Fergus J Caskey

University of the West of England, Bristol, Bristol, England, United Kingdom

Are you Fergus J Caskey?

Claim your profile

Publications (62)191.31 Total impact

  • Source
    [Show abstract] [Hide abstract]
    ABSTRACT: Background This article provides a summary of the 2013 European Renal Association–European Dialysis and Transplant Association (ERA-EDTA) Registry Annual Report (available at http://www.era-edta-reg.org), with a focus on patients with diabetes mellitus (DM) as the cause of end-stage renal disease (ESRD). Methods In 2015, the ERA-EDTA Registry received data on renal replacement therapy (RRT) for ESRD from 49 national or regional renal registries in 34 countries in Europe and bordering the Mediterranean Sea. Individual patient data were provided by 31 registries, while 18 registries provided aggregated data. The total population covered by the participating registries comprised 650 million people. Results In total, 72 933 patients started RRT for ESRD within the countries and regions reporting to the ERA-EDTA Registry, resulting in an overall incidence of 112 per million population (pmp). The overall prevalence on 31 December 2013 was 738 pmp (n = 478 990). Patients with DM as the cause of ESRD comprised 24% of the incident RRT patients (26 pmp) and 17% of the prevalent RRT patients (122 pmp). When compared with the USA, the incidence of patients starting RRT pmp secondary to DM in Europe was five times lower and the incidence of RRT due to other causes of ESRD was two times lower. Overall, 19 426 kidney transplants were performed (30 pmp). The 5-year adjusted survival for all RRT patients was 60.9% [95% confidence interval (CI) 60.5–61.3] and 50.6% (95% CI 49.9–51.2) for patients with DM as the cause of ESRD.
    Full-text · Article · Jan 2016 · CKJ: Clinical Kidney Journal
  • [Show abstract] [Hide abstract]
    ABSTRACT: Background: We evaluated the 15-year kidney allograft survival in patients with primary glomerulonephritis and determined if the risk of graft loss varied with donor source within each glomerulonephritis group. Methods: Using data from the European Renal Association-European Dialysis and Transplant Association Registry, Kaplan-Meier, competing risk, and Cox regression analyses were performed on adult, first kidney transplant recipients during 1991 to 2010 (n = 14 383). Follow-up was set to December 31, 2011. Adjustments for pretransplant dialysis duration, sex, country, and transplant era were made. "Death-adjusted graft survival" was assessed in patients with glomerulonephritis and compared with those with autosomal dominant polycystic kidney disease (ADPKD), in which the native kidney disease cannot recur. Additionally, death-adjusted graft survival was compared between living and deceased donor transplants within each glomerulonephritis group. Results: All glomerulonephritides had a 15-year death-adjusted graft survival probability above 55%. The 15-year risk of death-adjusted graft failure compared to ADPKD ranged from 1.17 (95% confidence interval [95% CI], 1.05-1.31) for immunoglobulin A nephropathy to 2.09 (95% CI, 1.56-2.78) for membranoproliferative glomerulonephritis type II. The expected survival benefits of living over deceased donor transplants were not present in membranoproliferative glomerulonephritis type I (adjusted hazard ratios [HRa], 1.08; 95% CI, 0.73-1.60) or type II (HRa, 0.90; 95% CI, 0.32-2.52) but present in immunoglobulin A nephropathy (HRa, 0.74; 95% CI, 0.59-0.92), membranous nephropathy (HRa, 0.47; 95% CI, 0.29-0.75), and focal segmental glomerulosclerosis (HRa, 0.69; 95% CI, 0.45-1.06). Conclusions: This large European study shows favorable long-term kidney graft survival in all primary glomerulonephritides, although this remains lower than graft survival in ADPKD, and confirms that the reluctance to use living donors in some primary glomerulonephritides remains unfounded. These data will further inform prospective renal transplant recipients and donors during pretransplant counselling.
    No preview · Article · Nov 2015 · Transplantation
  • Source
    [Show abstract] [Hide abstract]
    ABSTRACT: Background This study examines the time trends in incidence, prevalence, patient and kidney allograft survival and causes of death (COD) in patients receiving renal replacement therapy (RRT) in Europe. Methods Eighteen national or regional renal registries providing data to the European Renal Association-European Dialysis and Transplant Association Registry between 1998 and 2011 were included. Incidence and prevalence time trends between 2001 and 2011 were studied with Joinpoint and Poisson regression. Patient and kidney allograft survival and COD between 1998 and 2011 were analysed using Kaplan–Meier and competing risk methods and Cox regression. Results From 2001 to 2008, the adjusted incidence of RRT rose by 1.1% (95% CI: 0.6, 1.7) annually to 131 per million population (pmp). During 2008–2011, the adjusted incidence fell by 2.2% (95% CI: −4.2, −0.2) annually to 125 pmp. This decline occurred predominantly in patients aged 45–64 years, 65–74 years and in the primary renal diseases diabetes mellitus type 1 and 2, renovascular disease and glomerulonephritis. Between 2001 and 2011, the overall adjusted prevalence increased from 724 to 1032 pmp (+3.3% annually, 95% CI: 2.8, 3.8). The adjusted 5-year patient survival on RRT improved between 1998–2002 and 2003–2007 [adjusted hazard ratio (HRa) 0.85, 95% CI: 0.84, 0.86]. Comparing these time periods, the risk of cardiovascular deaths fell by 25% (HRa 0.75, 95% CI: 0.74, 0.77). However the risk of malignant death rose by 9% (HRa 1.09, 95% CI: 1.03, 1.16) in patients ≥65 years. Conclusion This European study shows a declining RRT incidence, particularly in patients aged 45–64 years, 65–74 years and secondary to diabetic nephropathy. Encouragingly, the adjusted RRT patient survival continues to improve. The risk of cardiovascular death has decreased, though the risk of death from malignancy has increased in the older population.
    Full-text · Article · Nov 2015 · Nephrology Dialysis Transplantation
  • Source
    [Show abstract] [Hide abstract]
    ABSTRACT: Background: Acute kidney injury (AKI) is common and often leads to significant morbidity and/or death. The development of AKI, or complications associated with it, may be due to use of certain medications in at-risk patients experiencing an intercurrent illness. Implicated drugs include diuretics, angiotensin-converting enzyme inhibitors/angiotensin receptor blockers/direct renin inhibitors, non-steroidal anti-inflammatory drugs (NSAIDs), metformin and sulfonylureas. Expert consensus opinion (and clinical guidelines) recommend considering discontinuation of diuretics, angiotensin-converting enzyme inhibitors/angiotensin receptor blockers/direct renin inhibitors, NSAIDs, metformin and sulfonylureas in the event of an intercurrent illness to prevent AKI onset or reduce severity or complications. However, the evidence base for these recommendations is very limited. This systematic review aims to address the available evidence for the temporary discontinuation of diuretics, ACE inhibitors, angiotensin receptor blockers, direct renin inhibitors, non-steroidal anti-inflammatories and metformin and sulfonylureas for those at risk of AKI or with newly diagnosed AKI. Methods/design: Randomised controlled trials; non-randomised trials; cohort studies; case-control studies; interrupted time series studies; and before-and-after studies featuring adults aged 18 and over in any setting currently taking diuretics, angiotensin-converting enzyme inhibitors/angiotensin receptor blockers/direct renin inhibitors, NSAIDs and metformin; experiencing an intercurrent illness; or undergoing a radiological/surgical procedure (planned or unplanned) will be searched for. Relevant trial registers and systematic review databases will be searched. Systematic reviews will be assessed for methodological quality using the ROBIS tool, trials will be assessed using the Cochrane risk of bias tool, and observational studies will be assessed using the ACROBAT-NRS tool. If sufficient studies assessing similar populations, study type, settings and outcomes are found, then a formal meta-analysis will be performed to estimate summary measures of effect. If not, a narrative synthesis will be adopted. Discussion: This review will synthesise evidence for the efficacy of discontinuing diuretics, angiotensin-converting enzyme inhibitors/angiotensin receptor blockers/direct renin inhibitors, NSAIDs, metformin or sulfonylureas to prevent or delay onset of AKI or associated complications. Results will provide guidance on efficacy and safety of this strategy and potentially help to develop an intervention to test the best mechanism of guiding medication discontinuation in at-risk populations. Systematic review registration: PROSPERO CRD42015023210.
    Full-text · Article · Oct 2015 · Systematic Reviews
  • Source
    [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.
    Full-text · Article · Aug 2015 · CKJ: Clinical Kidney Journal
  • [Show abstract] [Hide abstract]
    ABSTRACT: Background Although previous studies suggest similar patient survival for peritoneal dialysis (PD) and haemodialysis (HD), PD use has decreased worldwide. We aimed to study trends in the choice of first dialysis modality and relate these to variation in patient and technique survival and kidney transplant rates in Europe over the last 20 years. Methods We used data from 196 076 patients within the European Renal Association-European Dialysis and Transplant Association (ERA-EDTA) Registry who started renal replacement therapy (RRT) between 1993 and 2012. Trends in the incidence rate and prevalence on Day 91 after commencing RRT were quantified with Joinpoint regression. Crude and adjusted hazard ratios (HRs) for 5-year dialysis patient and technique survival were calculated using Cox regression. Analyses were repeated using propensity score matching to control for confounding by indication. Results PD prevalence dropped since 2007 and HD prevalence stabilized since 2009. Incidence rates of PD and HD decreased from 2000 and 2009, respectively, while the incidence of kidney transplantation increased from 1993 onwards. Similar 5-year patient survival for PD versus HD patients was found in 1993–97 [adjusted HR: 1.02, 95% confidence interval (95% CI): 0.98–1.06], while survival was higher for PD patients in 2003–07 (HR: 0.91, 95% CI: 0.88–0.95). Both PD (HR: 0.95, 95% CI: 0.91–1.00) and HD technique survival (HR: 0.93, 95% CI: 0.87–0.99) improved in 2003–07 compared with 1993–97. Conclusions Although initiating RRT on PD was associated with favourable patient survival when compared with starting on HD treatment, PD was often not selected as initial dialysis modality. Over time, we observed a significant decline in PD use and a stabilization in HD use. These observations were explained by the lower incidence rate of PD and HD and the increase in pre-emptive transplantation.
    No preview · Article · Aug 2015 · Nephrology Dialysis Transplantation
  • Source

    Full-text · Dataset · Jul 2015
  • [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.
    No preview · Article · Jul 2015 · British Journal of General Practice
  • Source
    [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). Methods: 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. Results: 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.
    Full-text · Article · Jun 2015 · CKJ: Clinical Kidney Journal
  • Source
    [Show abstract] [Hide abstract]
    ABSTRACT: Despite the potential for patient-reported outcome measures (PROMs) and experience measures (PREMs) to enhance understanding of patient experiences and outcomes they have not, to date, been widely incorporated into renal registry datasets. This report summarizes the main points learned from an ERA-EDTA QUEST-funded consensus meeting on how to routinely collect PROMs and PREMs in renal registries in Europe. In preparation for the meeting, we surveyed all European renal registries to establish current or planned efforts to collect PROMs/PREMs. A systematic review of the literature was performed. Publications reporting barriers and/or facilitators to PROMs/PREMs collection by registries were identified and a narrative synthesis undertaken. A group of renal registry representatives, PROMs/PREMs experts and patient representatives then met to (i) share any experience renal registries in Europe have in this area; (ii) establish how patient-reported data might be collected by understanding how registries currently collect routine data and how patient-reported data is collected in other settings; (iii) harmonize the future collection of patient-reported data by renal registries in Europe by agreeing upon preferred instruments and (iv) to identify the barriers to routine collection of patient-reported data in renal registries in Europe. In total, 23 of the 45 European renal registries responded to the survey. Two reported experience in collecting PROMs and three stated that they were actively exploring ways to do so. The systematic review identified 157 potentially relevant articles of which 9 met the inclusion criteria and were analysed for barriers and facilitators to routine PROM/PREM collection. Thirteen themes were identified and mapped to a three-stage framework around establishing the need, setting up and maintaining the routine collection of PROMs/PREMs. At the consensus meeting some PROMs instruments were agreed for routine renal registry collection (the generic SF-12, the disease-specific KDQOL™-36 and EQ-5D-5L to be able to derive quality-adjusted life years), but further work was felt to be needed before recommending PREMs. Routinely collecting PROMs and PREMs in renal registries is important if we are to better understand what matters to patients but it is likely to be challenging; close international collaboration will be beneficial. © The Author 2015. Published by Oxford University Press on behalf of ERA-EDTA.
    Full-text · Article · May 2015 · Nephrology Dialysis Transplantation
  • [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.
    No preview · Article · Feb 2015
  • [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.
    No preview · Article · Jan 2015
  • Source
    [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.
    Full-text · Article · Dec 2014
  • [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. 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-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. Conclusions: 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.
    No preview · Article · Nov 2014 · Clinical Journal of the American Society of Nephrology
  • Source
    [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.
    Full-text · Article · Oct 2014 · American Journal of Kidney Diseases
  • [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.
    No preview · Article · Oct 2014 · Clinical Journal of the American Society of Nephrology
  • Source
    [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.
    Full-text · Article · Sep 2014 · Nephrology Dialysis Transplantation
  • Source
    [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. Main conclusion: 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.
    Full-text · Conference Paper · Jun 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.
    No preview · Article · May 2014 · Kidney International
  • Source
    [Show abstract] [Hide abstract]
    ABSTRACT: Introduction and Aims: Continuous erythropoiesis receptor activator (C.E.R.A. [methoxy polyethylene glycol-epoetin beta]) allows once-monthly dosing and may be more convenient for patients compared to the more frequent application schedules for shorter acting erythropoiesis-stimulating agents (ESAs). To maintain a stable Hb after switching can be challenging in specific patient groups. In this analysis we looked at the validity of the proposed switch doses as described in the summary of product characteristics in 2060 HD patients. Furthermore, specific patient characteristics were analysed for their influence on dose requirements. Methods: The starting dose of C.E.R.A. was based on the last dose of the previous ESA, according to the Summary of Product Characteristics. The C.E.R.A. dose was adjusted during the titration and evaluation phases at the discretion of the investigator to maintain Hb concentrations within the pre-defined target concentration for each individual study. Pooled data were analysed for overall Hb stability and dose changes required. Subgroups were defined based on: Hb target range (Lower [L], 10.0_12.0 g/dL/ Upper [U], 10.5_13.0 g/dL); sex (F/M); age (<65/≥65); baseline N-terminal pro-B-type natriuretic peptide (NT-proBNP) levels (<5000/≥5000); CV risk factors (diabetes/cardiac/vascular/none). Results: C.E.R.A. QM maintained stable Hb concentrations uniformly across all subgroups considered. Notably, the proportion of dose modifications required among all administrations was generally low to moderate and seen uniformly across all subgroups.Patients with a lower target Hb range required a significantly lower C.E.R.A. dose than the upper Hb target subgroup (124.7 µg vs 136.9 µg; p=0.0008) (Table 1). ESA resistance index (RI) and baseline NT-proBNP were lower in the upper target group than in the lower target group: median ESA RI 0.8 vs 1.4 [p<0.0001]; median NT-proBNP (pg/mL) 2982 vs 4047 [p<0.0001].Patients in the low NT-proBNP group required a significantly lower C.E.R.A. dose than those in the high NT-proBNP group (124.3 µg vs 138.0 µg; p=0.0022). ESA RI was less in the low NT-proBNP group than in the high group; median ESA RI 1.1 vs 1.3 [p=0.0002].A non-significant trend towards lower dose requirements in the group with no CV risk factors was observed. Significantly lower baseline NT-proBNP levels were measured in the no CV risk group compared with those with diabetes, cardiac or vascular risk factors (median NT-proBNP (pg/mL): 2544 vs 3643 [p=0.0003], 5477 [p<0.0001] and 3753 [p=<0.0001], respectively). Conclusions: These data indicate that the approach to dose switching proposed in the summary of product characteristics for C.E.R.A. suffices. A higher Hb target requires a higher dose; furthermore a higher dose was seen in the patient group with higher NT-proBNP. The absence of cardiovascular risk factors seems to lower the dose requirement. View this table: In this window In a new window
    Full-text · Article · May 2014 · Nephrology Dialysis Transplantation

Publication Stats

555 Citations
191.31 Total Impact Points

Institutions

  • 2015
    • University of the West of England, Bristol
      Bristol, England, United Kingdom
  • 2010-2015
    • University of Bristol
      • School of Clinical Sciences
      Bristol, England, United Kingdom
  • 2006-2013
    • Bristol Hospital
      Bristol, Connecticut, United States
    • Humboldt-Universität zu Berlin
      Berlín, Berlin, Germany
  • 2012
    • University of Amsterdam
      Amsterdamo, North Holland, Netherlands
  • 2011
    • North Bristol NHS Trust
      Bristol, England, United Kingdom
  • 2007
    • University of Southampton
      Southampton, England, United Kingdom
  • 2003
    • University of Aberdeen
      • Health Economics Research Unit
      Aberdeen, Scotland, United Kingdom