[Show abstract][Hide abstract] ABSTRACT: This narrative review evaluates translational research with respect to five important risk factors for chronic kidney disease (CKD): physical inactivity, high salt intake, smoking, diabetes and hypertension. We discuss the translational research around prevention of CKD and its complications both at the level of the general population, and at the level of those at high risk, i.e. people at increased risk for CKD or CKD complications. At the population level, all three lifestyle risk factors (physical inactivity, high salt intake and smoking) have been translated into implemented measures and clear population health improvements have been observed. At the 'high-risk' level, the lifestyle studies reviewed have tended to focus on the individual impact of specific interventions, and their wider implementation and impact on CKD practice are more difficult to establish. The treatment of both diabetes and hypertension appears to have improved, however the impact on CKD and CKD complications was not always clear. Future studies need to investigate the most effective translational interventions in low and middle income countries.
[Show abstract][Hide abstract] ABSTRACT: Background Chronic kidney disease (CKD) has become a significant part of the GP’s workload since the introduction of the National Institute for Health and Care Excellence guidelines in 2008. Patients with advanced CKD (stages G4 and G5) often have comorbidities, varied disease progression, and are likely to be older. GPs may experience difficulties with management decisions for patients with advanced CKD, including when to refer to nephrology.
Aim To explore GPs’ views of managing patients with advanced CKD and referral to secondary care.
Design and setting Qualitative study with GPs in four areas of England: London, Bristol, Birmingham, and Stevenage.
Method Semi-structured interviews with 19 GPs. Transcribed interviews were thematically analysed.
Results GPs had little experience of managing patients with advanced CKD, including those on dialysis or having conservative care (treatment without dialysis or a transplant), and welcomed guidance. Some GPs referred patients based on renal function alone and some used wider criteria including age and multimorbidity. GPs reported a tension between national guidance and local advice, and some had learnt from experience that patients were discharged back to primary care. GPs with more experience of managing CKD referred patients later, or sometimes not at all, if there were no additional problems and if dialysis was seen as not in the patient’s interests.
Conclusion GPs want guidance on managing older patients with advanced CKD and comorbidities, which better incorporates agreement between local and national recommendations to clarify referral criteria. GPs are not generally aware of conservative care programmes provided by renal units, however, they appear happy to contribute to such care or alternatively, lead conservative management with input from renal teams.
British Journal of General Practice 07/2015; 65(636). DOI:10.3399/bjgp15X685693 · 2.29 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Background:
This article provides a summary of the 2011 ERA-EDTA Registry Annual Report (available at www.era-edta-reg.org).
Data on renal replacement therapy (RRT) for end-stage renal disease (ESRD) from national and regional renal registries in 30 countries in Europe and bordering the Mediterranean Sea were used. From 27 registries, individual patient data were received, whereas 17 registries contributed data in aggregated form. We present the incidence and prevalence of RRT, and renal transplant rates in 2011. In addition, survival probabilities and expected remaining lifetimes were calculated for those registries providing individual patient data.
The overall unadjusted incidence rate of RRT in 2011 among all registries reporting to the ERA-EDTA Registry was 117 per million population (pmp) (n = 71.631). Incidence rates varied from 24 pmp in Ukraine to 238 pmp in Turkey. The overall unadjusted prevalence of RRT for ESRD on 31 December 2011 was 692 pmp (n = 425 824). The highest prevalence was reported by Portugal (1662 pmp) and the lowest by Ukraine (131 pmp). Among all registries, a total of 22 814 renal transplantations were performed (37 pmp). The highest overall transplant rate was reported from Spain, Cantabria (81 pmp), whereas the highest rate of living donor transplants was reported from Turkey (39 pmp). For patients who started RRT between 2002 and 2006, the unadjusted 5-year patient survival on RRT was 46.8% [95% confidence interval (CI) 46.6-47.0], and on dialysis 39.3% (95% CI 39.2-39.4). The unadjusted 5-year patient survival after the first renal transplantation performed between 2002 and 2006 was 86.7% (95% CI 86.2-87.2) for kidneys from deceased donors and 94.3% (95% CI 93.6-95.0) for kidneys from living donors.
[Show abstract][Hide abstract] ABSTRACT: Introduction: Infection remains one of the leading causes of mortality in established renal failure patients receiving renal replacement therapy (RRT). Methods: Data were submitted to Public Health England (PHE) by NHS acute Trusts via Health Care Associated Infection Data Capture System (HCAI-DCS) including whether the patients were receiving dialysis. Individual renal units then confirmed the record either directly via the database or after being contacted. Data were collected for the period 1st May 2012 to the 30th April 2013. Results: There were 31 episodes of MRSA bacteraemia, an overall rate of 0.13 per 100 dialysis patient years, representing a further year-on-year fall in MRSA rate. There were a higher number of MSSA episodes, 372 in total, with an overall rate of 1.59 per 100 dialysis patient years. The number of episodes of E. coli and C. difficile were 308 (1.32 per 100 dialysis patient years) and 123 (0.55 per 100 dialysis patient years) respectively. The presence of a central venous catheter was associated with an elevated risk of MRSA and MSSA bacteraemia. Conclusions: We present data relating to infections in renal dialysis patients reported to PHE in one year. The rate of MRSA bacteraemia episodes in England continues to fall. There is a higher rate of MSSA infections. We also report the results of the second year of E. coli and C. difficile data collection. Future cycles will give further ideas of the trend in incidences of these infections. Further work to refine the definitions and data collection is necessary to ensure consistency of reporting across centres.
[Show abstract][Hide abstract] ABSTRACT: Introduction and Aims: The UK Renal Registry (UKRR) hosts a paediatric registry, which reports demographic, biochemical and outcomes data on all renal replacement therapy (RRT) patients under 18 years managed in UK paediatric centres. The paediatric registry was formed in 1995 and is entering its 20th year. We aim to describe the history and development of this registry, including challenges faced and its role today.
Methods: All UKRR reports were reviewed to establish timelines. Dr Malcolm Lewis (ML, a paediatric nephrologist who wrote the original database and remains an active subcommittee member) was interviewed to capture the processes and his reflections.
Results: ML had created a local clinical database in Filemaker in 1994. In 1995 a 2 year pilot project with the UKRR began with support from Prof Terry Feest and Dr David Ansell. This led to ML creating a dataset and database that would collect paediatric data, supported by the British Association of Paediatric Nephrology (BAPN). Roche Pharmaceuticals contributed £5000 funding, which was used to buy IT equipment and support travel to the 13 paediatric centres. The first paediatric report was written by ML and reviewed by the BAPN registry subgroup and presented with the second adult report in 1999. Initially all information technology support was done by both ML and Manchester Children’s Hospital renal data manager, Jo Shaw, with data collection shared with local clinical teams until the paediatric registry was moved to the Bristol UKRR offices in 2009 to support integration with the adult registry. A change in census date to conform with adult and European registries was also agreed. The results were initially published as a single chapter in the UKRR annual report, becoming 3 chapters (demography, growth and anaemia) in 2006 and the current format of a demography and biochemistry chapter from 2009. It was at this time that that UKRR registrars became involved in data analysis and report writing. The current processes remained similar until the appointment of a British Kidney Patient Association funded, Kidney Research UK managed research fellow in 2014 with the aim of bringing the adult and paediatric registries closer together.
The process has been challenging at times; the main frustration encountered was the retrograde step of moving from electronic to paper-based returns in 2000, which was intended as a short term step but lasted for the next 13 years.The leading challenges still faced are those of integrating the adult and paediatric databases to facilitate accurate reporting of data for 16-18 year olds, and moving from annual to quarterly returns.
Conclusions: The timeline presented demonstrates that enthusiasm, technology, funding and collaboration were the key components of this registry. The process has evolved from the input of a single individual with UKRR backing to a more integrated approach with better data management and statistical resources, greater information security and an overall more supported registry.
The paediatric registry’s value over time has become providing demographic data and biochemical data comprehensively on each UK paediatric RRT patient and allows benchmarking and comparison to national guidance and standards. It also provides data on trends since 1998, as well as being a research resource and basis for service planning and evaluation.
[Show abstract][Hide abstract] ABSTRACT: Background: Conservative kidney management (CKM) is recognised as an alternative to dialysis for a significant number of older adults with multi-morbid chronic kidney disease stage 5 (CKD5). However, little is known about the way CKM is delivered or how it is perceived.
Aim: To determine the practice patterns for CKM of older patients with CKD5, to inform service development and future research.
Objectives: i) To describe the differences between renal units in the extent and nature of CKM.
ii) To explore how decisions are made about treatment options for older patients with CKD5.
iii) To explore clinicians willingness to randomise patients with CKD5 to CKM versus dialysis.
iv) To describe the interface between renal units and primary care in managing CKD5.
v) To identify the resources involved and potential costs of CKM.
Methods: Mixed methods study. Interviews with 42 patients aged >75 with CKD5 and 60 renal unit staff in a purposive sample of nine UK renal units. Interviews informed the design of a survey to assess CKM practice, sent to all 71 UK units. Nineteen general practitioners were interviewed concerning referral of CKD patients to secondary care. We sought laboratory data on new CKD5 patients aged >75 years to link with the nine renal units’ records to assess referral patterns.
Results: 67/71 renal units completed the survey. Although terminology varied, there was general acceptance of the role of CKM. Only 52% of units were able to quantify the number of CKM patients. A wide range reflected varied interpretation of the designation ‘CKM’ by both staff and patients. It is used to characterise a future treatment option as well non dialysis care for end-stage kidney failure (ESKF, i.e. a disease state equivalent to being on dialysis), the number of patients in the latter group on CKM were relatively small (median 8 IQR 4.5-22). Patients’ expectations of CKM and dialysis were strongly influenced by renal staff. In a minority of units, CKM was not discussed. When discussed, often only limited information about illness progression was provided. Staff wanted more research into the relative benefits of CKM versus dialysis. There was almost universal support for an observational methodology and a quarter would definitely be willing to participate in a randomised clinical trial, indicating that clinicians placed value on high-quality evidence to inform decision making. Linked data indicated that most CKD5 patients were known to renal units. GPs expressed a need for guidance on when to refer older, multi-morbid patients with CKD5 to nephrology care. There was large variation in the scale and model of CKM delivery. In most, the CKM service was integrated within the service for all non-renal replacement therapy (RRT) CKD5 patients. A few units provided dedicated CKM clinics and some had dedicated modest funding for CKM.
Conclusions: CKM is accepted across UK renal units but there is much variation in the way it is described and delivered. For best practice in CKM to be developed and systematised across all renal units in the UK, we recommend: a) a standard definition and terminology for CKM; b) research to measure the relative benefits of CKM and dialysis; and c) development of evidence-based staff training and patient education interventions.
[Show abstract][Hide abstract] ABSTRACT: Background and objectives:
Conservative kidney management (CKM) has been developed in the United Kingdom (UK) as an alternative to dialysis for older patients with stage 5 CKD (CKD5) and multiple comorbidities. This national survey sought to describe the current scale and pattern of delivery of conservative care in UK renal units and identify their priorities for its future development.
Design, setting, participants, & measurements:
A survey on practice patterns of CKM for patients age 75 and older with CKD5 was sent to clinical directors of all 71 adult renal units in the UK in March 2013.
Sixty-seven units (94%) responded. All but one unit reported providing CKM for some patients. Terminology varied, although "conservative management" was the most frequently used term (46%). Lack of an agreed-upon definition of when a patient is receiving CKM made it difficult to obtain meaningful data on the numbers of such patients. Fifty-two percent provided the number of CKM patients age ≥ 75 years in 2012; the median was 45 per unit (interquartile range [IQR], 20-83). The median number of symptomatic CKM patients who would otherwise have started dialysis was eight (IQR, 4.5-22). CKM practice patterns varied: 35% had a written guideline, 23% had dedicated CKM clinics, 45% had dedicated staff, and 50% provided staff training on CKM. Most units (88%) provided primary care clinicians with information/advice regarding CKM. Eighty percent identified a need for better evidence comparing outcomes on CKM versus dialysis, and 65% considered it appropriate to enter patients into a randomized trial.
CKM is provided in almost all UK renal units, but scale and organization vary widely. Lack of common terminology and definitions hinders the development and assessment of CKM. Many survey respondents expressed support for further research comparing outcomes with conservative care versus dialysis.
Clinical Journal of the American Society of Nephrology 11/2014; 10(1). DOI:10.2215/CJN.05000514 · 4.61 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Background: Older adults with chronic kidney disease stage 5 may be offered a choice between dialysis and conservative management. Few studies have explored patients' reasons for choosing conservative management and none have compared the views of those who have chosen different treatments across renal units. Study Design: Qualitative study with semi-structured interviews. Settings & Participants: Patients 75 years or older recruited from 9 renal units. Units were chosen to reflect variation in the scale of delivery of conservative management. Methodology: Semi-structured interviews audio recorded and transcribed verbatim. Analytical Approach: Data were analyzed using thematic analysis. Results: 42 interviews were completed, 4 to 6 per renal unit. Patients were sampled from those receiving dialysis, those preparing for dialysis, and those choosing conservative management. 14 patients in each group were interviewed. Patients who had chosen different treatments held varying beliefs about what dialysis could offer. The information that patients reported receiving from clinical staff differed between units. Patients from units with a more established conservative management pathway were more aware of conservative management, less often believed that dialysis would guarantee longevity, and more often had discussed the future with staff. Some patients receiving conservative management reported that they would have dialysis if they became unwell in the future, indicating the conditional nature of their decision. Limitations: Recruitment of older adults with frailty and comorbid conditions was difficult and therefore transferability of findings to this population is limited. Conclusions: Older adults with chronic kidney disease stage 5 who have chosen different treatment options have contrasting beliefs about the likely outcomes of dialysis for those who are influenced by information provided by renal units. Supporting renal staff in discussing conservative management as a valid alternative to dialysis for a subset of patients will aid informed decision making. There is a need for better evidence about conservative management to support shared decision making for older people with chronic kidney failure.
American Journal of Kidney Diseases 10/2014; 65(3). DOI:10.1053/j.ajkd.2014.08.011 · 5.90 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Background and objectives: Conservative Kidney Management (CKM) has developed in the UK as an alternative to dialysis for older patients with stage 5 chronic kidney disease (CKD5) and multiple comorbidities. We report on a national survey which aims to describe the current scale and pattern of delivery of conservative care in UK renal units and identify their priorities for its future development.
Design, setting, participants, and measurements: A survey on practice patterns of CKM for patients aged over 75 years with CKD5 was sent to clinical directors of all 71 adult renal units in the UK in March 2013.
Results: Sixty-seven units (94%) responded. All but one unit reported providing CKM for some patients. Terminology varied, although ‘conservative management’ was the most frequently used term (46%). Lack of an agreed definition of when a patient is receiving CKM made it difficult to obtain meaningful data on the numbers of such patients. 52% provided the number of CKM patients aged ≥75 in 2012; the median was 45 per unit (IQR: 20-83). The median number of symptomatic CKM patients who would otherwise have started dialysis was 8 (IQR: 4.5-22). CKM practice patterns varied: 35% had a written guideline; 23% dedicated CKM clinics; 45% dedicated staff; and 50% provided staff training on CKM. Most units (88%) provided primary care clinicians with information/advice regarding CKM. 80% identified a need for better evidence comparing outcomes on CKM versus dialysis and 65% considered it appropriate to enter patients into a randomized trial.
Conclusions: CKM is provided in almost all UK renal units but with wide variation in scale and organization. Lack of common terminology and definitions hinders the development and assessment of CKM. Many survey respondents expressed support There is a need for clinical trials further research comparing outcomes with conservative care versus dialysis.
Clinical Journal of the American Society of Nephrology 10/2014; · 4.61 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: BACKGROUND: Autosomal dominant polycystic kidney disease (ADPKD) is the fourth most common renal disease requiring renal replacement therapy (RRT). Still, there are few epidemiological data on the prevalence of, and survival on RRT for ADPKD.
METHODS: This study used data from the ERA-EDTA Registry on RRT prevalence and survival on RRT in 12 European countries with 208 million inhabitants. We studied four 5-year periods (1991-2010). Survival analysis was performed by the Kaplan-Meier method and by Cox proportional hazards regression.
RESULTS: From the first to the last study period, the prevalence of RRT for ADPKD increased from 56.8 to 91.1 per million population (pmp). The percentage of prevalent RRT patients with ADPKD remained fairly stable at 9.8%. Two-year survival of ADPKD patients on RRT (adjusted for age, sex and country) increased significantly from 89.0 to 92.8%, and was higher than for non-ADPKD subjects. Improved survival was noted for all RRT modalities: haemodialysis [adjusted hazard ratio for mortality during the last versus first time period 0.75 (95% confidence interval 0.61-0.91), peritoneal dialysis 0.55 (0.38-0.80) and transplantation 0.52 (0.32-0.74)]. Cardiovascular mortality as a proportion of total mortality on RRT decreased more in ADPKD patients (from 53 to 29%), than in non-ADPKD patients (from 44 to 35%). Of note, the incidence rate of RRT for ADPKD remained relatively stable at 7.6 versus 8.3 pmp from the first to the last study period, which will be discussed in detail in a separate study.
CONCLUSIONS: In ADPKD patients on RRT, survival has improved markedly, especially due to a decrease in cardiovascular mortality. This has led to a considerable increase in the number of ADPKD patients being treated with RRT.
[Show abstract][Hide abstract] ABSTRACT: Background / Purpose:
Considerable variation exists in the provision of paediatric renal replacement therapy (RRT) across Europe. The current study aims to determine whether this variation arises from country differences in the occurrence of renal disease, or whether country-level access to care factors are responsible.
Inequalities exist in the provision of paediatric RRT throughout Europe. Most of which are explained by country differences in macroeconomics, that limit the provision of treatment particularly in the youngest patients.
51st Congress of the European Renal Association and European Dialysis and Transplant Association 2014; 06/2014
[Show abstract][Hide abstract] ABSTRACT: Autosomal dominant polycystic kidney disease (ADPKD) is a major cause of end-stage kidney failure, but is often identified early and therefore amenable to timely treatment. Interventions known to postpone the need for renal replacement therapy (RRT) in non-ADPKD patients have also been tested in ADPKD patients, but with inconclusive results. To help resolve this we determined changes in RRT incidence rates as an indicator for increasing effective renoprotection over time in ADPKD. We analyzed data from the European Renal Association-European Dialyses and Transplant Association Registry on 315,444 patients starting RRT in 12 European countries between 1991 and 2010, grouped into four 5-year periods. Of them, 20,596 were due to ADPKD. Between the first and last period the mean age at onset of RRT increased from 56.6 to 58.0 years. The age- and gender-adjusted incidence rate of RRT for ADPKD increased slightly over the four periods from 7.6 to 8.3 per million population. No change over time was found in the incidence of RRT for ADPKD up to age 50, whereas in recent time periods the incidence in patients above the age of 70 clearly increased. Among countries there was a significant positive association between RRT take-on rates for non-ADPKD kidney disease and ADPKD. Thus, the increased age at onset of RRT is most likely due to an increased access for elderly ADPKD patients or lower competing risk prior to the start of RRT rather than the consequence of effective emerging renoprotective treatments for ADPKD.Kidney International advance online publication, 14 May 2014; doi:10.1038/ki.2014.120.
Kidney International 05/2014; 86(6). DOI:10.1038/ki.2014.120 · 8.56 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Fatigue is commonly experienced in patients with advanced kidney disease and associated with poor outcomes. The prevalence of fatigue ranges from 42% to as high as 89% according to treatment modality and the measurement instruments used. This paper reviews studies examining sociodemographic, biological, and psychological factors associated with fatigue in advanced kidney disease. The association between fatigue and psychological factors, such as depression and anxiety, behavioral factors, such as sleep and nutrition, and cytokines, such as IL-6 and CRP corroborates the view of fatigue as a multidimensional and multifactorial problem. Although depression and fatigue are related, the relationship is typically moderate in size, thus fatigue should not simply be seen as a symptom of distress. Accordingly, it is important for treatment plans to address the complex etiology of fatigue through pharmacological and nonpharmacological interventions. To date, results of nonpharmacological interventions are promising, with physical exercise and cognitive-behavioral therapy showing beneficial results. Work conducted in other patient populations highlights the importance of cognitions and behaviors in the prediction and maintenance of fatigue. Such work could be applied to advanced kidney disease allowing a model of fatigue to be developed from which to base suitable interventions in this setting.Kidney International advance online publication, 2 April 2014; doi:10.1038/ki.2014.86.
Kidney International 04/2014; 86(3). DOI:10.1038/ki.2014.86 · 8.56 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: The marked variation that exists in renal replacement therapy (RRT) epidemiology between countries and within countries requires
careful systematic examination if the root causes are to be understood. While individual patient-level studies are undoubtedly
important, there is a complementary role for more population-level, area-based studies—an aetiological approach. The EVEREST
Study adopted such an approach, bringing RRT incidence rates, survival and modality mix together with macroeconomic factors,
general population factors and renal service organizational factors for up to 46 countries. This review considers the background
to EVEREST, its key results and then the main methodological lessons and their potential application to ongoing work.
[Show abstract][Hide abstract] ABSTRACT: Background. Incidence rates of renal replacement therapy (RRT) for end-stage renal disease vary consider-ably worldwide. This study examines the independent association between the general population, health care system and renal service characteristics and RRT inci-dence rates. Methods. RRT incidence data (2003–2005) were obtained from renal registries; general population age and health and macroeconomic indices were collected from secondary sources. Renal service organization and resource data were obtained through interviews and questionnaires. Linear regression models were built to establish the factors inde-pendently associated with RRT incidence, stratified by the Human Development Index where required. False discovery rate (FDR) correction was adjusted for multiple testing. Results. Across the 46 countries (population 1.25 billion), RRT incidence rates ranged from 12 to 455 (median 130) per million population. Gross domestic product (GDP) per cap-ita [incidence rate ratio (IRR): 1.02 per $1000 increase, P FDR ¼ 0.047], percentage of GDP spent on health care (IRR: 1.11 per % increase, P FDR ¼ 0.006) and dialysis facility reimbursement rate relative to GDP (IRR: 0.76 per GDP per capita-sized increase in reimbursement rate, P FDR ¼ 0.007) were independently associated with RRT incidence. In more developed countries, the private for-profit share of haemodialysis facilities was also associated with higher incidence (IRR: 1.009 per % increase, P FDR ¼ 0.003). Conclusions. Macroeconomic and renal service factors are more often associated with RRT incidence rates than measured demographic or general population health status factors.