Download 1 - The Scottish Renal Registry

Scottish Renal Association
ABSTRACT BOOKLET
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A1. Urinary steroid excretion is a significant independent predictor of proteinuria and left
ventricular mass in patients with chronic kidney disease
Emily P McQuarrie 1,2, E Marie Freel 1, Patrick B Mark
G Dargie 3, John M C Connell 4, Alan G Jardine 1,2
1,2
, Robert Fraser 1, Rajan K Patel
1,2
, Henry
1. BHF Glasgow Cardiovascular Research Centre, University of Glasgow, 126 University Place,
Glasgow G12 8TA, UK.
2. Department of Renal Medicine, Western Infirmary, Dumbarton Road, Glasgow, G11 6NT, UK.
3. Department of Cardiology, Western Infirmary, Dumbarton Road, Glasgow, G11 6NT, UK.
4. School of Medicine, University of Dundee, DD1 9SY
Background: Blockade of the mineralocorticoid receptor (MR) in CKD reduces left ventricular
mass index (LVMI) and proteinuria. The MR can be activated by aldosterone, cortisol and
deoxycorticosterone. We aimed to assess the impact of mineralocorticoids on LVMI and proteinuria
in patients with CKD.
Methods: 70 patients with CKD and 30 patients with essential hypertension (EH) were recruited.
Patients underwent clinical phenotyping; biochemical assessment and 24h urinary collection for
tetrahydroaldosterone (THAldo), tetrahydrodeoxycorticosterone (THDOC), cortisol metabolites
(measured using gas chromatography-mass spectrometry); urinary electrolytes and protein (QP).
LVMI was measured using cardiac magnetic resonance imaging. Factors which correlated
significantly with LVMI and proteinuria were entered into linear regression models.
Results: In patients with CKD, significant predictors of LVMI were male gender, systolic blood
pressure (SBP), QP, THAldo and THDOC excretion. Significant independent predictors on
multivariate analysis were THDOC excretion, SBP and male gender. In EH no association was
seen between THAldo or THDOC and LVMI; plasma aldosterone concentration was the only
significant independent predictor of LVMI in patients with EH.
Significant univariate determinants of proteinuria in patients with CKD were THALDO and THDOC
excretion, urinary sodium and SBP. Only THALDO excretion and SBP were significant multivariate
determinants.
Conclusions: Using cardiac MRI to determine LVMI we have demonstrated THDOC is a novel
independent predictor of LVMI in patients with CKD, differing from patients with EH. 24h THALDO
excretion is an independent determinant of proteinuria in patients with CKD. These data
emphasise the importance of MR activation in the pathogenesis of the adverse clinical phenotype
in CKD.
Funding: MRC, Darlinda’s Charity for Renal Research
A2. Incidence of acute kidney injury amongst hospital in-patients
Callum Carruthers1, Emma Aitken1, Lewis Gall1, Lynne Kerr1, Amy Martin2, Ruta Zaliunate2 & David
Kingsmore1
1
Department of Surgery, Western Infirmary, Glasgow
2
Department of Medicine, Western Infirmary Glasgow
Background: The incidence of acute kidney injury (AKI) is not well known 1. Underreporting and
variable definitions limit work in the existing literature2. Hospital in-patients are particularly
vulnerable to “pre-renal” insults1,2. This audit aims to evaluate the true incidence of AKI in our
population of hospitalised patients.
Methods: Retrospective data was collected for all 1,577 patients admitted to a University Teaching
Hospital during a one month period (April 2011). Baseline, admission and peak creatinine was
correlated with mortality and length of hospital admission. AKI was classified according to UK
Renal Society Guidelines RIFLE criteria3. Results were analysed by age and admitting speciality.
Data was analysed using SPSS v.15. Results are present as mean (SEM).
Results: Overall incidence of AKI (creatinine >1.5 x baseline) on admission was 4.6%, with 10.3%
of patients developing AKI whilst in hospital. Patients with AKI were significantly older than those
who did not (76.2+/-4y.o. vs. 59.6+/-2.1y.o.; p<0.001). Length of stay was longer with AKI on
admission 11.5+/-1.6 days vs. 4.9 +/-1.2; p<0.001). Length of hospital stay was longer for patients
who developed in hospital AKI (13.8+/-1.7days) vs. those patient admitted to hospital with AKI
(9.8+/-1.5 days) (p<0.01). All cause mortality was higher in the admission AKI group and inhospital AKI group compared to those with no AKI (18.8%, 20.2% and 3.8% respectively).
Breakdown of AKI by speciality is outline in table 1 below:
Medicine Orthopaedics
Admission AKI 6.9%
0%
In-hospital AKI 15.5%
5.7%
General Surgery
3.5%
6.9%
Vascular
4%
10%
Urology
11.1%
15.6%
Conclusion: AKI is common in patients admitted to hospital, and commonly develops de novo in
hospitalised patients. Patients with AKI have higher mortality and increased length of hospital
admission. Further work is required to evaluate the aetiology, early recognition and management,
particularly of in-patient acquired AKI.
1. Cerda J et al (2008) Epidemiology of Acute Kidney Injury. Clin.J.Am.Soc.Nephrol. 3: 881886
2. Chertow GM et al. (2005) Acute Kidney Injury, Mortality, Length of Stay, and Costs in
Hospitalised Patients. J. Am.Soc.Neph 16: 3365-3370
3. Lewington A & Kanagasundaram A(2011). Acute Kidney Injury, UK Renal Society.
Conflict of interest: None
A3. Graft site candidiasis and fungal ureteric obstruction of a transplanted paediatric horseshoe kidney: a case report
Aitken E., Kipgen D., Geddes, C., Murio, E., Shumeyko, V. Kingsmore, D.
Department of Renal Transplant, Western Infirmary, Glasgow
Background: We present an unusual case of graft site candidiasis presenting as fungal ureteric
obstruction in the adult recipient of a paediatric horseshoe kidney.
Case report: A 42 year-old woman with end-stage renal failure was transplanted a paediatric
(DBD) horseshoe kidney with duplex collecting system. The operative procedure was
uncomplicated. Proximal donor aorta and IVC were oversewn and the distal ends anastomosed
end-to-side to recipient external iliac artery and vein. The two donor ureters were spatulated,
anastomosed together and implanted onto bladder with two pigtail stents. The initial post-operative
course was uneventful. She was discharged home on day 10 with a serum creatinine of 140mg/dl.
6 weeks later she represented with oliguria. Serum creatinine was 427mg/dl. Ultrasound revealed
moderate hydronephrosis of the left moiety and a 8x4cm perinephric collection. Percutaenous
nephrostomy was performed and the collection drained. 48 hours later she developed generalised
urinary peritonitis, pyrexia and elevated inflammatory markers. CT abdomen with contrast via the
nephrostomy confirmed free intra-abdominal fluid, with leakage of contrast from the renal pelvis,
through a breach in the peritoneum, into the abdominal cavity. Failure to improve with broadspectrum antibiotics necessitated laparotomy. There was gross hydronephrosis and hydroureter of
both collecting systems. The ureters were filled with thick “cottage cheese like” material which
solidified into ureteric casts. The ureters were irrigated and re-implanted and the peritoneum
washed out. Candida albicans was isolated from peripheral blood, urine and ureteric casts.
Antimicrobial cover was provided with Tazocin and fluconazole (4mg/kg/day). The patient’s
condition transiently improved with anti-fungal treatment, however she again developed systemic
sepsis and on day 13 (two months after transplantation), the decision was taken to undertake
transplant nephrectomy. Macroscopically, the entire kidney capsule was covered in balls of white
fungus. Microscopically, necrotising granulomatous inflammation was noted within the renal cortex,
with fungal hyphae seen in both the renal pelvis and wall of the ureter. Post-transplant
nephrectomy, the patient remained on amphotericin B for a total of 30 days and received twice
daily bladder washouts. Her ongoing recovery was complicated by pulmonary thromboembolism,
infected haematoma and septic shock necessitating a short admission to ICU. However she was
eventually discharged after 6 weeks and has now made a complete recovery and is re-established
on haemodialysis.
Discussion: Whilst opportunistic infections in immunosuppressed patients are commonplace, graft
site candidiasis is rare affecting less than 1 in 1,000 renal transplants1. To our knowledge, there
are only two other cases of fungal ureteric obstruction following renal transplantation 2. In neither
case was the infection donor derived. We postulate that in this case the abnormal anatomy of the
donor kidney, predisposed to stagnation of the urine latent fungal infection reactivated in the
immunosuppressed recipient.
References:
1
Albano, L. et al (2009) Clinical Infectious Diseases 48(2), 194-202
2
Ashish, A. et al (2009) Urology Journal 6(2): 127-129
Conflict of interest: None
A4. Measurement of Protein:Creatinine Ratio in Acute Kidney Injury – is it useful?
J Bray, C Stirling. Renal Unit, Western Infirmary, Glasgow.
Renal textbooks report that increased urinary protein excretion common in acute kidney injury
(AKI) but is characteristically less than 1g/day if the injury is due to acute tubular necrosis (ATN).
However, there are very few studies quantifying proteinuria in patients with AKI, partly due to
difficulties obtaining 24hr urine samples. However, as we now measure proteinuria by
protein:creatinine ratio (PCR), we are able to quantify proteinuria in this setting more often. We
present a case of a young man with AKI secondary to paracetamol toxicity. His urinary PCR was
>1000mg/mmol on several occasions and he therefore went on to have a renal biopsy. This
showed ATN and his PCR returned to normal on resolution of AKI.
Aim: The aim of this further study was to quantify proteinuria using PCR in patients with AKI
requiring renal replacement therapy (RRT) and to examine whether PCR was a useful diagnostic
or prognostic marker.
Methods: Patients presenting to the Renal Unit at Glasgow Royal Infirmary between 1 st August
2007 and Jan 31st 2008 with AKI requiring RRT were studied. Baseline renal function prior to AKI
was retrieved retrospectively in addition to patient age, gender and likely aetiology of AKI by review
of the electronic patient record and casenotes. Data on PCR, albumin to creatinine ratio (ACR),
serum creatinine (sCr), urine creatinine (uCr), urine volume was retrieved at the time of
commencement of RRT. Outcome was determined at 6 months post commencement of RRT.
Renal outcome was defined as either recovery to baseline, recovery but not to baseline or no renal
recovery. Date of death was recorded if within 6 months of presentation of AKI.
Results: 45 patients were retrieved from the EPR during the 6 month period. 20 patients were
excluded due to missing data as was 1 patient who had a transplant and 1 who had acute on
chronic renal failure.
Median age at presentation was 71 years and 43% were female. 83% (19/23) had a diagnosis of
presumed ATN after reviewing results, U/S and casenotes.
Median PCR at time of RRT was 240 mg/mmol and median ACR was 91 mg/mmol. 63% patients
with ATN had a PCR>100mg/mmol and this group had a median PCR of 215mg/mmol.
40% patients died within 6 months of presentation of AKI and 3 patients were dialysis dependant
when they died. 7 patients recovered renal function to baseline and 4 patients recovered with CKD
at 6 months follow up.
There was no clear correlation between PCR at the time of initiation of dialysis and renal outcome
or death, although the patient numbers were small.
Conclusions: Our study shows that proteinuria of >1g/day (as measured by PCR) occurs in the
majority of patients with ATN requiring RRT and is contrary to information in current renal literature.
A larger prospective analysis would be useful to examine whether PCR can predict renal diagnosis
or prognosis in AKI. Our data also raises questions about whether there is additional glomerular
pathology in patients with ATN to explain the degree of proteinuria.
NO FUNDING OR CONFLICT OF INTEREST
A5. Two cases of renal thrombotic microangiopathy occurring after beta interferon use for
the management of multiple sclerosis
Iain Drummond1, Chris Bellamy2 John Neary1, Caroline Whitworth1, Morwenna Wood3
Renal Unit, Royal Infirmary of Edinburgh1, Pathology Department, Royal Infirmary of Edinburgh2,
Renal Unit, Queen Margaret Hospital, Dunfermline3
Introduction: Beta-interferon is commonly used in the management of multiple sclerosis and has
been associated with a range of renal side-effects including proteinuria, nephrotic syndrome and
interstitial nephritis. We describe 2 cases of renal thrombotic microangiopathy (TMA) occurring
following its use for the treatment of multiple sclerosis.
Case 1: A 41-year-old female with a 6 year history of multiple sclerosis presented with a 5 month
history of gradual deterioration in health. She had been using beta-interferon for 3 years. At
admission, she was hypertensive and had evidence of renal impairment requiring renal
replacement therapy and microangiopathic haemolytic anaemia (MAHA).
Renal biopsy
demonstrated thrombotic microangiopathy (TMA) with changes suggestive of incipient chronicity.
Beta-interferon was stopped. She remained dialysis dependent for 4 months but has regained
sufficient renal function to come off dialysis.
Case 2: A 54-year-old female with a 13 year history of multiple sclerosis presented with 1st
generalised tonic-clonic seizure. She had been using beta-interferon for 6 years. At admission,
she was markedly hypertensive and had evidence of significant renal impairment and MAHA.
Renal biopsy demonstrated TMA with changes suggestive of chronicity. Retrospective review
demonstrated that creatinine had first risen above baseline at least 3 months prior to presentation.
Beta-interferon was stopped. She remains dialysis dependent 4 months following presentation.
Discussion: Although there is a well documented association between alpha interferon and TMA,
there are only 2 clear cases of beta-interferon associated TMA described in the literature. The
incipient chronicity noted in our cases demonstrates a requirement for carefully monitoring renal
function in patients receiving interferon therapies.
A6. Study of the reliability of nitrite and leukocyte esterase dipstick tests in screening for
urinary tract infections in renal transplant patients
Joanna Ting and Robert Mactier, Glasgow Renal and Transplant Unit, Western Infirmary, Glasgow,
Scotland, UK, G11 6NT
Aim: This study was conducted to evaluate the use of nitrite and leukocyte esterase dipstick tests
in screening for UTI in renal transplant patients and to evaluate if a midstream urine culture
sample still needs to be sent to the microbiology laboratory in this patient group to exclude UTI.
Methods: Urinalysis and urine culture were performed prospectively in renal transplant patients
attending 9 consecutive transplant clinic sessions. Patients were divided into 238 patients who
were >3 months post-transplant (defined as “medical”) and 51 renal transplant patients who were
<3 months post-operation (defined as “surgical”). 22 “medical” and 6 “surgical” patients were
excluded from the study because the urine sample was contaminated or no urine sample was
obtained. A trace or negative leukocyte esterase dipstick was considered as negative. A UTI was
diagnosed if a positive urine culture with >105 organisms per ml was reported.
Results: The specificity and positive predictive value of combined leukocyte esterase and nitrite
tests were 100% for “medical” renal transplant patients. The sensitivity of nitrite dipstick test was
0.00% in “surgical” renal transplant patients. The sensitivity of leukocyte esterase was 57.14% for
“medical” and 66.67% for “surgical” patients.
Dipstick testing
True
positive
False
positive
False
negative
True
negative
Sensitivity
Specificity
Leukocyte
esterase
(medical)
Leukocyte
esterase
(surgical)
Nitrite (medical)
8
29
6
195
57.14
87.05
8
9
4
30
66.67
76.92
4
3
10
221
28.57
98.66
Nitrite (surgical)
0
0
12
39
0.00
100.00
Both leukocyte 3
esterase
and
nitrite (medical)
0
11
224
21.43
100.00
Conclusion: Negative urine dipstick testing for leukocyte esterase and nitrites can be used to
exclude UTI in “medical” renal transplant patients whilst positive nitrite and leukocyte esterase
testing reliably diagnoses a UTI in “medical” renal transplant patients. Nitrite dipstick tests are not
useful for screening for UTI in “surgical” transplant patients.
Conflicts of interest: The authors have no conflicts of interest.
A7. Living Life to the full on Home Haemodialysis
Chris Ridden, NHS Highland
Background: Home haemodialysis has been increasing in prominence in the U.K during the last
few years and has been recognised by many experts to be a cost effective treatment option for
people with end stage renal disease.
It was decided to expand the NHS Highland home haemodialysis programme in 2007 from 1patient
to 6 patients in a 2 year pilot using existing equipment. Funding through a capital grant each year
was used for home conversions to accommodate this equipment at a cost of up to £5000.00 per
instillation.
67% of these patients were on the transplant list and 4 out of the original 6 patients did receive
transplants there fore this became a costly element to the programme.
As we did not wish to exclude any patients which were on the transplant list from receiving home
haemodialysis a solution had to be found.
A home haemodialysis patient transferred into the NHS Highland area and was given the first Nx
Stage machine with cost of £150.00 for home conversion.
The Nx Stage machine is a small compact portable home haemodialysis machine which is
designed for short daily treatments.
Summary: We have since purchased a further Nx Stage machine with a very generous donation
form a French patient who briefly dialysed at Raigmore. The first patient to use this new machine
had already researched its potential and had seen the benefits of its use. This patient has since
decided to raise money to purchase a further 2 machines by holding charity events.
The first event was to canoe from Fort William to Inverness along the Caledonian Canal and
dialyse on route via a generator in wild camp sites over 6 days.
A8. Patient self-management of Warfarin
SN Carole Burns, SCN Yvonne Grieve, NHS Fife renal service
Within the continually evolving Renal Speciality, patient choice and patient participation is more
important than ever. Some patients embrace the opportunity to become involved with their care
giving them a sense of ownership. Developing the self-management of Warfarin was aimed to
allow the patient a sense of control within safe guidelines.
To achieve our aim, it was essential to chose suitable patients. These patients were then
assessed using the mini mental state examination. A structured educational programme was
followed ensuring a good understanding of Warfarin therapy and side effects. The patients were
then allowed to self prescribe using a dose adjustment chart, closely supervised by the nursing
staff who in turn informed the consultant of the results and dose changes. On the occasions
where the INR was out with the target range an assessment was carried out and causes
discussed. The trial was successfully completed with positive feedback from the patients.
A9. A unique patient journey towards home haemodialysis
Sean McCartney, (NHS Tayside)
No abstract received for printing.
A10. The prevalence of metabolic complications in stage 4 CKD patients attending a
General Renal Clinic, a retrospective audit.
Beng So, Christopher Deighan. Renal Unit, Western Infirmary Glasgow.
Aim: The number of patients with stage 4 CKD in any given general nephrology clinic constitutes
a significant proportion of its throughput. The majority of patients with stage 4 CKD will not require
renal replacement therapy. Referral guidelines suggest that most patients with stage 4 CKD
should be referred for nephrology assessment however it is less clear which patients require
nephrology follow-up. We carried out a retrospective audit to assess the prevalence of metabolic
complications in stage 4 CKD patients currently attending general nephrology clinics.
Methods: Using the unit’s EPR, we extracted all patients with stage 4 CKD (eGFR>15 &
<30ml/min) attending the general renal clinics in Greater Glasgow & Clyde during January and
February 2011. The first one hundred patients with stage 4 CKD were analysed in detail. Age,
sex, blood pressure, eGFR, eGFR 1 year earlier, proteinuria, acidosis, haemoglobin, haematinics,
bone profile and parathyroid hormone levels along with the use of phosphate binders, bicarbonate,
iron and ESA use, were collated and analysed.
Results: A total of 338 patients with stage 4 CKD were identified. Of the one hundred patients
analysed in detail, 53% were male, mean age was 68±14 yrs, eGFR 24.0±3.6 ml/min, urine PCR
94±121mg/mmol with mean systolic BP (mmHg) of 143±21 and diastolic 76±11. Over the
preceding year, eGFR fell by a mean of 4.8ml/min (95% CI: 2.8 to 6.7, p<0.001). Metabolic
complications were as follows, 66% with acidosis or taking bicarbonate, 19% on alfacalcidol
treatment, no patients were hypocalcaemic, 4% had a phosphate >1.5mmol/l with another 5%
taking phosphate binders. No patients were taking calcimimetics. 16% had Hb <10g/dl or on ESA,
and in the anaemia group, 69% were on ESA.
24% were identified as not having metabolic complications. This patient group were 50% male,
with higher eGFR (25.5 vs 23.6ml/min, p<0.03) and lower urinary protein (PCR 62 vs 105
mg/mmol, p<0.05), but had similar age and BP. Over the preceding year the drop in eGFR was
3.3ml/min (95% CI: 1.0 to 5.6) in the group without metabolic complications compared with
5.2ml/min (95% CI: 2.8 to 7.7) in the metabolic complications group (p=nsd).
Conclusions: From our sample of 100 patients with stage 4 CKD, we identified 24% of patients
without significant metabolic complications, who also appeared to have less proteinuria and more
stable renal function. We suggest that these patients could have regular follow-up in primary care
rather than at a general nephrology clinic. We intend to continue this audit by assessing the rest of
the stage 4 CKD patients that were identified. The audit loop could be closed following transition to
primary care by reviewing data transferred automatically to the renal EPR.
Funding and conflict of interest: None.
A11. Benefits of a multidisciplinary one stop General Nephrology Clinic
Robert Mactier1, Gus McKillop1, Keith Simpson1, Morag Gorrie1, Janette Quinn1, Sharon Brown1, Shona Horn1,
John Shand2, Joyce McFadyen3, Lorna McDonald4, New Stobhill Hospital, Glasgow Renal and Transplant Unit1,
and Radiology2, Medical Records3 and Outpatient Services4, NHS Greater Glasgow & Clyde
Introduction: The number of CKD patients who are referred to nephrology clinics and the range of
treatments which CKD patients require have increased in recent years. In contrast current workforce
planning does not provide for any expansion of outpatient sessions staffed by medical staff. For these
reasons the Thursday General Nephrology Clinics at New Stobhill have been developed as one stop,
multidisciplinary clinics by integrating an extended role for the CKD nurse specialist with organisational
changes to the clinic.
Methods: To improve the effectiveness of the clinics a number of stepwise organisational changes have
been introduced:
a) An abdominal ultrasound is scheduled in all new patients, who have not had a recent ultrasound, 40
minutes before their clinic appointment.
b) All new patients have their diagnoses and drugs preloaded on the electronic patient record by the
renal secretaries.
c) All patients have bar-coded (urine and blood) biochemistry and haematology requests pre-printed
before the clinics.
d) All patients have their urinalysis, weight (and height) and blood and urine tests performed by clinic
nursing staff.
e) Designated telephone numbers (and secretarial staff) are available to deal with enquiries before and
after clinic visits.
f) The clinics are supported by a CKD nurse specialist (GMcK), who has wide experience in
nephrology and has prescribing responsibilities. He reviews return patients independently who have
a management plan in place and are not receiving immunosuppressive medication.
g) When indicated the CKD nurse specialist also provides education for renal replacement therapy,
commences ESA therapy and administers intravenous iron and/or hepatitis B vaccine to any patient
attending the clinic.
h) The clinics have not used case-notes since October 2010.
The outpatient clinic data were reported by the medical records department. The workload of the CKD nurse
specialist was self reported.
Results: The outpatient activity and the additional episodes of care provided by the CKD nurse specialist in
the first year (1st July 2009-30th June 2010) and the second year (1st July 2010-30th June 2011) are shown in
the Table.
Year
Number of clinics
Number of new patients seen
Number of return patients seen
Total number of patients seen
Average number of patients seen per clinic
Number of clinics attended by GMcK
Number of patients seen by GMcK
RRT education
Hep B vaccination
Intravenous iron administration
Other episodes of care
Total episodes of care by GMcK
Average episodes of care per clinic by GMcK
2009-2010
51
303
2334
2637
52
32
201
50
10
8
3
272
8.5
2010-2011
51
263
2547
2810
55
35
231
61
41
26
15
374
10.7
Conclusion: The introduction of a range of improvements in renal outpatient clinic practices, including clinic
reviews by a CKD nurse specialist, has permitted a higher volume of clinic activity without additional medical
sessions. This has been combined with reducing the number of hospital attendances to a minimum by
performing same session renal ultrasound and the provision of additional episodes of renal care by a CKD
nurse specialist at the same time as clinic appointments.
Conflicts of interest: The authors have no conflicts of interest to declare.
A12. An Audit of the use of intravenous iron in the haemodialysis population.
Gemma McGrory, Jessica Selley, Elaine Spalding.
John Stevenson Lynch Dialysis Unit, Crosshouse Hospital.
Background: The benefits of intravenous iron in the maintenance of haemoglobin targets are
clear. In 2010 an audit was undertaken to assess compliance with the existing protocol for
intravenous iron administration in the Renal Dialysis Unit at Crosshouse Hospital. Alterations were
made to the protocol for iron administration and the audit was repeated in 2011.
Method: All of the haemodialysis patients attending Crosshouse Hospital were identified
retrospectively using SERPR and a single date was identified where ferritin, %Tsats and
haemoglobin had been checked (135 in March 2011 and 141 in September 2011). In addition, the
doses of iron and ESA were also recorded.
Results: In 2010 71% of patients were receiving iron with 36.7% receiving the correct dose
according to the existing protocol. However it was noted that the dose of iron was being
administered only 2 days before the monthly blood test was being taken. The schedule was
therefore altered such that the dose of iron was administered at least one week before the blood
test was taken. It was felt that this would give a more accurate estimation of iron stores.
At the second audit point 6 months later, 83% of haemodialysis patients were receiving iron. There
was no difference in the average levels of haemoglobin, ferritin or %tsats but the ESA
requirements fell between the two time points.
Conclusion: Between the first and second audit points the number of patients receiving
intravenous iron increased and the average ESA dose reduced. The change made in IV iron
prescription may simply have led to an increased awareness of patients requiring iron but may also
have contributed to more accurate assessment of the need for iron and thus an overall reduction in
the cost of anaemia management.
A13. An Audit of the efficacy of intravenous Ferric Carboxymaltose (Ferinject®) in predialysis CKD patients in Ayrshire and Arran.
K. Porch, A. Dunleavy , L. Kirkland, H. Wyper, P. Kaur-Singh, E.M. Spalding.
Renal Unit, Crosshouse Hospital, Kilmarnock
Background: Current NICE and Scottish Renal Registry guidelines recommend a target
haemoglobin (Hb) of 10-12g/dl, ferritin 200-500µg/l and transferrin saturation (TS) > 20% for predialysis CKD patients. Prior to August 2009 the IV iron preparation used in our Unit was Venofer ®,
typically administered as a fortnightly infusion of 100-200mg to a total dose of 600-1200mg during
multiple clinic visits. In August 2009 all pre-dialysis patients receiving IV iron were switched to
Ferinject, administered as a single infusion up to a total dose of 1000mg. The aim of this audit was
to determine if Ferinject is as effective as Venofer in increasing ferritin and haemoglobin levels.
Methods: Data was collected for all pre-dialysis patients attending Crosshouse Hospital and
receiving Ferinject from August 2009 to March 2011. Patient age, sex, weight and dose of Ferinject
were recorded. Hb, ferritin, transferrin saturation, ESA dose and eGFR were measured at baseline
and at 3 months post Ferinject administration. Patients were excluded from further analysis if the
data set was incomplete or if they had been converted to HD or PD. A similar data set was
collected for pre-dialysis patients receiving Venofer between December 2005 and March 2009.
Results: The sample size was n=84 for the Ferinject group and n=28 for the Venofer group. All
results are expressed as mean ± SD.
A single dose of Ferinject produced a greater rise in ferritin than multiple doses of Venofer. There
was no significant difference in Hb or TS between the Ferinject and Venofer groups at baseline or
at 3 months. The mean ESA dose over three months increased for patients receiving Venofer but
stayed the same for the Ferinject group.
Hb (g/dl)
Ferritin (µg/l)
TS (%)
ESA
(mcg/fortnight)
Baseline
3 months
Baseline
3 months
Ferinject
10.2±1.1
11.0±1.1
144.5±122.3
427.9±227.3
Venofer
10.4±1.8
10.5±1.4
102.8±62.2
193.4±115.8
Baseline
3 months
Baseline
3 months
21.6±9.1
31.1±11.7
25.2±35.4
25.8±34.6
23.5±8.8
27.8±13.8
29.6±39.2
39.2±34.0
Conclusion: Ferinject is as effective as Venofer in achieving desired iron targets and maintaining
haemoglobin. The administration requires fewer clinic visits resulting in reduced nursing time,
preserved IV access and greater patient satisfaction.
No external funding, no conflict of interest
A14. The Triple A Kidney Project: Baseline data from a community-based study of CKD
Methven, S1,2, Jardine, AG2, MacGregor, MS3
1
Glasgow Renal Unit, Western Infirmary, Glasgow
BHF Glasgow Cardiovascular Research Centre, University of Glasgow
3
John Stevenson Lynch Renal Unit, Crosshouse Hospital, Kilmarnock
2
Introduction: Most patients with stage 3 chronic kidney disease (CKD) are managed in primary
care, but this group of patients has been poorly characterised. We have three aims in this study: to
detail the characteristics of patients in the community with CKD3, and to subsequently identify
predictors of renal disease progression and the development of cardiovascular disease.
Methods: We searched general practices’ CKD registers, and invited participants to attend for a
baseline detailed medical history, assessment of quality of life, anthropomorphic measurements,
serum and urine biochemistry, DNA sampling and an electrocardiogram. This prospective cohort
will be followed for up to 10 years.
Results: 412 patients were recruited; the first 335 are shown. Results are presented as mean± SD
or median (IQR). Significant differences between groups* (p<0.05).
Total cohort
Number (% male)
Age (yrs)
Diabetes (%)
Hypertension (%)
CV disease (%)
Current smoker (%)
ACEi/ARB (%)
SBP (mmHg)
DBP (mmHg)
BMI (kg/m2)
eGFR (mL/min/1.73m2)
Urine ACR (mg/mmol)
Microalbuminuria (%)
Urine PCR (mg/mmol)
Adj Cal (mmol/L)
Phosphate (mmol/L)
PTH (pmol/L)
25-OH vitamin D (nmol/L)
Total cholesterol
Urate (mmol/L)
Haemoglobin (g/dL)
335 (39)
70.3 ± 9.8
18
76
41
10
71
141±22
80±23
31.3 ±19.1
54 (45 – 62)
0.9 (0.6-1.6)
17
10 (7-15)
2.24 ± 0.086
0.93 ± 0.22
9.0± 5.3
35 ± 21
4.9 ± 1.1
0.38 ± 0.096
13.6 ± 1.5
eGFR<45
mL/min/1.73m2
87 (36)
73.0 ± 10.7*
22.5
80
50
6
75
137 ± 22
78 ± 32
30.3 ± 5.9
40 (34-42)*
1.1 (0.6-6.4)*
31*
12.5 (7.5-18.1)*
2.26 ± 0.092*
1.00 ± 0.25*
11.9 ± 6.7*
35 ± 23
4.9 ± 1.3
0.44 ± 0.10*
13.1 ± 1.6*
eGFR≥45
mL/min/1.73m2
248 (41)
69.5 ± 9.3*
16
69
43
10
69
143 ± 22
81 ± 19
31.7 ± 22.7
58 (52-64)*
0.8 (0.5-1.4)*
12*
9.1 (6.4-14.4)*
2.24± 0.084*
0.90 ± 0.18*
8.0 ± 4.4*
35 ± 21
4.9 ± 1.1
0.37 ± 0.08*
13.8 ± 1.5*
Conclusion: Patients in the community with CKD, differ from typical secondary care populations.
They are predominantly elderly, female, and overweight with a large burden of vascular disease.
Proteinuria is of notably low prevalence. Urate, PTH, serum calcium, PCR and age are significantly
higher in those whose eGFR<45ml/min/1.73m2. CKD 3 is managed in primary care, using evidence
derived from secondary care. Prospective cohorts such as this may offer new insights into CKD,
and its management.
No conflict of interest
Unrestricted educational grant from Bristoll-Myers Squibb
A15. Tolerability of bisphosphonates in chronic kidney disease stage 4, 5 and 5D
Keith Gillis1, Jeetendra Rathod1, Jamie Traynor2and Scott Morris1
1
NHS Glasgow & Clyde
Monklands District General Hospital
2
Introduction: Patients with chronic kidney disease (CKD) have an increased fracture risk for a
variety of reasons including renal bone disease, reduced physical activity and an increased
prevalence of conditions treated with corticosteroids. In the general (non-renal) population,
bisphosphonates have proven efficacy in reducing the risk of steroid-induced osteoporosis and
also the risk of osteoporotic fractures. However, the use of bisphosphonates in patients with
eGFR<30ml/min remains controversial due to a lack of safety and tolerability data, concerns over
an increased risk of adynamic bone disease due to their mechanism of action as osteoclast
inhibitors, and concerns of nephrotoxicity. Nevertheless, it was our impression that a significant
number of patients with CKD attending our clinics were receiving these drugs.
Aim: To determine the safety and tolerability of bisphosphonate use in patients with chronic kidney
disease stage 4, 5 and 5D.
Methods: We used the Glasgow Royal Infirmary renal electronic patient record to retrospectively
identify CKD patients who had received a bisphosphonate between January 1991 and June 2010.
Patients whose eGFR was <30ml/min at the time of starting bisphosphonate treatment (including
those patients on dialysis) were included in the analysis. Patients with resolving acute kidney
injury, such as those with vasculitis receiving corticosteroids, were excluded. We recorded bone
mineral metabolism parameters (serum adjusted calcium, phosphate, parathyroid hormone) and
eGFR were measured at 12 and 6 before, and 3, 6 and 12 months following commencement of
bisphosphonates. In addition, we recorded the indications for commencement of bisphosphonate
and the reasons for discontinuation of treatment including adverse effects.
Results: We identified 155 patients with CKD 4 or 5, and 76 patients with CKD 5D whom had
received a bisphosphonate during the study period January 1991 to June 2011. The most frequent
bisphosphonate prescribed was alendronate and the commonest indications for the use of these
drugs were proven osteoporosis and bone protection during corticosteroid use. Overall they were
well tolerated with only 5.4% stopping drug due to an adverse drug effect, commonly
gastrointestinal side effects. No cases of femoral fragility fractures or of osteonecrosis of the jaw
were identified. There was an initial transient reduction in serum adjusted calcium in CKD 5D
patients which resolved through the remainder of the study period. Conversely, there was a small
but statistically significant rise in serum adjusted calcium in CKD 4 and 5 patients treated with
bisphosphonates from 2.36 to 2.40 mmol/l. Otherwise, no significant change in bone biochemistry
was observed. In this group there was also a significant rise in eGFR in and a reduction in
proteinuira. Porotic fractures were common in both groups prior to commencement of
bisphosphonates.
Conclusions: In this retrospective analysis, bisphosphonates appeared to be generally well
tolerated in patients with renal impairment or on renal replacement therapy. We found no evidence
of significant adverse effects or of nephrotoxicity. The small rise in adjusted calcium in the low
clearance patients does raise the question of reduced bone buffering due to adynamic bone and
this requires further study.
A16. A prospective national cohort study of peritoneal dialysis related peritonitis 2000-2010
Rajni Tejwani, Michaela Brown and Robert Mactier on behalf of the Scottish Renal Registry,
Glasgow Renal and Transplant Unit, Western Infirmary, Glasgow, Scotland, UK, G11 6NT
Introduction: This study reports the peritonitis rates in all of the adult PD population in Scotland in
the post-millennium period, with an update on the data from 2010.
Methods: The prospective audit data (episodes of peritonitis and causes of technique failure),
which were reported to Scottish Renal Registry (SRR) from all adult renal units in Scotland every 6
months from 01/01/2000-31/12/2010, have been analysed for this study.
Results: Peritonitis rates in each adult renal unit 2000-2010 are shown below.
Renal Unit
Aberdeen Royal Infirmary
Peritonitis rates (months between episodes)
2000 2008**
2009**
2010
2007*
17.7
23.0
33.3
19.3
Crosshouse Hospital,
Kilmarnock
Dumfries & Galloway Royal
Infirmary
Glasgow Royal Infirmary
27.2
22.8
22.4
20.8
29.8
38.6
17.1
24.8
19.7
25.9
29.0
***
Monklands Hospital,
Lanarkshire
Ninewells Hospital,
Dundee
Queen Margaret Hospital,
Dunfermline
Raigmore Hospital,
Inverness
Royal Infirmary of Edinburgh
Western Infirmary,
Glasgow
All Adult PD Patients in
Scotland
28.9
13.5
26.5
17.2
23.1
31.2
40.3
18.4
18.7
27.3
14.5
14.9
15.3
23.9
33.2
19.6
15.6
19.6
13.0
12.7
15.2
16.1
15.5
25.2
19.9
18.5
20.3
18.9
*
**
***
ePub Perit Dial Int 2011 doi:3747/pdi.2010.00185 and reported at the ISPD meeting,
Vancouver, 2009
this data was reported in the Scottish Renal Registry 2009 Report
the 2 units in Glasgow merged in August 2010 so data have been combined for 2010
The causative organisms of the 176 peritonitis episodes during 2010 were coagulase negative
Staphylococcus (55), Staphylococcus.aureus (23), Gram negative bacilli (23), other organisms e.g.
Streptococci (43), fungal (5) and culture negative (24). This spectrum of causative organisms is
similar to earlier reports. Peritonitis accounted for 35/88 (40%) of all PD technique failure during
2010.
Discussion: National peritonitis rates have remained unchanged over more than a decade and
every year continue to meet the standards set by the UK Renal Association. However there was
wide variation in peritonitis rates among the units in recent years and review of preventative
strategies across the country is warranted to identify best practice in the units with the lowest
incidence of peritonitis.
Conflicts of interest: The authors have no conflicts of interest to declare.
A17. Survey of preventive strategies to reduce peritoneal dialysis associated peritonitis
rates in adult renal units in Scotland
Dr Rajni Tejwani¹, Audrey Jones², Dr Robert Mactier¹, 1 Western Infirmary, Glasgow,
2
CrosshouseHospital, Kilmarnock
Introduction: Prospective audit data reported to the Scottish Renal Registry (SRR) from all adult
peritoneal dialysis (PD) units every 6 months have shown that national peritonitis rates have
remained unchanged for the past decade. Although the standards set by the UK Renal Association
have been achieved nationally each year, there has been wide variation in the incidence of
peritonitis reported by the individual units and the average interval between episodes of peritonitis
in the units in Scotland has ranged threefold from12.7 to 40.3 months within the past year.
Aim: This survey was performed to review the different preventive strategies for infective
complications of PD which have been adopted by Scottish renal units and identify if different
practices are used in the units with a lower incidence of peritoneal dialysis associated peritonitis.
Methods: The survey questionnaire was designed to address this question and was sent
electronically to each adult PD unit in Scotland.
Results: The results will be discussed in the meeting after analysing all the data.
Discussion: This survey will identify best practice which has been adopted by units with the
lowest rates of peritonitis. If protocols are identified which show clear evidence of reducing
peritonitis rates, then efforts should be made to establish these preventive measures as routine
clinical practice at a national level.
A18. Use of Autoflow to determine Dialysate flow rate has the potential to reduce dialysis
consumable costs but may impact on dialysis adequacy in patients with lower blood flow
rates.
Sean McArtney, Clinical Nurse Educator, Drew Henderson, Consultant Nephrologist
Renal Unit, Ninewells Hospital, Dundee, DD1 9SY
Background: The autoflow function on Fresenius 5008s dialysis machines allows dialysate flow
(Qd) rates to be determined by the blood pump speed (Qb) and be set at either 1.5 or 2 times Qb.
Increments in Qd should theoretically lead to increased dialysis efficiency but due to increasing
turbulence of flow as Qd increases dialyser efficiency does not increase to as great an extent.
Thus tailoring Qd for a specific patient according to Qb should allow optimal dialysis with a
reduction in dialysate use and therefore potential cost savings without impact on patient dialysis
dose.
Methods: A retrospective audit was carried out of all patients to determine the effect of a switch of
Qd from a standard 700ml/min to autoflow determined Qd (1.5 x Qb). All patients were treated with
post dilutional HDF on Fresenius 5008 dialysis machines. Data collected was Qd, Qb, Treatment
time (T) and Urea Reduction Ratio (URR) prior to and following a change to autoflow. Consumable
cost saving were predicted using costs for switches in consumable volumes predicted over the
next 12 months. Data was evaluated using paired t tests to identify significant changes.
Results: 163 patients were identified who had all data available for both time points.
6 patients were excluded due to either incomplete data or single needle dialysis. The median URR,
Qd, Qb and T were unchanged between the two time points. Qd fell significantly (695ml/min vs
487mls/min p<0.01). 49% of patients URR dropped. This group of patients had significantly lower
Qb compared with those whose URR did not change (Qb 306 vs 321mls/mi p=0.0045). 22% of
patients URR dropped by >5%. Qb was not lower in this group compared to those whose URR
dropped by <5%.
By limiting Qd using autoflow the projected cost savings over 1 year are £18,720 for reduction in
bicarbonate cartridge size (900g to 650g) and £14,040 reduction by reducing from 6 l to 5 l A
concentrate size.
Conclusions: A switch to autoflow will allow significant cost savings but a minimum Qd should be
instituted to limit the impact of reduced Qd on those with lower Qb.
A19. Quality improvement program of modifiable risk factors in hospital haemodialysis
Vishal Dey, Robert Mactier, Kath Kearny, Dalene Thomson, Val Jeffrey, Morag Ryan, Kath McCreadie,
Graeme Crawford, Morag Gorrie, Stuart Rodger, Siobhan McManus, Keith Simpson, Stobhill haemodialysis
unit, Glasgow Renal and Transplant Unit
Introduction: Data from the Dialysis Outcomes and Practice Patterns Study (DOPPS) have documented a
higher relative risk of death in haemodialysis (HD) patients who fail to achieve URR > 65% (RR 1.13, p =
0.0023), haemoglobin (Hb) >10g/dl (RR 1.21, p <0.0001), pre-dialysis serum phosphate <1.8mmol/l (RR
1.11, p=0.001) and facility central venous catheter use <10% (RR 1.20, p < 0.0001). The target URR should
be 70% or higher when aiming to achieve URR >65% every month and the target Hb concentration should
be 10.5g/dl or higher when aiming to achieve Hb concentrations above 10g/dl on a consistent basis.
Methods: As part of a quality improvement program (QIP) we performed a prospective, nurse led audit of
these 4 modifiable clinical risk factors in all of the patients in the Stobhill HD unit every month for 2 years
from August 2009 (maximum number of patients = 111). A QIP score of 1 or 0 was awarded according to
whether each of the following surrogate dialysis related variables were achieved or not each month:
URR = 70% or higher;
Hb 10.5 or higher;
pre-dialysis serum phosphate below 1.8;
fistula used as the current form of vascular access
When combined into a global score each patient may have a QIP score ranging between 0-4.
Results: The data (mean + 1SD) for each variable are shown in the Table.
6 monthly audit period
Mean % patients with URR >70%
Mean % patients with Hb >10.5 g/dl
Mean % patients with phosphate
< 1.8mmol/l
Mean % fistula use
Mean global score
Aug 2009
-Jan 2010
Feb 010
-Jul 2010
Aug 2010
-Jan 2011
Feb 2011
- Jul 2011
P value
76.0
6.93
76.8
2.94
61.3
2.64
71.0
2.27
2.93
0.09
77.6
7.47
72.7*
4.20
62.3
4.58
71.0
4.43
2.84
0.08
80.1
3.87
75.8
1.93
63.8
3.65
80.4**
1.57
3.00
0.09
90.0*
3.18
80.6
6.15
63.7
5.09
80.6*
1.44
3.16*
0.10
*0.0155
*0.0237
*0.001
**0.0001
*0.0232
Each audit period was compared to the baseline and previous 6 month periods and all significant results (p<
0.05) are shown in the Table. There was a significant improvement in the global score for all patients in the
final 6 months of the audit when compared with the first six months’ data; p = 0.0232). This was due to serial
improvements in the % of patients achieving monthly URR > 70% and higher use of fistulas.
Conclusion: In the second year of a QIP audit a significantly higher % of HD patients achieved a 6-monthly
average URR >70 % and fewer patients used central venous catheters for vascular access. There was only
a small rise in the % of patients achieving target Hb and phosphate levels. Monthly multidisciplinary nurse
led audit of modifiable risk factors in HD patients promotes patient and staff awareness of quality
improvement targets and this can increase the % of HD patients who consistently achieve audit measures
that are associated with improved patient outcomes.
Conflicts of Interest: None of the authors have any conflicts of interest to declare.
A20. Rotational Training and Development: The Renal Units Experience
Jason Graham, Senior Charge Nurse, Queen Margaret Hospital, Dunfermline
Executive summary: NHS Fife Renal Services have been forced to respond to year on year
expansion of the service to meet the needs of growing numbers of patients and significant planned
service change. In the last three years expansion of the service has been achieved through
increasing the nursing establishment and the development of a rotational training and development
programme. The aim of this research is to critically evaluate the rotational training and
development programme by examining the impact of the programme on renal nurses and the renal
service. Kirkpatrick’s’ (1959) Four Level model of training evaluation is used as a framework for
evaluation, focussing on participants reactions, learning, behaviour, and results.
The training program has been found to be of benefit in achieving strategic goals and improving
service provision.
Recommendations for improvement of the program are identified as improving the learning
experience.
The contribution of rotational development programs towards workforce planning is discussed.
A21. Outcome of infective endocarditis in haemodialysis patients – a 11-year prospective
cohort study
Hadi Oun and Jamie Traynor, Monklands Renal Unit, Airdrie
Background. Infective endocarditis (IE) is a cause of significant mortality and morbidity in
haemodialysis (HD) patients. We report the outcome of a prospective observational cohort series
of haemodialysis patients who developed IE over a period of 11 years.
Methods: Each case of IE diagnosed in our chronic haemodialysis patients at Monklands Hospital
over the 11-year period from January 2000 to December 2010 was followed up from the time of the
diagnosis to the end of 2010, or date of death. Demographic data included age, sex, causes of
ESRD, duration on haemodialysis prior to the episode of IE, vascular access, and cardiac
abnormalities prior to episodes of IE. Clinical data included the echocardiography results of the
valves involved with IE, microbiological organisms caused the infection, clinical management and
outcome.
Results: 27 HD patients developed IE over 11 years. The mean age was 57 years. 23 patients
had an abnormal echocardiography findings prior to development of IE. 19 were dialysed with
tunnelled cuffed venous catheters (TCVC), and the rest had native arterio-venous fistula (AVF).
Mitral valve alone was the commonest valve affected (48%) and Staphylococcus aureus was the
most frequently isolated organism (74%). 6 patients required surgical valve repair and 11 patients
died during the initial hospital admission. All 8 patients with MRSA endocarditis died during the
initial hospital admission. Of the 14 patients who were discharged home, only 5 survived more than
a year.
Conclusion: IE in haemodialysis is an important cause of mortality and morbidity. All patients who
had MRSA as the causative organism died during the initial admission.
A22. Audit of Smoking in Haemodialysis patients (and staff)
Cathy Burke, Hemanth Karahyi and Jamie Traynor, Monklands Hospital, Airdrie
In February 2011 we conducted an audit assessing the number of haemodialysis patients who
smoked within the renal unit and the number who wished to stop and required assistance.
Of the 172 haemodialysis patients, 37 (22%) smoked between 3 to 50 cigarettes per day (median
10 cpd) over a period of 1 to 52 years (median 25 years). 22 initially expressed an interest in
stopping and wished assistance from our smoking cessation team. Of these, only 12 were actually
ready to stop when approached by the smoking cessation team with the other 10 being described
as ‘pre-contemplating’. Although not part of the original aims, 8 members of staff became engaged
with the smoking cessation team with the aim of stopping.
The figure below shows the number of patients and staff who stopped smoking and who remained
off the cigarettes at 1 and 3 months.
Number of
smokers
Number
willing to
give up
Stopped
smoking at 1
month
Stopped
smoking at 3
month
Ready to try
again
Patients
22
12
4
4
3
Staff
8
7
5
2
2
Although initially time-intensive for the smoking-cessation team, targeting smoking in
haemodialysis patients seems very achievable and has also encouraged staff to stop too. The
patients with highest physical addiction levels as judged by Fagerstrom score were more likely to
benefit from nicotine replacement therapy.
A23. Temocillin – safe and effective empirical treatment for urinary sepsis in patients with
renal impairment.
Scott Oliver(1), Heather Kennedy(2), Dilip Nathwani(2), Samira Bell(1)
(1) Renal Unit and (2) Infectious Diseases Unit, Ninewells Hospital, Dundee DD1 9SY
Introduction: Many renal unit admissions involve Gram-negative urinary or bloodstream infection.
Broad-spectrum antibiotic treatment increases the risk of Clostridium difficile-associated diarrhoea
(CDAD), and contributes to the emergence of antibiotic resistance. In patients with renal
impairment therapeutic options are further limited by reduced efficacy and hazards like
nephrotoxicity and hyperkalaemia.
Temocillin is a non-carbapenem, narrow-spectrum antimicrobial agent active against
Enterobacteriaceae and Klebsiella species, including resistant forms. It has no anaerobic or Grampositive activity, and does not increase the likelihood of CDAD. Its efficacy in the general
population has been demonstrated, but its utility as empirical therapy specifically in patients with
renal impairment has not been examined.
Methods: We prospectively collated data on patients receiving Temocillin in the Renal Unit at
Ninewells Hospital. All patients were haemodialysis-dependent or had chronic kidney disease, a
functioning renal transplant, or an acute kidney injury at baseline.
Results: Temocillin was prescribed for 40 episodes in 34 patients during the period 1/6/10 31/8/11.
Microorganisms were isolated from blood (18 cases), urine (13 cases), sputum (2 cases) and
peritoneal fluid (1 case). In some cases microorganisms were grown from multiple cultures. In 10
cases no microorganism was grown. The commonest isolates were Escherichia coli (11 cases)
and Klebsiella spp (6 cases). All were sensitive to Temocillin, including seven isolates resistant to
alternatives such as Amoxicillin or Trimethoprim.
Clinical cure was achieved in 34 episodes, with a mean 1.5g daily Temocillin dose. Two further
patients with Gram-positive bacteraemias needed alternative antibiotics. One patient with infective
endocarditis needed ongoing outpatient antibiotics. Two patients given empirical antibiotic therapy
were subsequently considered not to have sepsis.
Thirteen patients had diarrhoea during their admission. In 5 cases the diarrhoea started after the
first temocillin dose. Three patients had had CDAD in the 12 months prior to admission, but none
had recurrent CDAD after temocillin use. Only one patient, who had received other antibiotics
along with temocillin, developed CDAD.
Temocillin treatment was well tolerated. Five patients who received Temocillin died: the causes of
death were dialysis withdrawal (3 cases), disseminated malignancy (1 case) and intra-abdominal
sepsis with a temocillin-resistant Gram-positive organism (1 case). None of the deaths were
considered attributable to temocillin use by the treating physician.
Conclusion: This non-controlled observational study demonstrates the safety, tolerability and
efficacy of temocillin as empirical therapy for presumed urinary sepsis in patients with renal
impairment. Further study is merited in this complex and vulnerable patient group.
A24. Prospective Audit of Gentamicin Use in patients receiving renal replacement therapy
for acute kidney injury
Joanne Sloan, Michelle Kao, Vinod Dibbur, Saffa Elawad, Graham Stewart,
Renal Department, Ninewells Hospital, Dundee
Background: Gentamicin is a well recognised nephrotoxic drug. Within NHS Tayside its use has
increased since the introduction of a new Hospital antibiotic protocol. The new policy advises
gentamicin for 1st line treatment of –severe hospital acquired pneumonia and aspiration
pneumonia, endocarditis, peritonitis /biliary tract/intra-abdominal sepsis, complicated UTI or female
upper UTI and sepsis of unknown source. The aim of this study is to determine if the introduction
of gentamicin has lead to an increase in the number of cases of acute kidney injury requiring
dialysis.
Method: Data was collected on all patients who were acutely dialysed over a 20 week period in
2009.This included information on patient demographics, diagnosis, co-morbidities, nephrotoxic
drug administration, contrast administration and Gentamicin administration, including dose and
frequency. This data was then compared to results collected over the same 20 week period in
2006 prior to the new hospital antibiotic policy introduction.
Results: 73 patients were acutely dialysed in the 2009 sample, (478.1 patients/million/year). 68
patients were dialysed in the 2006 sample, (451.5 patients/million/year), (p>0.05, chi squared test).
8 patients dialysed in 2009 received gentamicin while 4 received it in 2006, (p=0.37, Fisher’s exact
test)
Conclusions:The introduction of a new hospital antibiotic policy, with gentamicin as first line for
many conditions, has not resulted in a significant increase in the absolute number of patients
dialysed acutely. Of those dialysed, there was no significant difference in the numbers who had
received gentamicin.
There are no known conflicts of interest with this study.
A25. Compliance with cytomegalovirus (CMV) prophylaxis policy in a renal transplant unit.
Steven Bamford ¹, Catherine Mclean², Heather Black¹. Department of Pharmacy¹, Renal Unit²,
Western Infirmary, Glasgow
Background: Immunosuppression after transplantation carries a risk of CMV viraemia and CMV
disease. Seronegative recipients who receive organs from seropositive donors are at higher risk
and receive chemoprophylaxis with valganciclovir. Valganciclovir is associated with a risk of
neutropaenia however neutropaenia can also be due CMV disease, antiproliferative
immunosuppressants or co-trimoxazole. During the first year post-transplant, the risk of CMV
viraemia and CMV disease is reduced when 200 days prophylaxis is given compared with 100
days prophylaxis1. In line with this, the Renal Unit of the Western Infirmary Glasgow has changed
the CMV prophylaxis policy to recommend 6 months rather than 3 months prophylaxis. The new
policy came into place in May 2011. We set out to review the compliance with the previous policy
and the associated side effects.
Methods: Patients who received a renal transplant between March 2007 and March 2010 were
identified from a database along with patient demographics. Seropositive to seronegative
transplants were identified and data on valganciclovir prescribing, CMV viraemia (>5000 copies/ml)
and neutropaenia (neutrophils <1.0x109/l) during 12 months post-transplant was manually retrieved
from electronic records.
Results: A total of 260 transplants were identified. Sixteen were excluded due to incomplete data.
Fifty patients with seropositive to seronegative transplants were identified, of whom 46 received
prophylaxis. In one case prophylaxis was inadvertently omitted. Three cases had a transplant
nephrectomy.
There were 33 episodes of CMV viraemia in 23 patients. Sixteen episodes were treated with
therapeutic valganciclovir and 9 required hospital admission. Four episodes occurred at 0-100
days, one in the patient who did not receive prophylaxis. Ten occurred at 100-200 days posttransplantation and 19 at >200 days.
The mean duration of prophylaxis was 114(36-223) days. The appropriateness of dosing was
reviewed in relation to creatinine clearance. At discharge from hospital, dosing data was missing
in 6 patients, 18 patients received the correct dose, 17 a high dose and 5 a low dose. Twentyeight patients had a recorded dose change. The revised dose was correct in 23 cases (4
treatment,
19
prophylaxis).
There were 31 episodes of neutropaenia in 23 patients. On 4 occasions this was attributed to
CMV disease. Twenty-three episodes occurred while taking valganciclovir. Eleven patients were
on the recommended dose of valganciclovir, 8 of whom were on 900mg daily. Seven patients
were on a high dose of valganciclovir. Twenty-four episodes of neutropaenia resulted in dose
reduction or suspension of antiproliferative therapy.
Discussion: Neutropaenia due to valganciclovir may prompt reduction in immunosuppression.
Further to our data and evidence from Kalil et al2, the prophylaxis policy now limits the prophylactic
dose of valganciclovir to 450mg daily.
Ensuring the correct dosing and recording of valganciclovir prophylaxis is a key priority and we
hope to demonstrate an improvement when re-auditing occurs.
1) Humar et al, The efficacy and safety of 200 days Valganciclovir Cytomegalovirus prophylaxis in
high-risk kidney transplant recipients (2010) American Journal of transplantation, 10, p.1228-1237.
5) Kalil et al, Effectiveness of valganciclovir 900 mg vs. 450 mg for CMV prophylaxis in
transplantation: direct and indirect treatment comparison meta-analysis (2011) Clinical Infectious
Diseases, 52 (3) 313-321
Funding: None
Conflict of interest: None
A26. The incidence of polyoma virus & its impact on kidney graft outcome - a study of the
Edinburgh renal transplant population.
R Bright, I Johannessen, W Metcalfe, LK Henderson,Royal Infirmary of Edinburgh
Background: Polyoma or BK virus-associated nephropathy is an emerging cause of kidney
transplant failure affecting 2-10% of patients. Uncertainty exists regarding risk factors, diagnosis,
and management.
Methods: All serum samples that were positive for polyoma virus PCR (defined as BK viraemia)
between April 1st 2009 and August 31st 2011 in the Royal Infirmary of Edinburgh virology computer
system were identified. We retrospectively analysed the electronic case notes, determined further
investigations taken, detailed clinical action, and consequent impact on graft function and survival.
Results: Of the 197 kidney and combined kidney/pancreas transplants carried out over the study
period, 9 patients were diagnosed with BK viraemia – an incidence of 4.6%. All patients had
received standard immunosuppression with basiliximab, tacrolimus, prednisolone and either MMF
or azathioprine. In all cases samples were sent following an unexplained rise in creatinine.
Of the 9 patients identified with BK viraemia: 4 had already been diagnosed with BK virus
associated nephropathy (BKVAN) on biopsy; 2 patients went on to have a renal biopsy confirming
BKVAN; 1 had a normal biopsy, and 2 had no biopsy performed. In all 9 patients
immunosuppression was reduced. 2 patients received additional treatment with ciprofloxacin, and
1 received leflunomide and cidofovir.
At last follow-up 1 patient had died, 1 graft had failed, and of the remaining 7 patients 6 had a
reduction in eGFR (mean creatinine clearance (CrCl) 45 to 25 ml/min), and 1 patient showed an
improvement in renal function with a rise in CrCl from 37 to 68 ml/min.
Conclusion: The incidence of BK viraemia in our population is similar to reported rates. Response
to a reduction in immunosuppression is variable and especially poor following the diagnosis of
BKVAN. Based on the current data, the morbidity associated with BKVAN supports a potential role
for an early screening programme.
A27. Interpretation of a sensitive troponin assay in patients with chronic kidney disease and
suspected acute coronary syndrome
David Ferenbach1, Bryan Conway1, Wendy Metcalfe1, David E Newby2 and Nicholas L Mills2
Departments of Renal Medicine1 and Cardiology2, Royal Infirmary of Edinburgh
Introduction: Renal excretion contributes to clearance of circulating cardiac troponins. We
evaluate the impact of sensitive troponin assays on the management and clinical outcome of
patients with suspected acute coronary syndrome (ACS) who have chronic kidney disease.
Methods: We identified all consecutive patients admitted with suspected ACS to the Royal
Infirmary of Edinburgh, UK, before (n=1,016; February 1-July 31, 2008- validation phase) and after
(n=1,043; February 1-July 31, 2009- implementation phase) lowering the threshold of detection for
myocardial necrosis from 0.20 to 0.05 ng/mL using a sensitive troponin I assay. Patients were
stratified into groups by troponin concentration (<0.05 ng/mL, 0.05-0.19 ng/mL, and0.20 ng/mL),
and by renal function (eGFR, <60 versus 60 mL/min). During the validation phase, only
concentrations above the previous diagnostic threshold of 0.20 ng/mL were reported to clinicians.
Results: Patients with an eGFR<60 mL/min were more likely to have troponin concentrations
above 0.05 ng/mL than patients with normal renal function (47.2% versus 31.6%; p<0.001), but
were less likely to undergo revascularization or be commenced on preventative medications
(p<0.001 for both). During the validation phase patients with troponin concentrations 0.05-0.19
ng/mL were at high risk of recurrent myocardial infarction (34% versus 26% for <60 and 60
mL/min respectively; p=0.43) and death 31% versus 19% for <60 and 60 mL/min respectively;
p=0.16) irrespective of eGFR. Implementation of the sensitive assay was associated with
increased specialist cardiology input (p=0.0002) and a reduction in recurrent myocardial infarction
to 11% and 9% in those patients with eGFR<60 mL/min (p=0.017) and 60 mL/min (p=0.012)
respectively, but all-cause mortality remained significantly higher in patients with eGFR <60
mL/min compared with those with normal renal function (19% versus 2%; p=0.01).
Conclusion: Use of a sensitive troponin I assay increases the number of patients with renal
impairment diagnosed with myocardial infarction, but was associated with a significant reduction in
recurrent non-fatal events that was equivalent to those patients with normal renal function. Renal
impairment is a major risk factor for cardiovascular death in acute coronary syndrome with new
strategies to reduce cardiovascular risk urgently required.
A28. Contrast Induced Nephropathy: epidemiology, outcomes and preventative measures in
a district general hospital.
Dr Robin Berger (FY2) and Dr Achyut Valluri (SpR)
Acute kidney injury in hospitalised patients is associated with not only increased length of stay, but
also higher inpatient and long-term mortality (Chertow, 2005). Iatrogenic complications are the third
leading cause, and radiocontrast-induced nephropathy (CIN) has been well described in the
literature (Weisbord, 2005). To date, no effective treatment has been identified, so prevention is
key to avoiding unnecessary harm. Our aim was to evaluate the implementation of current
prophylaxis guidelines and innovate strategies to improve quality of care.
There were two phases to this study:
 First, a retrospective review was undertaken of all medical inpatients undergoing contrast CT
studies over a six-month period at a district general hospital (n = 293). The management of
those patients at risk of CIN was compared to current best practice. Areas of concern were
identified and presented to medical staff at the hospital’s clinical effectiveness meeting.
 A second period of observation was undertaken to establish whether management had
improved during the two weeks after this intervention (n = 29), and if this effect was sustained
two months later by the same cohort of doctors (n = 28).
The incidence of CIN in the larger first study was in keeping with literature estimates of 11%
(Newhouse, 2008). Initially, complete adherence to the prophylaxis protocol was poor (13%), but
improved (100%) after presentation of the initial data only to fall again (0%) two months later. More
specifically, patients having appropriate nephrotoxic medication discontinued rose from 19% to
71% after the intervention only to fall to 33%, while the provision of renal protection rose from 26%
to 50% falling to 22%, and post-scan monitoring of renal function rose from 57% to 100% declining
to 78%.
These findings illustrate endemic poor compliance with CIN prophylaxis guidelines, causing
unnecessary harm to patients. We have demonstrated that practice can be improved through
raising the general awareness of medical staff, but that this effect is not sustained for long. Our
proposed solution is to incorporate alerts into forthcoming electronic test requesting systems, a
simulation of which was demonstrated at the Scottish Renal Association meeting.
1.
Chertow GM et al. Acute Kidney Injury, Mortality, Length of Stay, and Costs in Hospitalized
Patients. J Am Soc Nephrol. 2005;16:3365-3370.
2.
Weisbord SD, Palevsky PM. Radiocontrast-induced acute renal failure. J Intensive Care
Med. 2005;20(2):63.
3.
Newhouse JH et al. Frequency of serum creatinine changes in the absence of iodinated
contrast material: implications for studies of contrast nephrotoxicity. Am J Roentgenol.
2008;191(2):376.