Scottish Renal Association
ABSTRACT BOOKLET
Friday 7th March 2014
Saturday 8th March 2014
Carnegie Conference Centre
Halbeath Road
Dunfermline
KY11 8DY
1. RECOGNITION AND TREATMENT OF HYPERKALAEMIA IN THE
SECONDARY CARE SETTING
Waugh FR, Phelps RG, Goddard J, Vernon MA
Department of Renal Medicine, Royal Infirmary of Edinburgh
Introduction: The aim of this study was to examine if episodes of hyperkalaemia in a
secondary care setting were recognised and, if so, what treatment they received and
how this compared to Clinical Practice guidelines published from the Renal
Association in 2012.
Methods: Over a 4 week period in a large hospital providing secondary and tertiary
care we prospectively identified all episodes of hyperkalaemia (>6.0 mmol/l) via an
automated alerting system. Episodes from the haemodialysis unit were excluded, but
all other episodes were investigated including review of the medical and nursing
paper and electronic records to determine how the episode was recognised and
managed against the RA guidelines.
Results: In the 4 week period there were 109 episodes of hyperkalaemia identified in
45 patients. 67% of episodes were of moderate hyperkalaemia (serum K+ of 6.0-6.4)
and 33% were of severe hyperkalaemia (K+ of 6.5).
Treatment to lower potassium was administered in response to 33/36 (91.6%)
episodes of severe hyperkalaemia: 30 episodes prompted potassium lowering
medication; 3 episodes were managed by haemodialysis (HD). In the moderate
hyperkalaemia group 45 of 73 (62%) episodes: 37 were treated with K+ lowering
medication and 8 were chronic HD patients who received HD treatment.
There was very poor compliance with the recommendation that patients with
hyperkalamia have an ECG. Almost a third (29%) of patients with moderate
hyperkalaemia did not have either an ECG or continuous cardiac monitoring at any
point and only 47% of patients with a K+6.5 had continuous cardiac monitoring. An
abnormal ECG was noted in 16% of episodes and calcium gluconate (10mls 10%)
was given in 21% of all hyperkalemic episodes and in 1 episode this was without an
ECG/cardiac monitoring being performed at all.
Over 90% of episodes of severe hyperkalaemia were treated by insulin/dextrose
infusion (the majority of patients received 10 units of actrapid in 50mls/50%
dextrose), but only 33% of infusions were succeeded by checks of blood glucose and
1 patients developed symptomatic hypoglycaemia after 10 units of actrapid without
monitoring. Where Salbutomol nebulisers were used for severe hyperkalaemia, most
(69%) were at given less than the recommended dose of 10-20mg. In moderate
hyperkalaemia 60% of hyperkalaemic episodes were treated with insulin/dextrose
and 33% of these received adjuvant salbutamol therapy (but only 33% at
recommended dose).
Sodium bicarbonate was used in 20% of treated episodes and resins were used
acutely in 15%. Only 23% of episodes were followed up with repeat serum K+
measurements within the recommended 2 hours post treatment and 55% were not
remeasured within 6 hours. Acute kidney injury was associated with hyperkalaemia in
73% of treated episodes and chronic kidney disease in 15%.
Conclusion: The evaluation, treatment and monitoring of response and vigilance
regarding complications in the treatment of hyperkalaemia compares poorly to
published Clinical Practice guidelines. Awareness and implementation of national
guidance at local level is required for improved patient safety.
2. Sudden, severe headache: an unexpected culprit
Presented by: Stephen Fenning1
Co-authors: Samantha Conlin1, Graeme Weir2, Zahid Raza3, Richard Phelps1, Fiona
Gifford1
1. Department of Renal Medicine, Royal Infirmary of Edinburgh
2. Department of Radiology, Royal Infirmary of Edinburgh
3. Department of Vascular Surgery, Royal Infirmary of Edinburgh
Here, we present the unusual case of a 48 year old female ex-smoker with end-stage
renal failure who was admitted from the dialysis unit with acute severe fronto-occipital
headache associated with nausea, blurred vision and photophobia. Of note, she had
recently undergone anastomotic revision of a stenosed left brachiocephalic fistula.
We discuss the initial investigations and management of her headache and reveal
how, by revisiting the patient’s history, we were able to identify an interesting and
unexpected culprit for her symptoms.
4. Erythropoietin Stimulating Agents Resistance and Survival in UK
RRT population
Anirudh Raoab, Julie Gilga, Fergus Caskey abc
a
UK Renal Registry, Bristol, UK; b Southmead Hospital, Bristol, UK; c School of Social
and Community Medicine, University of Bristol, UK
Background: RA guidelines define resistance to ESA therapy as ‘failure to reach
the target Hb level despite SC epoetin dose >300 IU/kg/week (450 IU/kg/week IV
epoetin) or darbepoetin dose >1.5mcg/kg/week’. The aim of this study was to
describe the prevalence of ESA resistance in RRT population, to identify predictors
for ESA resistance and 1 year survival in the UK dialysis population.
Methods: Patients receiving RRT in England, Wales or Northern Ireland on 31st
December 2011 were included. The erythropoietin resistance index (ERI) was
calculated as the weekly weight-adjusted dose of ESA divided by the haemoglobin
level. Patients were stratified into: group A, Hb ≥10 g/dl and not on ESA; group B,
ERI <5; group C, ERI=5–15; group D, ERI>15 IU/kg/week/g per dl and group E,
Hb<10 g/dl and not on ESA. Univariate and multivariate logistic regression analyses
were used to assess the association of clinical and laboratory markers with the binary
outcome of ESA resistance (yes/no). For the regression analysis groups D&E were
used as outcome group vs groups A, B &C. But for the survival analysis group A was
used as the baseline group vs group B&C and group D&E. Cox proportional hazards
models were used to investigate the effect of ESA resistance on survival with
adjustments made for clinical and laboratory markers.
Results: The analysis included 6,833 patients from 30 centres for Haemodialysis
(HD), 471 patients from 17 centres for Peritoneal dialysis (PD) and 2,687 patients
from 10 centres for Transplant (Xp) which equated to 35%, 15%, 12% of HD PD and
Xp stable prevalent patients respectively. The dose range for patients with high dose
ESA for HD was 450-847 IU/kg/week, for PD 312-596 IU/kg/week and Xp 348-424
IU/kg/week. The prevalence of ESA resistance including patients with Hb <10 g/dl
and on a high dose of ESA and Hb < 10g/dl and not on ESA was 1.2% (N=82) for
HD, 2.8% (N=13) for PD and 2.4% (N=65) for Xp.
In the univariate models of HD patients, age <50 years (OR 1.40, p 0.0001); female
sex (OR 1.68, p <.0001); longer dialysis vintage (OR 1.01, p = 0.05); URR<65% (OR
1.46, p <.0001); ferritin >800 µg/L (OR 1.59 p <.0001) and lower albumin (OR 0.92, p
<.0001) were identified as predictors of ESA resistance. In the multivariate model all
but dialysis vintage (OR 1.01 p = 0.13) remained significant. In the univariate models
for PD patients, female sex (OR 2.07, p = 0.03); longer dialysis vintage (OR 1.26, p
<.0001); ferritin >800 µg/L (OR 3.75 p = 0.02) and lower albumin (OR 0.89, p =
0.0001) were identified as predictors of ESA resistance. In the multivariate model all
but female sex (OR 1.27, p= 0.53) remained significant.
For both HD and PD there was worse survival for patients in the ESA resistance
group. For PD there was no relationship between ESA resistance and survival when
further adjustments were made for clinical and laboratory markers. This could be due
to the relatively small number of events compared to the number of parameters being
fitted in this model.
Table 1.0 Unadjusted and adjusted 1 year survival, HR and (p-value), for HD &
PD patients
HD (N=5588)
Group
Unadjusted
Adj for age
& sex
A
-
-
B&C
D&E
1.2(0.24)
1.1(0.57)
PD(N=455)
+ URR,
dialysis vintage,
ferritin
& albumin
1.0(0.92)
Unadjusted
Adj for age
& sex
-
-
1.0(0.99)
1.0(0.97)
2.5(<.0001)
2.6(<.0001)
2.0(<.0001)
2.2(0.08)
2.4(0.06)
Conclusion: ESA resistance has implications beyond the management of anaemia
with its presence portending mortal outcomes.
4. Renal Patient View users are more likely to begin RRT on a homebased modality: an effective source of pre-dialysis education?
Rao Aa, Pitcher Da, Phelps R Gb
a
UK Renal Registry, UK; b University of Edinburgh.
Background: Renal Patient View (RPV) is an established Electronic Personal Health
Records (EPR) designed to educate patients as well as enable them to participate in
the monitoring and management of their renal disease in UK. It may therefore have a
role in equipping patients to make an informed choice of dialysis modality when
beginning RRT, one of the key standards proposed in The National Service
Framework (NSF) for Renal Services. Most patients offered an informed choice
choose a home-based modality, and pre-dialysis education has been reported to
strengthen this trend. On this background we hypothesised that patients that utilised
RPV are better informed about choice of modality and more likely to choose homebased modalities for first RRT provision. The aim was to investigate first dialysis
modality in RPV users and non-users.
Methods: The RPV user database extant on January 25th 2012 was linked by patient
CHI / NHS number with the UK renal registry and anonymised data extracted for
analysis.
The extract was restricted to adult patients and included patient
demography, deprivation indices, ethnicity, UKRR timeline data and referral time
(time between first referral to nephrologist and date of starting RRT), date of
beginning RRT, date of first logon to RPV, and measures of patient utilization of RPV
derived from log file analysis as reported elsewhere. Patients with a referral time of
<90 days were excluded. RPV users were grouped by the interval between their first
logon to RPV and their date of starting RRT, and comparison made between patients
that had been users of RPV for at least 90 days before beginning RRT (longer term
users) and users that began their use of RPV after starting RRT (late users). Logistic
regression and Chi-squared tests were performed using SAS v 9.3.
Results: Longer term RPV users were more likely than late users to begin RRT on a
home based modalities (Home Hemodialysis or Peritoneal dialysis) than hospital
hemodialysis (571/1345 and 543/1453 respectively, p = 0.006). The association was
stronger for longer term users that logged into RPV more persistently suggesting the
effect was related to the patients themselves rather than any selection by the centre
of patients offered RPV (481/1068, p = 0.0001). By 90 days after starting RRT the
difference in prevalence of home-based modality provision to longer term and late
RPV users had waned but was still significant (p = 0.037, 0.032 for persistent RPV
users). The results were not just a proxy for a longer referral period (so more time to
initiate RPV) as a similar pattern was found when patients with referral time <6
months of < 1 year were excluded. Controlling for age, sex, deprivation and ethnicity,
longer term persistent RPV users were 31% (10-57%, 95% CI) more likely to begin
RRT on a home- based modality than late users, and almost three times more likely
than the overall RRT population.
Longer term RPV users were more likely to begin RRT with a live transplant
compared to late users (217/342 and 150/274 respectively, p = 0.029), even when
controlling for age, sex and deprivation, and similarly, this association had weakened
by 90 days after starting RRT (p = 0.22).
Conclusion: The results demonstrate an association between using RPV and
beginning RRT on a home-based modality or with a live donor transplant. The
greater strength of the association for users that make greater use of RPV is
consistent with our hypothesis that RPV is contributing to patient’s discovery around
RRT modality choice.
5. Effectiveness of BuTrans Patches for Pain Relief in Patients with
Advanced CKD - A Case Series.
JM Sloan, SM Cathcart, ME Lafferty and CA Douglas. Renal Unit, Ninewells
Hospital, Dundee, DD1 9SY
Background
Studies have shown that approximately 50% of patients with advanced CKD
experience moderate to severe pain. Many of the commonly prescribed opioids such
as codeine and dihydrocodeine are not tolerated in renal failure as they are
metabolised to active metabolites and both the metabolites and the unchanged
parent opioid are excreted renally At present there is no SMC approved analgesia
which is ideal for use in CKD patients on step 2 of the WHO pain ladder. Within NHS
Tayside, the Renal Supportive Care Team have been increasingly using
Buprenorphine patches in this group under Individual Patient Treatment Request
(IPTR) approval. A 5mcg patch is equivalent to 30mg codeine four times daily. The
aim of this case series was to assess the effect of Buprenorphine on pain relief and
its side effect profile.
Method
We performed a retrospective case note review of patients with advanced CKD
managed conservatively or on dialysis, who were commenced on a Buprenorphine
patch. At each clinic visit the patient completes a symptom assessment score
(Patient Outcome Score - renal) which is a validated tool in CKD. It scores 17
symptoms each on a scale from 0-4 (none, mild, moderate, severe, overwhelming).
Data collected included the cause of pain, previously tried analgesics, dose of
Buprenorphine and POSs scores before and after commencement of the patch.
Results
9 patients were included in the case series. 1 patient was intolerant due to local skin
irritation to the patch. Of the remaining patients, 6 patients were for conservative
management and 2 were on dialysis. The majority of patients experienced
musculoskeletal pain. Pain scores were reduced in all, with 3 patients experiencing
complete resolution of pain. Nausea was reduced in 4 patients, and increased in 1.
Appetite improved in 2 patients and worsened in 1. Anxiety and depression scores
were also reduced in several patients. Overall the total symptom burden score was
reduced from an average of 16.5 to 13.6.
Conclusions
Buprenorphine is metabolised to compounds with little activity and the parent drug is
excreted through the biliary system. Therefore it may be safer and better tolerated
than drugs such as codeine and Tramadol which often cause significant side-effects
and respiratory depression in patients with advanced CKD. This case series
suggests that Buprenorphine patches may be a safe and effective analgesic for
patients with CKD who require a step 2 opioid.
6. URINE NEUTROPHIL GELATINASE-ASSOCIATED LIPOCALIN AS A
BIOMARKER OF ACTIVE LUPUS NEPHRITIS.
Muhammad Iqbal AH, Lim SK, Tan LP, Ng KP, Keng TC, Wong CM, Chong YB, Wan
Hafiz MA.
Nephrology Unit, Department of Medicine, Universiti Malaya, Kuala Lumpur,
Malaysia.
Introduction: Urine neutrophil gelatinase-associated lipocalin (NGAL) is a novel
marker of acute kidney injury. Recently it has been shown that urine NGAL is raised
in patients with active lupus nephritis (LN). These studies however diagnosed LN
using an SLE based disease activity scoring system, while some measured urine
NGAL in patients with LN who had been biopsied months earlier and was already on
treatment.
Objective: We sought to determine whether there is any difference between the
levels of urine NGAL in patients with biopsy proven LN compared to SLE patients
without LN and to healthy individuals.
Method: We conducted a cross sectional study over 8 months and identified 12
biopsy proven patients with newly diagnosed or a flare of LN. The urine NGAL levels
were measured and compared to SLE patients without LN (n=33) and to healthy
individuals (n=27). The urine protein creatinine ratio (UPCR), ESR, anti-dsDNA, C3,
C4 and eGFR were also measured to determine their association with urine NGAL.
Results: We found that patients with LN had significantly higher levels of urine NGAL
(median 21.95 ng/ml IQR 6.35- 52.2) compared to both the SLE patients without LN
(median 3.4 ng/ml IQR 1.75 – 10.8)(p<0.01) and the healthy individuals (median 8.5
ng/ml IQR 3.5 – 20.4) (p<0.05). Although the urine NGAL levels were higher in the
healthy individuals as compared to the SLE with no LN group, this difference was not
statistically significant. We did not find any correlation between urine NGAL and other
markers of LN.
Conclusion: Our study supports previous findings that urine NGAL is raised in active
LN. Urine NGAL may be a promising tool for screening of LN given that it is a simple
and non-invasive test. Serial measurement of urine NGAL in LN may even delineate
its role in predicting flares of the disease.
The author has nothing to declare.
7. Clinical and histological features of patients having renal biopsy for
AKI
Gemma M McGrory, Bruce MacKinnon, Colin C Geddes, Glasgow Renal and
Transplant Unit.
Background: Only a minority of patients with AKI have a renal biopsy because the
majority of cases of AKI are due to acute tubular necrosis (ATN). The decision to do
a biopsy is difficult and is carried out because of clinical features that suggest there
may be a diagnosis requiring urgent specific therapy.
Aims: The aim of this study was to determine the incidence of the histological
diagnoses in all patients having a renal biopsy for AKI, describe the delays from
presentation to histological diagnosis and explore the possibility that clinical and
laboratory features can identify sufficiently high negative predictive value for
diagnoses that require urgent specific therapy.
Methods: All patients in our centre in whom the nephrologist performing the biopsy
recorded the indication for biopsy as AKI at the time of biopsy from 01/01/2010 –
31/12/2012 were identified from the prospectively maintained electronic patient
record along with associated demographic and laboratory data. The time from first
evidence of AKI (presentation), to referral to nephrology services, and to diagnostic
biopsy were calculated for each patient.
Results: 155 patients underwent renal biopsy for AKI during the study period (45%
female, 55% male) giving an incidence of 41 per million population per year. Mean
age at biopsy was 62.4 years (range 16.4 - 89.2). The diagnoses obtained from renal
biopsy were: focal necrotising glomerulonephritis (FNGN) (n=45 [29.6%]); acute
interstitial nephritis (AIN) (n=29 [19%]); primary glomerulonephritis (n=22 [15%]);
ATN (n=17 [11%]); thrombotic microangiopathy (TMA) (n=7 [4.6%]); chronic damage
(n=6 [4%]); plasma cell dyscrasias (PCD) (n=5 [3%]); diabetic nephropathy (n=5;
[3%]); lupus nephritis (LN) (n=3 [2%]; others (n=4 [2.6%]); ischaemia (n=3 [2%]); and
chronic interstitial nephritis (n=2 [1.3%]). The median times from presentation to
referral to nephrology and then to biopsy were 5.5 days and 8 days respectively. For
diagnoses where urgent specific therapy is usually indicated (FNGN, AIN, TMA,
PCD, LN) median delays were 5 and 7 days respectively. Pre-biopsy C reactive
protein (CRP) <60mg/L had a negative predictive value of 76% for FNGN, however,
analysis of eGFR, proteinuria, serum albumin, eosinophils and immunology results
before biopsy had no meaningful predictive value.
Conclusions: The range of possible diagnoses and the delays to biopsy illustrate the
challenge of identifying patients with AKI who might have conditions requiring urgent
specific therapy. Further analysis of clinical and laboratory data may provide
diagnostic support to nephrologists considering the utility of renal biopsy in patients
with AKI.
8. What is the incidence of ureteric stricture in renal transplant patients?
An observational study
A Davidson, Fifth Year Medical Student, University of Aberdeen and I.H. Khan,
Consultant Nephrologist, NHS Grampian.
Introduction: Renal transplantation is the most effective treatment for end stage
renal failure. However, in addition to allograft rejection and glomerular disease,
urological complications such as ureteric stricture can endanger renal function, and
even lead to graft failure. An observational study was carried out to assess the rate of
stricture in relation with other centres in the UK and abroad.
Methods: This study investigated the rate of stricture in a cohort of 102 patients who
had a renal transplantation in the past 4 years at the Royal Infirmary of Edinburgh
(RIE), and received post-transplant rehabilitation at Aberdeen Royal Infirmary (ARI).
Risk factors such as age, gender, and stent removal time were also analysed and
compared with the literature.
Results: A stricture rate of 3.9% in this study was found to be higher than a majority
of the literature. Nevertheless, when compared with a larger study at another UK
centre achieving a rate of 3.7% with similar patient demographics, it could be argued
that the rate of stricture in this study is on par with UK figures. Male gender and age
were found to be potential risk factors, although, there was no evidence to suggest
that prolonged stent removal time was a factor.
Conclusion: The findings of this study do appear to have some similarity with the
literature with respect to risk factors and stricture rate. However, due to the small
patient numbers involved in the analysis, it is recommended that further research is
carried out involving larger numbers of transplant cases that have been conducted
consecutively.
Declaration: This study was part of a medical school elective project, and there are
no conflicts of interest to declare.
9. ROBUST INDUCTION OF HEMEOXYGENASE-1 EXPRESSION DOES
NOT AUGMENT TUBULAR REGENERATION IN 20-MONTH-OLD MICE
FOLLOWING ACUTE KIDNEY INJURY
Peng Ding, David Ferenbach, David Kluth and Jeremy Hughes MRC Centre for
Inflammation Research, The Queen’s Medical Research Institute, University of
Edinburgh
Introduction: Elderly individuals are more prone to acute kidney injury (AKI). Our
previous work indicated that ‘middle-aged’ 12-month old female FVB/nj mice
developed more severe AKI compared to young 8-week old mice following renal
ischaemia-reperfusion injury (IRI). Compared to young mice, 12-month old mice
exhibited reduced medullary upregulation of the anti-inflammatory enzyme
hemeoxygenase-1 (HO-1) whilst pre-treatment of 12-month old mice with the potent
HO-1 inducer hemearginate (HA) strongly upregulated HO-1 and afforded marked
protection from AKI (KI 2011). We extended this work and demonstrated that pretreatment with HA also protected 20-month-old mice from ischaemic AKI despite the
presence of interstitial fibrosis at baseline (Renal Association 2012).
Objective: This study aimed to determine whether the administration of HA to 20month-old mice after the induction of AKI augmented tubular cell regeneration.
Methods: Initial studies involved 20-month-old female FVB/nj mice undergoing a
right nephrectomy (to provide baseline tissue) and IRI of the left kidney induced by
clamping the left renal pedicle for 20 minutes. However this functional AKI model
resulted in an excessively high mortality and we thus opted to leave the right kidney
in situ and focus on histological parameters. Mice received IV HA (30mg/kg) or PBS
at days 1 and 4 following the induction of AKI (4-7 mice/group). Tissue was
harvested at day 1 to determine injury severity and day 5 to assess tubular
regeneration. Readouts included HO-1 expression (immunostaining quantified by
computer image analysis), acute tubular necrosis (ATN) score (determined on PAS
stained sections) and tubular cell proliferation (Ki-67 immunostaining). Data is
expressed as % total area stained (HO-1), % of tubules exhibiting cell necrosis (ATN
score) and the number of Ki-67+ cells per high power field (hpf). Data is expressed as
mean±SEM.
Results: In the absence of HA treatment, 20-month-old mice exhibited minimal HO-1
expression at day 1 (cortex 0.9±0.4% total area, medulla 0.2±0.1%) or day 5 (cortex
0.3±0.1% total area, medulla 0.2±0.1%). HA administration at days 1 and 4 following
IRI induced dramatic HO-1 expression at day 5 (cortex 10.2±3.2% total area, medulla
4.7±1.7%). The ATN score at day 1 was 40±17% indicating significant injury. The
ATN score fell to 12±8% at day 5 in the PBS treated group indicating significant
restoration of tubular integrity. However, HA treated mice exhibited a comparable
ATN score of 12±6% at day 5. Limited tubular cell proliferation was evident at day 1
(Cortex 4.5±0.8, Medulla 6.3±3.6 Ki67+ cells/hpf). Although there was a trend
towards increased tubular cell proliferation in HA treated mice in both the renal cortex
and medulla this did not reach statistical significance (Cortex 25±7.9 vs 38±8.4 Ki67+
cells/hpf; PBS vs HA; p>0.05 and Medulla 34±13.6 vs 46±14.6 Ki67+ cells/hpf; PBS
vs HA; p>0.05).
Conclusion: 20-month old mice exhibit very limited HO-1 expression at days 1 or 5
following AKI consistent with our previous work. Treatment with HA at days 1 and 4
following injury strongly upregulated HO-1 expression in the renal cortex and
medulla. The ATN score exhibited a comparable reduction between days 1 and 5 in
HA and PBS treated groups. HA administration and subsequent HO-1 induction was
associated with a trend to increased tubular cell proliferation but this was not
statistically significant. Although the pretreatment of aged mice with HA is markedly
renoprotective, the administration of HA after injury is established does not
significantly promote tubular regeneration.
10. Skin cancer screening in renal transplant recipients
Michelle L Anderson (a), Jack AA Fairweather (b), Scott W Oliver (c), Lorna J
Mackintosh (d), Colin C Geddes (e)
Specialty Registrar in Dermatology (a), Core Medical Trainee (b), Specialty Registrar
in Renal Medicine (c), Consultant Dermatologist (d) Consultant Nephrologist (e)
Introduction
Renal transplant recipients have a high risk of developing skin cancer (1). This has
been confirmed in our local patient cohort (2). Guidelines recommend annual skin
screening for all renal transplant recipients (3) and a screening clinic was established
in Glasgow in September 2005. The purpose of this study was to determine
attendance at skin-screening by our local cohort of renal transplant recipients.
Secondary outcomes were the performance of skin biopsies and the incidence of
skin malignancy.
Methods
Patients with functioning renal transplants for at least 12 months, and who lived
within the NHS Greater Glasgow & Clyde (NHSGGC) catchment, were followed from
1/7/10 until 13/12/13. Data were collected prospectively via the West of Scotland
Electronic Renal Patient Record (SERPR), including any skin biopsy results reported
during this period. This was matched with NHSGGC Clinical Portal data to record
screening clinic attendance.
Results
There were 849 prevalent patients on 1/7/10. Having excluded 171 patients who
lived outwith the NHSGGC catchment area or who had incomplete data, there were
678 study patients. 268 (39.5%) patients attended a dermatology clinic at any time
during the study, with 171 (25%) screened in the preceding 12 months. 161 skin
biopsies were performed, demonstrating malignant (92 patients, 13.6%) or
premalignant (57 patients, 8.4%) lesions. These were basal cell carcinoma (BCC, 45
patients), squamous cell carcinoma (SCC, 43 patients), malignant melanoma (4
patients), actinic keratosis (26 patients) and Bowen’s disease (31 patients). 14
patients had both SCC and BCC.
Conclusions
Malignant and premalignant skin lesions are common in this patient group, yet most
renal transplant recipients do not attend for screening within the recommended
timescale.
References
1. Bordea C, Wojnarowska F, Millard PR et al; Skin cancer in renal transplant
recipients occur more frequently than previously recognised in a temperate climate;
Transplantation 2004; 77: 574-579
2. Mackintosh LJ, Geddes CC, Herd RM; Skin tumours in the West of Scotland renal
transplant population; Brit J Dermatol 2013; 168: 1047-1053
3. Renal Association; Postoperative care of the kidney transplant recipient (5th
edition); February 2011
Funding: None
Conflicts of interest: None
11. A retrospective observational study of the outcomes of synthetic
arteriovenous grafts used for haemodialysis in NHS Grampian.
L Ciriello1, A Humphrey3, A Marks1, M Sharp2, D Walbaum3
1
University of Aberdeen, 2Department of Vascular Surgery and
Aberdeen Royal Infirmary.
3
Renal Unit,
Aim
To investigate the outcome of vascular access grafts used for haemodialysis in NHS
Grampian.
Method
Data was collected from local databases for all synthetic arteriovenous grafts
inserted between 1st January 2008 and 31st December 2012. Patency was recorded
up to October 2013. Patients were censored by death, transplantation or reaching the
end of the observation period. A graft was only placed if there was no fistula option
available according to KDOQI guidelines. During the study period grafts from three
manufacturers were used: Vascutec Seal PTFE, Gore Propaten and Atrium Flixene.
The type of graft was chosen according to surgeon preference and availability.
Flixene was only used to avoid placement of a CVC line that would otherwise have
been required for immediate dialysis access.
Results
68 Patients had 102 grafts placed. 57% were female. 48% of patients were diabetic.
57% had a non-dominant straight upper arm graft while 25% had a similar graft in the
dominant arm. 94% of patients were taking an anti-platelet or were anti-coagulated.
Median graft survival was 2 years. No statistical difference in patency was observed
between the different grafts. (KM survival probability Log rank test p=0.97). After
intervention for graft occlusion the median survival was 2 months, however 20%
continued to be used for more than one year. Grafts were lost to infection in 2 cases.
2 patients suffered from steal syndrome after graft placement.
Discussion
The performance of grafts in our study population was similar to that recorded in the
best published studies. We were unable to demonstrate the claimed 10%
improvement in patency of Heparin bonded grafts; however our study is an audit, not
a prospective study with groups matched and adequately powered. Flixene
performed no worse than other PTFE in a more challenging patient group. Because
of the instant needling capability of Flixene, its role could be extended not only to
avoid the placement of a CVC line but also to reduce the length of time an already
placed line is left in situ.
No funding received, and no conflict of interests to be declared.
12. An approach to atypical Haemolytic Uraemic Syndrome- A case
vignette with discussion of recent changes to investigation and
treatment.
Allan C, Harvey C, Richards A, Neary J
Renal Dept, Royal Infirmary of Edinburgh
A 36 year old female presented with acute kidney injury of uncertain aetiology. She
was found to be anaemic and thrombocytopenic with evidence of red cell fragments
on blood film and raised LDH levels. There was no history of diarrhoea or other
infection. Her stool culture was negative for E. Coli 0157. Despite Plasma exchange,
her renal impairment was progressive and she commenced haemodialysis within 5
days of admission. Subsequent investigations including an ADAMST13 level and
complement gene screening were sent.
Atypical Haemolytic Uraemic Syndrome (aHUS) is characterised by microangiopathic
haemolytic anaemia, thrombocytopenia and acute kidney injury, negative
investigations for Shiga toxin producing E. coli and an ADAMTS13 level >10%. It is a
rare presentation accounting for less than 10% cases of HUS, and is generally
associated with abnormalities in the complement system.
Appropriate investigation and treatment of aHUS is vitally important. The use of a
monoclonal antibody, Eculizumab, has changed the outcome of this disease
considerably1 but is associated with considerable cost. A recent Scotland-wide
survey asked Renal physicians about their opinions on appropriate investigation and
treatment of aHUS (specifically treatment with Eculizumab). The consensus was that
most physicians felt that a clinical care pathway would aid diagnosis and that early
treatment would improve outcomes. Although Eculizumab was felt to be a highly
effective treatment, concerns about its availability (due to variable individual patient
treatment request – IPTR - processes) were raised.
Discussion of management of the case will refer to new clinical care pathway and the
new Peer Approved Clinical System (PACS) which replace the IPTR process in May
2014.
1
Legendre et al, NEJM, 2013; 368: 2169-81