contact 01224 552927 01236 712644
Title Sharing of Adverse Events in Renal Units across Scotland
Introduction Background The Scottish Renal Nurses Strategy Group (SRNSG) are a group of senior nurses from Renal
Units across Scotland who meet 3-4 times per year to discuss and implement best practice At the last meeting it was agreed that it would be good practice for each Health Board to share
their adverse events reported on the Datix System and deliver a presentation with an action plan to prevent incidents and improve patient safety across Scotland NHS Grampian and NHS Lanarkshire will be the first to deliver this presentation discussing adverse events from both Health Boards with an action plan
Top 5 adverse events over the past 12 months Renal Unit NHS Grampian 1 Violence and Aggression 2 Accidents including needlesticks slips trips and falls 3 Medication Errors 4 Infrastructure Staffing and Estates 5 Machines and Equipment
Top 5 adverse events over past 12 months Renal Unit NHS Lanarkshire
1 Slips Trips or Falls 2 Medicine errors 3 Treatment problems 4 Transfer problems 5 Breach of policy
The presentation will also focus on any serious adverse events which may not be in the top 5 categories
Aim Objective Each Health Board to share their adverse events with the aim to prevent them from occurring in other units to improve staff and patient safety and wellbeing across Scotland
Method Power Point Presentation
Outcome Results Sharing of adverse events resulting in the development of a national Action Plan to prevent these incidents improving safety and well being of staff and patients in Renal Units across Scotland
NA2
SRA Oct 2017 Abstract
BBV Never Event - The whats whys and hows
Staff Nurse Gillian Wilson Aberdeen Royal Infirmary
This presentation shares our experience of a never event that occurred and was not picked up for
a period of 18 months
Hepatitis C (HCV) positive antibodies were found in a previously negative patient
These results were a low positive with no biochemistry changes to suggest any liver damage
however steps were put immediately in place to isolate and investigate
Was it contamination from a dialysis machine was it related to a blood transfusion given prior to
first positive result was it faulty diagnostic tests in the laboratory
In Aberdeen we go over and above national guidelines and isolate all our BBV patients whether
they have positive blood results or are PCR negative
Further bloods tested at an external laboratory confirmed negative results
It highlighted that communication errors were to blame for the lack of speed in detecting this issue
Investigations concluded no real answers as to why this happened
NA3
Living Donation Scotland Changing attitudes towards living donor kidney transplantation
Jen Lumsdaine Julie Glen On behalf of the Living Donation Scotland Project Board
Background and aims
The rate of living donor transplantation has remained fairly static in Scotland over the past 10 years
Recent data has shown inequity of access to living donor transplantation throughout the UK so
there is potential to significantly increase this optimum form of treatment for patients with end-stage
renal failure in Scotland The Living Donation Project Board was formed in 2016 aiming to double
the number of living donor transplants by 2020
Method
The two key areas
1 Do recipients receive adequate and appropriate information at the right time about living
kidney donation
2 Informing the general public about altruistic donation
All patients active on the transplant list in Scotland were invited to an information event A follow-up
questionnaire was performed in the East of Scotland examining outcome or reasons for not
attending A scoping exercise looked at information provided by each unit was performed and link
nephrologists and low clearance nurses attended meeting to discuss strategies for early education
Outcome
An information pack containing both recipient and donor written information and short films on DVD
has been produced with the support of the Scottish Government for all recipients and potential
donors in Scotland A new website with comprehensive information both written and visual and
postcode finder to improve ease of access to local unit contact details has been developed
Two national media campaigns have been launched with a significant rise in the number of enquiries
from potential donors and actual increase in altruistic donor numbers
Nursing abstract ndash no conflict of interest
NA4Authors Susan Easson Charge Nurse Ward 4C QEUH Glasgow
e- mail contact SusanEassonggcscotnhsuk
Phone contact 0141 452 3300
Title A Conversational approach to find out ldquoWhat matters to yourdquo in a Renal Transplant ward
Introduction Background Finding out ldquo What Mattersrdquo to people using health and careservices is crucial to delivering safe effective and person centred care It is a simple yet profoundconcept and tries to get to the essence of person centred care by creating deeply personalengagements with patients and their families through a conversational approach However careexperience feedback all too often provides innumerable examples of where what really matters topatients and their family members is poorly understood or not addressed Using care experienceas the driver for change the nursing staff in Ward 4C used improvement approaches to explorehow to hold more meaningful ldquoWhat Matters to yourdquo conversations on a daily basis
Aim Objective To improve the patient experience by utilising a person centred approach
Method Using Care experience feedback What Matters to Me boards and the conversationalapproach
Outcome Results Improvements in patient experience will be shared using examples ofpractice and care experience feedback
There was no additional funding required for this project We worked in collaboration with theperson centred team whorsquos aim is to improve patient experience
NA5
The implementation of a renal education programme and its impact on clinical practice
The purpose was to implement a Renal Education Programme and to evaluate its impact on
clinical practise
It was identified that there was a need for an educational programme to be set up within Forth
Valley Royal Hospital There is no inpatient renal unit in FVRH on site for our renal patients they
attend Queen Elizabeth University Hospital We are an outpatient haemodialysis unit with
outpatient clinics on site Therefore it was identified that there was a need for nursing staff within
FVRH to be educated on all renal complexities for the benefit of our patients
This was done through a work-based learning approach which brought tangible benefits for our
patients However it did not come without pitfalls as educational programmes are often seen as
making very little difference to clinical practise
T
his study describes what methods were used and examines the advantages and disadvantages in
setting up an educational programme and evaluating its impact on clinical practise
NA6
Nursing Abstract ndash SRA Meeting ndash 26 October 2017
Chris McGee Tonya Broe Ken Weir
Renal Unit Forth Valley Royal Hospital
Use of the Therapy Monitor Haemodialysis Patient Record System Can we aim for a paper-
free dialysis unit
We are trialling a new haemodialysis patient monitoring system to work in conjunction with SERPR
and which is intended to supersede the Finesse system used previously
We are in the early stages of this process but with continuing staff education and regular tech
support we are hoping to gather sufficient evidence to evaluate whether the use of paper case
notes needs to continue
Is it a realistic goal to aim for a completely paper-free unit
NA7
THE CLINICAL USES OF APHERESIS WITHIN NHS TAYSIDE
Laura Thomson CN
Ninewells Hospital Dundee
NHS Tayside took over the apheresis service from BTS in 2012 The service has since expanded
with the benefits of carrying out this treatment has been widely recognised within NHS Tayside
and is now more commonly being offered to treat a wider range of conditions with the number of
treatments carried out each year rising
This presentation will highlight the progression of the apheresis service within NHS Tayside We
will identify the various conditions it is currently being used to treat and also identify the decision
making process involved in carrying out these treatments ie which replacement fluid will be used
anticoagulation medication administered
We will highlight the benefits and challenges we face in providing this expanding service within the
Renal Service
NA8Authors Linda McDougall Renal Physiotherapist NHS Highland
e- mail contact lindamcdougall1nhsnet
Phone contact 01463 706022
Title lsquoExercise on Haemodialysis- Keeping the Wheels in Motionrsquo
Introduction Background The impact of CKD on physical fitness functional ability independence amp ultimately quality of life cannot be underestimated Current national guidelines recommend that all individuals with CKD are encouraged to participate in regular exercise programmes between or during dialysis sessions if on HD Following a successful pilot study funding was approved to establish an lsquoExercise on Dialysisrsquo (EOD) programme across NHS Highland through the appointment of a dedicated renal physiotherapist in 2008 A successful programme was soon established but for several years post-vacancies and increasing in-patient demands limited the physiotherapy servicersquos ability to deliver the programme The need to improve the long-term sustainability of the service was recognised and in late 2016 funding was approved to develop a Band 4 PT HCSW role for this purpose
Aim ObjectiveTo optimise the sustainability and continuity of the lsquoExercise on Dialysisrsquo service across NHSHighland through development of a Band 4 PT HCSW role
Method The potential parameters of the role and limits of autonomy were scoped out using current NES resources and guidelines Service and task analysis was then carried out to establish which components of the EOD protocol could be undertaken by a Band 4 A series of competencies were developed in line with the clinical protocol and one-to-one training and supervision provided to the post-holder to ensure competency achieved in delivering the programme
Outcome Results A 10 WTE Band 4 PT HCSW was appointed in Jan 2017 with a dual role between the renal unit and acute medical wards Although training is not yet complete the post-holder is already running the day-to-day delivery and monthly audit of the EOD service with senior physiotherapist input only required for individual patient safety queries and general discussion around patientsrsquo progress and goals The benefit to the unit has been considerable as the band 4 is available to support patients and staff with EOD provision 5 days a week This allows for one-to-one supervision of patients who need more support to participate in EOD regular feedback on performance and reviews of outcome measures and goals to maintain motivation levels Feedback on the post has been very positive and its scope will only continue to expand as we look to further develop renal rehabilitation services across NHS Highland
NA9Authors Nadine Lyall and Kerry Guthrie
e- mail contact nadinelyallbordersscotnhsuk kerryguthriebordersscotnhsuk
Phone contact 01896 826637
Title The Developing Role of the NMP in a Satellite Dialysis Unit
Introduction Background
We have been practising as NMPrsquos for nearly 3 years working in the dialysis unit at the BGH The unit is a satellite unit of the ERI and we have expanded over the last 6 years The unit provides haemodialysis for 12 patients at any one time 3 sessions a day 6 days a week We are nurse-led and have 2 renal consultants who are based at the ERI
We saw an opportunity to use our knowledge and experience to develop our role By becoming NMPrsquos we have enhanced our professional development and we feel we meet the changing needs of the dialysis patient in a more holistic manner
Aim Objective
Our aim is to deliver effective care as we are better placed to deal with issues that often arise byacting swiftly this in turn is cost effective and convenient For example good anaemia and bonemanagement is important for their health wellbeing and lifespanTo help understand our role we will use a power point presentation highlighting issues we dealwith and the drugs we prescribe under the following headings Cardiovascular infection painanticoagulant disequilibrium diet renal bone disease and renal anaemia
Method Power point
Outcome Results
In the future we hope to further develop and have greater autonomy in our role We have great support from our renal consultants and have already built up a great relationship with our patients We hope to undertake the Clinical Decision Making course and this in turn will allow us to deal effectively with acute illness giving the dialysis patient better care We are keen to get feedback from other renal nurses in Scotland to enable us to develop our role further and in turn raise awareness of the NMP role in a dialysis unit We record all our prescribing decisions and keep the consultants up to date regularly Currently we are working on auditing our prescribing practice so that we can improve the service we can provide
NA10 Title Komunikacja w szkoleniu dializy ortzewnowej
Author Senior Charge Nurse Rhoda Bell
Address Raigmore Hospital Old Perth Road Inverness IV2 3UJ
Email rhodabellnhsnet Telephone 01463706023
Introduction Background Case study on lady with Polish as her first language she has some English but requires an interpreter to carry out Peritoneal Dialysis training and attend clinic She had some gynaecological issues that we were not aware of which impacted on the functionality of PD and therefore the success of treatment There were areas of concern in low clearance clinic with signs the patient had a reluctance to engage in decision making
AimObjective
Methods Discussion through the case study highlighted issues with communication between different PD staff and patients Areas of concern include different staffing techniques environment factors on training success Also language and communication issues the patient had were not fully apparent so training could not be individualised
Results We plan to trial training at home and have more individualised training schedule for patients The training step by step guides have been reviewed and practise standardised In collaboration with low clearance nurse we have developed a check list which will highlight concerns before the transition to PD ie language issues and need for training aids in another language gynaecological conditions
Conclusions Everyone learns differently and training methodsaids must be individualised for all It may not be apparent until training has commenced that there are concerns Having one to one training with the same nurse will consolidate training and build confidence in the patient Having a close working relationship with members of the MDT will help make a supportive PD journey
Would we do things differently if we knew about prolapse or lack of English both spoken and written
Key words - Peritoneal dialysis patient training communication
N11
Telehealth amp PDAudrey Jones
Advantages
Information on a daily basis about treatment weight and blood pressure
Change programme remotely via computer or mobile
Earlier intervention for machineprogramme issues
Reduction in home visits ie patient trained but still requires volume increases
No need to download cards to see what problems have been
Can have more detailed information available at clinics
Disadvantages
Relying on patient input data correctly
Machine is noisy especially first wave of machine
Still the same bag connection system and patient connection system (difficult for manual
dexterity problems)
Relying on patient having good signal
Modem problems
NA12Autosomal Dominant Polycystic Kidney Disease A cruel inheritance but new hopeAlistair Lawrie Renal Unit Victoria Hospital KirkcaldySadaf Arshad Corry Dunnigan Paul Phelan Neil Turner Renal Unit Royal Infirmary of Edinburgh
Background Autosomal Dominant Polycystic Kidney Disease (ADPKD) is the most prevalent single gene human genetic disorder and the most common of the inherited cystic and interstitial kidney diseases It is estimated to affect 1 in every 1000 individuals worldwide with over 50 of sufferers eventually developing end stage kidney disease and requiring dialysis or transplantation Symptoms include spasmodic severe pain hypertension haematuria infection and kidney failure There is currently no cure for ADPKD Management of the condition has traditionally involved lifestyle modification BP control and analgesia however a recent study (Torres et al 2012) demonstrated that treatment with V2-receptor antagonist drugs slowed increase in total kidney volume reduced the rate of functional decline and showed a reduced incidence of kidney pain
Aim Provision of a tolvaptan prescribing and monitoring service
Methods Experiential finding report of initial twelve months period of multidisciplinary ADPKDtolvaptan clinic
Results Early results are comparable with TEMPO study outcomes
Conclusion Due to the long term nature of this treatment results available at this time are showing only the earliest benefits of the intervention More quantifiable results such as increased time before the necessity for RRT will only be evident in coming years Torres VE et al (2012) Tolvaptan in Patients with Autosomal Dominant Polycystic Kidney Disease New England Journal of Medicine 367 pp 2407-2418 DOI 101056NEJMoa1205311
No funding requirement No conflict of interest
A20 lsquoDOES IT DIALYSE OUTrsquo - THE EFFECT OF RENAL REPLACEMENT THERAPY ON THE BRAIN Mark Findlay Jesse Dawson David Dickie Deborah McGlynn Patrick Mark Institute of Cardiovascular and Medical Science University of Glasgow amp Queen Elizabeth University Hospital Glasgow
Introduction Cerebrovascular disease is common in end-stage renal disease (ESRD) on renal replacement therapy (RRT) We investigated the effect of RRT on cerebral structure and cognitive function over 12 months Methods Observational cohort study in ESRD patients receiving HD Prior cognitive impairment or cerebrovascular disease were exclusion criteria Multi-domain cognitive testing was performed at baseline and at follow-up Transcranial Doppler was used to assess intra-dialysis related alterations in mean flow velocity (MFV) ndash a marker of cerebral blood flow MR imaging was performed at 0 and 12 months We performed T1 T2 FLAIR and DWI sequences and used volumetric software to calculate white matter hyperintensity (WMH) burden markers of atrophy mean diffusivity and fractional anisotropy (FA) to describe structural changes at 1 year Results 97 patients median age 59 years 412 female At follow-up 15 patients were transplanted 6 died 4 withdrew and the remainder continued HD Those who were transplanted were younger (median age 51 vs 60 years p=0019) and had been on dialysis for a shorter period (median 06 vs 21 years p=0003) MFV declined during HD median 475cms to 405cms plt0001 and correlated with lower scores of executive and frontal lobe function during HD (Rho 045 p lt0001 and Rho -0313 p lt001 respectively) In all patients MR imaging demonstrated a significant decline in frontal parietal and temporal lobe volume at follow-up Median WMH volume increased in those who remained on HD but not in transplanted patients (median change 023 vs -012ml p=0018) WMH burden correlated with worsening scores of frontal lobe tests Rho 0585 p0005 and worse mood Rho -0485 p0026 FA improved following renal transplant (028 to 029 p=0016) and correlated with improved executive function testing at follow-up Rho 089 p0019 Conclusion Cerebral blood flow is reduced during haemodialysis and correlates with a reduction in intradialytic executive function There is an improvement in FA following transplantation WMH volume increases in those who remain on dialysis and the degree of increase correlates with executive and frontal lobe function This suggests that haemodialysis is associated with clinically significant changes in the brain and that these may be ameliorated by transplantation
Source of fundingconflicts MF is funded by a KRUK fellowship
A21 Pathological classification of IgA nephropathy to predict renal outcomes ndash is there a better way to score tubulointerstitial inflammation
Alastair Rankin David Kipgen Bruce Mackinnon Jonathan Fox Colin Geddes Emily McQuarrie Glasgow Renal and Transplant Unit On behalf of the Scottish Renal Biopsy Registry
Background The Oxford pathological classification of IgA nephropathy (IgAN MEST-C score) is limited by the fact that individual features of the score are not all predictive and its utility in assisting clinical decision-making is questioned The addition of tubulointerstitial inflammation to the existing scoring system is appealing but is not currently included due to reportedly wide inter-observer variability We report a novel method to score percentage of cortex containing tubulo-interstitial inflammation in non-atrophic renal cortex (ATIN) in patients with IgAN similar to that used in transplant biopsy reporting and assess its utility to predict clinical outcomes
Methods All adult patients with a native renal biopsy diagnosis of IgAN between 2010 and 2015 in a unit serving 15 million people were identified Baseline characteristics biopsy reports and outcome data were collected ATIN was calculated by subtracting the percentage of atrophic cortex from the percentage of total cortex with tubulo-interstitial inflammation withge10 representing significant tubulo-interstitial inflammation in non-atrophic cortex The primary outcome was a composite of requiring renal replacement therapy (RRT) or doubling of serum creatinine (sCr)
Results 153 new cases of IgAN were identified 33 were excluded (24 had lt8 glomeruli on biopsy 6 inadequate biopsy for MEST scoring and 3 on RRT at time of biopsy) In addition patients with a tubular atrophy (T) score of 2 were also excluded (n=9) Of the remaining 111 patients 76 (68) were male Mean age at biopsy was 52 years (+- 167) and 18 (16) had a co-existing clinical diagnosis of henoch-schonlein purpura (HSP) Median sCr was 156 micromoll (IQR 101-212) and 54 (49) had ATIN on biopsy During a median follow-up of 23 years 34 (31) reached the primary outcome 20 (18) received immunosuppression and 16 (14) died On univariate Cox regression survival analysis ATIN was associated with a four-fold increase in the primary outcome (HR 49 (21-113)) On multivariate analysis mesangial hypercellularity (M) T and ATIN independently predicted renal outcome while endocapillary proliferation (E) and segmental sclerosis (S) did not (plt002 for ATIN) Excluding patients with HSP or those who received immunosuppression did not change the result
Conclusion Within our centre ATIN predicts renal outcome for IgAN independently of established histological features Assessment of inter-observer reproducibility and validation in other cohorts is still required but these results suggest ATIN could be a worthwhile addition to current pathological scoring systems for IgAN
Source of funding none Conflicts of interest none
P1 Polypharmacy in Renal Replacement Therapy Patients
Jason McMinn Colin Geddes Glasgow Renal and Transplant Unit Queen Elizabeth University Hospital
Introduction
Prescribing is often led by evidence from studies containing participants with single health conditions and without multimorbidity Polypharmacy is becoming increasingly recognised in patients with multiple chronic health conditions Additional medications are more likely to result in diminishing returns in benefit with an increased risk of harm Patients with established renal failure (ERF) are likely to be susceptible to medication-related harm A high pill burden is also likely to contribute adversely to an already restricted quality of life and has been associated with poor medication adherence The aim of this study was to analyse polypharmacy in all patients with ERF attending our service
Methods
We extracted medication records for all prevalent ERF patients attending the Glasgow Renal and Transplant Unit from the West of Scotland Electronic Renal Patient Record (SERPR) as of 01012017 The records were analysed to calculate the number of regular medications and total pill burden of each patient These medications were categorised as being lsquopreventativersquo or lsquosymptomaticrsquo We also analysed the prescription of specific drug classes to examine the prevalence of these medications
Results
We identified 1091 transplant follow-up 529 hospital haemodialysis and 46 peritoneal dialysis patients who were on a mean of 94 13 and 129 different medications respectively Overall pill burden was 139 tablets a day in transplant follow-up patients 141 in haemodialysis patients and 162 in peritoneal dialysis patients There were similar rates of prescribing between the different dialysis units and clinics within our service
The proportions of medications deemed as preventative rather than symptomatic were 76 in transplant 69 in haemodialysis and 60 in peritoneal dialysis
In transplant patients decreasing renal function was associated with a higher pill burden but even patients with a transplant eGFR gt 60 were on a mean of 126 tablets per day including a mean of 14 antihypertensives
Rates of antidepressant prescribing were 15 in transplant patients and 20 in hospital haemodialysis patients 53 of haemodialysis patients were on a statin 39 on aspirin 61 on a proton pump inhibitor and 7 were on warfarin
Conclusion
Patients undergoing all forms of renal replacement therapy are likely to be on a considerable number of medications Whilst these drugs are inevitably prescribed for valid reasons this data demonstrates the need for clinicians to engage with patients to explore opportunities to reduce pill burden
Conflict of Interest None Sources of Funding None
P2 An audit of Acute Kidney Injury (AKI) on an acute stroke ward before and after plannedinterventions to review and maintain hydration
Clare Harris1 Simon Hart2 Fiona Duthie3 1 University of Edinburgh Medical School 2 Stroke Unit Royal Infirmary of Edinburgh 3 Renal Unit Royal Infirmary of Edinburgh
Background Dehydration is an important factor in the development of acute kidney injury which is associated with increased morbidity and mortality particularly in the elderly population Poor fluid intake is common post stroke (1) and dehydration is associated with poorer outcomes 3 months post stroke (2) In late 2014 there was no system of identifying patients with poor oral intake on the stroke ward at the Royal Infirmary of Edinburgh a hydration protocol and education programme were implemented aiming to improve fluid balance This included the use of prescribed water either orally or by nasogastric tube An audit pre and post intervention demonstrated that hydration as measured by ureacreatinine ratio significantly improved after the protocol introduction (3) We aimed to determine whether the incidence of AKI by KDIGO criteria was also reduced as this could have implications for reducing patient morbidity and mortality in this elderly comorbid patient cohort
Method 150 inpatients to the acute stroke ward during JulAug 2014 and JulAug 2015 were selected (n= 80 2014 n=70 2015) Patient data and creatinine values were collected from the electronic patient record and medical notes and retrospectively analysed Baseline creatinine values were calculated and cases of AKI were identified and staged using KDIGO criteria (4) Chi-Squared tests were performed to determine P values Individual patient notes were reviewed for both quantitative and qualitative data of patient management
Results Incidence of AKI (of any stage) was 263 pre-protocol and 200 post-protocol (P=03646) Incidence of AKI stages 23 was 100 pre-protocol and 715 post-protocol (P=05374) In hospital post stroke mortality was 338 pre-protocol and 1286 post protocol (P=00028) AKI was also associated with increased length of stay
Conclusions Despite a trend in benefit there was no significant difference in incidence of AKI pre and post hydration protocol nor in incidence of severe AKI (stage 23) AKI is influenced by many factors one of which is hydration status Further studies are needed to determine whether the trend of benefit exhibited in this sample is significant in a greater sample size if this were the case such a protocol could have great benefit to patient care on stroke units and elsewhere There was a significant difference in inpatient post stroke mortality following introduction of the hydration protocol Further investigations are needed to explain underlying reasons for this factors other than hydration may play an important role
References 1 Whelan K Inadequate fluid intakes in dysphagic acute stroke Clinical Nutrition (2001) 20(5)
423-428 2 Bhalla A Sankaralingam S Dundas R Swaminathan R Wolfe CDA Rudd AG The influence of
raised plasma osmolality on clinical outcome after acute stroke Stroke (2000) 312043ndash2048 3 Hart SR Craig R Berry E Lane N Gad A Farrugia M Burton L Paquay A What Happens to
Acute Stroke Patientsrsquo Fluid Balance Renal Status and Dehydration in the First Two Weeks How Can They Be Markedly Improved doi 101111ijs12634_13
4 KDIGO Clinical Practice Guideline for Acute Kidney InjuryKidney international supplements (2012) 2(1) 1-138
No funding or conflict of interest to declare
P3NHS Highland-Improving the management of hyperkalaemia using a kit Initial resultsCantley N1 Abedin T2 Lambie S3
1FY2 NHS Highland 2ST4 Renal Medicine NHS Grampian 3Renal Consultant Renal unitRaigmore Hospital Inverness
Introduction The incidence of hyperkalaemia in hospitalised in patients is between 1 and 10 Guidelines in Northern Ireland promote the use of a Hyperkalaemia Kit to improve management of hyperkalaemia We assessed the management of hyperkalaemia in Raigmore Hospital including post-treatment monitoring of serum potassium and blood glucose at baseline and after the introduction of a lsquoHyperkalaemia Kitrsquo which contains a pro forma for the management of hyperkalaemia and all the relevant equipment and drugs for treatment
Method Between July and September 2016 an automated algorithm identified 34 patients with a potassium result 65 mmoll or above on laboratory results 12 received no specific treatment of these 6 results were spurious 4 patients died before treatment could be started and 2 patients were chronic haemodialysis patients We introduced the Hyperkalaemia Kit to the Acute Medical Admissions Unit in Raigmore Hospital Since then 15 patients have been identified with serum potassium measurements above 65 and the pro forma and kit was used with eight of these patients One of these patients proceeded straight to acute renal replacement therapy
Results Prior to our intervention all 22 patients that were actively treated received at least one prescription of appropriate doses of Insulin with Dextrose However only 16 patients received intravenous calcium and only 7 received nebulised Salbutamol Potassium was measured at 4 hours in 5 cases and by 12 hours in 17 cases Monitoring of any capillary blood glucose was only documented in 8 cases Of the 22 treated 2 needed acute renal replacement therapy 3 required further doses of insulin and dextrose 2 were treated with Calcium Resonium
Eight cases of hyperkalaemia have been managed with the use of the kit and pro-forma so far An initial ECG was performed in all eight and four patients had continuous cardiac monitoring Intravenous calcium was given in seven and nebulised Salbutamol was given in five out of the eight cases Six out of eight patients had at least three blood sugar measurements One had two measurements documented and one patient was stopped from further monitoring following senior review and decision to palliate Seven patients had appropriate monitoring of their serum potassium by 4h and 12h again one patient was not monitored due to palliation
Conclusion Baseline results showed very low rates of prescription of nebulised Salbutamol low rates of Calcium Gluconate use and very low monitoring of blood sugars and potassium post treatment This has the potential for serious adverse outcomes particularly the potential for iatrogenic hypoglycaemia Our initial data shows the use of a Hyperkalaemia pro forma and kit improves the rate of prescription of intravenous calcium and nebulised Salbutamol and the post-treatment monitoring of serum potassium and blood sugar levels
P4Rituximab as maintenance therapy in ANCA associated vasculitisndash a single centre experience Rathnamalala NK Mcmenamin J Robertson S Almond A Kelly M Muniraju T M Renal Unit Dumfries and Galloway Royal Infirmary NHS Dumfries and Galloway Background The introduction of Cyclophosphamide and high dose steroids transformed ANCA associate vasculitis (AAV) from a disease of high mortality to a relapsing remitting disease Maintenance of remission however still remains a major challenge A two randomised clinical trials have looked at the use of Rituximab in remission induction in AAV and reported similar remission rates between Cyclophosphamide and Rituximab 12 Both these trials used Azathioprine as maintenance therapy and in the follow up showed similar remission rates with either agent for induction The role of Rituximab for maintenance therapy after cyclophosphamide induction was studied in the MAINRITSAN trial 3 Rituximab was compared with azathioprine and found that the relapse rate was significantly lower in the Rituximab group There have been several other retrospective studies that have suggested regular Rituximab infusions are successful in maintaining remission however has not been thoroughly evaluated 4 5678910 Here we share our centrersquos experience using Rituximab for maintenance of remission of AAV Materials and methods We conducted a retrospective review of electronic medical records of all patients who had received Rituximab as maintenance therapy for 12 months or longer between January 2014 to July 2016 Disease activity was assessed using Birmingham Vasculitis Activity Score ( BVAS) Version 3 and complete remission was defined as a score of 0 and partial remission as a score of lt50 of the value at diagnosis Due to uncertainties associated with sub classification we did not assign specific diagnosis but broadly classified as ANCA associated vasculitis Results 6 patients received Rituximab as maintenance therapy during the study period 3 (50) of them had eye ear nose and upper airway manifestations consistent with Granulomatosis with Polyangitis (GPA) All patients were PR3 ANCA positive except for one at initial diagnosis The mean BVAS score at the time of initiation of Rituximab was 4 All patients were initiated on Rituximab for relapses while on maintenance therapy with Azathioprine 4 patients received 6 monthly doses of Rituximab while two received annual doses All of them were also maintained on 5-10 mg of Prednisolone The mean BVAS score by 6 months was 0 and remained 0 at 12 months The mean PR3 titre was 562 at the initiation of treatment while at 12 months it had come down to 68 All patients remained in complete clinical remission at the end of 12 months after initiation of therapy Rituximab was well tolerated by all patients except one who developed pyrexia during an administration
Conclusions All patients had sustained remission at 6 months and 12 months after initiating Rituximab Rituximab has a potential role as maintenance therapy in AAV
P5 Chronic Myelo-Monocytic Leukaemia (CMML) as a contraindication to renal biopsy Alastair Rankin Emily McQuarrie Jennifer Lees Bruce MacKinnon Glasgow Renal and Transplant Unit On behalf of the Scottish Renal Biopsy Registry
Abstract Chronic Myelo-Monocytic Leukaemia (CMML) is a relatively rare mixed myelodysplastic myeloproliferative disorder that predominately affects patients over the age of 65 years Renal impairment in patients with CMML is well described with several different mechanisms reported including tumour infiltration lysozyme-induced injury amyloid deposition and tubulointerstitial nephritis From anecdotal evidence within our centre we are concerned that patients with CMML have an excessive risk of clinically significant bleeding following native renal biopsy This risk appears disproportionate to the degree of any co-existing thrombocytopenia or coagulopathy
We review the cases of 4 patients with an existing diagnosis of CMML who were referred to the renal clinic with proteinuria and excretory renal dysfunction Two of these patients underwent renal biopsy with subsequent major haemorrhage post-procedure despite normal bleeding parameters pre-procedure Patient 1 presented with flank pain 8 days post-biopsy A CT confirmed peri-nephric haematoma with retroperitoneal extension A total of 6 units of packed red cells (PRCs) were transfused prior to successful CT-guided emoblisation Histology from the biopsy revealed chronic tubulointerstitial nephritis Patient 2 experienced haemodynamic instability and haematuria one hour post-biopsy A total of 11 units of PRCs 7 units of fresh frozen plasma 2 pools of platelets intravenous tranexamic acid and 2 attempts at CT-guided embolization were required until haemostasis was achieved Histology later showed evidence of tumour infiltration with associated vasculitis Patient 3 presented with renal impairment and proteinuria on the background of known CMML Following discussion with haematology the risk of bleeding following renal biopsy was considered unjustifiable despite their platelets and coagulation screen being within normal range The patient was treated for presumed renal tumour infiltration with hydroxycarbamide Patient 4 was referred to the renal clinic with acute onset nephrotic syndrome Urinary proteincreatinine ratio was elevated over 800 mgmmol with serum albumin of 23 gL but normal excretory renal function The patient attends the haematology clinic with suspected CMML and chronic thrombocytopenia but previously declined bone marrow biopsy Following discussion with the patient there are no plans to proceed with renal biopsy given potential risks These cases highlight that while CMML is rare these patients are being referred to renal clinics with features that would commonly justify renal biopsy in other settings but in whom there may be an increased risk of bleeding post-procedure Our in-centre risk of major bleeding is 2 therefore to have such extreme amounts of bleeding in 2 patients with this underlying diagnosis is remarkable This creates a dilemma for the clinician as there is a wide range of potential renal pathology associated with CMML some of which will have disease specific but relatively toxic treatments available
Source of funding none Conflicts of interest none
P6 NHS Highland-Prograf to Adoport switch McCulloch K1 Peel R2 Lambie S3
1Renal Pharmacist Renal unit Raigmore Hospital Inverness 23Renal Consultant Renal unit Raigmore Hospital Inverness
Introduction NHS Highland (NHSH) is the first health board in Scotland to implement a switch from Prograf to Adoport for renal transplant patients This will provide considerable cost savings Adoport meets the bioequivalence criteria for drugs with a narrow therapeutic index set by the European Medicines agency and studies indicate therapeutic equivalence1 with the proviso that brands are non- interchangeable unless the switch is overseen by a Renal Consultant and post-conversion therapeutic drug monitoring is conducted23 The switch has been undertaken by a majority of transplant centres in England the main difference being that they have undergone repatriation NHSH Patients receive their transplant primarily at Royal Infirmary of Edinburgh and occasionally at Queen Elizabeth University Hospital Glasgow Care is transferred to NHS Highland on discharge NHS Highland cares for approximately 170 renal transplant patients 110 being prescribed Prograf These patients may live as far as 110 miles from Raigmore Hospital Given that prescribing is carried out by primary care clear communication with patients GPs and community pharmacy is essential to avoid inadvertent switching between brands
Method Clinically it was agreed a switch could be safely undertaken A business case was submitted and funding secured for pharmacist time laboratory costs and primary care time GPs have been informed via GP subgroup and local prescribing bulletin lsquoThe Pink Onersquo Community pharmacies are being informed by phone A protocol has been agreed Eligible patients selected by Renal Consultant and Renal Pharmacist Patients sent letter signed by Renal Consultant and Renal pharmacist Patients phoned prior to clinic to agree Adoport start date and address concerns Patient seen by Renal Consultant and pharmacist + given 1 month of Adoport Tacrolimus level and UampEs checked 5-7 days after commencing Adoport and patient
contacted by phone to check if tolerated If stable letter sent to GP and community pharmacy to continue supply
Results and Evaluation Letters have been sent to all eligible patients Seven patients have been reviewed One has received a one month supply of Adoport and 5 others are due to switch One patient was deemed non-eligible at present as they have a 6 month surplus of Prograf A database will be maintained and analysed at the end and primary care savings will be monitored Extra pharmacist input will give us the opportunity to review how immunosuppression is managed and to evaluate the benefit of having a renal transplant pharmacist Conclusion The switch is at an early stage Ultimately we hope to show that the switch from Prograf to Adoport can be managed safely with extra pharmacist input to a remote and rural population with prescribing being conducted by primary care
Fundingconflicts of interest none 1 McDevitt-Potter LM Sadaka B Tichy EM Rogers CC Gabardi S Transplantation 2011 A multicenter experience with
generic tacrolimus conversion 2 Medicines and Health Products Regulatory Agency Drug Safety Update 2012 Accessed online via
wwwmhragovukSafetyinformationDrugSafetyUpdateCON1557563 ESPRIT Guidance on management of repatriation and immunosuppressant switches in transplant patients 2015
Accessed online via httpwwwespritorgukwp-contentuploads201508Switch-guidance-document-final-Aug-31-2015pdf
P7 NHS Highland-Tacrolimus baseline dataMcCulloch K1 Peel R2 Lambie S3
1Renal Pharmacist Renal unit Raigmore Hospital Inverness 2Renal Consultant Renal unitRaigmore Hospital Inverness 3Renal Consultant Renal unit Raigmore Hospital Inverness
BackgroundAs part of planning a switch from using tacrolimus Prograf to Adoport we assessed baseline data for our transplant patients currently using Prograf After converting patients to Adoport we will compare their tacrolimus levels to their individual target range We assessed our use of appropriate target ranges and our current performance in achieving tacrolimus levels within target range on Prograf therapy
Method 107 renal transplant patients taking Prograf were identified a sample of 19 of these were analysed using electronic patient records and results Time from transplant ranged from 1 month to 18 years All tacrolimus levels for the preceding year were analysed and compared to the target range specified at the time of the level being done The assay used has a Coefficient of Variation of lt5 at the lower limit of the assay
Results All 19 patients had a target range for tacrolimus clearly identified and recorded in clinic letterswhich are routinely copied to the patients themselves A variety of target ranges were specifiedThe commonest used was 5-8 microgramsl in 7 patients followed by 5-7 in a further 4 patientswith another 6 different target ranges being used for the remaining 8 patients The ranges usedhad a breadth of 3 microgramsl in 2 cases the rest had a breadth of 2 microgramslPatients had a median of 12 (range 3-72) tacrolimus levels over the preceding year Results werewithin specified target ranges for 54 +- 22 (Medan +- SD) of results checked
Conclusion We currently use a large number of different target ranges The majority of the ranges used had a breadth of just 2 microgramsl These factors help to account for the low proportion of test results which were within the specified target ranges This is important to bear in mind when interpreting whether tacrolimus levels are within target ranges after switching to Adoport We should consider aligning our target ranges and widening them
P8 Eculizumab use in Scottish paediatric dense deposit disease Stewart D1 David Hughes1 Lynne Riach2 Craig Oxley2 Athavale D1
1Royal Hospital for Children Glasgow 2Royal Aberdeen Childrenrsquos Hospital Aberdeen
Introduction The revised MPGN classification and increasing recognition of Dense Deposit Disease (DDD) a C3 glomerulopathy as an alternative complement pathway disorder suggests Eculizumab an anti-C5 monoclonal antibody may be beneficial in treatment However the experience of Eculizumab as an off-label and expensive treatment in children with DDD is limited with variable clinical response reported in the literature
Method We present the outcomes of the only 2 paediatric patients in Scotland who have received Eculizumab for the management of DDD
Results Case 1 A 10 year old male presented with proteinuria and haematuria resistant to steroid treatment with preserved renal function Initial biopsy confirmed DDD Conservative management with an angiotensin converting enzyme inhibitor and diuretics for symptom control continued until 14 years Due to worsening symptoms (oedema lethargy poor growth) and renal function deterioration along with elevated terminal complement complex (TCC) Eculizumab was commenced A repeat biopsy whilst suggestive of chronic irreversible damage showed 25 glomerular architecture preservation Symptom improvement was noted There was a reduction in proteinuria and renal function stabilisation fall in TCC and discontinuation of diuretics Eculizumab was discontinued after 24 months Progression of renal function decline was seen in the final months of Eculizumab therapy With recurrence of symptoms and increasing proteinuria following discontinuation Eculizumab was recommenced after 6 months Symptomatic improvement has since been noted
Case 2 A 5 year old girl presented with painless frank haematuria and proteinuria Initial biopsy confirmed DDD Proteinuria was unresponsive to steroid therapy and 5 months following diagnosis she rapidly progressed towards end stage renal disease despite the introduction of Mycophenolate Mofetil and plasmapheresis Haemodialysis was subsequently commenced TCC level was elevated and Eculizumab treatment was started 7 months after diagnosis Renal biopsy prior to treatment demonstrated continued severe pathological changes in all visible glomeruli However due to lack of clinical response Eculizumab was discontinued after 2 months and the patient remained dialysis dependent
Conclusions Our experience with Eculizumab in Scotland has demonstrated variable results in our 2 patients with one patient showing a positive response whilst the other experienced no improvement Eculizumab was administered to both patients at varying points in their clinical journey with differing progressive features on biopsy To date the outcomes of 9 paediatric patients with DDD treated with Eculizumab have been described in the literature with 8 experiencing some positive response to treatment including 2 patients who were able to stop renal replacement therapy within 12 weeks of treatment A role for Eculizumab in DDD may be guided by clinical and pathological features Well designed clinical trials will be necessary to define the role of complement inhibition therapy in DDD
No conflict of interest and no funding requested
P9 Examining markers of safety in the use of non-tunnelled central venous catheters
James WT Millar (Speciality Registrar) Scott W Oliver (Speciality Registrar) Peter C Thomson (Consultant Nephrologist) Glasgow Renal and Transplant Unit Queen Elizabeth University Hospital Glasgow
Background Non-tunnelled central venous catheters (NTCVC) remain an essential means of vascular access for incident haemodialysis Associated morbidity is well recognised for example in the form of Staphylococcus aureus bloodstream infections (SAB)[1]
Previous quality improvement initiatives in our unit have sought to both improve traditional markers of quality (such as SAB) and to identify additional areas of clinical risk In 2014 Oliver et al [2] suggested several additional quality measures including peri-procedure haemoglobin drop the need for a further NTCVC during the same clinical episode and the NTCVC insertion site This study further evaluated NTCVC related clinical practice within our unit
Methods The potential markers of clinical quality identified in a previous project were examined using prospectively collected data stored in the electronic patient record Identified cases of SAB significant peri-procedure haemoglobin drop and multiple NTCVC insertion were investigated by case note review
Results Between March 2016 and March 2017 a total of 222 patients received 346 NTCVC 54 patients (243) had more than one NTCVC inserted in a 21-day period (range 2-5) When considering NTCVC insertion site there were 159 (459) femoral vein catheters and 183 (541) internal jugular vein catheters No pneumothoraces were reported
15 SABrsquos were reported during this period equating to 43 of all NTCVC 5 arose in patients with femoral NTCVC (333) and 10 from internal jugular catheters (667) Mean time from line insertion to positive blood culture was 86 days 15 (67) patients had a drop in haemoglobin of greater than 20mgdl with no other source of blood loss identified on review of clinical notes
Discussion These data demonstrate that NTCVC-associated SAB rates remain low and significantly below Scottish government audit standards [3] Of interest is the continued trend towards the use of femoral catheters at 45 of lines compared with 38 in 2014 [2] Although traditionally thought of as having a higher incidence of infectious complications our data has shown fewer bacteraemia events associated with femoral catheters compared with internal jugular Our data also demonstrates a significant rate of peri-procedure haemorrhage arising in up to 1 in 20 cases Together these findings present opportunities to development practice and improve patient safety
References
[1] Murray E Deighan C Geddes CC Thomson PC Reducing haemodialysis bacteraemia rates Scottish Renal Association Glasgow November 2013 [2] Oliver SW Thomson PC Jardine AG defining safe effective and patient-centred dialysis catheter placement Scottish Renal Association Edinburgh September 2014 [3] The Staphylococcus aureus bacteraemia quarterly report of cumulative data from all NHS Boards in Scotland Health Protection Scotland January 2015
Sources of funding none Conflicts of interest none
P10 Prescribing of tolvaptan-The NHS Highland experience Lambie S1 McCulloch K2 Garrod J3
1Renal Consultant Renal unit Raigmore Hospital Inverness 2Renal Pharmacist Renal unit Raigmore Hospital Inverness 3Renal Pharmacist Renal unit Raigmore Hospital Inverness
Introduction Tolvaptan is a vasopressin antagonist It was accepted for use in Scotland by SMC in Jan 2016 to slow the progression of cyst development and renal insufficiency of autosomal dominant polycystic kidney disease in adults with chronic kidney disease (CKD) stage 1 to 3 at initiation of treatment with evidence of rapidly progressing disease1 Adverse effects related to aquaresis may affect patientsrsquo ability to achieve the optimum therapeutic dose and the risk of hepatic toxicity necessitates regular LFT monitoring The geography of NHS Highland required the implementation of novel methods of managing these patients and as a result a MDT approach with an emphasis on pharmacist input was adopted Consultant role Patient selection on the basis of evidence of rapidly progressing kidney disease declining
eGFR large volume kidneys on ultrasound and evidence of complications of PKD Side effects and potential benefits discussed Potential medication interactions reviewed Jinarc risk management prescriber training
Pharmacist role Undertook Jinarc risk management pharmacist training Prepares accurate drug history and reviews for potential drug interactions Carries out patient counselling and supplies patient education material sick day rules card
and lsquogot to gorsquo card Supplies GP education leaflet Provides advice on selection of new drug therapies eg for gout Manages stock and coordinates supply to patients
Results Prescribing commenced May 2016 patients currently prescribed tolvaptan 11 7 Female 4 male Number on target dose 73 n = 811 2 patients are still being titrated One patient did
not tolerate target dose due to aquaresis side effects and is being trialled on the middle dose
Withdrawals One patient has withdrawn due to agoraphobia and an inability to attend for monitoring and another is on hold due to having major surgery
Conclusion The MDT approach between the Renal Consultant and Pharmacist at Raigmore Hospital has enabled tolvaptan prescribing to be efficiently and safely implemented to patients living within a challenging geographical location
1 Scottish Medicines Consortium Detailed Advice Document tolvaptan 15mg 30mg 45mg 60mg and 90mg tablets (Jinarcreg) SMC No 111415 January 2016
NA1 Authors SCN Jacqueline Ross NHS Grampian
SCN Alan Somerville NHS Lanarkshire SCN Jane Humphrey NHS Lanarkshire
e- mail contact jacquelinerossnhsnet Alansommervillelanarkshirescotnhsuk
Janehumphreylanarkshirescotnhsuk
Phone contact 01224 552927 01236 712644
Title Sharing of Adverse Events in Renal Units across Scotland
Introduction Background The Scottish Renal Nurses Strategy Group (SRNSG) are a group of senior nurses from Renal
Units across Scotland who meet 3-4 times per year to discuss and implement best practice At the last meeting it was agreed that it would be good practice for each Health Board to share
their adverse events reported on the Datix System and deliver a presentation with an action plan to prevent incidents and improve patient safety across Scotland NHS Grampian and NHS Lanarkshire will be the first to deliver this presentation discussing adverse events from both Health Boards with an action plan
Top 5 adverse events over the past 12 months Renal Unit NHS Grampian 1 Violence and Aggression 2 Accidents including needlesticks slips trips and falls 3 Medication Errors 4 Infrastructure Staffing and Estates 5 Machines and Equipment
Top 5 adverse events over past 12 months Renal Unit NHS Lanarkshire
1 Slips Trips or Falls 2 Medicine errors 3 Treatment problems 4 Transfer problems 5 Breach of policy
The presentation will also focus on any serious adverse events which may not be in the top 5 categories
Aim Objective Each Health Board to share their adverse events with the aim to prevent them from occurring in other units to improve staff and patient safety and wellbeing across Scotland
Method Power Point Presentation
Outcome Results Sharing of adverse events resulting in the development of a national Action Plan to prevent these incidents improving safety and well being of staff and patients in Renal Units across Scotland
NA2
SRA Oct 2017 Abstract
BBV Never Event - The whats whys and hows
Staff Nurse Gillian Wilson Aberdeen Royal Infirmary
This presentation shares our experience of a never event that occurred and was not picked up for
a period of 18 months
Hepatitis C (HCV) positive antibodies were found in a previously negative patient
These results were a low positive with no biochemistry changes to suggest any liver damage
however steps were put immediately in place to isolate and investigate
Was it contamination from a dialysis machine was it related to a blood transfusion given prior to
first positive result was it faulty diagnostic tests in the laboratory
In Aberdeen we go over and above national guidelines and isolate all our BBV patients whether
they have positive blood results or are PCR negative
Further bloods tested at an external laboratory confirmed negative results
It highlighted that communication errors were to blame for the lack of speed in detecting this issue
Investigations concluded no real answers as to why this happened
NA3
Living Donation Scotland Changing attitudes towards living donor kidney transplantation
Jen Lumsdaine Julie Glen On behalf of the Living Donation Scotland Project Board
Background and aims
The rate of living donor transplantation has remained fairly static in Scotland over the past 10 years
Recent data has shown inequity of access to living donor transplantation throughout the UK so
there is potential to significantly increase this optimum form of treatment for patients with end-stage
renal failure in Scotland The Living Donation Project Board was formed in 2016 aiming to double
the number of living donor transplants by 2020
Method
The two key areas
1 Do recipients receive adequate and appropriate information at the right time about living
kidney donation
2 Informing the general public about altruistic donation
All patients active on the transplant list in Scotland were invited to an information event A follow-up
questionnaire was performed in the East of Scotland examining outcome or reasons for not
attending A scoping exercise looked at information provided by each unit was performed and link
nephrologists and low clearance nurses attended meeting to discuss strategies for early education
Outcome
An information pack containing both recipient and donor written information and short films on DVD
has been produced with the support of the Scottish Government for all recipients and potential
donors in Scotland A new website with comprehensive information both written and visual and
postcode finder to improve ease of access to local unit contact details has been developed
Two national media campaigns have been launched with a significant rise in the number of enquiries
from potential donors and actual increase in altruistic donor numbers
Nursing abstract ndash no conflict of interest
NA4Authors Susan Easson Charge Nurse Ward 4C QEUH Glasgow
e- mail contact SusanEassonggcscotnhsuk
Phone contact 0141 452 3300
Title A Conversational approach to find out ldquoWhat matters to yourdquo in a Renal Transplant ward
Introduction Background Finding out ldquo What Mattersrdquo to people using health and careservices is crucial to delivering safe effective and person centred care It is a simple yet profoundconcept and tries to get to the essence of person centred care by creating deeply personalengagements with patients and their families through a conversational approach However careexperience feedback all too often provides innumerable examples of where what really matters topatients and their family members is poorly understood or not addressed Using care experienceas the driver for change the nursing staff in Ward 4C used improvement approaches to explorehow to hold more meaningful ldquoWhat Matters to yourdquo conversations on a daily basis
Aim Objective To improve the patient experience by utilising a person centred approach
Method Using Care experience feedback What Matters to Me boards and the conversationalapproach
Outcome Results Improvements in patient experience will be shared using examples ofpractice and care experience feedback
There was no additional funding required for this project We worked in collaboration with theperson centred team whorsquos aim is to improve patient experience
NA5
The implementation of a renal education programme and its impact on clinical practice
The purpose was to implement a Renal Education Programme and to evaluate its impact on
clinical practise
It was identified that there was a need for an educational programme to be set up within Forth
Valley Royal Hospital There is no inpatient renal unit in FVRH on site for our renal patients they
attend Queen Elizabeth University Hospital We are an outpatient haemodialysis unit with
outpatient clinics on site Therefore it was identified that there was a need for nursing staff within
FVRH to be educated on all renal complexities for the benefit of our patients
This was done through a work-based learning approach which brought tangible benefits for our
patients However it did not come without pitfalls as educational programmes are often seen as
making very little difference to clinical practise
T
his study describes what methods were used and examines the advantages and disadvantages in
setting up an educational programme and evaluating its impact on clinical practise
NA6
Nursing Abstract ndash SRA Meeting ndash 26 October 2017
Chris McGee Tonya Broe Ken Weir
Renal Unit Forth Valley Royal Hospital
Use of the Therapy Monitor Haemodialysis Patient Record System Can we aim for a paper-
free dialysis unit
We are trialling a new haemodialysis patient monitoring system to work in conjunction with SERPR
and which is intended to supersede the Finesse system used previously
We are in the early stages of this process but with continuing staff education and regular tech
support we are hoping to gather sufficient evidence to evaluate whether the use of paper case
notes needs to continue
Is it a realistic goal to aim for a completely paper-free unit
NA7
THE CLINICAL USES OF APHERESIS WITHIN NHS TAYSIDE
Laura Thomson CN
Ninewells Hospital Dundee
NHS Tayside took over the apheresis service from BTS in 2012 The service has since expanded
with the benefits of carrying out this treatment has been widely recognised within NHS Tayside
and is now more commonly being offered to treat a wider range of conditions with the number of
treatments carried out each year rising
This presentation will highlight the progression of the apheresis service within NHS Tayside We
will identify the various conditions it is currently being used to treat and also identify the decision
making process involved in carrying out these treatments ie which replacement fluid will be used
anticoagulation medication administered
We will highlight the benefits and challenges we face in providing this expanding service within the
Renal Service
NA8Authors Linda McDougall Renal Physiotherapist NHS Highland
e- mail contact lindamcdougall1nhsnet
Phone contact 01463 706022
Title lsquoExercise on Haemodialysis- Keeping the Wheels in Motionrsquo
Introduction Background The impact of CKD on physical fitness functional ability independence amp ultimately quality of life cannot be underestimated Current national guidelines recommend that all individuals with CKD are encouraged to participate in regular exercise programmes between or during dialysis sessions if on HD Following a successful pilot study funding was approved to establish an lsquoExercise on Dialysisrsquo (EOD) programme across NHS Highland through the appointment of a dedicated renal physiotherapist in 2008 A successful programme was soon established but for several years post-vacancies and increasing in-patient demands limited the physiotherapy servicersquos ability to deliver the programme The need to improve the long-term sustainability of the service was recognised and in late 2016 funding was approved to develop a Band 4 PT HCSW role for this purpose
Aim ObjectiveTo optimise the sustainability and continuity of the lsquoExercise on Dialysisrsquo service across NHSHighland through development of a Band 4 PT HCSW role
Method The potential parameters of the role and limits of autonomy were scoped out using current NES resources and guidelines Service and task analysis was then carried out to establish which components of the EOD protocol could be undertaken by a Band 4 A series of competencies were developed in line with the clinical protocol and one-to-one training and supervision provided to the post-holder to ensure competency achieved in delivering the programme
Outcome Results A 10 WTE Band 4 PT HCSW was appointed in Jan 2017 with a dual role between the renal unit and acute medical wards Although training is not yet complete the post-holder is already running the day-to-day delivery and monthly audit of the EOD service with senior physiotherapist input only required for individual patient safety queries and general discussion around patientsrsquo progress and goals The benefit to the unit has been considerable as the band 4 is available to support patients and staff with EOD provision 5 days a week This allows for one-to-one supervision of patients who need more support to participate in EOD regular feedback on performance and reviews of outcome measures and goals to maintain motivation levels Feedback on the post has been very positive and its scope will only continue to expand as we look to further develop renal rehabilitation services across NHS Highland
NA9Authors Nadine Lyall and Kerry Guthrie
e- mail contact nadinelyallbordersscotnhsuk kerryguthriebordersscotnhsuk
Phone contact 01896 826637
Title The Developing Role of the NMP in a Satellite Dialysis Unit
Introduction Background
We have been practising as NMPrsquos for nearly 3 years working in the dialysis unit at the BGH The unit is a satellite unit of the ERI and we have expanded over the last 6 years The unit provides haemodialysis for 12 patients at any one time 3 sessions a day 6 days a week We are nurse-led and have 2 renal consultants who are based at the ERI
We saw an opportunity to use our knowledge and experience to develop our role By becoming NMPrsquos we have enhanced our professional development and we feel we meet the changing needs of the dialysis patient in a more holistic manner
Aim Objective
Our aim is to deliver effective care as we are better placed to deal with issues that often arise byacting swiftly this in turn is cost effective and convenient For example good anaemia and bonemanagement is important for their health wellbeing and lifespanTo help understand our role we will use a power point presentation highlighting issues we dealwith and the drugs we prescribe under the following headings Cardiovascular infection painanticoagulant disequilibrium diet renal bone disease and renal anaemia
Method Power point
Outcome Results
In the future we hope to further develop and have greater autonomy in our role We have great support from our renal consultants and have already built up a great relationship with our patients We hope to undertake the Clinical Decision Making course and this in turn will allow us to deal effectively with acute illness giving the dialysis patient better care We are keen to get feedback from other renal nurses in Scotland to enable us to develop our role further and in turn raise awareness of the NMP role in a dialysis unit We record all our prescribing decisions and keep the consultants up to date regularly Currently we are working on auditing our prescribing practice so that we can improve the service we can provide
NA10 Title Komunikacja w szkoleniu dializy ortzewnowej
Author Senior Charge Nurse Rhoda Bell
Address Raigmore Hospital Old Perth Road Inverness IV2 3UJ
Email rhodabellnhsnet Telephone 01463706023
Introduction Background Case study on lady with Polish as her first language she has some English but requires an interpreter to carry out Peritoneal Dialysis training and attend clinic She had some gynaecological issues that we were not aware of which impacted on the functionality of PD and therefore the success of treatment There were areas of concern in low clearance clinic with signs the patient had a reluctance to engage in decision making
AimObjective
Methods Discussion through the case study highlighted issues with communication between different PD staff and patients Areas of concern include different staffing techniques environment factors on training success Also language and communication issues the patient had were not fully apparent so training could not be individualised
Results We plan to trial training at home and have more individualised training schedule for patients The training step by step guides have been reviewed and practise standardised In collaboration with low clearance nurse we have developed a check list which will highlight concerns before the transition to PD ie language issues and need for training aids in another language gynaecological conditions
Conclusions Everyone learns differently and training methodsaids must be individualised for all It may not be apparent until training has commenced that there are concerns Having one to one training with the same nurse will consolidate training and build confidence in the patient Having a close working relationship with members of the MDT will help make a supportive PD journey
Would we do things differently if we knew about prolapse or lack of English both spoken and written
Key words - Peritoneal dialysis patient training communication
N11
Telehealth amp PDAudrey Jones
Advantages
Information on a daily basis about treatment weight and blood pressure
Change programme remotely via computer or mobile
Earlier intervention for machineprogramme issues
Reduction in home visits ie patient trained but still requires volume increases
No need to download cards to see what problems have been
Can have more detailed information available at clinics
Disadvantages
Relying on patient input data correctly
Machine is noisy especially first wave of machine
Still the same bag connection system and patient connection system (difficult for manual
dexterity problems)
Relying on patient having good signal
Modem problems
NA12Autosomal Dominant Polycystic Kidney Disease A cruel inheritance but new hopeAlistair Lawrie Renal Unit Victoria Hospital KirkcaldySadaf Arshad Corry Dunnigan Paul Phelan Neil Turner Renal Unit Royal Infirmary of Edinburgh
Background Autosomal Dominant Polycystic Kidney Disease (ADPKD) is the most prevalent single gene human genetic disorder and the most common of the inherited cystic and interstitial kidney diseases It is estimated to affect 1 in every 1000 individuals worldwide with over 50 of sufferers eventually developing end stage kidney disease and requiring dialysis or transplantation Symptoms include spasmodic severe pain hypertension haematuria infection and kidney failure There is currently no cure for ADPKD Management of the condition has traditionally involved lifestyle modification BP control and analgesia however a recent study (Torres et al 2012) demonstrated that treatment with V2-receptor antagonist drugs slowed increase in total kidney volume reduced the rate of functional decline and showed a reduced incidence of kidney pain
Aim Provision of a tolvaptan prescribing and monitoring service
Methods Experiential finding report of initial twelve months period of multidisciplinary ADPKDtolvaptan clinic
Results Early results are comparable with TEMPO study outcomes
Conclusion Due to the long term nature of this treatment results available at this time are showing only the earliest benefits of the intervention More quantifiable results such as increased time before the necessity for RRT will only be evident in coming years Torres VE et al (2012) Tolvaptan in Patients with Autosomal Dominant Polycystic Kidney Disease New England Journal of Medicine 367 pp 2407-2418 DOI 101056NEJMoa1205311
No funding requirement No conflict of interest
A21 Pathological classification of IgA nephropathy to predict renal outcomes ndash is there a better way to score tubulointerstitial inflammation
Alastair Rankin David Kipgen Bruce Mackinnon Jonathan Fox Colin Geddes Emily McQuarrie Glasgow Renal and Transplant Unit On behalf of the Scottish Renal Biopsy Registry
Background The Oxford pathological classification of IgA nephropathy (IgAN MEST-C score) is limited by the fact that individual features of the score are not all predictive and its utility in assisting clinical decision-making is questioned The addition of tubulointerstitial inflammation to the existing scoring system is appealing but is not currently included due to reportedly wide inter-observer variability We report a novel method to score percentage of cortex containing tubulo-interstitial inflammation in non-atrophic renal cortex (ATIN) in patients with IgAN similar to that used in transplant biopsy reporting and assess its utility to predict clinical outcomes
Methods All adult patients with a native renal biopsy diagnosis of IgAN between 2010 and 2015 in a unit serving 15 million people were identified Baseline characteristics biopsy reports and outcome data were collected ATIN was calculated by subtracting the percentage of atrophic cortex from the percentage of total cortex with tubulo-interstitial inflammation withge10 representing significant tubulo-interstitial inflammation in non-atrophic cortex The primary outcome was a composite of requiring renal replacement therapy (RRT) or doubling of serum creatinine (sCr)
Results 153 new cases of IgAN were identified 33 were excluded (24 had lt8 glomeruli on biopsy 6 inadequate biopsy for MEST scoring and 3 on RRT at time of biopsy) In addition patients with a tubular atrophy (T) score of 2 were also excluded (n=9) Of the remaining 111 patients 76 (68) were male Mean age at biopsy was 52 years (+- 167) and 18 (16) had a co-existing clinical diagnosis of henoch-schonlein purpura (HSP) Median sCr was 156 micromoll (IQR 101-212) and 54 (49) had ATIN on biopsy During a median follow-up of 23 years 34 (31) reached the primary outcome 20 (18) received immunosuppression and 16 (14) died On univariate Cox regression survival analysis ATIN was associated with a four-fold increase in the primary outcome (HR 49 (21-113)) On multivariate analysis mesangial hypercellularity (M) T and ATIN independently predicted renal outcome while endocapillary proliferation (E) and segmental sclerosis (S) did not (plt002 for ATIN) Excluding patients with HSP or those who received immunosuppression did not change the result
Conclusion Within our centre ATIN predicts renal outcome for IgAN independently of established histological features Assessment of inter-observer reproducibility and validation in other cohorts is still required but these results suggest ATIN could be a worthwhile addition to current pathological scoring systems for IgAN
Source of funding none Conflicts of interest none
P1 Polypharmacy in Renal Replacement Therapy Patients
Jason McMinn Colin Geddes Glasgow Renal and Transplant Unit Queen Elizabeth University Hospital
Introduction
Prescribing is often led by evidence from studies containing participants with single health conditions and without multimorbidity Polypharmacy is becoming increasingly recognised in patients with multiple chronic health conditions Additional medications are more likely to result in diminishing returns in benefit with an increased risk of harm Patients with established renal failure (ERF) are likely to be susceptible to medication-related harm A high pill burden is also likely to contribute adversely to an already restricted quality of life and has been associated with poor medication adherence The aim of this study was to analyse polypharmacy in all patients with ERF attending our service
Methods
We extracted medication records for all prevalent ERF patients attending the Glasgow Renal and Transplant Unit from the West of Scotland Electronic Renal Patient Record (SERPR) as of 01012017 The records were analysed to calculate the number of regular medications and total pill burden of each patient These medications were categorised as being lsquopreventativersquo or lsquosymptomaticrsquo We also analysed the prescription of specific drug classes to examine the prevalence of these medications
Results
We identified 1091 transplant follow-up 529 hospital haemodialysis and 46 peritoneal dialysis patients who were on a mean of 94 13 and 129 different medications respectively Overall pill burden was 139 tablets a day in transplant follow-up patients 141 in haemodialysis patients and 162 in peritoneal dialysis patients There were similar rates of prescribing between the different dialysis units and clinics within our service
The proportions of medications deemed as preventative rather than symptomatic were 76 in transplant 69 in haemodialysis and 60 in peritoneal dialysis
In transplant patients decreasing renal function was associated with a higher pill burden but even patients with a transplant eGFR gt 60 were on a mean of 126 tablets per day including a mean of 14 antihypertensives
Rates of antidepressant prescribing were 15 in transplant patients and 20 in hospital haemodialysis patients 53 of haemodialysis patients were on a statin 39 on aspirin 61 on a proton pump inhibitor and 7 were on warfarin
Conclusion
Patients undergoing all forms of renal replacement therapy are likely to be on a considerable number of medications Whilst these drugs are inevitably prescribed for valid reasons this data demonstrates the need for clinicians to engage with patients to explore opportunities to reduce pill burden
Conflict of Interest None Sources of Funding None
P2 An audit of Acute Kidney Injury (AKI) on an acute stroke ward before and after plannedinterventions to review and maintain hydration
Clare Harris1 Simon Hart2 Fiona Duthie3 1 University of Edinburgh Medical School 2 Stroke Unit Royal Infirmary of Edinburgh 3 Renal Unit Royal Infirmary of Edinburgh
Background Dehydration is an important factor in the development of acute kidney injury which is associated with increased morbidity and mortality particularly in the elderly population Poor fluid intake is common post stroke (1) and dehydration is associated with poorer outcomes 3 months post stroke (2) In late 2014 there was no system of identifying patients with poor oral intake on the stroke ward at the Royal Infirmary of Edinburgh a hydration protocol and education programme were implemented aiming to improve fluid balance This included the use of prescribed water either orally or by nasogastric tube An audit pre and post intervention demonstrated that hydration as measured by ureacreatinine ratio significantly improved after the protocol introduction (3) We aimed to determine whether the incidence of AKI by KDIGO criteria was also reduced as this could have implications for reducing patient morbidity and mortality in this elderly comorbid patient cohort
Method 150 inpatients to the acute stroke ward during JulAug 2014 and JulAug 2015 were selected (n= 80 2014 n=70 2015) Patient data and creatinine values were collected from the electronic patient record and medical notes and retrospectively analysed Baseline creatinine values were calculated and cases of AKI were identified and staged using KDIGO criteria (4) Chi-Squared tests were performed to determine P values Individual patient notes were reviewed for both quantitative and qualitative data of patient management
Results Incidence of AKI (of any stage) was 263 pre-protocol and 200 post-protocol (P=03646) Incidence of AKI stages 23 was 100 pre-protocol and 715 post-protocol (P=05374) In hospital post stroke mortality was 338 pre-protocol and 1286 post protocol (P=00028) AKI was also associated with increased length of stay
Conclusions Despite a trend in benefit there was no significant difference in incidence of AKI pre and post hydration protocol nor in incidence of severe AKI (stage 23) AKI is influenced by many factors one of which is hydration status Further studies are needed to determine whether the trend of benefit exhibited in this sample is significant in a greater sample size if this were the case such a protocol could have great benefit to patient care on stroke units and elsewhere There was a significant difference in inpatient post stroke mortality following introduction of the hydration protocol Further investigations are needed to explain underlying reasons for this factors other than hydration may play an important role
References 1 Whelan K Inadequate fluid intakes in dysphagic acute stroke Clinical Nutrition (2001) 20(5)
423-428 2 Bhalla A Sankaralingam S Dundas R Swaminathan R Wolfe CDA Rudd AG The influence of
raised plasma osmolality on clinical outcome after acute stroke Stroke (2000) 312043ndash2048 3 Hart SR Craig R Berry E Lane N Gad A Farrugia M Burton L Paquay A What Happens to
Acute Stroke Patientsrsquo Fluid Balance Renal Status and Dehydration in the First Two Weeks How Can They Be Markedly Improved doi 101111ijs12634_13
4 KDIGO Clinical Practice Guideline for Acute Kidney InjuryKidney international supplements (2012) 2(1) 1-138
No funding or conflict of interest to declare
P3NHS Highland-Improving the management of hyperkalaemia using a kit Initial resultsCantley N1 Abedin T2 Lambie S3
1FY2 NHS Highland 2ST4 Renal Medicine NHS Grampian 3Renal Consultant Renal unitRaigmore Hospital Inverness
Introduction The incidence of hyperkalaemia in hospitalised in patients is between 1 and 10 Guidelines in Northern Ireland promote the use of a Hyperkalaemia Kit to improve management of hyperkalaemia We assessed the management of hyperkalaemia in Raigmore Hospital including post-treatment monitoring of serum potassium and blood glucose at baseline and after the introduction of a lsquoHyperkalaemia Kitrsquo which contains a pro forma for the management of hyperkalaemia and all the relevant equipment and drugs for treatment
Method Between July and September 2016 an automated algorithm identified 34 patients with a potassium result 65 mmoll or above on laboratory results 12 received no specific treatment of these 6 results were spurious 4 patients died before treatment could be started and 2 patients were chronic haemodialysis patients We introduced the Hyperkalaemia Kit to the Acute Medical Admissions Unit in Raigmore Hospital Since then 15 patients have been identified with serum potassium measurements above 65 and the pro forma and kit was used with eight of these patients One of these patients proceeded straight to acute renal replacement therapy
Results Prior to our intervention all 22 patients that were actively treated received at least one prescription of appropriate doses of Insulin with Dextrose However only 16 patients received intravenous calcium and only 7 received nebulised Salbutamol Potassium was measured at 4 hours in 5 cases and by 12 hours in 17 cases Monitoring of any capillary blood glucose was only documented in 8 cases Of the 22 treated 2 needed acute renal replacement therapy 3 required further doses of insulin and dextrose 2 were treated with Calcium Resonium
Eight cases of hyperkalaemia have been managed with the use of the kit and pro-forma so far An initial ECG was performed in all eight and four patients had continuous cardiac monitoring Intravenous calcium was given in seven and nebulised Salbutamol was given in five out of the eight cases Six out of eight patients had at least three blood sugar measurements One had two measurements documented and one patient was stopped from further monitoring following senior review and decision to palliate Seven patients had appropriate monitoring of their serum potassium by 4h and 12h again one patient was not monitored due to palliation
Conclusion Baseline results showed very low rates of prescription of nebulised Salbutamol low rates of Calcium Gluconate use and very low monitoring of blood sugars and potassium post treatment This has the potential for serious adverse outcomes particularly the potential for iatrogenic hypoglycaemia Our initial data shows the use of a Hyperkalaemia pro forma and kit improves the rate of prescription of intravenous calcium and nebulised Salbutamol and the post-treatment monitoring of serum potassium and blood sugar levels
P4Rituximab as maintenance therapy in ANCA associated vasculitisndash a single centre experience Rathnamalala NK Mcmenamin J Robertson S Almond A Kelly M Muniraju T M Renal Unit Dumfries and Galloway Royal Infirmary NHS Dumfries and Galloway Background The introduction of Cyclophosphamide and high dose steroids transformed ANCA associate vasculitis (AAV) from a disease of high mortality to a relapsing remitting disease Maintenance of remission however still remains a major challenge A two randomised clinical trials have looked at the use of Rituximab in remission induction in AAV and reported similar remission rates between Cyclophosphamide and Rituximab 12 Both these trials used Azathioprine as maintenance therapy and in the follow up showed similar remission rates with either agent for induction The role of Rituximab for maintenance therapy after cyclophosphamide induction was studied in the MAINRITSAN trial 3 Rituximab was compared with azathioprine and found that the relapse rate was significantly lower in the Rituximab group There have been several other retrospective studies that have suggested regular Rituximab infusions are successful in maintaining remission however has not been thoroughly evaluated 4 5678910 Here we share our centrersquos experience using Rituximab for maintenance of remission of AAV Materials and methods We conducted a retrospective review of electronic medical records of all patients who had received Rituximab as maintenance therapy for 12 months or longer between January 2014 to July 2016 Disease activity was assessed using Birmingham Vasculitis Activity Score ( BVAS) Version 3 and complete remission was defined as a score of 0 and partial remission as a score of lt50 of the value at diagnosis Due to uncertainties associated with sub classification we did not assign specific diagnosis but broadly classified as ANCA associated vasculitis Results 6 patients received Rituximab as maintenance therapy during the study period 3 (50) of them had eye ear nose and upper airway manifestations consistent with Granulomatosis with Polyangitis (GPA) All patients were PR3 ANCA positive except for one at initial diagnosis The mean BVAS score at the time of initiation of Rituximab was 4 All patients were initiated on Rituximab for relapses while on maintenance therapy with Azathioprine 4 patients received 6 monthly doses of Rituximab while two received annual doses All of them were also maintained on 5-10 mg of Prednisolone The mean BVAS score by 6 months was 0 and remained 0 at 12 months The mean PR3 titre was 562 at the initiation of treatment while at 12 months it had come down to 68 All patients remained in complete clinical remission at the end of 12 months after initiation of therapy Rituximab was well tolerated by all patients except one who developed pyrexia during an administration
Conclusions All patients had sustained remission at 6 months and 12 months after initiating Rituximab Rituximab has a potential role as maintenance therapy in AAV
P5 Chronic Myelo-Monocytic Leukaemia (CMML) as a contraindication to renal biopsy Alastair Rankin Emily McQuarrie Jennifer Lees Bruce MacKinnon Glasgow Renal and Transplant Unit On behalf of the Scottish Renal Biopsy Registry
Abstract Chronic Myelo-Monocytic Leukaemia (CMML) is a relatively rare mixed myelodysplastic myeloproliferative disorder that predominately affects patients over the age of 65 years Renal impairment in patients with CMML is well described with several different mechanisms reported including tumour infiltration lysozyme-induced injury amyloid deposition and tubulointerstitial nephritis From anecdotal evidence within our centre we are concerned that patients with CMML have an excessive risk of clinically significant bleeding following native renal biopsy This risk appears disproportionate to the degree of any co-existing thrombocytopenia or coagulopathy
We review the cases of 4 patients with an existing diagnosis of CMML who were referred to the renal clinic with proteinuria and excretory renal dysfunction Two of these patients underwent renal biopsy with subsequent major haemorrhage post-procedure despite normal bleeding parameters pre-procedure Patient 1 presented with flank pain 8 days post-biopsy A CT confirmed peri-nephric haematoma with retroperitoneal extension A total of 6 units of packed red cells (PRCs) were transfused prior to successful CT-guided emoblisation Histology from the biopsy revealed chronic tubulointerstitial nephritis Patient 2 experienced haemodynamic instability and haematuria one hour post-biopsy A total of 11 units of PRCs 7 units of fresh frozen plasma 2 pools of platelets intravenous tranexamic acid and 2 attempts at CT-guided embolization were required until haemostasis was achieved Histology later showed evidence of tumour infiltration with associated vasculitis Patient 3 presented with renal impairment and proteinuria on the background of known CMML Following discussion with haematology the risk of bleeding following renal biopsy was considered unjustifiable despite their platelets and coagulation screen being within normal range The patient was treated for presumed renal tumour infiltration with hydroxycarbamide Patient 4 was referred to the renal clinic with acute onset nephrotic syndrome Urinary proteincreatinine ratio was elevated over 800 mgmmol with serum albumin of 23 gL but normal excretory renal function The patient attends the haematology clinic with suspected CMML and chronic thrombocytopenia but previously declined bone marrow biopsy Following discussion with the patient there are no plans to proceed with renal biopsy given potential risks These cases highlight that while CMML is rare these patients are being referred to renal clinics with features that would commonly justify renal biopsy in other settings but in whom there may be an increased risk of bleeding post-procedure Our in-centre risk of major bleeding is 2 therefore to have such extreme amounts of bleeding in 2 patients with this underlying diagnosis is remarkable This creates a dilemma for the clinician as there is a wide range of potential renal pathology associated with CMML some of which will have disease specific but relatively toxic treatments available
Source of funding none Conflicts of interest none
P6 NHS Highland-Prograf to Adoport switch McCulloch K1 Peel R2 Lambie S3
1Renal Pharmacist Renal unit Raigmore Hospital Inverness 23Renal Consultant Renal unit Raigmore Hospital Inverness
Introduction NHS Highland (NHSH) is the first health board in Scotland to implement a switch from Prograf to Adoport for renal transplant patients This will provide considerable cost savings Adoport meets the bioequivalence criteria for drugs with a narrow therapeutic index set by the European Medicines agency and studies indicate therapeutic equivalence1 with the proviso that brands are non- interchangeable unless the switch is overseen by a Renal Consultant and post-conversion therapeutic drug monitoring is conducted23 The switch has been undertaken by a majority of transplant centres in England the main difference being that they have undergone repatriation NHSH Patients receive their transplant primarily at Royal Infirmary of Edinburgh and occasionally at Queen Elizabeth University Hospital Glasgow Care is transferred to NHS Highland on discharge NHS Highland cares for approximately 170 renal transplant patients 110 being prescribed Prograf These patients may live as far as 110 miles from Raigmore Hospital Given that prescribing is carried out by primary care clear communication with patients GPs and community pharmacy is essential to avoid inadvertent switching between brands
Method Clinically it was agreed a switch could be safely undertaken A business case was submitted and funding secured for pharmacist time laboratory costs and primary care time GPs have been informed via GP subgroup and local prescribing bulletin lsquoThe Pink Onersquo Community pharmacies are being informed by phone A protocol has been agreed Eligible patients selected by Renal Consultant and Renal Pharmacist Patients sent letter signed by Renal Consultant and Renal pharmacist Patients phoned prior to clinic to agree Adoport start date and address concerns Patient seen by Renal Consultant and pharmacist + given 1 month of Adoport Tacrolimus level and UampEs checked 5-7 days after commencing Adoport and patient
contacted by phone to check if tolerated If stable letter sent to GP and community pharmacy to continue supply
Results and Evaluation Letters have been sent to all eligible patients Seven patients have been reviewed One has received a one month supply of Adoport and 5 others are due to switch One patient was deemed non-eligible at present as they have a 6 month surplus of Prograf A database will be maintained and analysed at the end and primary care savings will be monitored Extra pharmacist input will give us the opportunity to review how immunosuppression is managed and to evaluate the benefit of having a renal transplant pharmacist Conclusion The switch is at an early stage Ultimately we hope to show that the switch from Prograf to Adoport can be managed safely with extra pharmacist input to a remote and rural population with prescribing being conducted by primary care
Fundingconflicts of interest none 1 McDevitt-Potter LM Sadaka B Tichy EM Rogers CC Gabardi S Transplantation 2011 A multicenter experience with
generic tacrolimus conversion 2 Medicines and Health Products Regulatory Agency Drug Safety Update 2012 Accessed online via
wwwmhragovukSafetyinformationDrugSafetyUpdateCON1557563 ESPRIT Guidance on management of repatriation and immunosuppressant switches in transplant patients 2015
Accessed online via httpwwwespritorgukwp-contentuploads201508Switch-guidance-document-final-Aug-31-2015pdf
P7 NHS Highland-Tacrolimus baseline dataMcCulloch K1 Peel R2 Lambie S3
1Renal Pharmacist Renal unit Raigmore Hospital Inverness 2Renal Consultant Renal unitRaigmore Hospital Inverness 3Renal Consultant Renal unit Raigmore Hospital Inverness
BackgroundAs part of planning a switch from using tacrolimus Prograf to Adoport we assessed baseline data for our transplant patients currently using Prograf After converting patients to Adoport we will compare their tacrolimus levels to their individual target range We assessed our use of appropriate target ranges and our current performance in achieving tacrolimus levels within target range on Prograf therapy
Method 107 renal transplant patients taking Prograf were identified a sample of 19 of these were analysed using electronic patient records and results Time from transplant ranged from 1 month to 18 years All tacrolimus levels for the preceding year were analysed and compared to the target range specified at the time of the level being done The assay used has a Coefficient of Variation of lt5 at the lower limit of the assay
Results All 19 patients had a target range for tacrolimus clearly identified and recorded in clinic letterswhich are routinely copied to the patients themselves A variety of target ranges were specifiedThe commonest used was 5-8 microgramsl in 7 patients followed by 5-7 in a further 4 patientswith another 6 different target ranges being used for the remaining 8 patients The ranges usedhad a breadth of 3 microgramsl in 2 cases the rest had a breadth of 2 microgramslPatients had a median of 12 (range 3-72) tacrolimus levels over the preceding year Results werewithin specified target ranges for 54 +- 22 (Medan +- SD) of results checked
Conclusion We currently use a large number of different target ranges The majority of the ranges used had a breadth of just 2 microgramsl These factors help to account for the low proportion of test results which were within the specified target ranges This is important to bear in mind when interpreting whether tacrolimus levels are within target ranges after switching to Adoport We should consider aligning our target ranges and widening them
P8 Eculizumab use in Scottish paediatric dense deposit disease Stewart D1 David Hughes1 Lynne Riach2 Craig Oxley2 Athavale D1
1Royal Hospital for Children Glasgow 2Royal Aberdeen Childrenrsquos Hospital Aberdeen
Introduction The revised MPGN classification and increasing recognition of Dense Deposit Disease (DDD) a C3 glomerulopathy as an alternative complement pathway disorder suggests Eculizumab an anti-C5 monoclonal antibody may be beneficial in treatment However the experience of Eculizumab as an off-label and expensive treatment in children with DDD is limited with variable clinical response reported in the literature
Method We present the outcomes of the only 2 paediatric patients in Scotland who have received Eculizumab for the management of DDD
Results Case 1 A 10 year old male presented with proteinuria and haematuria resistant to steroid treatment with preserved renal function Initial biopsy confirmed DDD Conservative management with an angiotensin converting enzyme inhibitor and diuretics for symptom control continued until 14 years Due to worsening symptoms (oedema lethargy poor growth) and renal function deterioration along with elevated terminal complement complex (TCC) Eculizumab was commenced A repeat biopsy whilst suggestive of chronic irreversible damage showed 25 glomerular architecture preservation Symptom improvement was noted There was a reduction in proteinuria and renal function stabilisation fall in TCC and discontinuation of diuretics Eculizumab was discontinued after 24 months Progression of renal function decline was seen in the final months of Eculizumab therapy With recurrence of symptoms and increasing proteinuria following discontinuation Eculizumab was recommenced after 6 months Symptomatic improvement has since been noted
Case 2 A 5 year old girl presented with painless frank haematuria and proteinuria Initial biopsy confirmed DDD Proteinuria was unresponsive to steroid therapy and 5 months following diagnosis she rapidly progressed towards end stage renal disease despite the introduction of Mycophenolate Mofetil and plasmapheresis Haemodialysis was subsequently commenced TCC level was elevated and Eculizumab treatment was started 7 months after diagnosis Renal biopsy prior to treatment demonstrated continued severe pathological changes in all visible glomeruli However due to lack of clinical response Eculizumab was discontinued after 2 months and the patient remained dialysis dependent
Conclusions Our experience with Eculizumab in Scotland has demonstrated variable results in our 2 patients with one patient showing a positive response whilst the other experienced no improvement Eculizumab was administered to both patients at varying points in their clinical journey with differing progressive features on biopsy To date the outcomes of 9 paediatric patients with DDD treated with Eculizumab have been described in the literature with 8 experiencing some positive response to treatment including 2 patients who were able to stop renal replacement therapy within 12 weeks of treatment A role for Eculizumab in DDD may be guided by clinical and pathological features Well designed clinical trials will be necessary to define the role of complement inhibition therapy in DDD
No conflict of interest and no funding requested
P9 Examining markers of safety in the use of non-tunnelled central venous catheters
James WT Millar (Speciality Registrar) Scott W Oliver (Speciality Registrar) Peter C Thomson (Consultant Nephrologist) Glasgow Renal and Transplant Unit Queen Elizabeth University Hospital Glasgow
Background Non-tunnelled central venous catheters (NTCVC) remain an essential means of vascular access for incident haemodialysis Associated morbidity is well recognised for example in the form of Staphylococcus aureus bloodstream infections (SAB)[1]
Previous quality improvement initiatives in our unit have sought to both improve traditional markers of quality (such as SAB) and to identify additional areas of clinical risk In 2014 Oliver et al [2] suggested several additional quality measures including peri-procedure haemoglobin drop the need for a further NTCVC during the same clinical episode and the NTCVC insertion site This study further evaluated NTCVC related clinical practice within our unit
Methods The potential markers of clinical quality identified in a previous project were examined using prospectively collected data stored in the electronic patient record Identified cases of SAB significant peri-procedure haemoglobin drop and multiple NTCVC insertion were investigated by case note review
Results Between March 2016 and March 2017 a total of 222 patients received 346 NTCVC 54 patients (243) had more than one NTCVC inserted in a 21-day period (range 2-5) When considering NTCVC insertion site there were 159 (459) femoral vein catheters and 183 (541) internal jugular vein catheters No pneumothoraces were reported
15 SABrsquos were reported during this period equating to 43 of all NTCVC 5 arose in patients with femoral NTCVC (333) and 10 from internal jugular catheters (667) Mean time from line insertion to positive blood culture was 86 days 15 (67) patients had a drop in haemoglobin of greater than 20mgdl with no other source of blood loss identified on review of clinical notes
Discussion These data demonstrate that NTCVC-associated SAB rates remain low and significantly below Scottish government audit standards [3] Of interest is the continued trend towards the use of femoral catheters at 45 of lines compared with 38 in 2014 [2] Although traditionally thought of as having a higher incidence of infectious complications our data has shown fewer bacteraemia events associated with femoral catheters compared with internal jugular Our data also demonstrates a significant rate of peri-procedure haemorrhage arising in up to 1 in 20 cases Together these findings present opportunities to development practice and improve patient safety
References
[1] Murray E Deighan C Geddes CC Thomson PC Reducing haemodialysis bacteraemia rates Scottish Renal Association Glasgow November 2013 [2] Oliver SW Thomson PC Jardine AG defining safe effective and patient-centred dialysis catheter placement Scottish Renal Association Edinburgh September 2014 [3] The Staphylococcus aureus bacteraemia quarterly report of cumulative data from all NHS Boards in Scotland Health Protection Scotland January 2015
Sources of funding none Conflicts of interest none
P10 Prescribing of tolvaptan-The NHS Highland experience Lambie S1 McCulloch K2 Garrod J3
1Renal Consultant Renal unit Raigmore Hospital Inverness 2Renal Pharmacist Renal unit Raigmore Hospital Inverness 3Renal Pharmacist Renal unit Raigmore Hospital Inverness
Introduction Tolvaptan is a vasopressin antagonist It was accepted for use in Scotland by SMC in Jan 2016 to slow the progression of cyst development and renal insufficiency of autosomal dominant polycystic kidney disease in adults with chronic kidney disease (CKD) stage 1 to 3 at initiation of treatment with evidence of rapidly progressing disease1 Adverse effects related to aquaresis may affect patientsrsquo ability to achieve the optimum therapeutic dose and the risk of hepatic toxicity necessitates regular LFT monitoring The geography of NHS Highland required the implementation of novel methods of managing these patients and as a result a MDT approach with an emphasis on pharmacist input was adopted Consultant role Patient selection on the basis of evidence of rapidly progressing kidney disease declining
eGFR large volume kidneys on ultrasound and evidence of complications of PKD Side effects and potential benefits discussed Potential medication interactions reviewed Jinarc risk management prescriber training
Pharmacist role Undertook Jinarc risk management pharmacist training Prepares accurate drug history and reviews for potential drug interactions Carries out patient counselling and supplies patient education material sick day rules card
and lsquogot to gorsquo card Supplies GP education leaflet Provides advice on selection of new drug therapies eg for gout Manages stock and coordinates supply to patients
Results Prescribing commenced May 2016 patients currently prescribed tolvaptan 11 7 Female 4 male Number on target dose 73 n = 811 2 patients are still being titrated One patient did
not tolerate target dose due to aquaresis side effects and is being trialled on the middle dose
Withdrawals One patient has withdrawn due to agoraphobia and an inability to attend for monitoring and another is on hold due to having major surgery
Conclusion The MDT approach between the Renal Consultant and Pharmacist at Raigmore Hospital has enabled tolvaptan prescribing to be efficiently and safely implemented to patients living within a challenging geographical location
1 Scottish Medicines Consortium Detailed Advice Document tolvaptan 15mg 30mg 45mg 60mg and 90mg tablets (Jinarcreg) SMC No 111415 January 2016
NA1 Authors SCN Jacqueline Ross NHS Grampian
SCN Alan Somerville NHS Lanarkshire SCN Jane Humphrey NHS Lanarkshire
e- mail contact jacquelinerossnhsnet Alansommervillelanarkshirescotnhsuk
Janehumphreylanarkshirescotnhsuk
Phone contact 01224 552927 01236 712644
Title Sharing of Adverse Events in Renal Units across Scotland
Introduction Background The Scottish Renal Nurses Strategy Group (SRNSG) are a group of senior nurses from Renal
Units across Scotland who meet 3-4 times per year to discuss and implement best practice At the last meeting it was agreed that it would be good practice for each Health Board to share
their adverse events reported on the Datix System and deliver a presentation with an action plan to prevent incidents and improve patient safety across Scotland NHS Grampian and NHS Lanarkshire will be the first to deliver this presentation discussing adverse events from both Health Boards with an action plan
Top 5 adverse events over the past 12 months Renal Unit NHS Grampian 1 Violence and Aggression 2 Accidents including needlesticks slips trips and falls 3 Medication Errors 4 Infrastructure Staffing and Estates 5 Machines and Equipment
Top 5 adverse events over past 12 months Renal Unit NHS Lanarkshire
1 Slips Trips or Falls 2 Medicine errors 3 Treatment problems 4 Transfer problems 5 Breach of policy
The presentation will also focus on any serious adverse events which may not be in the top 5 categories
Aim Objective Each Health Board to share their adverse events with the aim to prevent them from occurring in other units to improve staff and patient safety and wellbeing across Scotland
Method Power Point Presentation
Outcome Results Sharing of adverse events resulting in the development of a national Action Plan to prevent these incidents improving safety and well being of staff and patients in Renal Units across Scotland
NA2
SRA Oct 2017 Abstract
BBV Never Event - The whats whys and hows
Staff Nurse Gillian Wilson Aberdeen Royal Infirmary
This presentation shares our experience of a never event that occurred and was not picked up for
a period of 18 months
Hepatitis C (HCV) positive antibodies were found in a previously negative patient
These results were a low positive with no biochemistry changes to suggest any liver damage
however steps were put immediately in place to isolate and investigate
Was it contamination from a dialysis machine was it related to a blood transfusion given prior to
first positive result was it faulty diagnostic tests in the laboratory
In Aberdeen we go over and above national guidelines and isolate all our BBV patients whether
they have positive blood results or are PCR negative
Further bloods tested at an external laboratory confirmed negative results
It highlighted that communication errors were to blame for the lack of speed in detecting this issue
Investigations concluded no real answers as to why this happened
NA3
Living Donation Scotland Changing attitudes towards living donor kidney transplantation
Jen Lumsdaine Julie Glen On behalf of the Living Donation Scotland Project Board
Background and aims
The rate of living donor transplantation has remained fairly static in Scotland over the past 10 years
Recent data has shown inequity of access to living donor transplantation throughout the UK so
there is potential to significantly increase this optimum form of treatment for patients with end-stage
renal failure in Scotland The Living Donation Project Board was formed in 2016 aiming to double
the number of living donor transplants by 2020
Method
The two key areas
1 Do recipients receive adequate and appropriate information at the right time about living
kidney donation
2 Informing the general public about altruistic donation
All patients active on the transplant list in Scotland were invited to an information event A follow-up
questionnaire was performed in the East of Scotland examining outcome or reasons for not
attending A scoping exercise looked at information provided by each unit was performed and link
nephrologists and low clearance nurses attended meeting to discuss strategies for early education
Outcome
An information pack containing both recipient and donor written information and short films on DVD
has been produced with the support of the Scottish Government for all recipients and potential
donors in Scotland A new website with comprehensive information both written and visual and
postcode finder to improve ease of access to local unit contact details has been developed
Two national media campaigns have been launched with a significant rise in the number of enquiries
from potential donors and actual increase in altruistic donor numbers
Nursing abstract ndash no conflict of interest
NA4Authors Susan Easson Charge Nurse Ward 4C QEUH Glasgow
e- mail contact SusanEassonggcscotnhsuk
Phone contact 0141 452 3300
Title A Conversational approach to find out ldquoWhat matters to yourdquo in a Renal Transplant ward
Introduction Background Finding out ldquo What Mattersrdquo to people using health and careservices is crucial to delivering safe effective and person centred care It is a simple yet profoundconcept and tries to get to the essence of person centred care by creating deeply personalengagements with patients and their families through a conversational approach However careexperience feedback all too often provides innumerable examples of where what really matters topatients and their family members is poorly understood or not addressed Using care experienceas the driver for change the nursing staff in Ward 4C used improvement approaches to explorehow to hold more meaningful ldquoWhat Matters to yourdquo conversations on a daily basis
Aim Objective To improve the patient experience by utilising a person centred approach
Method Using Care experience feedback What Matters to Me boards and the conversationalapproach
Outcome Results Improvements in patient experience will be shared using examples ofpractice and care experience feedback
There was no additional funding required for this project We worked in collaboration with theperson centred team whorsquos aim is to improve patient experience
NA5
The implementation of a renal education programme and its impact on clinical practice
The purpose was to implement a Renal Education Programme and to evaluate its impact on
clinical practise
It was identified that there was a need for an educational programme to be set up within Forth
Valley Royal Hospital There is no inpatient renal unit in FVRH on site for our renal patients they
attend Queen Elizabeth University Hospital We are an outpatient haemodialysis unit with
outpatient clinics on site Therefore it was identified that there was a need for nursing staff within
FVRH to be educated on all renal complexities for the benefit of our patients
This was done through a work-based learning approach which brought tangible benefits for our
patients However it did not come without pitfalls as educational programmes are often seen as
making very little difference to clinical practise
T
his study describes what methods were used and examines the advantages and disadvantages in
setting up an educational programme and evaluating its impact on clinical practise
NA6
Nursing Abstract ndash SRA Meeting ndash 26 October 2017
Chris McGee Tonya Broe Ken Weir
Renal Unit Forth Valley Royal Hospital
Use of the Therapy Monitor Haemodialysis Patient Record System Can we aim for a paper-
free dialysis unit
We are trialling a new haemodialysis patient monitoring system to work in conjunction with SERPR
and which is intended to supersede the Finesse system used previously
We are in the early stages of this process but with continuing staff education and regular tech
support we are hoping to gather sufficient evidence to evaluate whether the use of paper case
notes needs to continue
Is it a realistic goal to aim for a completely paper-free unit
NA7
THE CLINICAL USES OF APHERESIS WITHIN NHS TAYSIDE
Laura Thomson CN
Ninewells Hospital Dundee
NHS Tayside took over the apheresis service from BTS in 2012 The service has since expanded
with the benefits of carrying out this treatment has been widely recognised within NHS Tayside
and is now more commonly being offered to treat a wider range of conditions with the number of
treatments carried out each year rising
This presentation will highlight the progression of the apheresis service within NHS Tayside We
will identify the various conditions it is currently being used to treat and also identify the decision
making process involved in carrying out these treatments ie which replacement fluid will be used
anticoagulation medication administered
We will highlight the benefits and challenges we face in providing this expanding service within the
Renal Service
NA8Authors Linda McDougall Renal Physiotherapist NHS Highland
e- mail contact lindamcdougall1nhsnet
Phone contact 01463 706022
Title lsquoExercise on Haemodialysis- Keeping the Wheels in Motionrsquo
Introduction Background The impact of CKD on physical fitness functional ability independence amp ultimately quality of life cannot be underestimated Current national guidelines recommend that all individuals with CKD are encouraged to participate in regular exercise programmes between or during dialysis sessions if on HD Following a successful pilot study funding was approved to establish an lsquoExercise on Dialysisrsquo (EOD) programme across NHS Highland through the appointment of a dedicated renal physiotherapist in 2008 A successful programme was soon established but for several years post-vacancies and increasing in-patient demands limited the physiotherapy servicersquos ability to deliver the programme The need to improve the long-term sustainability of the service was recognised and in late 2016 funding was approved to develop a Band 4 PT HCSW role for this purpose
Aim ObjectiveTo optimise the sustainability and continuity of the lsquoExercise on Dialysisrsquo service across NHSHighland through development of a Band 4 PT HCSW role
Method The potential parameters of the role and limits of autonomy were scoped out using current NES resources and guidelines Service and task analysis was then carried out to establish which components of the EOD protocol could be undertaken by a Band 4 A series of competencies were developed in line with the clinical protocol and one-to-one training and supervision provided to the post-holder to ensure competency achieved in delivering the programme
Outcome Results A 10 WTE Band 4 PT HCSW was appointed in Jan 2017 with a dual role between the renal unit and acute medical wards Although training is not yet complete the post-holder is already running the day-to-day delivery and monthly audit of the EOD service with senior physiotherapist input only required for individual patient safety queries and general discussion around patientsrsquo progress and goals The benefit to the unit has been considerable as the band 4 is available to support patients and staff with EOD provision 5 days a week This allows for one-to-one supervision of patients who need more support to participate in EOD regular feedback on performance and reviews of outcome measures and goals to maintain motivation levels Feedback on the post has been very positive and its scope will only continue to expand as we look to further develop renal rehabilitation services across NHS Highland
NA9Authors Nadine Lyall and Kerry Guthrie
e- mail contact nadinelyallbordersscotnhsuk kerryguthriebordersscotnhsuk
Phone contact 01896 826637
Title The Developing Role of the NMP in a Satellite Dialysis Unit
Introduction Background
We have been practising as NMPrsquos for nearly 3 years working in the dialysis unit at the BGH The unit is a satellite unit of the ERI and we have expanded over the last 6 years The unit provides haemodialysis for 12 patients at any one time 3 sessions a day 6 days a week We are nurse-led and have 2 renal consultants who are based at the ERI
We saw an opportunity to use our knowledge and experience to develop our role By becoming NMPrsquos we have enhanced our professional development and we feel we meet the changing needs of the dialysis patient in a more holistic manner
Aim Objective
Our aim is to deliver effective care as we are better placed to deal with issues that often arise byacting swiftly this in turn is cost effective and convenient For example good anaemia and bonemanagement is important for their health wellbeing and lifespanTo help understand our role we will use a power point presentation highlighting issues we dealwith and the drugs we prescribe under the following headings Cardiovascular infection painanticoagulant disequilibrium diet renal bone disease and renal anaemia
Method Power point
Outcome Results
In the future we hope to further develop and have greater autonomy in our role We have great support from our renal consultants and have already built up a great relationship with our patients We hope to undertake the Clinical Decision Making course and this in turn will allow us to deal effectively with acute illness giving the dialysis patient better care We are keen to get feedback from other renal nurses in Scotland to enable us to develop our role further and in turn raise awareness of the NMP role in a dialysis unit We record all our prescribing decisions and keep the consultants up to date regularly Currently we are working on auditing our prescribing practice so that we can improve the service we can provide
NA10 Title Komunikacja w szkoleniu dializy ortzewnowej
Author Senior Charge Nurse Rhoda Bell
Address Raigmore Hospital Old Perth Road Inverness IV2 3UJ
Email rhodabellnhsnet Telephone 01463706023
Introduction Background Case study on lady with Polish as her first language she has some English but requires an interpreter to carry out Peritoneal Dialysis training and attend clinic She had some gynaecological issues that we were not aware of which impacted on the functionality of PD and therefore the success of treatment There were areas of concern in low clearance clinic with signs the patient had a reluctance to engage in decision making
AimObjective
Methods Discussion through the case study highlighted issues with communication between different PD staff and patients Areas of concern include different staffing techniques environment factors on training success Also language and communication issues the patient had were not fully apparent so training could not be individualised
Results We plan to trial training at home and have more individualised training schedule for patients The training step by step guides have been reviewed and practise standardised In collaboration with low clearance nurse we have developed a check list which will highlight concerns before the transition to PD ie language issues and need for training aids in another language gynaecological conditions
Conclusions Everyone learns differently and training methodsaids must be individualised for all It may not be apparent until training has commenced that there are concerns Having one to one training with the same nurse will consolidate training and build confidence in the patient Having a close working relationship with members of the MDT will help make a supportive PD journey
Would we do things differently if we knew about prolapse or lack of English both spoken and written
Key words - Peritoneal dialysis patient training communication
N11
Telehealth amp PDAudrey Jones
Advantages
Information on a daily basis about treatment weight and blood pressure
Change programme remotely via computer or mobile
Earlier intervention for machineprogramme issues
Reduction in home visits ie patient trained but still requires volume increases
No need to download cards to see what problems have been
Can have more detailed information available at clinics
Disadvantages
Relying on patient input data correctly
Machine is noisy especially first wave of machine
Still the same bag connection system and patient connection system (difficult for manual
dexterity problems)
Relying on patient having good signal
Modem problems
NA12Autosomal Dominant Polycystic Kidney Disease A cruel inheritance but new hopeAlistair Lawrie Renal Unit Victoria Hospital KirkcaldySadaf Arshad Corry Dunnigan Paul Phelan Neil Turner Renal Unit Royal Infirmary of Edinburgh
Background Autosomal Dominant Polycystic Kidney Disease (ADPKD) is the most prevalent single gene human genetic disorder and the most common of the inherited cystic and interstitial kidney diseases It is estimated to affect 1 in every 1000 individuals worldwide with over 50 of sufferers eventually developing end stage kidney disease and requiring dialysis or transplantation Symptoms include spasmodic severe pain hypertension haematuria infection and kidney failure There is currently no cure for ADPKD Management of the condition has traditionally involved lifestyle modification BP control and analgesia however a recent study (Torres et al 2012) demonstrated that treatment with V2-receptor antagonist drugs slowed increase in total kidney volume reduced the rate of functional decline and showed a reduced incidence of kidney pain
Aim Provision of a tolvaptan prescribing and monitoring service
Methods Experiential finding report of initial twelve months period of multidisciplinary ADPKDtolvaptan clinic
Results Early results are comparable with TEMPO study outcomes
Conclusion Due to the long term nature of this treatment results available at this time are showing only the earliest benefits of the intervention More quantifiable results such as increased time before the necessity for RRT will only be evident in coming years Torres VE et al (2012) Tolvaptan in Patients with Autosomal Dominant Polycystic Kidney Disease New England Journal of Medicine 367 pp 2407-2418 DOI 101056NEJMoa1205311
No funding requirement No conflict of interest
P1 Polypharmacy in Renal Replacement Therapy Patients
Jason McMinn Colin Geddes Glasgow Renal and Transplant Unit Queen Elizabeth University Hospital
Introduction
Prescribing is often led by evidence from studies containing participants with single health conditions and without multimorbidity Polypharmacy is becoming increasingly recognised in patients with multiple chronic health conditions Additional medications are more likely to result in diminishing returns in benefit with an increased risk of harm Patients with established renal failure (ERF) are likely to be susceptible to medication-related harm A high pill burden is also likely to contribute adversely to an already restricted quality of life and has been associated with poor medication adherence The aim of this study was to analyse polypharmacy in all patients with ERF attending our service
Methods
We extracted medication records for all prevalent ERF patients attending the Glasgow Renal and Transplant Unit from the West of Scotland Electronic Renal Patient Record (SERPR) as of 01012017 The records were analysed to calculate the number of regular medications and total pill burden of each patient These medications were categorised as being lsquopreventativersquo or lsquosymptomaticrsquo We also analysed the prescription of specific drug classes to examine the prevalence of these medications
Results
We identified 1091 transplant follow-up 529 hospital haemodialysis and 46 peritoneal dialysis patients who were on a mean of 94 13 and 129 different medications respectively Overall pill burden was 139 tablets a day in transplant follow-up patients 141 in haemodialysis patients and 162 in peritoneal dialysis patients There were similar rates of prescribing between the different dialysis units and clinics within our service
The proportions of medications deemed as preventative rather than symptomatic were 76 in transplant 69 in haemodialysis and 60 in peritoneal dialysis
In transplant patients decreasing renal function was associated with a higher pill burden but even patients with a transplant eGFR gt 60 were on a mean of 126 tablets per day including a mean of 14 antihypertensives
Rates of antidepressant prescribing were 15 in transplant patients and 20 in hospital haemodialysis patients 53 of haemodialysis patients were on a statin 39 on aspirin 61 on a proton pump inhibitor and 7 were on warfarin
Conclusion
Patients undergoing all forms of renal replacement therapy are likely to be on a considerable number of medications Whilst these drugs are inevitably prescribed for valid reasons this data demonstrates the need for clinicians to engage with patients to explore opportunities to reduce pill burden
Conflict of Interest None Sources of Funding None
P2 An audit of Acute Kidney Injury (AKI) on an acute stroke ward before and after plannedinterventions to review and maintain hydration
Clare Harris1 Simon Hart2 Fiona Duthie3 1 University of Edinburgh Medical School 2 Stroke Unit Royal Infirmary of Edinburgh 3 Renal Unit Royal Infirmary of Edinburgh
Background Dehydration is an important factor in the development of acute kidney injury which is associated with increased morbidity and mortality particularly in the elderly population Poor fluid intake is common post stroke (1) and dehydration is associated with poorer outcomes 3 months post stroke (2) In late 2014 there was no system of identifying patients with poor oral intake on the stroke ward at the Royal Infirmary of Edinburgh a hydration protocol and education programme were implemented aiming to improve fluid balance This included the use of prescribed water either orally or by nasogastric tube An audit pre and post intervention demonstrated that hydration as measured by ureacreatinine ratio significantly improved after the protocol introduction (3) We aimed to determine whether the incidence of AKI by KDIGO criteria was also reduced as this could have implications for reducing patient morbidity and mortality in this elderly comorbid patient cohort
Method 150 inpatients to the acute stroke ward during JulAug 2014 and JulAug 2015 were selected (n= 80 2014 n=70 2015) Patient data and creatinine values were collected from the electronic patient record and medical notes and retrospectively analysed Baseline creatinine values were calculated and cases of AKI were identified and staged using KDIGO criteria (4) Chi-Squared tests were performed to determine P values Individual patient notes were reviewed for both quantitative and qualitative data of patient management
Results Incidence of AKI (of any stage) was 263 pre-protocol and 200 post-protocol (P=03646) Incidence of AKI stages 23 was 100 pre-protocol and 715 post-protocol (P=05374) In hospital post stroke mortality was 338 pre-protocol and 1286 post protocol (P=00028) AKI was also associated with increased length of stay
Conclusions Despite a trend in benefit there was no significant difference in incidence of AKI pre and post hydration protocol nor in incidence of severe AKI (stage 23) AKI is influenced by many factors one of which is hydration status Further studies are needed to determine whether the trend of benefit exhibited in this sample is significant in a greater sample size if this were the case such a protocol could have great benefit to patient care on stroke units and elsewhere There was a significant difference in inpatient post stroke mortality following introduction of the hydration protocol Further investigations are needed to explain underlying reasons for this factors other than hydration may play an important role
References 1 Whelan K Inadequate fluid intakes in dysphagic acute stroke Clinical Nutrition (2001) 20(5)
423-428 2 Bhalla A Sankaralingam S Dundas R Swaminathan R Wolfe CDA Rudd AG The influence of
raised plasma osmolality on clinical outcome after acute stroke Stroke (2000) 312043ndash2048 3 Hart SR Craig R Berry E Lane N Gad A Farrugia M Burton L Paquay A What Happens to
Acute Stroke Patientsrsquo Fluid Balance Renal Status and Dehydration in the First Two Weeks How Can They Be Markedly Improved doi 101111ijs12634_13
4 KDIGO Clinical Practice Guideline for Acute Kidney InjuryKidney international supplements (2012) 2(1) 1-138
No funding or conflict of interest to declare
P3NHS Highland-Improving the management of hyperkalaemia using a kit Initial resultsCantley N1 Abedin T2 Lambie S3
1FY2 NHS Highland 2ST4 Renal Medicine NHS Grampian 3Renal Consultant Renal unitRaigmore Hospital Inverness
Introduction The incidence of hyperkalaemia in hospitalised in patients is between 1 and 10 Guidelines in Northern Ireland promote the use of a Hyperkalaemia Kit to improve management of hyperkalaemia We assessed the management of hyperkalaemia in Raigmore Hospital including post-treatment monitoring of serum potassium and blood glucose at baseline and after the introduction of a lsquoHyperkalaemia Kitrsquo which contains a pro forma for the management of hyperkalaemia and all the relevant equipment and drugs for treatment
Method Between July and September 2016 an automated algorithm identified 34 patients with a potassium result 65 mmoll or above on laboratory results 12 received no specific treatment of these 6 results were spurious 4 patients died before treatment could be started and 2 patients were chronic haemodialysis patients We introduced the Hyperkalaemia Kit to the Acute Medical Admissions Unit in Raigmore Hospital Since then 15 patients have been identified with serum potassium measurements above 65 and the pro forma and kit was used with eight of these patients One of these patients proceeded straight to acute renal replacement therapy
Results Prior to our intervention all 22 patients that were actively treated received at least one prescription of appropriate doses of Insulin with Dextrose However only 16 patients received intravenous calcium and only 7 received nebulised Salbutamol Potassium was measured at 4 hours in 5 cases and by 12 hours in 17 cases Monitoring of any capillary blood glucose was only documented in 8 cases Of the 22 treated 2 needed acute renal replacement therapy 3 required further doses of insulin and dextrose 2 were treated with Calcium Resonium
Eight cases of hyperkalaemia have been managed with the use of the kit and pro-forma so far An initial ECG was performed in all eight and four patients had continuous cardiac monitoring Intravenous calcium was given in seven and nebulised Salbutamol was given in five out of the eight cases Six out of eight patients had at least three blood sugar measurements One had two measurements documented and one patient was stopped from further monitoring following senior review and decision to palliate Seven patients had appropriate monitoring of their serum potassium by 4h and 12h again one patient was not monitored due to palliation
Conclusion Baseline results showed very low rates of prescription of nebulised Salbutamol low rates of Calcium Gluconate use and very low monitoring of blood sugars and potassium post treatment This has the potential for serious adverse outcomes particularly the potential for iatrogenic hypoglycaemia Our initial data shows the use of a Hyperkalaemia pro forma and kit improves the rate of prescription of intravenous calcium and nebulised Salbutamol and the post-treatment monitoring of serum potassium and blood sugar levels
P4Rituximab as maintenance therapy in ANCA associated vasculitisndash a single centre experience Rathnamalala NK Mcmenamin J Robertson S Almond A Kelly M Muniraju T M Renal Unit Dumfries and Galloway Royal Infirmary NHS Dumfries and Galloway Background The introduction of Cyclophosphamide and high dose steroids transformed ANCA associate vasculitis (AAV) from a disease of high mortality to a relapsing remitting disease Maintenance of remission however still remains a major challenge A two randomised clinical trials have looked at the use of Rituximab in remission induction in AAV and reported similar remission rates between Cyclophosphamide and Rituximab 12 Both these trials used Azathioprine as maintenance therapy and in the follow up showed similar remission rates with either agent for induction The role of Rituximab for maintenance therapy after cyclophosphamide induction was studied in the MAINRITSAN trial 3 Rituximab was compared with azathioprine and found that the relapse rate was significantly lower in the Rituximab group There have been several other retrospective studies that have suggested regular Rituximab infusions are successful in maintaining remission however has not been thoroughly evaluated 4 5678910 Here we share our centrersquos experience using Rituximab for maintenance of remission of AAV Materials and methods We conducted a retrospective review of electronic medical records of all patients who had received Rituximab as maintenance therapy for 12 months or longer between January 2014 to July 2016 Disease activity was assessed using Birmingham Vasculitis Activity Score ( BVAS) Version 3 and complete remission was defined as a score of 0 and partial remission as a score of lt50 of the value at diagnosis Due to uncertainties associated with sub classification we did not assign specific diagnosis but broadly classified as ANCA associated vasculitis Results 6 patients received Rituximab as maintenance therapy during the study period 3 (50) of them had eye ear nose and upper airway manifestations consistent with Granulomatosis with Polyangitis (GPA) All patients were PR3 ANCA positive except for one at initial diagnosis The mean BVAS score at the time of initiation of Rituximab was 4 All patients were initiated on Rituximab for relapses while on maintenance therapy with Azathioprine 4 patients received 6 monthly doses of Rituximab while two received annual doses All of them were also maintained on 5-10 mg of Prednisolone The mean BVAS score by 6 months was 0 and remained 0 at 12 months The mean PR3 titre was 562 at the initiation of treatment while at 12 months it had come down to 68 All patients remained in complete clinical remission at the end of 12 months after initiation of therapy Rituximab was well tolerated by all patients except one who developed pyrexia during an administration
Conclusions All patients had sustained remission at 6 months and 12 months after initiating Rituximab Rituximab has a potential role as maintenance therapy in AAV
P5 Chronic Myelo-Monocytic Leukaemia (CMML) as a contraindication to renal biopsy Alastair Rankin Emily McQuarrie Jennifer Lees Bruce MacKinnon Glasgow Renal and Transplant Unit On behalf of the Scottish Renal Biopsy Registry
Abstract Chronic Myelo-Monocytic Leukaemia (CMML) is a relatively rare mixed myelodysplastic myeloproliferative disorder that predominately affects patients over the age of 65 years Renal impairment in patients with CMML is well described with several different mechanisms reported including tumour infiltration lysozyme-induced injury amyloid deposition and tubulointerstitial nephritis From anecdotal evidence within our centre we are concerned that patients with CMML have an excessive risk of clinically significant bleeding following native renal biopsy This risk appears disproportionate to the degree of any co-existing thrombocytopenia or coagulopathy
We review the cases of 4 patients with an existing diagnosis of CMML who were referred to the renal clinic with proteinuria and excretory renal dysfunction Two of these patients underwent renal biopsy with subsequent major haemorrhage post-procedure despite normal bleeding parameters pre-procedure Patient 1 presented with flank pain 8 days post-biopsy A CT confirmed peri-nephric haematoma with retroperitoneal extension A total of 6 units of packed red cells (PRCs) were transfused prior to successful CT-guided emoblisation Histology from the biopsy revealed chronic tubulointerstitial nephritis Patient 2 experienced haemodynamic instability and haematuria one hour post-biopsy A total of 11 units of PRCs 7 units of fresh frozen plasma 2 pools of platelets intravenous tranexamic acid and 2 attempts at CT-guided embolization were required until haemostasis was achieved Histology later showed evidence of tumour infiltration with associated vasculitis Patient 3 presented with renal impairment and proteinuria on the background of known CMML Following discussion with haematology the risk of bleeding following renal biopsy was considered unjustifiable despite their platelets and coagulation screen being within normal range The patient was treated for presumed renal tumour infiltration with hydroxycarbamide Patient 4 was referred to the renal clinic with acute onset nephrotic syndrome Urinary proteincreatinine ratio was elevated over 800 mgmmol with serum albumin of 23 gL but normal excretory renal function The patient attends the haematology clinic with suspected CMML and chronic thrombocytopenia but previously declined bone marrow biopsy Following discussion with the patient there are no plans to proceed with renal biopsy given potential risks These cases highlight that while CMML is rare these patients are being referred to renal clinics with features that would commonly justify renal biopsy in other settings but in whom there may be an increased risk of bleeding post-procedure Our in-centre risk of major bleeding is 2 therefore to have such extreme amounts of bleeding in 2 patients with this underlying diagnosis is remarkable This creates a dilemma for the clinician as there is a wide range of potential renal pathology associated with CMML some of which will have disease specific but relatively toxic treatments available
Source of funding none Conflicts of interest none
P6 NHS Highland-Prograf to Adoport switch McCulloch K1 Peel R2 Lambie S3
1Renal Pharmacist Renal unit Raigmore Hospital Inverness 23Renal Consultant Renal unit Raigmore Hospital Inverness
Introduction NHS Highland (NHSH) is the first health board in Scotland to implement a switch from Prograf to Adoport for renal transplant patients This will provide considerable cost savings Adoport meets the bioequivalence criteria for drugs with a narrow therapeutic index set by the European Medicines agency and studies indicate therapeutic equivalence1 with the proviso that brands are non- interchangeable unless the switch is overseen by a Renal Consultant and post-conversion therapeutic drug monitoring is conducted23 The switch has been undertaken by a majority of transplant centres in England the main difference being that they have undergone repatriation NHSH Patients receive their transplant primarily at Royal Infirmary of Edinburgh and occasionally at Queen Elizabeth University Hospital Glasgow Care is transferred to NHS Highland on discharge NHS Highland cares for approximately 170 renal transplant patients 110 being prescribed Prograf These patients may live as far as 110 miles from Raigmore Hospital Given that prescribing is carried out by primary care clear communication with patients GPs and community pharmacy is essential to avoid inadvertent switching between brands
Method Clinically it was agreed a switch could be safely undertaken A business case was submitted and funding secured for pharmacist time laboratory costs and primary care time GPs have been informed via GP subgroup and local prescribing bulletin lsquoThe Pink Onersquo Community pharmacies are being informed by phone A protocol has been agreed Eligible patients selected by Renal Consultant and Renal Pharmacist Patients sent letter signed by Renal Consultant and Renal pharmacist Patients phoned prior to clinic to agree Adoport start date and address concerns Patient seen by Renal Consultant and pharmacist + given 1 month of Adoport Tacrolimus level and UampEs checked 5-7 days after commencing Adoport and patient
contacted by phone to check if tolerated If stable letter sent to GP and community pharmacy to continue supply
Results and Evaluation Letters have been sent to all eligible patients Seven patients have been reviewed One has received a one month supply of Adoport and 5 others are due to switch One patient was deemed non-eligible at present as they have a 6 month surplus of Prograf A database will be maintained and analysed at the end and primary care savings will be monitored Extra pharmacist input will give us the opportunity to review how immunosuppression is managed and to evaluate the benefit of having a renal transplant pharmacist Conclusion The switch is at an early stage Ultimately we hope to show that the switch from Prograf to Adoport can be managed safely with extra pharmacist input to a remote and rural population with prescribing being conducted by primary care
Fundingconflicts of interest none 1 McDevitt-Potter LM Sadaka B Tichy EM Rogers CC Gabardi S Transplantation 2011 A multicenter experience with
generic tacrolimus conversion 2 Medicines and Health Products Regulatory Agency Drug Safety Update 2012 Accessed online via
wwwmhragovukSafetyinformationDrugSafetyUpdateCON1557563 ESPRIT Guidance on management of repatriation and immunosuppressant switches in transplant patients 2015
Accessed online via httpwwwespritorgukwp-contentuploads201508Switch-guidance-document-final-Aug-31-2015pdf
P7 NHS Highland-Tacrolimus baseline dataMcCulloch K1 Peel R2 Lambie S3
1Renal Pharmacist Renal unit Raigmore Hospital Inverness 2Renal Consultant Renal unitRaigmore Hospital Inverness 3Renal Consultant Renal unit Raigmore Hospital Inverness
BackgroundAs part of planning a switch from using tacrolimus Prograf to Adoport we assessed baseline data for our transplant patients currently using Prograf After converting patients to Adoport we will compare their tacrolimus levels to their individual target range We assessed our use of appropriate target ranges and our current performance in achieving tacrolimus levels within target range on Prograf therapy
Method 107 renal transplant patients taking Prograf were identified a sample of 19 of these were analysed using electronic patient records and results Time from transplant ranged from 1 month to 18 years All tacrolimus levels for the preceding year were analysed and compared to the target range specified at the time of the level being done The assay used has a Coefficient of Variation of lt5 at the lower limit of the assay
Results All 19 patients had a target range for tacrolimus clearly identified and recorded in clinic letterswhich are routinely copied to the patients themselves A variety of target ranges were specifiedThe commonest used was 5-8 microgramsl in 7 patients followed by 5-7 in a further 4 patientswith another 6 different target ranges being used for the remaining 8 patients The ranges usedhad a breadth of 3 microgramsl in 2 cases the rest had a breadth of 2 microgramslPatients had a median of 12 (range 3-72) tacrolimus levels over the preceding year Results werewithin specified target ranges for 54 +- 22 (Medan +- SD) of results checked
Conclusion We currently use a large number of different target ranges The majority of the ranges used had a breadth of just 2 microgramsl These factors help to account for the low proportion of test results which were within the specified target ranges This is important to bear in mind when interpreting whether tacrolimus levels are within target ranges after switching to Adoport We should consider aligning our target ranges and widening them
P8 Eculizumab use in Scottish paediatric dense deposit disease Stewart D1 David Hughes1 Lynne Riach2 Craig Oxley2 Athavale D1
1Royal Hospital for Children Glasgow 2Royal Aberdeen Childrenrsquos Hospital Aberdeen
Introduction The revised MPGN classification and increasing recognition of Dense Deposit Disease (DDD) a C3 glomerulopathy as an alternative complement pathway disorder suggests Eculizumab an anti-C5 monoclonal antibody may be beneficial in treatment However the experience of Eculizumab as an off-label and expensive treatment in children with DDD is limited with variable clinical response reported in the literature
Method We present the outcomes of the only 2 paediatric patients in Scotland who have received Eculizumab for the management of DDD
Results Case 1 A 10 year old male presented with proteinuria and haematuria resistant to steroid treatment with preserved renal function Initial biopsy confirmed DDD Conservative management with an angiotensin converting enzyme inhibitor and diuretics for symptom control continued until 14 years Due to worsening symptoms (oedema lethargy poor growth) and renal function deterioration along with elevated terminal complement complex (TCC) Eculizumab was commenced A repeat biopsy whilst suggestive of chronic irreversible damage showed 25 glomerular architecture preservation Symptom improvement was noted There was a reduction in proteinuria and renal function stabilisation fall in TCC and discontinuation of diuretics Eculizumab was discontinued after 24 months Progression of renal function decline was seen in the final months of Eculizumab therapy With recurrence of symptoms and increasing proteinuria following discontinuation Eculizumab was recommenced after 6 months Symptomatic improvement has since been noted
Case 2 A 5 year old girl presented with painless frank haematuria and proteinuria Initial biopsy confirmed DDD Proteinuria was unresponsive to steroid therapy and 5 months following diagnosis she rapidly progressed towards end stage renal disease despite the introduction of Mycophenolate Mofetil and plasmapheresis Haemodialysis was subsequently commenced TCC level was elevated and Eculizumab treatment was started 7 months after diagnosis Renal biopsy prior to treatment demonstrated continued severe pathological changes in all visible glomeruli However due to lack of clinical response Eculizumab was discontinued after 2 months and the patient remained dialysis dependent
Conclusions Our experience with Eculizumab in Scotland has demonstrated variable results in our 2 patients with one patient showing a positive response whilst the other experienced no improvement Eculizumab was administered to both patients at varying points in their clinical journey with differing progressive features on biopsy To date the outcomes of 9 paediatric patients with DDD treated with Eculizumab have been described in the literature with 8 experiencing some positive response to treatment including 2 patients who were able to stop renal replacement therapy within 12 weeks of treatment A role for Eculizumab in DDD may be guided by clinical and pathological features Well designed clinical trials will be necessary to define the role of complement inhibition therapy in DDD
No conflict of interest and no funding requested
P9 Examining markers of safety in the use of non-tunnelled central venous catheters
James WT Millar (Speciality Registrar) Scott W Oliver (Speciality Registrar) Peter C Thomson (Consultant Nephrologist) Glasgow Renal and Transplant Unit Queen Elizabeth University Hospital Glasgow
Background Non-tunnelled central venous catheters (NTCVC) remain an essential means of vascular access for incident haemodialysis Associated morbidity is well recognised for example in the form of Staphylococcus aureus bloodstream infections (SAB)[1]
Previous quality improvement initiatives in our unit have sought to both improve traditional markers of quality (such as SAB) and to identify additional areas of clinical risk In 2014 Oliver et al [2] suggested several additional quality measures including peri-procedure haemoglobin drop the need for a further NTCVC during the same clinical episode and the NTCVC insertion site This study further evaluated NTCVC related clinical practice within our unit
Methods The potential markers of clinical quality identified in a previous project were examined using prospectively collected data stored in the electronic patient record Identified cases of SAB significant peri-procedure haemoglobin drop and multiple NTCVC insertion were investigated by case note review
Results Between March 2016 and March 2017 a total of 222 patients received 346 NTCVC 54 patients (243) had more than one NTCVC inserted in a 21-day period (range 2-5) When considering NTCVC insertion site there were 159 (459) femoral vein catheters and 183 (541) internal jugular vein catheters No pneumothoraces were reported
15 SABrsquos were reported during this period equating to 43 of all NTCVC 5 arose in patients with femoral NTCVC (333) and 10 from internal jugular catheters (667) Mean time from line insertion to positive blood culture was 86 days 15 (67) patients had a drop in haemoglobin of greater than 20mgdl with no other source of blood loss identified on review of clinical notes
Discussion These data demonstrate that NTCVC-associated SAB rates remain low and significantly below Scottish government audit standards [3] Of interest is the continued trend towards the use of femoral catheters at 45 of lines compared with 38 in 2014 [2] Although traditionally thought of as having a higher incidence of infectious complications our data has shown fewer bacteraemia events associated with femoral catheters compared with internal jugular Our data also demonstrates a significant rate of peri-procedure haemorrhage arising in up to 1 in 20 cases Together these findings present opportunities to development practice and improve patient safety
References
[1] Murray E Deighan C Geddes CC Thomson PC Reducing haemodialysis bacteraemia rates Scottish Renal Association Glasgow November 2013 [2] Oliver SW Thomson PC Jardine AG defining safe effective and patient-centred dialysis catheter placement Scottish Renal Association Edinburgh September 2014 [3] The Staphylococcus aureus bacteraemia quarterly report of cumulative data from all NHS Boards in Scotland Health Protection Scotland January 2015
Sources of funding none Conflicts of interest none
P10 Prescribing of tolvaptan-The NHS Highland experience Lambie S1 McCulloch K2 Garrod J3
1Renal Consultant Renal unit Raigmore Hospital Inverness 2Renal Pharmacist Renal unit Raigmore Hospital Inverness 3Renal Pharmacist Renal unit Raigmore Hospital Inverness
Introduction Tolvaptan is a vasopressin antagonist It was accepted for use in Scotland by SMC in Jan 2016 to slow the progression of cyst development and renal insufficiency of autosomal dominant polycystic kidney disease in adults with chronic kidney disease (CKD) stage 1 to 3 at initiation of treatment with evidence of rapidly progressing disease1 Adverse effects related to aquaresis may affect patientsrsquo ability to achieve the optimum therapeutic dose and the risk of hepatic toxicity necessitates regular LFT monitoring The geography of NHS Highland required the implementation of novel methods of managing these patients and as a result a MDT approach with an emphasis on pharmacist input was adopted Consultant role Patient selection on the basis of evidence of rapidly progressing kidney disease declining
eGFR large volume kidneys on ultrasound and evidence of complications of PKD Side effects and potential benefits discussed Potential medication interactions reviewed Jinarc risk management prescriber training
Pharmacist role Undertook Jinarc risk management pharmacist training Prepares accurate drug history and reviews for potential drug interactions Carries out patient counselling and supplies patient education material sick day rules card
and lsquogot to gorsquo card Supplies GP education leaflet Provides advice on selection of new drug therapies eg for gout Manages stock and coordinates supply to patients
Results Prescribing commenced May 2016 patients currently prescribed tolvaptan 11 7 Female 4 male Number on target dose 73 n = 811 2 patients are still being titrated One patient did
not tolerate target dose due to aquaresis side effects and is being trialled on the middle dose
Withdrawals One patient has withdrawn due to agoraphobia and an inability to attend for monitoring and another is on hold due to having major surgery
Conclusion The MDT approach between the Renal Consultant and Pharmacist at Raigmore Hospital has enabled tolvaptan prescribing to be efficiently and safely implemented to patients living within a challenging geographical location
1 Scottish Medicines Consortium Detailed Advice Document tolvaptan 15mg 30mg 45mg 60mg and 90mg tablets (Jinarcreg) SMC No 111415 January 2016
NA1 Authors SCN Jacqueline Ross NHS Grampian
SCN Alan Somerville NHS Lanarkshire SCN Jane Humphrey NHS Lanarkshire
e- mail contact jacquelinerossnhsnet Alansommervillelanarkshirescotnhsuk
Janehumphreylanarkshirescotnhsuk
Phone contact 01224 552927 01236 712644
Title Sharing of Adverse Events in Renal Units across Scotland
Introduction Background The Scottish Renal Nurses Strategy Group (SRNSG) are a group of senior nurses from Renal
Units across Scotland who meet 3-4 times per year to discuss and implement best practice At the last meeting it was agreed that it would be good practice for each Health Board to share
their adverse events reported on the Datix System and deliver a presentation with an action plan to prevent incidents and improve patient safety across Scotland NHS Grampian and NHS Lanarkshire will be the first to deliver this presentation discussing adverse events from both Health Boards with an action plan
Top 5 adverse events over the past 12 months Renal Unit NHS Grampian 1 Violence and Aggression 2 Accidents including needlesticks slips trips and falls 3 Medication Errors 4 Infrastructure Staffing and Estates 5 Machines and Equipment
Top 5 adverse events over past 12 months Renal Unit NHS Lanarkshire
1 Slips Trips or Falls 2 Medicine errors 3 Treatment problems 4 Transfer problems 5 Breach of policy
The presentation will also focus on any serious adverse events which may not be in the top 5 categories
Aim Objective Each Health Board to share their adverse events with the aim to prevent them from occurring in other units to improve staff and patient safety and wellbeing across Scotland
Method Power Point Presentation
Outcome Results Sharing of adverse events resulting in the development of a national Action Plan to prevent these incidents improving safety and well being of staff and patients in Renal Units across Scotland
NA2
SRA Oct 2017 Abstract
BBV Never Event - The whats whys and hows
Staff Nurse Gillian Wilson Aberdeen Royal Infirmary
This presentation shares our experience of a never event that occurred and was not picked up for
a period of 18 months
Hepatitis C (HCV) positive antibodies were found in a previously negative patient
These results were a low positive with no biochemistry changes to suggest any liver damage
however steps were put immediately in place to isolate and investigate
Was it contamination from a dialysis machine was it related to a blood transfusion given prior to
first positive result was it faulty diagnostic tests in the laboratory
In Aberdeen we go over and above national guidelines and isolate all our BBV patients whether
they have positive blood results or are PCR negative
Further bloods tested at an external laboratory confirmed negative results
It highlighted that communication errors were to blame for the lack of speed in detecting this issue
Investigations concluded no real answers as to why this happened
NA3
Living Donation Scotland Changing attitudes towards living donor kidney transplantation
Jen Lumsdaine Julie Glen On behalf of the Living Donation Scotland Project Board
Background and aims
The rate of living donor transplantation has remained fairly static in Scotland over the past 10 years
Recent data has shown inequity of access to living donor transplantation throughout the UK so
there is potential to significantly increase this optimum form of treatment for patients with end-stage
renal failure in Scotland The Living Donation Project Board was formed in 2016 aiming to double
the number of living donor transplants by 2020
Method
The two key areas
1 Do recipients receive adequate and appropriate information at the right time about living
kidney donation
2 Informing the general public about altruistic donation
All patients active on the transplant list in Scotland were invited to an information event A follow-up
questionnaire was performed in the East of Scotland examining outcome or reasons for not
attending A scoping exercise looked at information provided by each unit was performed and link
nephrologists and low clearance nurses attended meeting to discuss strategies for early education
Outcome
An information pack containing both recipient and donor written information and short films on DVD
has been produced with the support of the Scottish Government for all recipients and potential
donors in Scotland A new website with comprehensive information both written and visual and
postcode finder to improve ease of access to local unit contact details has been developed
Two national media campaigns have been launched with a significant rise in the number of enquiries
from potential donors and actual increase in altruistic donor numbers
Nursing abstract ndash no conflict of interest
NA4Authors Susan Easson Charge Nurse Ward 4C QEUH Glasgow
e- mail contact SusanEassonggcscotnhsuk
Phone contact 0141 452 3300
Title A Conversational approach to find out ldquoWhat matters to yourdquo in a Renal Transplant ward
Introduction Background Finding out ldquo What Mattersrdquo to people using health and careservices is crucial to delivering safe effective and person centred care It is a simple yet profoundconcept and tries to get to the essence of person centred care by creating deeply personalengagements with patients and their families through a conversational approach However careexperience feedback all too often provides innumerable examples of where what really matters topatients and their family members is poorly understood or not addressed Using care experienceas the driver for change the nursing staff in Ward 4C used improvement approaches to explorehow to hold more meaningful ldquoWhat Matters to yourdquo conversations on a daily basis
Aim Objective To improve the patient experience by utilising a person centred approach
Method Using Care experience feedback What Matters to Me boards and the conversationalapproach
Outcome Results Improvements in patient experience will be shared using examples ofpractice and care experience feedback
There was no additional funding required for this project We worked in collaboration with theperson centred team whorsquos aim is to improve patient experience
NA5
The implementation of a renal education programme and its impact on clinical practice
The purpose was to implement a Renal Education Programme and to evaluate its impact on
clinical practise
It was identified that there was a need for an educational programme to be set up within Forth
Valley Royal Hospital There is no inpatient renal unit in FVRH on site for our renal patients they
attend Queen Elizabeth University Hospital We are an outpatient haemodialysis unit with
outpatient clinics on site Therefore it was identified that there was a need for nursing staff within
FVRH to be educated on all renal complexities for the benefit of our patients
This was done through a work-based learning approach which brought tangible benefits for our
patients However it did not come without pitfalls as educational programmes are often seen as
making very little difference to clinical practise
T
his study describes what methods were used and examines the advantages and disadvantages in
setting up an educational programme and evaluating its impact on clinical practise
NA6
Nursing Abstract ndash SRA Meeting ndash 26 October 2017
Chris McGee Tonya Broe Ken Weir
Renal Unit Forth Valley Royal Hospital
Use of the Therapy Monitor Haemodialysis Patient Record System Can we aim for a paper-
free dialysis unit
We are trialling a new haemodialysis patient monitoring system to work in conjunction with SERPR
and which is intended to supersede the Finesse system used previously
We are in the early stages of this process but with continuing staff education and regular tech
support we are hoping to gather sufficient evidence to evaluate whether the use of paper case
notes needs to continue
Is it a realistic goal to aim for a completely paper-free unit
NA7
THE CLINICAL USES OF APHERESIS WITHIN NHS TAYSIDE
Laura Thomson CN
Ninewells Hospital Dundee
NHS Tayside took over the apheresis service from BTS in 2012 The service has since expanded
with the benefits of carrying out this treatment has been widely recognised within NHS Tayside
and is now more commonly being offered to treat a wider range of conditions with the number of
treatments carried out each year rising
This presentation will highlight the progression of the apheresis service within NHS Tayside We
will identify the various conditions it is currently being used to treat and also identify the decision
making process involved in carrying out these treatments ie which replacement fluid will be used
anticoagulation medication administered
We will highlight the benefits and challenges we face in providing this expanding service within the
Renal Service
NA8Authors Linda McDougall Renal Physiotherapist NHS Highland
e- mail contact lindamcdougall1nhsnet
Phone contact 01463 706022
Title lsquoExercise on Haemodialysis- Keeping the Wheels in Motionrsquo
Introduction Background The impact of CKD on physical fitness functional ability independence amp ultimately quality of life cannot be underestimated Current national guidelines recommend that all individuals with CKD are encouraged to participate in regular exercise programmes between or during dialysis sessions if on HD Following a successful pilot study funding was approved to establish an lsquoExercise on Dialysisrsquo (EOD) programme across NHS Highland through the appointment of a dedicated renal physiotherapist in 2008 A successful programme was soon established but for several years post-vacancies and increasing in-patient demands limited the physiotherapy servicersquos ability to deliver the programme The need to improve the long-term sustainability of the service was recognised and in late 2016 funding was approved to develop a Band 4 PT HCSW role for this purpose
Aim ObjectiveTo optimise the sustainability and continuity of the lsquoExercise on Dialysisrsquo service across NHSHighland through development of a Band 4 PT HCSW role
Method The potential parameters of the role and limits of autonomy were scoped out using current NES resources and guidelines Service and task analysis was then carried out to establish which components of the EOD protocol could be undertaken by a Band 4 A series of competencies were developed in line with the clinical protocol and one-to-one training and supervision provided to the post-holder to ensure competency achieved in delivering the programme
Outcome Results A 10 WTE Band 4 PT HCSW was appointed in Jan 2017 with a dual role between the renal unit and acute medical wards Although training is not yet complete the post-holder is already running the day-to-day delivery and monthly audit of the EOD service with senior physiotherapist input only required for individual patient safety queries and general discussion around patientsrsquo progress and goals The benefit to the unit has been considerable as the band 4 is available to support patients and staff with EOD provision 5 days a week This allows for one-to-one supervision of patients who need more support to participate in EOD regular feedback on performance and reviews of outcome measures and goals to maintain motivation levels Feedback on the post has been very positive and its scope will only continue to expand as we look to further develop renal rehabilitation services across NHS Highland
NA9Authors Nadine Lyall and Kerry Guthrie
e- mail contact nadinelyallbordersscotnhsuk kerryguthriebordersscotnhsuk
Phone contact 01896 826637
Title The Developing Role of the NMP in a Satellite Dialysis Unit
Introduction Background
We have been practising as NMPrsquos for nearly 3 years working in the dialysis unit at the BGH The unit is a satellite unit of the ERI and we have expanded over the last 6 years The unit provides haemodialysis for 12 patients at any one time 3 sessions a day 6 days a week We are nurse-led and have 2 renal consultants who are based at the ERI
We saw an opportunity to use our knowledge and experience to develop our role By becoming NMPrsquos we have enhanced our professional development and we feel we meet the changing needs of the dialysis patient in a more holistic manner
Aim Objective
Our aim is to deliver effective care as we are better placed to deal with issues that often arise byacting swiftly this in turn is cost effective and convenient For example good anaemia and bonemanagement is important for their health wellbeing and lifespanTo help understand our role we will use a power point presentation highlighting issues we dealwith and the drugs we prescribe under the following headings Cardiovascular infection painanticoagulant disequilibrium diet renal bone disease and renal anaemia
Method Power point
Outcome Results
In the future we hope to further develop and have greater autonomy in our role We have great support from our renal consultants and have already built up a great relationship with our patients We hope to undertake the Clinical Decision Making course and this in turn will allow us to deal effectively with acute illness giving the dialysis patient better care We are keen to get feedback from other renal nurses in Scotland to enable us to develop our role further and in turn raise awareness of the NMP role in a dialysis unit We record all our prescribing decisions and keep the consultants up to date regularly Currently we are working on auditing our prescribing practice so that we can improve the service we can provide
NA10 Title Komunikacja w szkoleniu dializy ortzewnowej
Author Senior Charge Nurse Rhoda Bell
Address Raigmore Hospital Old Perth Road Inverness IV2 3UJ
Email rhodabellnhsnet Telephone 01463706023
Introduction Background Case study on lady with Polish as her first language she has some English but requires an interpreter to carry out Peritoneal Dialysis training and attend clinic She had some gynaecological issues that we were not aware of which impacted on the functionality of PD and therefore the success of treatment There were areas of concern in low clearance clinic with signs the patient had a reluctance to engage in decision making
AimObjective
Methods Discussion through the case study highlighted issues with communication between different PD staff and patients Areas of concern include different staffing techniques environment factors on training success Also language and communication issues the patient had were not fully apparent so training could not be individualised
Results We plan to trial training at home and have more individualised training schedule for patients The training step by step guides have been reviewed and practise standardised In collaboration with low clearance nurse we have developed a check list which will highlight concerns before the transition to PD ie language issues and need for training aids in another language gynaecological conditions
Conclusions Everyone learns differently and training methodsaids must be individualised for all It may not be apparent until training has commenced that there are concerns Having one to one training with the same nurse will consolidate training and build confidence in the patient Having a close working relationship with members of the MDT will help make a supportive PD journey
Would we do things differently if we knew about prolapse or lack of English both spoken and written
Key words - Peritoneal dialysis patient training communication
N11
Telehealth amp PDAudrey Jones
Advantages
Information on a daily basis about treatment weight and blood pressure
Change programme remotely via computer or mobile
Earlier intervention for machineprogramme issues
Reduction in home visits ie patient trained but still requires volume increases
No need to download cards to see what problems have been
Can have more detailed information available at clinics
Disadvantages
Relying on patient input data correctly
Machine is noisy especially first wave of machine
Still the same bag connection system and patient connection system (difficult for manual
dexterity problems)
Relying on patient having good signal
Modem problems
NA12Autosomal Dominant Polycystic Kidney Disease A cruel inheritance but new hopeAlistair Lawrie Renal Unit Victoria Hospital KirkcaldySadaf Arshad Corry Dunnigan Paul Phelan Neil Turner Renal Unit Royal Infirmary of Edinburgh
Background Autosomal Dominant Polycystic Kidney Disease (ADPKD) is the most prevalent single gene human genetic disorder and the most common of the inherited cystic and interstitial kidney diseases It is estimated to affect 1 in every 1000 individuals worldwide with over 50 of sufferers eventually developing end stage kidney disease and requiring dialysis or transplantation Symptoms include spasmodic severe pain hypertension haematuria infection and kidney failure There is currently no cure for ADPKD Management of the condition has traditionally involved lifestyle modification BP control and analgesia however a recent study (Torres et al 2012) demonstrated that treatment with V2-receptor antagonist drugs slowed increase in total kidney volume reduced the rate of functional decline and showed a reduced incidence of kidney pain
Aim Provision of a tolvaptan prescribing and monitoring service
Methods Experiential finding report of initial twelve months period of multidisciplinary ADPKDtolvaptan clinic
Results Early results are comparable with TEMPO study outcomes
Conclusion Due to the long term nature of this treatment results available at this time are showing only the earliest benefits of the intervention More quantifiable results such as increased time before the necessity for RRT will only be evident in coming years Torres VE et al (2012) Tolvaptan in Patients with Autosomal Dominant Polycystic Kidney Disease New England Journal of Medicine 367 pp 2407-2418 DOI 101056NEJMoa1205311
No funding requirement No conflict of interest
P2 An audit of Acute Kidney Injury (AKI) on an acute stroke ward before and after plannedinterventions to review and maintain hydration
Clare Harris1 Simon Hart2 Fiona Duthie3 1 University of Edinburgh Medical School 2 Stroke Unit Royal Infirmary of Edinburgh 3 Renal Unit Royal Infirmary of Edinburgh
Background Dehydration is an important factor in the development of acute kidney injury which is associated with increased morbidity and mortality particularly in the elderly population Poor fluid intake is common post stroke (1) and dehydration is associated with poorer outcomes 3 months post stroke (2) In late 2014 there was no system of identifying patients with poor oral intake on the stroke ward at the Royal Infirmary of Edinburgh a hydration protocol and education programme were implemented aiming to improve fluid balance This included the use of prescribed water either orally or by nasogastric tube An audit pre and post intervention demonstrated that hydration as measured by ureacreatinine ratio significantly improved after the protocol introduction (3) We aimed to determine whether the incidence of AKI by KDIGO criteria was also reduced as this could have implications for reducing patient morbidity and mortality in this elderly comorbid patient cohort
Method 150 inpatients to the acute stroke ward during JulAug 2014 and JulAug 2015 were selected (n= 80 2014 n=70 2015) Patient data and creatinine values were collected from the electronic patient record and medical notes and retrospectively analysed Baseline creatinine values were calculated and cases of AKI were identified and staged using KDIGO criteria (4) Chi-Squared tests were performed to determine P values Individual patient notes were reviewed for both quantitative and qualitative data of patient management
Results Incidence of AKI (of any stage) was 263 pre-protocol and 200 post-protocol (P=03646) Incidence of AKI stages 23 was 100 pre-protocol and 715 post-protocol (P=05374) In hospital post stroke mortality was 338 pre-protocol and 1286 post protocol (P=00028) AKI was also associated with increased length of stay
Conclusions Despite a trend in benefit there was no significant difference in incidence of AKI pre and post hydration protocol nor in incidence of severe AKI (stage 23) AKI is influenced by many factors one of which is hydration status Further studies are needed to determine whether the trend of benefit exhibited in this sample is significant in a greater sample size if this were the case such a protocol could have great benefit to patient care on stroke units and elsewhere There was a significant difference in inpatient post stroke mortality following introduction of the hydration protocol Further investigations are needed to explain underlying reasons for this factors other than hydration may play an important role
References 1 Whelan K Inadequate fluid intakes in dysphagic acute stroke Clinical Nutrition (2001) 20(5)
423-428 2 Bhalla A Sankaralingam S Dundas R Swaminathan R Wolfe CDA Rudd AG The influence of
raised plasma osmolality on clinical outcome after acute stroke Stroke (2000) 312043ndash2048 3 Hart SR Craig R Berry E Lane N Gad A Farrugia M Burton L Paquay A What Happens to
Acute Stroke Patientsrsquo Fluid Balance Renal Status and Dehydration in the First Two Weeks How Can They Be Markedly Improved doi 101111ijs12634_13
4 KDIGO Clinical Practice Guideline for Acute Kidney InjuryKidney international supplements (2012) 2(1) 1-138
No funding or conflict of interest to declare
P3NHS Highland-Improving the management of hyperkalaemia using a kit Initial resultsCantley N1 Abedin T2 Lambie S3
1FY2 NHS Highland 2ST4 Renal Medicine NHS Grampian 3Renal Consultant Renal unitRaigmore Hospital Inverness
Introduction The incidence of hyperkalaemia in hospitalised in patients is between 1 and 10 Guidelines in Northern Ireland promote the use of a Hyperkalaemia Kit to improve management of hyperkalaemia We assessed the management of hyperkalaemia in Raigmore Hospital including post-treatment monitoring of serum potassium and blood glucose at baseline and after the introduction of a lsquoHyperkalaemia Kitrsquo which contains a pro forma for the management of hyperkalaemia and all the relevant equipment and drugs for treatment
Method Between July and September 2016 an automated algorithm identified 34 patients with a potassium result 65 mmoll or above on laboratory results 12 received no specific treatment of these 6 results were spurious 4 patients died before treatment could be started and 2 patients were chronic haemodialysis patients We introduced the Hyperkalaemia Kit to the Acute Medical Admissions Unit in Raigmore Hospital Since then 15 patients have been identified with serum potassium measurements above 65 and the pro forma and kit was used with eight of these patients One of these patients proceeded straight to acute renal replacement therapy
Results Prior to our intervention all 22 patients that were actively treated received at least one prescription of appropriate doses of Insulin with Dextrose However only 16 patients received intravenous calcium and only 7 received nebulised Salbutamol Potassium was measured at 4 hours in 5 cases and by 12 hours in 17 cases Monitoring of any capillary blood glucose was only documented in 8 cases Of the 22 treated 2 needed acute renal replacement therapy 3 required further doses of insulin and dextrose 2 were treated with Calcium Resonium
Eight cases of hyperkalaemia have been managed with the use of the kit and pro-forma so far An initial ECG was performed in all eight and four patients had continuous cardiac monitoring Intravenous calcium was given in seven and nebulised Salbutamol was given in five out of the eight cases Six out of eight patients had at least three blood sugar measurements One had two measurements documented and one patient was stopped from further monitoring following senior review and decision to palliate Seven patients had appropriate monitoring of their serum potassium by 4h and 12h again one patient was not monitored due to palliation
Conclusion Baseline results showed very low rates of prescription of nebulised Salbutamol low rates of Calcium Gluconate use and very low monitoring of blood sugars and potassium post treatment This has the potential for serious adverse outcomes particularly the potential for iatrogenic hypoglycaemia Our initial data shows the use of a Hyperkalaemia pro forma and kit improves the rate of prescription of intravenous calcium and nebulised Salbutamol and the post-treatment monitoring of serum potassium and blood sugar levels
P4Rituximab as maintenance therapy in ANCA associated vasculitisndash a single centre experience Rathnamalala NK Mcmenamin J Robertson S Almond A Kelly M Muniraju T M Renal Unit Dumfries and Galloway Royal Infirmary NHS Dumfries and Galloway Background The introduction of Cyclophosphamide and high dose steroids transformed ANCA associate vasculitis (AAV) from a disease of high mortality to a relapsing remitting disease Maintenance of remission however still remains a major challenge A two randomised clinical trials have looked at the use of Rituximab in remission induction in AAV and reported similar remission rates between Cyclophosphamide and Rituximab 12 Both these trials used Azathioprine as maintenance therapy and in the follow up showed similar remission rates with either agent for induction The role of Rituximab for maintenance therapy after cyclophosphamide induction was studied in the MAINRITSAN trial 3 Rituximab was compared with azathioprine and found that the relapse rate was significantly lower in the Rituximab group There have been several other retrospective studies that have suggested regular Rituximab infusions are successful in maintaining remission however has not been thoroughly evaluated 4 5678910 Here we share our centrersquos experience using Rituximab for maintenance of remission of AAV Materials and methods We conducted a retrospective review of electronic medical records of all patients who had received Rituximab as maintenance therapy for 12 months or longer between January 2014 to July 2016 Disease activity was assessed using Birmingham Vasculitis Activity Score ( BVAS) Version 3 and complete remission was defined as a score of 0 and partial remission as a score of lt50 of the value at diagnosis Due to uncertainties associated with sub classification we did not assign specific diagnosis but broadly classified as ANCA associated vasculitis Results 6 patients received Rituximab as maintenance therapy during the study period 3 (50) of them had eye ear nose and upper airway manifestations consistent with Granulomatosis with Polyangitis (GPA) All patients were PR3 ANCA positive except for one at initial diagnosis The mean BVAS score at the time of initiation of Rituximab was 4 All patients were initiated on Rituximab for relapses while on maintenance therapy with Azathioprine 4 patients received 6 monthly doses of Rituximab while two received annual doses All of them were also maintained on 5-10 mg of Prednisolone The mean BVAS score by 6 months was 0 and remained 0 at 12 months The mean PR3 titre was 562 at the initiation of treatment while at 12 months it had come down to 68 All patients remained in complete clinical remission at the end of 12 months after initiation of therapy Rituximab was well tolerated by all patients except one who developed pyrexia during an administration
Conclusions All patients had sustained remission at 6 months and 12 months after initiating Rituximab Rituximab has a potential role as maintenance therapy in AAV
P5 Chronic Myelo-Monocytic Leukaemia (CMML) as a contraindication to renal biopsy Alastair Rankin Emily McQuarrie Jennifer Lees Bruce MacKinnon Glasgow Renal and Transplant Unit On behalf of the Scottish Renal Biopsy Registry
Abstract Chronic Myelo-Monocytic Leukaemia (CMML) is a relatively rare mixed myelodysplastic myeloproliferative disorder that predominately affects patients over the age of 65 years Renal impairment in patients with CMML is well described with several different mechanisms reported including tumour infiltration lysozyme-induced injury amyloid deposition and tubulointerstitial nephritis From anecdotal evidence within our centre we are concerned that patients with CMML have an excessive risk of clinically significant bleeding following native renal biopsy This risk appears disproportionate to the degree of any co-existing thrombocytopenia or coagulopathy
We review the cases of 4 patients with an existing diagnosis of CMML who were referred to the renal clinic with proteinuria and excretory renal dysfunction Two of these patients underwent renal biopsy with subsequent major haemorrhage post-procedure despite normal bleeding parameters pre-procedure Patient 1 presented with flank pain 8 days post-biopsy A CT confirmed peri-nephric haematoma with retroperitoneal extension A total of 6 units of packed red cells (PRCs) were transfused prior to successful CT-guided emoblisation Histology from the biopsy revealed chronic tubulointerstitial nephritis Patient 2 experienced haemodynamic instability and haematuria one hour post-biopsy A total of 11 units of PRCs 7 units of fresh frozen plasma 2 pools of platelets intravenous tranexamic acid and 2 attempts at CT-guided embolization were required until haemostasis was achieved Histology later showed evidence of tumour infiltration with associated vasculitis Patient 3 presented with renal impairment and proteinuria on the background of known CMML Following discussion with haematology the risk of bleeding following renal biopsy was considered unjustifiable despite their platelets and coagulation screen being within normal range The patient was treated for presumed renal tumour infiltration with hydroxycarbamide Patient 4 was referred to the renal clinic with acute onset nephrotic syndrome Urinary proteincreatinine ratio was elevated over 800 mgmmol with serum albumin of 23 gL but normal excretory renal function The patient attends the haematology clinic with suspected CMML and chronic thrombocytopenia but previously declined bone marrow biopsy Following discussion with the patient there are no plans to proceed with renal biopsy given potential risks These cases highlight that while CMML is rare these patients are being referred to renal clinics with features that would commonly justify renal biopsy in other settings but in whom there may be an increased risk of bleeding post-procedure Our in-centre risk of major bleeding is 2 therefore to have such extreme amounts of bleeding in 2 patients with this underlying diagnosis is remarkable This creates a dilemma for the clinician as there is a wide range of potential renal pathology associated with CMML some of which will have disease specific but relatively toxic treatments available
Source of funding none Conflicts of interest none
P6 NHS Highland-Prograf to Adoport switch McCulloch K1 Peel R2 Lambie S3
1Renal Pharmacist Renal unit Raigmore Hospital Inverness 23Renal Consultant Renal unit Raigmore Hospital Inverness
Introduction NHS Highland (NHSH) is the first health board in Scotland to implement a switch from Prograf to Adoport for renal transplant patients This will provide considerable cost savings Adoport meets the bioequivalence criteria for drugs with a narrow therapeutic index set by the European Medicines agency and studies indicate therapeutic equivalence1 with the proviso that brands are non- interchangeable unless the switch is overseen by a Renal Consultant and post-conversion therapeutic drug monitoring is conducted23 The switch has been undertaken by a majority of transplant centres in England the main difference being that they have undergone repatriation NHSH Patients receive their transplant primarily at Royal Infirmary of Edinburgh and occasionally at Queen Elizabeth University Hospital Glasgow Care is transferred to NHS Highland on discharge NHS Highland cares for approximately 170 renal transplant patients 110 being prescribed Prograf These patients may live as far as 110 miles from Raigmore Hospital Given that prescribing is carried out by primary care clear communication with patients GPs and community pharmacy is essential to avoid inadvertent switching between brands
Method Clinically it was agreed a switch could be safely undertaken A business case was submitted and funding secured for pharmacist time laboratory costs and primary care time GPs have been informed via GP subgroup and local prescribing bulletin lsquoThe Pink Onersquo Community pharmacies are being informed by phone A protocol has been agreed Eligible patients selected by Renal Consultant and Renal Pharmacist Patients sent letter signed by Renal Consultant and Renal pharmacist Patients phoned prior to clinic to agree Adoport start date and address concerns Patient seen by Renal Consultant and pharmacist + given 1 month of Adoport Tacrolimus level and UampEs checked 5-7 days after commencing Adoport and patient
contacted by phone to check if tolerated If stable letter sent to GP and community pharmacy to continue supply
Results and Evaluation Letters have been sent to all eligible patients Seven patients have been reviewed One has received a one month supply of Adoport and 5 others are due to switch One patient was deemed non-eligible at present as they have a 6 month surplus of Prograf A database will be maintained and analysed at the end and primary care savings will be monitored Extra pharmacist input will give us the opportunity to review how immunosuppression is managed and to evaluate the benefit of having a renal transplant pharmacist Conclusion The switch is at an early stage Ultimately we hope to show that the switch from Prograf to Adoport can be managed safely with extra pharmacist input to a remote and rural population with prescribing being conducted by primary care
Fundingconflicts of interest none 1 McDevitt-Potter LM Sadaka B Tichy EM Rogers CC Gabardi S Transplantation 2011 A multicenter experience with
generic tacrolimus conversion 2 Medicines and Health Products Regulatory Agency Drug Safety Update 2012 Accessed online via
wwwmhragovukSafetyinformationDrugSafetyUpdateCON1557563 ESPRIT Guidance on management of repatriation and immunosuppressant switches in transplant patients 2015
Accessed online via httpwwwespritorgukwp-contentuploads201508Switch-guidance-document-final-Aug-31-2015pdf
P7 NHS Highland-Tacrolimus baseline dataMcCulloch K1 Peel R2 Lambie S3
1Renal Pharmacist Renal unit Raigmore Hospital Inverness 2Renal Consultant Renal unitRaigmore Hospital Inverness 3Renal Consultant Renal unit Raigmore Hospital Inverness
BackgroundAs part of planning a switch from using tacrolimus Prograf to Adoport we assessed baseline data for our transplant patients currently using Prograf After converting patients to Adoport we will compare their tacrolimus levels to their individual target range We assessed our use of appropriate target ranges and our current performance in achieving tacrolimus levels within target range on Prograf therapy
Method 107 renal transplant patients taking Prograf were identified a sample of 19 of these were analysed using electronic patient records and results Time from transplant ranged from 1 month to 18 years All tacrolimus levels for the preceding year were analysed and compared to the target range specified at the time of the level being done The assay used has a Coefficient of Variation of lt5 at the lower limit of the assay
Results All 19 patients had a target range for tacrolimus clearly identified and recorded in clinic letterswhich are routinely copied to the patients themselves A variety of target ranges were specifiedThe commonest used was 5-8 microgramsl in 7 patients followed by 5-7 in a further 4 patientswith another 6 different target ranges being used for the remaining 8 patients The ranges usedhad a breadth of 3 microgramsl in 2 cases the rest had a breadth of 2 microgramslPatients had a median of 12 (range 3-72) tacrolimus levels over the preceding year Results werewithin specified target ranges for 54 +- 22 (Medan +- SD) of results checked
Conclusion We currently use a large number of different target ranges The majority of the ranges used had a breadth of just 2 microgramsl These factors help to account for the low proportion of test results which were within the specified target ranges This is important to bear in mind when interpreting whether tacrolimus levels are within target ranges after switching to Adoport We should consider aligning our target ranges and widening them
P8 Eculizumab use in Scottish paediatric dense deposit disease Stewart D1 David Hughes1 Lynne Riach2 Craig Oxley2 Athavale D1
1Royal Hospital for Children Glasgow 2Royal Aberdeen Childrenrsquos Hospital Aberdeen
Introduction The revised MPGN classification and increasing recognition of Dense Deposit Disease (DDD) a C3 glomerulopathy as an alternative complement pathway disorder suggests Eculizumab an anti-C5 monoclonal antibody may be beneficial in treatment However the experience of Eculizumab as an off-label and expensive treatment in children with DDD is limited with variable clinical response reported in the literature
Method We present the outcomes of the only 2 paediatric patients in Scotland who have received Eculizumab for the management of DDD
Results Case 1 A 10 year old male presented with proteinuria and haematuria resistant to steroid treatment with preserved renal function Initial biopsy confirmed DDD Conservative management with an angiotensin converting enzyme inhibitor and diuretics for symptom control continued until 14 years Due to worsening symptoms (oedema lethargy poor growth) and renal function deterioration along with elevated terminal complement complex (TCC) Eculizumab was commenced A repeat biopsy whilst suggestive of chronic irreversible damage showed 25 glomerular architecture preservation Symptom improvement was noted There was a reduction in proteinuria and renal function stabilisation fall in TCC and discontinuation of diuretics Eculizumab was discontinued after 24 months Progression of renal function decline was seen in the final months of Eculizumab therapy With recurrence of symptoms and increasing proteinuria following discontinuation Eculizumab was recommenced after 6 months Symptomatic improvement has since been noted
Case 2 A 5 year old girl presented with painless frank haematuria and proteinuria Initial biopsy confirmed DDD Proteinuria was unresponsive to steroid therapy and 5 months following diagnosis she rapidly progressed towards end stage renal disease despite the introduction of Mycophenolate Mofetil and plasmapheresis Haemodialysis was subsequently commenced TCC level was elevated and Eculizumab treatment was started 7 months after diagnosis Renal biopsy prior to treatment demonstrated continued severe pathological changes in all visible glomeruli However due to lack of clinical response Eculizumab was discontinued after 2 months and the patient remained dialysis dependent
Conclusions Our experience with Eculizumab in Scotland has demonstrated variable results in our 2 patients with one patient showing a positive response whilst the other experienced no improvement Eculizumab was administered to both patients at varying points in their clinical journey with differing progressive features on biopsy To date the outcomes of 9 paediatric patients with DDD treated with Eculizumab have been described in the literature with 8 experiencing some positive response to treatment including 2 patients who were able to stop renal replacement therapy within 12 weeks of treatment A role for Eculizumab in DDD may be guided by clinical and pathological features Well designed clinical trials will be necessary to define the role of complement inhibition therapy in DDD
No conflict of interest and no funding requested
P9 Examining markers of safety in the use of non-tunnelled central venous catheters
James WT Millar (Speciality Registrar) Scott W Oliver (Speciality Registrar) Peter C Thomson (Consultant Nephrologist) Glasgow Renal and Transplant Unit Queen Elizabeth University Hospital Glasgow
Background Non-tunnelled central venous catheters (NTCVC) remain an essential means of vascular access for incident haemodialysis Associated morbidity is well recognised for example in the form of Staphylococcus aureus bloodstream infections (SAB)[1]
Previous quality improvement initiatives in our unit have sought to both improve traditional markers of quality (such as SAB) and to identify additional areas of clinical risk In 2014 Oliver et al [2] suggested several additional quality measures including peri-procedure haemoglobin drop the need for a further NTCVC during the same clinical episode and the NTCVC insertion site This study further evaluated NTCVC related clinical practice within our unit
Methods The potential markers of clinical quality identified in a previous project were examined using prospectively collected data stored in the electronic patient record Identified cases of SAB significant peri-procedure haemoglobin drop and multiple NTCVC insertion were investigated by case note review
Results Between March 2016 and March 2017 a total of 222 patients received 346 NTCVC 54 patients (243) had more than one NTCVC inserted in a 21-day period (range 2-5) When considering NTCVC insertion site there were 159 (459) femoral vein catheters and 183 (541) internal jugular vein catheters No pneumothoraces were reported
15 SABrsquos were reported during this period equating to 43 of all NTCVC 5 arose in patients with femoral NTCVC (333) and 10 from internal jugular catheters (667) Mean time from line insertion to positive blood culture was 86 days 15 (67) patients had a drop in haemoglobin of greater than 20mgdl with no other source of blood loss identified on review of clinical notes
Discussion These data demonstrate that NTCVC-associated SAB rates remain low and significantly below Scottish government audit standards [3] Of interest is the continued trend towards the use of femoral catheters at 45 of lines compared with 38 in 2014 [2] Although traditionally thought of as having a higher incidence of infectious complications our data has shown fewer bacteraemia events associated with femoral catheters compared with internal jugular Our data also demonstrates a significant rate of peri-procedure haemorrhage arising in up to 1 in 20 cases Together these findings present opportunities to development practice and improve patient safety
References
[1] Murray E Deighan C Geddes CC Thomson PC Reducing haemodialysis bacteraemia rates Scottish Renal Association Glasgow November 2013 [2] Oliver SW Thomson PC Jardine AG defining safe effective and patient-centred dialysis catheter placement Scottish Renal Association Edinburgh September 2014 [3] The Staphylococcus aureus bacteraemia quarterly report of cumulative data from all NHS Boards in Scotland Health Protection Scotland January 2015
Sources of funding none Conflicts of interest none
P10 Prescribing of tolvaptan-The NHS Highland experience Lambie S1 McCulloch K2 Garrod J3
1Renal Consultant Renal unit Raigmore Hospital Inverness 2Renal Pharmacist Renal unit Raigmore Hospital Inverness 3Renal Pharmacist Renal unit Raigmore Hospital Inverness
Introduction Tolvaptan is a vasopressin antagonist It was accepted for use in Scotland by SMC in Jan 2016 to slow the progression of cyst development and renal insufficiency of autosomal dominant polycystic kidney disease in adults with chronic kidney disease (CKD) stage 1 to 3 at initiation of treatment with evidence of rapidly progressing disease1 Adverse effects related to aquaresis may affect patientsrsquo ability to achieve the optimum therapeutic dose and the risk of hepatic toxicity necessitates regular LFT monitoring The geography of NHS Highland required the implementation of novel methods of managing these patients and as a result a MDT approach with an emphasis on pharmacist input was adopted Consultant role Patient selection on the basis of evidence of rapidly progressing kidney disease declining
eGFR large volume kidneys on ultrasound and evidence of complications of PKD Side effects and potential benefits discussed Potential medication interactions reviewed Jinarc risk management prescriber training
Pharmacist role Undertook Jinarc risk management pharmacist training Prepares accurate drug history and reviews for potential drug interactions Carries out patient counselling and supplies patient education material sick day rules card
and lsquogot to gorsquo card Supplies GP education leaflet Provides advice on selection of new drug therapies eg for gout Manages stock and coordinates supply to patients
Results Prescribing commenced May 2016 patients currently prescribed tolvaptan 11 7 Female 4 male Number on target dose 73 n = 811 2 patients are still being titrated One patient did
not tolerate target dose due to aquaresis side effects and is being trialled on the middle dose
Withdrawals One patient has withdrawn due to agoraphobia and an inability to attend for monitoring and another is on hold due to having major surgery
Conclusion The MDT approach between the Renal Consultant and Pharmacist at Raigmore Hospital has enabled tolvaptan prescribing to be efficiently and safely implemented to patients living within a challenging geographical location
1 Scottish Medicines Consortium Detailed Advice Document tolvaptan 15mg 30mg 45mg 60mg and 90mg tablets (Jinarcreg) SMC No 111415 January 2016
NA1 Authors SCN Jacqueline Ross NHS Grampian
SCN Alan Somerville NHS Lanarkshire SCN Jane Humphrey NHS Lanarkshire
e- mail contact jacquelinerossnhsnet Alansommervillelanarkshirescotnhsuk
Janehumphreylanarkshirescotnhsuk
Phone contact 01224 552927 01236 712644
Title Sharing of Adverse Events in Renal Units across Scotland
Introduction Background The Scottish Renal Nurses Strategy Group (SRNSG) are a group of senior nurses from Renal
Units across Scotland who meet 3-4 times per year to discuss and implement best practice At the last meeting it was agreed that it would be good practice for each Health Board to share
their adverse events reported on the Datix System and deliver a presentation with an action plan to prevent incidents and improve patient safety across Scotland NHS Grampian and NHS Lanarkshire will be the first to deliver this presentation discussing adverse events from both Health Boards with an action plan
Top 5 adverse events over the past 12 months Renal Unit NHS Grampian 1 Violence and Aggression 2 Accidents including needlesticks slips trips and falls 3 Medication Errors 4 Infrastructure Staffing and Estates 5 Machines and Equipment
Top 5 adverse events over past 12 months Renal Unit NHS Lanarkshire
1 Slips Trips or Falls 2 Medicine errors 3 Treatment problems 4 Transfer problems 5 Breach of policy
The presentation will also focus on any serious adverse events which may not be in the top 5 categories
Aim Objective Each Health Board to share their adverse events with the aim to prevent them from occurring in other units to improve staff and patient safety and wellbeing across Scotland
Method Power Point Presentation
Outcome Results Sharing of adverse events resulting in the development of a national Action Plan to prevent these incidents improving safety and well being of staff and patients in Renal Units across Scotland
NA2
SRA Oct 2017 Abstract
BBV Never Event - The whats whys and hows
Staff Nurse Gillian Wilson Aberdeen Royal Infirmary
This presentation shares our experience of a never event that occurred and was not picked up for
a period of 18 months
Hepatitis C (HCV) positive antibodies were found in a previously negative patient
These results were a low positive with no biochemistry changes to suggest any liver damage
however steps were put immediately in place to isolate and investigate
Was it contamination from a dialysis machine was it related to a blood transfusion given prior to
first positive result was it faulty diagnostic tests in the laboratory
In Aberdeen we go over and above national guidelines and isolate all our BBV patients whether
they have positive blood results or are PCR negative
Further bloods tested at an external laboratory confirmed negative results
It highlighted that communication errors were to blame for the lack of speed in detecting this issue
Investigations concluded no real answers as to why this happened
NA3
Living Donation Scotland Changing attitudes towards living donor kidney transplantation
Jen Lumsdaine Julie Glen On behalf of the Living Donation Scotland Project Board
Background and aims
The rate of living donor transplantation has remained fairly static in Scotland over the past 10 years
Recent data has shown inequity of access to living donor transplantation throughout the UK so
there is potential to significantly increase this optimum form of treatment for patients with end-stage
renal failure in Scotland The Living Donation Project Board was formed in 2016 aiming to double
the number of living donor transplants by 2020
Method
The two key areas
1 Do recipients receive adequate and appropriate information at the right time about living
kidney donation
2 Informing the general public about altruistic donation
All patients active on the transplant list in Scotland were invited to an information event A follow-up
questionnaire was performed in the East of Scotland examining outcome or reasons for not
attending A scoping exercise looked at information provided by each unit was performed and link
nephrologists and low clearance nurses attended meeting to discuss strategies for early education
Outcome
An information pack containing both recipient and donor written information and short films on DVD
has been produced with the support of the Scottish Government for all recipients and potential
donors in Scotland A new website with comprehensive information both written and visual and
postcode finder to improve ease of access to local unit contact details has been developed
Two national media campaigns have been launched with a significant rise in the number of enquiries
from potential donors and actual increase in altruistic donor numbers
Nursing abstract ndash no conflict of interest
NA4Authors Susan Easson Charge Nurse Ward 4C QEUH Glasgow
e- mail contact SusanEassonggcscotnhsuk
Phone contact 0141 452 3300
Title A Conversational approach to find out ldquoWhat matters to yourdquo in a Renal Transplant ward
Introduction Background Finding out ldquo What Mattersrdquo to people using health and careservices is crucial to delivering safe effective and person centred care It is a simple yet profoundconcept and tries to get to the essence of person centred care by creating deeply personalengagements with patients and their families through a conversational approach However careexperience feedback all too often provides innumerable examples of where what really matters topatients and their family members is poorly understood or not addressed Using care experienceas the driver for change the nursing staff in Ward 4C used improvement approaches to explorehow to hold more meaningful ldquoWhat Matters to yourdquo conversations on a daily basis
Aim Objective To improve the patient experience by utilising a person centred approach
Method Using Care experience feedback What Matters to Me boards and the conversationalapproach
Outcome Results Improvements in patient experience will be shared using examples ofpractice and care experience feedback
There was no additional funding required for this project We worked in collaboration with theperson centred team whorsquos aim is to improve patient experience
NA5
The implementation of a renal education programme and its impact on clinical practice
The purpose was to implement a Renal Education Programme and to evaluate its impact on
clinical practise
It was identified that there was a need for an educational programme to be set up within Forth
Valley Royal Hospital There is no inpatient renal unit in FVRH on site for our renal patients they
attend Queen Elizabeth University Hospital We are an outpatient haemodialysis unit with
outpatient clinics on site Therefore it was identified that there was a need for nursing staff within
FVRH to be educated on all renal complexities for the benefit of our patients
This was done through a work-based learning approach which brought tangible benefits for our
patients However it did not come without pitfalls as educational programmes are often seen as
making very little difference to clinical practise
T
his study describes what methods were used and examines the advantages and disadvantages in
setting up an educational programme and evaluating its impact on clinical practise
NA6
Nursing Abstract ndash SRA Meeting ndash 26 October 2017
Chris McGee Tonya Broe Ken Weir
Renal Unit Forth Valley Royal Hospital
Use of the Therapy Monitor Haemodialysis Patient Record System Can we aim for a paper-
free dialysis unit
We are trialling a new haemodialysis patient monitoring system to work in conjunction with SERPR
and which is intended to supersede the Finesse system used previously
We are in the early stages of this process but with continuing staff education and regular tech
support we are hoping to gather sufficient evidence to evaluate whether the use of paper case
notes needs to continue
Is it a realistic goal to aim for a completely paper-free unit
NA7
THE CLINICAL USES OF APHERESIS WITHIN NHS TAYSIDE
Laura Thomson CN
Ninewells Hospital Dundee
NHS Tayside took over the apheresis service from BTS in 2012 The service has since expanded
with the benefits of carrying out this treatment has been widely recognised within NHS Tayside
and is now more commonly being offered to treat a wider range of conditions with the number of
treatments carried out each year rising
This presentation will highlight the progression of the apheresis service within NHS Tayside We
will identify the various conditions it is currently being used to treat and also identify the decision
making process involved in carrying out these treatments ie which replacement fluid will be used
anticoagulation medication administered
We will highlight the benefits and challenges we face in providing this expanding service within the
Renal Service
NA8Authors Linda McDougall Renal Physiotherapist NHS Highland
e- mail contact lindamcdougall1nhsnet
Phone contact 01463 706022
Title lsquoExercise on Haemodialysis- Keeping the Wheels in Motionrsquo
Introduction Background The impact of CKD on physical fitness functional ability independence amp ultimately quality of life cannot be underestimated Current national guidelines recommend that all individuals with CKD are encouraged to participate in regular exercise programmes between or during dialysis sessions if on HD Following a successful pilot study funding was approved to establish an lsquoExercise on Dialysisrsquo (EOD) programme across NHS Highland through the appointment of a dedicated renal physiotherapist in 2008 A successful programme was soon established but for several years post-vacancies and increasing in-patient demands limited the physiotherapy servicersquos ability to deliver the programme The need to improve the long-term sustainability of the service was recognised and in late 2016 funding was approved to develop a Band 4 PT HCSW role for this purpose
Aim ObjectiveTo optimise the sustainability and continuity of the lsquoExercise on Dialysisrsquo service across NHSHighland through development of a Band 4 PT HCSW role
Method The potential parameters of the role and limits of autonomy were scoped out using current NES resources and guidelines Service and task analysis was then carried out to establish which components of the EOD protocol could be undertaken by a Band 4 A series of competencies were developed in line with the clinical protocol and one-to-one training and supervision provided to the post-holder to ensure competency achieved in delivering the programme
Outcome Results A 10 WTE Band 4 PT HCSW was appointed in Jan 2017 with a dual role between the renal unit and acute medical wards Although training is not yet complete the post-holder is already running the day-to-day delivery and monthly audit of the EOD service with senior physiotherapist input only required for individual patient safety queries and general discussion around patientsrsquo progress and goals The benefit to the unit has been considerable as the band 4 is available to support patients and staff with EOD provision 5 days a week This allows for one-to-one supervision of patients who need more support to participate in EOD regular feedback on performance and reviews of outcome measures and goals to maintain motivation levels Feedback on the post has been very positive and its scope will only continue to expand as we look to further develop renal rehabilitation services across NHS Highland
NA9Authors Nadine Lyall and Kerry Guthrie
e- mail contact nadinelyallbordersscotnhsuk kerryguthriebordersscotnhsuk
Phone contact 01896 826637
Title The Developing Role of the NMP in a Satellite Dialysis Unit
Introduction Background
We have been practising as NMPrsquos for nearly 3 years working in the dialysis unit at the BGH The unit is a satellite unit of the ERI and we have expanded over the last 6 years The unit provides haemodialysis for 12 patients at any one time 3 sessions a day 6 days a week We are nurse-led and have 2 renal consultants who are based at the ERI
We saw an opportunity to use our knowledge and experience to develop our role By becoming NMPrsquos we have enhanced our professional development and we feel we meet the changing needs of the dialysis patient in a more holistic manner
Aim Objective
Our aim is to deliver effective care as we are better placed to deal with issues that often arise byacting swiftly this in turn is cost effective and convenient For example good anaemia and bonemanagement is important for their health wellbeing and lifespanTo help understand our role we will use a power point presentation highlighting issues we dealwith and the drugs we prescribe under the following headings Cardiovascular infection painanticoagulant disequilibrium diet renal bone disease and renal anaemia
Method Power point
Outcome Results
In the future we hope to further develop and have greater autonomy in our role We have great support from our renal consultants and have already built up a great relationship with our patients We hope to undertake the Clinical Decision Making course and this in turn will allow us to deal effectively with acute illness giving the dialysis patient better care We are keen to get feedback from other renal nurses in Scotland to enable us to develop our role further and in turn raise awareness of the NMP role in a dialysis unit We record all our prescribing decisions and keep the consultants up to date regularly Currently we are working on auditing our prescribing practice so that we can improve the service we can provide
NA10 Title Komunikacja w szkoleniu dializy ortzewnowej
Author Senior Charge Nurse Rhoda Bell
Address Raigmore Hospital Old Perth Road Inverness IV2 3UJ
Email rhodabellnhsnet Telephone 01463706023
Introduction Background Case study on lady with Polish as her first language she has some English but requires an interpreter to carry out Peritoneal Dialysis training and attend clinic She had some gynaecological issues that we were not aware of which impacted on the functionality of PD and therefore the success of treatment There were areas of concern in low clearance clinic with signs the patient had a reluctance to engage in decision making
AimObjective
Methods Discussion through the case study highlighted issues with communication between different PD staff and patients Areas of concern include different staffing techniques environment factors on training success Also language and communication issues the patient had were not fully apparent so training could not be individualised
Results We plan to trial training at home and have more individualised training schedule for patients The training step by step guides have been reviewed and practise standardised In collaboration with low clearance nurse we have developed a check list which will highlight concerns before the transition to PD ie language issues and need for training aids in another language gynaecological conditions
Conclusions Everyone learns differently and training methodsaids must be individualised for all It may not be apparent until training has commenced that there are concerns Having one to one training with the same nurse will consolidate training and build confidence in the patient Having a close working relationship with members of the MDT will help make a supportive PD journey
Would we do things differently if we knew about prolapse or lack of English both spoken and written
Key words - Peritoneal dialysis patient training communication
N11
Telehealth amp PDAudrey Jones
Advantages
Information on a daily basis about treatment weight and blood pressure
Change programme remotely via computer or mobile
Earlier intervention for machineprogramme issues
Reduction in home visits ie patient trained but still requires volume increases
No need to download cards to see what problems have been
Can have more detailed information available at clinics
Disadvantages
Relying on patient input data correctly
Machine is noisy especially first wave of machine
Still the same bag connection system and patient connection system (difficult for manual
dexterity problems)
Relying on patient having good signal
Modem problems
NA12Autosomal Dominant Polycystic Kidney Disease A cruel inheritance but new hopeAlistair Lawrie Renal Unit Victoria Hospital KirkcaldySadaf Arshad Corry Dunnigan Paul Phelan Neil Turner Renal Unit Royal Infirmary of Edinburgh
Background Autosomal Dominant Polycystic Kidney Disease (ADPKD) is the most prevalent single gene human genetic disorder and the most common of the inherited cystic and interstitial kidney diseases It is estimated to affect 1 in every 1000 individuals worldwide with over 50 of sufferers eventually developing end stage kidney disease and requiring dialysis or transplantation Symptoms include spasmodic severe pain hypertension haematuria infection and kidney failure There is currently no cure for ADPKD Management of the condition has traditionally involved lifestyle modification BP control and analgesia however a recent study (Torres et al 2012) demonstrated that treatment with V2-receptor antagonist drugs slowed increase in total kidney volume reduced the rate of functional decline and showed a reduced incidence of kidney pain
Aim Provision of a tolvaptan prescribing and monitoring service
Methods Experiential finding report of initial twelve months period of multidisciplinary ADPKDtolvaptan clinic
Results Early results are comparable with TEMPO study outcomes
Conclusion Due to the long term nature of this treatment results available at this time are showing only the earliest benefits of the intervention More quantifiable results such as increased time before the necessity for RRT will only be evident in coming years Torres VE et al (2012) Tolvaptan in Patients with Autosomal Dominant Polycystic Kidney Disease New England Journal of Medicine 367 pp 2407-2418 DOI 101056NEJMoa1205311
No funding requirement No conflict of interest
P3NHS Highland-Improving the management of hyperkalaemia using a kit Initial resultsCantley N1 Abedin T2 Lambie S3
1FY2 NHS Highland 2ST4 Renal Medicine NHS Grampian 3Renal Consultant Renal unitRaigmore Hospital Inverness
Introduction The incidence of hyperkalaemia in hospitalised in patients is between 1 and 10 Guidelines in Northern Ireland promote the use of a Hyperkalaemia Kit to improve management of hyperkalaemia We assessed the management of hyperkalaemia in Raigmore Hospital including post-treatment monitoring of serum potassium and blood glucose at baseline and after the introduction of a lsquoHyperkalaemia Kitrsquo which contains a pro forma for the management of hyperkalaemia and all the relevant equipment and drugs for treatment
Method Between July and September 2016 an automated algorithm identified 34 patients with a potassium result 65 mmoll or above on laboratory results 12 received no specific treatment of these 6 results were spurious 4 patients died before treatment could be started and 2 patients were chronic haemodialysis patients We introduced the Hyperkalaemia Kit to the Acute Medical Admissions Unit in Raigmore Hospital Since then 15 patients have been identified with serum potassium measurements above 65 and the pro forma and kit was used with eight of these patients One of these patients proceeded straight to acute renal replacement therapy
Results Prior to our intervention all 22 patients that were actively treated received at least one prescription of appropriate doses of Insulin with Dextrose However only 16 patients received intravenous calcium and only 7 received nebulised Salbutamol Potassium was measured at 4 hours in 5 cases and by 12 hours in 17 cases Monitoring of any capillary blood glucose was only documented in 8 cases Of the 22 treated 2 needed acute renal replacement therapy 3 required further doses of insulin and dextrose 2 were treated with Calcium Resonium
Eight cases of hyperkalaemia have been managed with the use of the kit and pro-forma so far An initial ECG was performed in all eight and four patients had continuous cardiac monitoring Intravenous calcium was given in seven and nebulised Salbutamol was given in five out of the eight cases Six out of eight patients had at least three blood sugar measurements One had two measurements documented and one patient was stopped from further monitoring following senior review and decision to palliate Seven patients had appropriate monitoring of their serum potassium by 4h and 12h again one patient was not monitored due to palliation
Conclusion Baseline results showed very low rates of prescription of nebulised Salbutamol low rates of Calcium Gluconate use and very low monitoring of blood sugars and potassium post treatment This has the potential for serious adverse outcomes particularly the potential for iatrogenic hypoglycaemia Our initial data shows the use of a Hyperkalaemia pro forma and kit improves the rate of prescription of intravenous calcium and nebulised Salbutamol and the post-treatment monitoring of serum potassium and blood sugar levels
P4Rituximab as maintenance therapy in ANCA associated vasculitisndash a single centre experience Rathnamalala NK Mcmenamin J Robertson S Almond A Kelly M Muniraju T M Renal Unit Dumfries and Galloway Royal Infirmary NHS Dumfries and Galloway Background The introduction of Cyclophosphamide and high dose steroids transformed ANCA associate vasculitis (AAV) from a disease of high mortality to a relapsing remitting disease Maintenance of remission however still remains a major challenge A two randomised clinical trials have looked at the use of Rituximab in remission induction in AAV and reported similar remission rates between Cyclophosphamide and Rituximab 12 Both these trials used Azathioprine as maintenance therapy and in the follow up showed similar remission rates with either agent for induction The role of Rituximab for maintenance therapy after cyclophosphamide induction was studied in the MAINRITSAN trial 3 Rituximab was compared with azathioprine and found that the relapse rate was significantly lower in the Rituximab group There have been several other retrospective studies that have suggested regular Rituximab infusions are successful in maintaining remission however has not been thoroughly evaluated 4 5678910 Here we share our centrersquos experience using Rituximab for maintenance of remission of AAV Materials and methods We conducted a retrospective review of electronic medical records of all patients who had received Rituximab as maintenance therapy for 12 months or longer between January 2014 to July 2016 Disease activity was assessed using Birmingham Vasculitis Activity Score ( BVAS) Version 3 and complete remission was defined as a score of 0 and partial remission as a score of lt50 of the value at diagnosis Due to uncertainties associated with sub classification we did not assign specific diagnosis but broadly classified as ANCA associated vasculitis Results 6 patients received Rituximab as maintenance therapy during the study period 3 (50) of them had eye ear nose and upper airway manifestations consistent with Granulomatosis with Polyangitis (GPA) All patients were PR3 ANCA positive except for one at initial diagnosis The mean BVAS score at the time of initiation of Rituximab was 4 All patients were initiated on Rituximab for relapses while on maintenance therapy with Azathioprine 4 patients received 6 monthly doses of Rituximab while two received annual doses All of them were also maintained on 5-10 mg of Prednisolone The mean BVAS score by 6 months was 0 and remained 0 at 12 months The mean PR3 titre was 562 at the initiation of treatment while at 12 months it had come down to 68 All patients remained in complete clinical remission at the end of 12 months after initiation of therapy Rituximab was well tolerated by all patients except one who developed pyrexia during an administration
Conclusions All patients had sustained remission at 6 months and 12 months after initiating Rituximab Rituximab has a potential role as maintenance therapy in AAV
P5 Chronic Myelo-Monocytic Leukaemia (CMML) as a contraindication to renal biopsy Alastair Rankin Emily McQuarrie Jennifer Lees Bruce MacKinnon Glasgow Renal and Transplant Unit On behalf of the Scottish Renal Biopsy Registry
Abstract Chronic Myelo-Monocytic Leukaemia (CMML) is a relatively rare mixed myelodysplastic myeloproliferative disorder that predominately affects patients over the age of 65 years Renal impairment in patients with CMML is well described with several different mechanisms reported including tumour infiltration lysozyme-induced injury amyloid deposition and tubulointerstitial nephritis From anecdotal evidence within our centre we are concerned that patients with CMML have an excessive risk of clinically significant bleeding following native renal biopsy This risk appears disproportionate to the degree of any co-existing thrombocytopenia or coagulopathy
We review the cases of 4 patients with an existing diagnosis of CMML who were referred to the renal clinic with proteinuria and excretory renal dysfunction Two of these patients underwent renal biopsy with subsequent major haemorrhage post-procedure despite normal bleeding parameters pre-procedure Patient 1 presented with flank pain 8 days post-biopsy A CT confirmed peri-nephric haematoma with retroperitoneal extension A total of 6 units of packed red cells (PRCs) were transfused prior to successful CT-guided emoblisation Histology from the biopsy revealed chronic tubulointerstitial nephritis Patient 2 experienced haemodynamic instability and haematuria one hour post-biopsy A total of 11 units of PRCs 7 units of fresh frozen plasma 2 pools of platelets intravenous tranexamic acid and 2 attempts at CT-guided embolization were required until haemostasis was achieved Histology later showed evidence of tumour infiltration with associated vasculitis Patient 3 presented with renal impairment and proteinuria on the background of known CMML Following discussion with haematology the risk of bleeding following renal biopsy was considered unjustifiable despite their platelets and coagulation screen being within normal range The patient was treated for presumed renal tumour infiltration with hydroxycarbamide Patient 4 was referred to the renal clinic with acute onset nephrotic syndrome Urinary proteincreatinine ratio was elevated over 800 mgmmol with serum albumin of 23 gL but normal excretory renal function The patient attends the haematology clinic with suspected CMML and chronic thrombocytopenia but previously declined bone marrow biopsy Following discussion with the patient there are no plans to proceed with renal biopsy given potential risks These cases highlight that while CMML is rare these patients are being referred to renal clinics with features that would commonly justify renal biopsy in other settings but in whom there may be an increased risk of bleeding post-procedure Our in-centre risk of major bleeding is 2 therefore to have such extreme amounts of bleeding in 2 patients with this underlying diagnosis is remarkable This creates a dilemma for the clinician as there is a wide range of potential renal pathology associated with CMML some of which will have disease specific but relatively toxic treatments available
Source of funding none Conflicts of interest none
P6 NHS Highland-Prograf to Adoport switch McCulloch K1 Peel R2 Lambie S3
1Renal Pharmacist Renal unit Raigmore Hospital Inverness 23Renal Consultant Renal unit Raigmore Hospital Inverness
Introduction NHS Highland (NHSH) is the first health board in Scotland to implement a switch from Prograf to Adoport for renal transplant patients This will provide considerable cost savings Adoport meets the bioequivalence criteria for drugs with a narrow therapeutic index set by the European Medicines agency and studies indicate therapeutic equivalence1 with the proviso that brands are non- interchangeable unless the switch is overseen by a Renal Consultant and post-conversion therapeutic drug monitoring is conducted23 The switch has been undertaken by a majority of transplant centres in England the main difference being that they have undergone repatriation NHSH Patients receive their transplant primarily at Royal Infirmary of Edinburgh and occasionally at Queen Elizabeth University Hospital Glasgow Care is transferred to NHS Highland on discharge NHS Highland cares for approximately 170 renal transplant patients 110 being prescribed Prograf These patients may live as far as 110 miles from Raigmore Hospital Given that prescribing is carried out by primary care clear communication with patients GPs and community pharmacy is essential to avoid inadvertent switching between brands
Method Clinically it was agreed a switch could be safely undertaken A business case was submitted and funding secured for pharmacist time laboratory costs and primary care time GPs have been informed via GP subgroup and local prescribing bulletin lsquoThe Pink Onersquo Community pharmacies are being informed by phone A protocol has been agreed Eligible patients selected by Renal Consultant and Renal Pharmacist Patients sent letter signed by Renal Consultant and Renal pharmacist Patients phoned prior to clinic to agree Adoport start date and address concerns Patient seen by Renal Consultant and pharmacist + given 1 month of Adoport Tacrolimus level and UampEs checked 5-7 days after commencing Adoport and patient
contacted by phone to check if tolerated If stable letter sent to GP and community pharmacy to continue supply
Results and Evaluation Letters have been sent to all eligible patients Seven patients have been reviewed One has received a one month supply of Adoport and 5 others are due to switch One patient was deemed non-eligible at present as they have a 6 month surplus of Prograf A database will be maintained and analysed at the end and primary care savings will be monitored Extra pharmacist input will give us the opportunity to review how immunosuppression is managed and to evaluate the benefit of having a renal transplant pharmacist Conclusion The switch is at an early stage Ultimately we hope to show that the switch from Prograf to Adoport can be managed safely with extra pharmacist input to a remote and rural population with prescribing being conducted by primary care
Fundingconflicts of interest none 1 McDevitt-Potter LM Sadaka B Tichy EM Rogers CC Gabardi S Transplantation 2011 A multicenter experience with
generic tacrolimus conversion 2 Medicines and Health Products Regulatory Agency Drug Safety Update 2012 Accessed online via
wwwmhragovukSafetyinformationDrugSafetyUpdateCON1557563 ESPRIT Guidance on management of repatriation and immunosuppressant switches in transplant patients 2015
Accessed online via httpwwwespritorgukwp-contentuploads201508Switch-guidance-document-final-Aug-31-2015pdf
P7 NHS Highland-Tacrolimus baseline dataMcCulloch K1 Peel R2 Lambie S3
1Renal Pharmacist Renal unit Raigmore Hospital Inverness 2Renal Consultant Renal unitRaigmore Hospital Inverness 3Renal Consultant Renal unit Raigmore Hospital Inverness
BackgroundAs part of planning a switch from using tacrolimus Prograf to Adoport we assessed baseline data for our transplant patients currently using Prograf After converting patients to Adoport we will compare their tacrolimus levels to their individual target range We assessed our use of appropriate target ranges and our current performance in achieving tacrolimus levels within target range on Prograf therapy
Method 107 renal transplant patients taking Prograf were identified a sample of 19 of these were analysed using electronic patient records and results Time from transplant ranged from 1 month to 18 years All tacrolimus levels for the preceding year were analysed and compared to the target range specified at the time of the level being done The assay used has a Coefficient of Variation of lt5 at the lower limit of the assay
Results All 19 patients had a target range for tacrolimus clearly identified and recorded in clinic letterswhich are routinely copied to the patients themselves A variety of target ranges were specifiedThe commonest used was 5-8 microgramsl in 7 patients followed by 5-7 in a further 4 patientswith another 6 different target ranges being used for the remaining 8 patients The ranges usedhad a breadth of 3 microgramsl in 2 cases the rest had a breadth of 2 microgramslPatients had a median of 12 (range 3-72) tacrolimus levels over the preceding year Results werewithin specified target ranges for 54 +- 22 (Medan +- SD) of results checked
Conclusion We currently use a large number of different target ranges The majority of the ranges used had a breadth of just 2 microgramsl These factors help to account for the low proportion of test results which were within the specified target ranges This is important to bear in mind when interpreting whether tacrolimus levels are within target ranges after switching to Adoport We should consider aligning our target ranges and widening them
P8 Eculizumab use in Scottish paediatric dense deposit disease Stewart D1 David Hughes1 Lynne Riach2 Craig Oxley2 Athavale D1
1Royal Hospital for Children Glasgow 2Royal Aberdeen Childrenrsquos Hospital Aberdeen
Introduction The revised MPGN classification and increasing recognition of Dense Deposit Disease (DDD) a C3 glomerulopathy as an alternative complement pathway disorder suggests Eculizumab an anti-C5 monoclonal antibody may be beneficial in treatment However the experience of Eculizumab as an off-label and expensive treatment in children with DDD is limited with variable clinical response reported in the literature
Method We present the outcomes of the only 2 paediatric patients in Scotland who have received Eculizumab for the management of DDD
Results Case 1 A 10 year old male presented with proteinuria and haematuria resistant to steroid treatment with preserved renal function Initial biopsy confirmed DDD Conservative management with an angiotensin converting enzyme inhibitor and diuretics for symptom control continued until 14 years Due to worsening symptoms (oedema lethargy poor growth) and renal function deterioration along with elevated terminal complement complex (TCC) Eculizumab was commenced A repeat biopsy whilst suggestive of chronic irreversible damage showed 25 glomerular architecture preservation Symptom improvement was noted There was a reduction in proteinuria and renal function stabilisation fall in TCC and discontinuation of diuretics Eculizumab was discontinued after 24 months Progression of renal function decline was seen in the final months of Eculizumab therapy With recurrence of symptoms and increasing proteinuria following discontinuation Eculizumab was recommenced after 6 months Symptomatic improvement has since been noted
Case 2 A 5 year old girl presented with painless frank haematuria and proteinuria Initial biopsy confirmed DDD Proteinuria was unresponsive to steroid therapy and 5 months following diagnosis she rapidly progressed towards end stage renal disease despite the introduction of Mycophenolate Mofetil and plasmapheresis Haemodialysis was subsequently commenced TCC level was elevated and Eculizumab treatment was started 7 months after diagnosis Renal biopsy prior to treatment demonstrated continued severe pathological changes in all visible glomeruli However due to lack of clinical response Eculizumab was discontinued after 2 months and the patient remained dialysis dependent
Conclusions Our experience with Eculizumab in Scotland has demonstrated variable results in our 2 patients with one patient showing a positive response whilst the other experienced no improvement Eculizumab was administered to both patients at varying points in their clinical journey with differing progressive features on biopsy To date the outcomes of 9 paediatric patients with DDD treated with Eculizumab have been described in the literature with 8 experiencing some positive response to treatment including 2 patients who were able to stop renal replacement therapy within 12 weeks of treatment A role for Eculizumab in DDD may be guided by clinical and pathological features Well designed clinical trials will be necessary to define the role of complement inhibition therapy in DDD
No conflict of interest and no funding requested
P9 Examining markers of safety in the use of non-tunnelled central venous catheters
James WT Millar (Speciality Registrar) Scott W Oliver (Speciality Registrar) Peter C Thomson (Consultant Nephrologist) Glasgow Renal and Transplant Unit Queen Elizabeth University Hospital Glasgow
Background Non-tunnelled central venous catheters (NTCVC) remain an essential means of vascular access for incident haemodialysis Associated morbidity is well recognised for example in the form of Staphylococcus aureus bloodstream infections (SAB)[1]
Previous quality improvement initiatives in our unit have sought to both improve traditional markers of quality (such as SAB) and to identify additional areas of clinical risk In 2014 Oliver et al [2] suggested several additional quality measures including peri-procedure haemoglobin drop the need for a further NTCVC during the same clinical episode and the NTCVC insertion site This study further evaluated NTCVC related clinical practice within our unit
Methods The potential markers of clinical quality identified in a previous project were examined using prospectively collected data stored in the electronic patient record Identified cases of SAB significant peri-procedure haemoglobin drop and multiple NTCVC insertion were investigated by case note review
Results Between March 2016 and March 2017 a total of 222 patients received 346 NTCVC 54 patients (243) had more than one NTCVC inserted in a 21-day period (range 2-5) When considering NTCVC insertion site there were 159 (459) femoral vein catheters and 183 (541) internal jugular vein catheters No pneumothoraces were reported
15 SABrsquos were reported during this period equating to 43 of all NTCVC 5 arose in patients with femoral NTCVC (333) and 10 from internal jugular catheters (667) Mean time from line insertion to positive blood culture was 86 days 15 (67) patients had a drop in haemoglobin of greater than 20mgdl with no other source of blood loss identified on review of clinical notes
Discussion These data demonstrate that NTCVC-associated SAB rates remain low and significantly below Scottish government audit standards [3] Of interest is the continued trend towards the use of femoral catheters at 45 of lines compared with 38 in 2014 [2] Although traditionally thought of as having a higher incidence of infectious complications our data has shown fewer bacteraemia events associated with femoral catheters compared with internal jugular Our data also demonstrates a significant rate of peri-procedure haemorrhage arising in up to 1 in 20 cases Together these findings present opportunities to development practice and improve patient safety
References
[1] Murray E Deighan C Geddes CC Thomson PC Reducing haemodialysis bacteraemia rates Scottish Renal Association Glasgow November 2013 [2] Oliver SW Thomson PC Jardine AG defining safe effective and patient-centred dialysis catheter placement Scottish Renal Association Edinburgh September 2014 [3] The Staphylococcus aureus bacteraemia quarterly report of cumulative data from all NHS Boards in Scotland Health Protection Scotland January 2015
Sources of funding none Conflicts of interest none
P10 Prescribing of tolvaptan-The NHS Highland experience Lambie S1 McCulloch K2 Garrod J3
1Renal Consultant Renal unit Raigmore Hospital Inverness 2Renal Pharmacist Renal unit Raigmore Hospital Inverness 3Renal Pharmacist Renal unit Raigmore Hospital Inverness
Introduction Tolvaptan is a vasopressin antagonist It was accepted for use in Scotland by SMC in Jan 2016 to slow the progression of cyst development and renal insufficiency of autosomal dominant polycystic kidney disease in adults with chronic kidney disease (CKD) stage 1 to 3 at initiation of treatment with evidence of rapidly progressing disease1 Adverse effects related to aquaresis may affect patientsrsquo ability to achieve the optimum therapeutic dose and the risk of hepatic toxicity necessitates regular LFT monitoring The geography of NHS Highland required the implementation of novel methods of managing these patients and as a result a MDT approach with an emphasis on pharmacist input was adopted Consultant role Patient selection on the basis of evidence of rapidly progressing kidney disease declining
eGFR large volume kidneys on ultrasound and evidence of complications of PKD Side effects and potential benefits discussed Potential medication interactions reviewed Jinarc risk management prescriber training
Pharmacist role Undertook Jinarc risk management pharmacist training Prepares accurate drug history and reviews for potential drug interactions Carries out patient counselling and supplies patient education material sick day rules card
and lsquogot to gorsquo card Supplies GP education leaflet Provides advice on selection of new drug therapies eg for gout Manages stock and coordinates supply to patients
Results Prescribing commenced May 2016 patients currently prescribed tolvaptan 11 7 Female 4 male Number on target dose 73 n = 811 2 patients are still being titrated One patient did
not tolerate target dose due to aquaresis side effects and is being trialled on the middle dose
Withdrawals One patient has withdrawn due to agoraphobia and an inability to attend for monitoring and another is on hold due to having major surgery
Conclusion The MDT approach between the Renal Consultant and Pharmacist at Raigmore Hospital has enabled tolvaptan prescribing to be efficiently and safely implemented to patients living within a challenging geographical location
1 Scottish Medicines Consortium Detailed Advice Document tolvaptan 15mg 30mg 45mg 60mg and 90mg tablets (Jinarcreg) SMC No 111415 January 2016
NA1 Authors SCN Jacqueline Ross NHS Grampian
SCN Alan Somerville NHS Lanarkshire SCN Jane Humphrey NHS Lanarkshire
e- mail contact jacquelinerossnhsnet Alansommervillelanarkshirescotnhsuk
Janehumphreylanarkshirescotnhsuk
Phone contact 01224 552927 01236 712644
Title Sharing of Adverse Events in Renal Units across Scotland
Introduction Background The Scottish Renal Nurses Strategy Group (SRNSG) are a group of senior nurses from Renal
Units across Scotland who meet 3-4 times per year to discuss and implement best practice At the last meeting it was agreed that it would be good practice for each Health Board to share
their adverse events reported on the Datix System and deliver a presentation with an action plan to prevent incidents and improve patient safety across Scotland NHS Grampian and NHS Lanarkshire will be the first to deliver this presentation discussing adverse events from both Health Boards with an action plan
Top 5 adverse events over the past 12 months Renal Unit NHS Grampian 1 Violence and Aggression 2 Accidents including needlesticks slips trips and falls 3 Medication Errors 4 Infrastructure Staffing and Estates 5 Machines and Equipment
Top 5 adverse events over past 12 months Renal Unit NHS Lanarkshire
1 Slips Trips or Falls 2 Medicine errors 3 Treatment problems 4 Transfer problems 5 Breach of policy
The presentation will also focus on any serious adverse events which may not be in the top 5 categories
Aim Objective Each Health Board to share their adverse events with the aim to prevent them from occurring in other units to improve staff and patient safety and wellbeing across Scotland
Method Power Point Presentation
Outcome Results Sharing of adverse events resulting in the development of a national Action Plan to prevent these incidents improving safety and well being of staff and patients in Renal Units across Scotland
NA2
SRA Oct 2017 Abstract
BBV Never Event - The whats whys and hows
Staff Nurse Gillian Wilson Aberdeen Royal Infirmary
This presentation shares our experience of a never event that occurred and was not picked up for
a period of 18 months
Hepatitis C (HCV) positive antibodies were found in a previously negative patient
These results were a low positive with no biochemistry changes to suggest any liver damage
however steps were put immediately in place to isolate and investigate
Was it contamination from a dialysis machine was it related to a blood transfusion given prior to
first positive result was it faulty diagnostic tests in the laboratory
In Aberdeen we go over and above national guidelines and isolate all our BBV patients whether
they have positive blood results or are PCR negative
Further bloods tested at an external laboratory confirmed negative results
It highlighted that communication errors were to blame for the lack of speed in detecting this issue
Investigations concluded no real answers as to why this happened
NA3
Living Donation Scotland Changing attitudes towards living donor kidney transplantation
Jen Lumsdaine Julie Glen On behalf of the Living Donation Scotland Project Board
Background and aims
The rate of living donor transplantation has remained fairly static in Scotland over the past 10 years
Recent data has shown inequity of access to living donor transplantation throughout the UK so
there is potential to significantly increase this optimum form of treatment for patients with end-stage
renal failure in Scotland The Living Donation Project Board was formed in 2016 aiming to double
the number of living donor transplants by 2020
Method
The two key areas
1 Do recipients receive adequate and appropriate information at the right time about living
kidney donation
2 Informing the general public about altruistic donation
All patients active on the transplant list in Scotland were invited to an information event A follow-up
questionnaire was performed in the East of Scotland examining outcome or reasons for not
attending A scoping exercise looked at information provided by each unit was performed and link
nephrologists and low clearance nurses attended meeting to discuss strategies for early education
Outcome
An information pack containing both recipient and donor written information and short films on DVD
has been produced with the support of the Scottish Government for all recipients and potential
donors in Scotland A new website with comprehensive information both written and visual and
postcode finder to improve ease of access to local unit contact details has been developed
Two national media campaigns have been launched with a significant rise in the number of enquiries
from potential donors and actual increase in altruistic donor numbers
Nursing abstract ndash no conflict of interest
NA4Authors Susan Easson Charge Nurse Ward 4C QEUH Glasgow
e- mail contact SusanEassonggcscotnhsuk
Phone contact 0141 452 3300
Title A Conversational approach to find out ldquoWhat matters to yourdquo in a Renal Transplant ward
Introduction Background Finding out ldquo What Mattersrdquo to people using health and careservices is crucial to delivering safe effective and person centred care It is a simple yet profoundconcept and tries to get to the essence of person centred care by creating deeply personalengagements with patients and their families through a conversational approach However careexperience feedback all too often provides innumerable examples of where what really matters topatients and their family members is poorly understood or not addressed Using care experienceas the driver for change the nursing staff in Ward 4C used improvement approaches to explorehow to hold more meaningful ldquoWhat Matters to yourdquo conversations on a daily basis
Aim Objective To improve the patient experience by utilising a person centred approach
Method Using Care experience feedback What Matters to Me boards and the conversationalapproach
Outcome Results Improvements in patient experience will be shared using examples ofpractice and care experience feedback
There was no additional funding required for this project We worked in collaboration with theperson centred team whorsquos aim is to improve patient experience
NA5
The implementation of a renal education programme and its impact on clinical practice
The purpose was to implement a Renal Education Programme and to evaluate its impact on
clinical practise
It was identified that there was a need for an educational programme to be set up within Forth
Valley Royal Hospital There is no inpatient renal unit in FVRH on site for our renal patients they
attend Queen Elizabeth University Hospital We are an outpatient haemodialysis unit with
outpatient clinics on site Therefore it was identified that there was a need for nursing staff within
FVRH to be educated on all renal complexities for the benefit of our patients
This was done through a work-based learning approach which brought tangible benefits for our
patients However it did not come without pitfalls as educational programmes are often seen as
making very little difference to clinical practise
T
his study describes what methods were used and examines the advantages and disadvantages in
setting up an educational programme and evaluating its impact on clinical practise
NA6
Nursing Abstract ndash SRA Meeting ndash 26 October 2017
Chris McGee Tonya Broe Ken Weir
Renal Unit Forth Valley Royal Hospital
Use of the Therapy Monitor Haemodialysis Patient Record System Can we aim for a paper-
free dialysis unit
We are trialling a new haemodialysis patient monitoring system to work in conjunction with SERPR
and which is intended to supersede the Finesse system used previously
We are in the early stages of this process but with continuing staff education and regular tech
support we are hoping to gather sufficient evidence to evaluate whether the use of paper case
notes needs to continue
Is it a realistic goal to aim for a completely paper-free unit
NA7
THE CLINICAL USES OF APHERESIS WITHIN NHS TAYSIDE
Laura Thomson CN
Ninewells Hospital Dundee
NHS Tayside took over the apheresis service from BTS in 2012 The service has since expanded
with the benefits of carrying out this treatment has been widely recognised within NHS Tayside
and is now more commonly being offered to treat a wider range of conditions with the number of
treatments carried out each year rising
This presentation will highlight the progression of the apheresis service within NHS Tayside We
will identify the various conditions it is currently being used to treat and also identify the decision
making process involved in carrying out these treatments ie which replacement fluid will be used
anticoagulation medication administered
We will highlight the benefits and challenges we face in providing this expanding service within the
Renal Service
NA8Authors Linda McDougall Renal Physiotherapist NHS Highland
e- mail contact lindamcdougall1nhsnet
Phone contact 01463 706022
Title lsquoExercise on Haemodialysis- Keeping the Wheels in Motionrsquo
Introduction Background The impact of CKD on physical fitness functional ability independence amp ultimately quality of life cannot be underestimated Current national guidelines recommend that all individuals with CKD are encouraged to participate in regular exercise programmes between or during dialysis sessions if on HD Following a successful pilot study funding was approved to establish an lsquoExercise on Dialysisrsquo (EOD) programme across NHS Highland through the appointment of a dedicated renal physiotherapist in 2008 A successful programme was soon established but for several years post-vacancies and increasing in-patient demands limited the physiotherapy servicersquos ability to deliver the programme The need to improve the long-term sustainability of the service was recognised and in late 2016 funding was approved to develop a Band 4 PT HCSW role for this purpose
Aim ObjectiveTo optimise the sustainability and continuity of the lsquoExercise on Dialysisrsquo service across NHSHighland through development of a Band 4 PT HCSW role
Method The potential parameters of the role and limits of autonomy were scoped out using current NES resources and guidelines Service and task analysis was then carried out to establish which components of the EOD protocol could be undertaken by a Band 4 A series of competencies were developed in line with the clinical protocol and one-to-one training and supervision provided to the post-holder to ensure competency achieved in delivering the programme
Outcome Results A 10 WTE Band 4 PT HCSW was appointed in Jan 2017 with a dual role between the renal unit and acute medical wards Although training is not yet complete the post-holder is already running the day-to-day delivery and monthly audit of the EOD service with senior physiotherapist input only required for individual patient safety queries and general discussion around patientsrsquo progress and goals The benefit to the unit has been considerable as the band 4 is available to support patients and staff with EOD provision 5 days a week This allows for one-to-one supervision of patients who need more support to participate in EOD regular feedback on performance and reviews of outcome measures and goals to maintain motivation levels Feedback on the post has been very positive and its scope will only continue to expand as we look to further develop renal rehabilitation services across NHS Highland
NA9Authors Nadine Lyall and Kerry Guthrie
e- mail contact nadinelyallbordersscotnhsuk kerryguthriebordersscotnhsuk
Phone contact 01896 826637
Title The Developing Role of the NMP in a Satellite Dialysis Unit
Introduction Background
We have been practising as NMPrsquos for nearly 3 years working in the dialysis unit at the BGH The unit is a satellite unit of the ERI and we have expanded over the last 6 years The unit provides haemodialysis for 12 patients at any one time 3 sessions a day 6 days a week We are nurse-led and have 2 renal consultants who are based at the ERI
We saw an opportunity to use our knowledge and experience to develop our role By becoming NMPrsquos we have enhanced our professional development and we feel we meet the changing needs of the dialysis patient in a more holistic manner
Aim Objective
Our aim is to deliver effective care as we are better placed to deal with issues that often arise byacting swiftly this in turn is cost effective and convenient For example good anaemia and bonemanagement is important for their health wellbeing and lifespanTo help understand our role we will use a power point presentation highlighting issues we dealwith and the drugs we prescribe under the following headings Cardiovascular infection painanticoagulant disequilibrium diet renal bone disease and renal anaemia
Method Power point
Outcome Results
In the future we hope to further develop and have greater autonomy in our role We have great support from our renal consultants and have already built up a great relationship with our patients We hope to undertake the Clinical Decision Making course and this in turn will allow us to deal effectively with acute illness giving the dialysis patient better care We are keen to get feedback from other renal nurses in Scotland to enable us to develop our role further and in turn raise awareness of the NMP role in a dialysis unit We record all our prescribing decisions and keep the consultants up to date regularly Currently we are working on auditing our prescribing practice so that we can improve the service we can provide
NA10 Title Komunikacja w szkoleniu dializy ortzewnowej
Author Senior Charge Nurse Rhoda Bell
Address Raigmore Hospital Old Perth Road Inverness IV2 3UJ
Email rhodabellnhsnet Telephone 01463706023
Introduction Background Case study on lady with Polish as her first language she has some English but requires an interpreter to carry out Peritoneal Dialysis training and attend clinic She had some gynaecological issues that we were not aware of which impacted on the functionality of PD and therefore the success of treatment There were areas of concern in low clearance clinic with signs the patient had a reluctance to engage in decision making
AimObjective
Methods Discussion through the case study highlighted issues with communication between different PD staff and patients Areas of concern include different staffing techniques environment factors on training success Also language and communication issues the patient had were not fully apparent so training could not be individualised
Results We plan to trial training at home and have more individualised training schedule for patients The training step by step guides have been reviewed and practise standardised In collaboration with low clearance nurse we have developed a check list which will highlight concerns before the transition to PD ie language issues and need for training aids in another language gynaecological conditions
Conclusions Everyone learns differently and training methodsaids must be individualised for all It may not be apparent until training has commenced that there are concerns Having one to one training with the same nurse will consolidate training and build confidence in the patient Having a close working relationship with members of the MDT will help make a supportive PD journey
Would we do things differently if we knew about prolapse or lack of English both spoken and written
Key words - Peritoneal dialysis patient training communication
N11
Telehealth amp PDAudrey Jones
Advantages
Information on a daily basis about treatment weight and blood pressure
Change programme remotely via computer or mobile
Earlier intervention for machineprogramme issues
Reduction in home visits ie patient trained but still requires volume increases
No need to download cards to see what problems have been
Can have more detailed information available at clinics
Disadvantages
Relying on patient input data correctly
Machine is noisy especially first wave of machine
Still the same bag connection system and patient connection system (difficult for manual
dexterity problems)
Relying on patient having good signal
Modem problems
NA12Autosomal Dominant Polycystic Kidney Disease A cruel inheritance but new hopeAlistair Lawrie Renal Unit Victoria Hospital KirkcaldySadaf Arshad Corry Dunnigan Paul Phelan Neil Turner Renal Unit Royal Infirmary of Edinburgh
Background Autosomal Dominant Polycystic Kidney Disease (ADPKD) is the most prevalent single gene human genetic disorder and the most common of the inherited cystic and interstitial kidney diseases It is estimated to affect 1 in every 1000 individuals worldwide with over 50 of sufferers eventually developing end stage kidney disease and requiring dialysis or transplantation Symptoms include spasmodic severe pain hypertension haematuria infection and kidney failure There is currently no cure for ADPKD Management of the condition has traditionally involved lifestyle modification BP control and analgesia however a recent study (Torres et al 2012) demonstrated that treatment with V2-receptor antagonist drugs slowed increase in total kidney volume reduced the rate of functional decline and showed a reduced incidence of kidney pain
Aim Provision of a tolvaptan prescribing and monitoring service
Methods Experiential finding report of initial twelve months period of multidisciplinary ADPKDtolvaptan clinic
Results Early results are comparable with TEMPO study outcomes
Conclusion Due to the long term nature of this treatment results available at this time are showing only the earliest benefits of the intervention More quantifiable results such as increased time before the necessity for RRT will only be evident in coming years Torres VE et al (2012) Tolvaptan in Patients with Autosomal Dominant Polycystic Kidney Disease New England Journal of Medicine 367 pp 2407-2418 DOI 101056NEJMoa1205311
No funding requirement No conflict of interest
