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Scottish Renal Association ABSTRACT BOOKLET F Frriid daayy 1111tthh N No ovveem mb beerr 22001111 S Saattu urrd daayy 1122tthh N No ovveem mb beerr 22001111 H Hiillttoonn S Sttrraatthhccllyyddee H Hootteell,, P Phhooeenniixx C Crreesscceenntt,, B Beellllsshhiillll M MLL44 33JJQ Q Please try and recycle any conference papers after meeting 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, and0.20 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.