Quality of Life Before and After Living Donor Kidney Transplantation
J A Lumsdaine1 A Wray2 M J Power3 N V Jamieson2 M Akyol1 J A Bradley2 JLR
Forsythe1 S J Wigmore1
1
Transplant Unit, Royal Infirmary of Edinburgh; 2Transplant Unit, Addenbrookes
Hospital, Cambridge, 3 Department of Psychiatry, Royal Edinburgh Hospital
Aim: To assess the impact of donating and receiving a kidney before and after living
kidney donor transplantation on quality of life, concerns and relationship issues.
Method: Prospective, longitudinal study in two transplants centres in the United
Kingdom. Both donor and recipient were requested to complete the World Health
Organisation Quality of Life questionnaire (WHOQOL) along with additional
questions concerning relationships between donor and recipient and other family
members. The questionnaires were completed before surgery, 6 weeks and one year
after live donor transplant.
Results: Forty-eight donor-recipient pairings agreed to participate (3 declined). Sixweek follow-up data is complete for 40 pairs, one year follow-up data is available for
30 pairs with the remainder due by November 2003.
The WHOQOL physical domain score of donors deteriorated at six weeks after
donation but had returned to pre-operative values by one year (p=<0.0001). Recipient
physical and psychological domain scores continued to improve throughout the postoperative period (p=<0.0001). The social and environmental domains were unchanged
in both donor and recipient.
Additional questions concerning the relationships between donor and recipient
showed a significant improvement in the recipient’s perception of relationship with
the donor (p<0.015). The donor’s relationship with the recipient also improves. The
concern for the donor by the recipient reduced immediately post donation. The
donors’ concerns about living with a solitary kidney remained low throughout the
time period. Despite some negative responses from donors, high scores both 6 weeks
and one year post donation confirmed their willingness to undergo the procedure
again if it were possible.
Conclusion: Reassuringly, donor physical quality of life returns to pre-donation
levels and recipient physical quality of life improves significantly. Further results
will clarify donor relationship issues and provide valuable data for future live kidney
donors.
Outcome of Pregnancy Following Renal Transplantation in Grampian
Louise Murray, David Walbaum, Alison MacLeod
Renal Unit, Dept of Medicine & Therapeutics, Aberdeen Royal Infirmary, AB25 2ZD
Introduction: Successful renal transplantation usually restores fertility in women of
childbearing age. Most studies report over 80% of pregnancies in transplant recipients
result in a surviving infant; and that pregnancy does not adversely affect graft
function, as long as pre-conception renal function is good.
We present a retrospective study of pregnancy following renal transplantation in
Grampian, looking at both graft and obstetric outcomes.
Methods: A list of all pregnancies in transplant patients under the care of Aberdeen
Royal Infirmary between 1991 and 2001 was obtained from the U.K. Transplant
database. Medical and obstetric case note review gave details of graft function and
hypertension, along with pregnancy outcome. Patients that completed a successful
pregnancy were interviewed.
Results: During the ten-year period, 18 pregnancies occurred in 12 patients,
representing 24% of the female transplant recipients of childbearing age (16-50 yrs).
Hypertension complicated 11 (61%) pregnancies, proteinuria of 2+ or greater
developed in 4 (22%), with pre-eclampsia occurring in 1 (6%).
At 6 months post-partum 34% had a serum creatinine more than 10% above preconception levels. However, of the 10 women with a stable serum creatinine less than
150μmol/l pre-conception, only 2 (20%) had a creatinine greater than baseline +10%
at 6 months post-partum, compared with 4 (50%) of the 8 women with a stable
creatinine above this level pre-conception.
Live birth resulted from 15 (83%) pregnancies, spontaneous abortion occurred in 2
(11%) and therapeutic abortion was undertaken in 1 (6%). For mothers with preconception creatinine below 150μmol/l, 90% (9) resulted in live births, compared
with 75% (6) for mothers with creatinine above this level. Of pregnancies that reached
28 weeks, all 15 (100%) resulted in live births.
Of the 15 live births, 8 (53%) were delivered by caesarean section. 9 (60%) of the
neonates were premature (<37 weeks), of which 4 (27%) were low birth weight
(<2.5kg). One newborn had a patent ductus arteriosus (7%) and one had a single
umbilical artery (7%).
Discussion: Pregnancy in renal transplant recipients remains a high-risk condition
with a higher frequency of complications for both mother and neonate than in the
general population. However, if pre-conception creatinine is stable below 150μmol/l
the outcome for both the pregnancy and maternal graft function is good.
Conflict of interest: none
Funding: none
An unusual cause for anaemia in a transplant recipient!
M Subramaniam, N Joss†, RL Soutar*, BJR Junor†, LJ Buist
Renal Transplant Unit, Western Infirmary, Glasgow
†Renal Unit, Western Infirmary, Glasgow
* Department of Haematology, Western Infirmary, Glasgow
A 36 year old lady underwent cadaveric renal transplantation in July 2003. Her initial
immunosuppression was prednisolone, mycophenolate mofetil and cyclosporine but
this was changed to include tacrolimus when a biopsy showed cyclosporine toxicity
although cyclosporin trough levels were therapeutic. She remained anaemic despite
improving renal function and erythropoietin and iron were administered with no
improvement. By 6 weeks post transplant her haemoglobin had fallen to 6gm% with
no evidence of blood loss. White cell and platelet counts remained normal.
Haematological investigations were performed and haemolysis was not detected.
Bone marrow aspiration and biopsy revealed pure red cell aplasia. Mycophenolate
mofetil was stopped, tacrolimus reduced and she received blood transfusions. IVIg
has not been given. Although anaemic (Hb 8gm%) her haemoglobin level is no longer
falling. Viral studies were positive for erythrovirus B19. Previously obtained sera
showed her to have been negative for this virus and her donor to have been positive.
Although anaemia is seen in about 40% of recipients of renal transplants, reports of
erythrovirus induced red cell aplasia or haemophagocytosis are rare. Could this
condition be more common than we think?
Persistent dipstick haematuria following renal transplantation
K.J. McDonald, M.A. McMillan, R.S.C. Rodger, B.J.R. Junor, C.C. Geddes, J.D.
Briggs and A.G. Jardine, Renal Unit, Western Infirmary, Glasgow
Despite widespread testing for dipstick haematuria following renal transplantation,
there are no published series describing the prevalence and possible causes of this
complication in an adult population. A cross-sectional study of 640 renal transplant
recipients under review at our follow up clinic was performed. Persistent haematuria
was defined as a minimum of 1+ of blood on urinalysis stick testing detected at not
fewer than 75% of clinic visits since its onset, or since the start of routine testing,
present over a period of at least 4 weeks. The prevalence of persistent dipstick
haematuria was 13.3%. Median
serum creatinine was higher in
patients
with
persistent
haematuria but age, gender and
length
of
time
since
transplantation
were
not
significantly different. Potential
explanations
for
persistent
haematuria in 21 of the 85
affected patients were chronic
infection; ureteric stent without
chronic infection; regular or
intermittent self-catheterisation;
persistent menstrual bleeding;
anticoagulant therapy; graft
calculus; and allograft renal cell
carcinoma. Recurrent or de novo
Progression of renal transplant recipients to graft failure or
glomerular
disease
was
death. The thicker, broken line represents those patients with
haematuria. p=0.029 (log rank test) for difference between
confirmed by graft biopsy in 10
groups.
of the 85 patients. Among the 41
recipients whose original cause
of renal failure was IgA nephropathy (IgAN), the prevalence of persistent haematuria
was 31.7% compared with 12.0% in the remaining patients (relative risk 2.6, 95%
confidence interval 1.6 - 4.3). Persistent haematuria in IgAN patients was not
associated with gender, age or time since transplantation. After 29 months of follow
up, 20.0% of patients with haematuria had progressed to graft failure or death
compared to 13.2% of the unaffected group (p=0.029). However, despite the
association with earlier graft failure, haematuria did not predict this endpoint
independently of renal function.
KJM was supported by Darlinda’s Charity for Renal Research and the National Kidney Research Fund (Training
Fellowship TF19/2002). No conflicts of interest.
The Epidemiology of Acute Renal failure treated with Renal Replacement
Therapy in Scotland; a national, population based study
Jyoti Baharani 1*, Wendy Metcalfe 3, Heather Martin 1, Lawson Loraine 1, W Cairns
Smith 3, Keith Simpson 2, Alison MacLeod 1 and Izhar Khan 1
1
Medicine and Therapeutics, University of Aberdeen, Aberdeen, United Kingdom; 2 Public Health
Medicine, University of Aberdeen, Aberdeen, United Kingdom and 3 Scottish Renal Registry,
Glasgow, United Kingdom
Background and Methods
Acute renal failure remains a common condition affecting 5-20% of all hospitalised
patients. Little is known, however, about its incidence in a fixed population base. We
have conducted the first comprehensive, prospective national study of the incidence
of ARF receiving RRT in Scotland. The Acute Renal Failure in Scotland study
(ARFS) has registered adult patients in Scotland (population 5 122 500) with ARF,
acute on chronic renal failure (ACRF) and CRF receiving their first RRT over a 9month period. The aim being, to establish the incidence of ARF receiving RRT in a
defined population and to determine the outcome of these patients at a 90-day
period. All adult patients in Scotland receiving their first RRT were identified by
regular phone calls and visits to all 20 Scottish hospitals offering this treatment. In
addition to this, some Scottish patients may occasionally receive RRT in the north of
England and these hospitals were included in our study. For the purpose of data
collection we divided Scotland into 3 regions. We completed a standard data
collection form for each patient registered into the study.
Results
Over a recruitment period of 36 weeks, 841 patients fulfilling study criteria for ARF
and ACRF were identified (mean age 62.8 years, 61% male). This equates to an
incidence of 297 p.m.p/year receiving RRT for ARF in Scotland; a quarter of these
cases occurred in-patients with a degree of pre-existing renal impairment (ACRF).






No significant trend was observed in the incidence of ARF based on
deprivation categories.
There were wide differences in incidence of ARF across Health Boards.
Almost half ARF patients were treated in ICU.
The mortality of ARF in Scotland was 47% by 90 days of starting RRT
Patients with ARF who had sepsis had a 1.7 times increased risk of mortality
than those without sepsis.
Of the patients that survived, 75% were discharged home without further RRT
by 90 days and 25% remained RRT dependent at 90 days.
Conclusion
In this first comprehensive prospective national study of ARF receiving RRT in a
defined population we have found that the incidence of ARF requiring RRT is much
higher than that previously reported from the UK (Khan et al, QJM 1997 90: 781785). The mortality for patients with ARF continues to remain high and over half the
patients have their initial treatment in the intensive care unit.
Monitoring of Therapy in Takayasu’s Arteritis using MR angiography and noninvasive pulse-wave analysis
S.H.Lambie, M.Sigrist and C.W.McIntyre
Dept of Renal Medicine, Derby City General Hospital
Takayasu’s arteritis affects large arteries, primarily the aorta and its major branches,
causing chronic inflammation often with a granulomatous appearance. The aetiology
of this disease is unknown. It is most commonly seen in patients of Asian origin, is
usually diagnosed in those aged 10 to twenty years old, and has a female to male ratio
of 9:1.
A 20-year-old woman of Eastern European presented originally in 2001 with mild
diarrhoea, a PUO and non-specific evidence of inflammation including a CRP of 100
and ESR of 93. An indeterminate colitis was discovered, probably Crohns, but despite
treatment for this, and improvement in her GI symptoms, her pyrexia and raised
inflammatory markers continued. She was noted to have weak pulses in her left arm.
A diagnosis of Takayasu’s arteritis was made based on MR angiography
demonstrating a short occlusion of the left subclavian artery and a long stenosis of the
left axillary and brachial branches. She received immunosupression initially with
prednisolone and azathioprine, and more recently with mycophenolate mofetil.
Despite this treatment, her inflammatory markers have remained above normal and
her disease has proven difficult to control, complicated by intercurrent infective
episodes which have also caused an increase in her inflammatory markers.
Intra-arterial angiography demonstrated an improvement in her arteritis with her left
subclavian artery now showing stenosis but no occlusion. Repeat MRA, done 3
months later, confirmed the improvement in appearance of the subclavian artery but
continued to show active arteritis.
At this point non-invasive pulse-wave analysis and pulse wave velocity were
measured using the SphygmoCor. This demonstrated blunting of the waveform in the
left side and reduced pulse wave velocity on that side compared to her right side.
Velocity on both sides was reduced in comparison with a normal age and sex-matched
control. The Augmentation Index was increased on both sides (compared to an age
and sex matched normal control).
Measurement of pulse wave velocity does show discrepancy from normal, and a
difference between more and less affected vessels. It may prove to be of value as a
method of tracking change and disease activity over time within this individual.
Effect of ACE Inhibition on Haemoglobin in Chronic
Renal Failure: A Randomised Controlled Trial.
Mark S. MacGregor1,2, Christopher J. Deighan1, R. Stuart C. Rodger 2
and J. Michael Boulton-Jones1.
1. Renal Unit, Walton Building,Royal Infirmary, Glasgow, G4 0SF
2. Renal Unit, Western Infirmary, Glasgow, G11 6NT
Abstract
ACE inhibitors may cause anaemia in renal transplant recipients, and indeed are used
as a treatment for post transplant erythrocytosis. However, it remains controversial
whether they can cause anaemia or erythropoietin resistance in chronic renal failure
patients. We carried out a randomised controlled trial of ACE inhibition in
progressive renal failure (STARF). Here we present an analysis of the effect of
quinapril on haemoglobin in these patients.
Seventy three patients with progressive non-diabetic chronic renal failure were
randomised to quinapril (Q; n=28), amlodipine (A; n=28) or both drugs (QA; n=17)
and followed for four years. Haemoglobin was measured quarterly, and erythropoietin
use recorded. Follow-up was censored if patients were put on renal replacement
therapy, died or if an ACE inhibitor was stopped (groups Q, QA) or started (group A).
Renal function was poor, but equal between the three groups (GFR 20.3±10.5
ml/min/1.73m2). Eighteen patients had polycystic kidney disease. Excluding them
from the analysis did not change the results. Haemoglobin was equal in all three
groups at baseline (Q 11.7±1.9 g/dl, A 12.0±2.2 g/dl, QA 12.1±2.0 g/dl). Baseline use
of erythropoietin was similar (Q n=1, dose 4000 units/week; A n=1, dose 2000
units/week; QA n=2, mean dose 1500 units/week). The quinapril groups had a
consistently lower mean haemoglobin than group A from months 3 to 27 (0.27-1.06
g/dl), but this was not significant. Erythropoietin use was generally higher in the
quinapril groups, but only significantly at month 6. Group Q had a lower mean
haemoglobin than group A from months 3 to 36 (0.19-1.46 g/dl), which approached
significance in months 3, 15 and 21. Erythropoietin use was significantly higher in
group QA compared to group A in months 6, 9 and 12. There was no correlation
between baseline GFR and change in haemoglobin at 3, 6 or 12 months in any of the
groups.
Quinapril appeared to worsen anemia or increase erythropietin use during this four
year trial. However the effect of ACE inhibition on haemoglobin in chronic renal
failure is likely to be too small to be of clinical significance, even in patients with
relatively advanced renal failure. It should nevertheless, be considered as a cause of
anaemia in individual patients.
Outcomes of Atherosclerotic Renal Artery Disease in a Low
Intervention Unit.
Samira Siddiqui, Mark S. MacGregor, Christopher J. Deighan
Renal Unit, Walton Building, Glasgow Royal Infirmary, G4 0SF.
Introduction
The natural progression of atherosclerotic renal artery disease remains unclear. The
Renal Unit at Glasgow Royal Infirmary historically has adopted an aggressive
approach towards blood pressure and lipid control but has had a low incidence of
renal artery stenting. This has allowed us to assess the progression of renal disease
and outcome in a group of patients whose management has been primarily medical.
Methods
We identified retrospectively, using the electronic patient record, all patients attending
the out-patient clinic at GRI who had evidence of renovascular disease on MRA
scanning up until the first patient randomised into the ASTRAL trial. Baseline data
and data over follow up for Creat, Creat Clearance, BP, cholesterol, CRP and
eosinophil count were extracted. End points studied were death, death and dialysis
and rate of progression of renal failure. We also looked at co-morbid vascular disease,
anti-platelet, statin, ACE inhibitor and ARA therapy.
Results
112 patients with renal artery stenosis on MRA were identified. Only 9% (10) of these
underwent renal artery stenting.16% (18) commenced RRT. 35% (39) died of whom
30 died before commencing RRT. Overall median follow-up was 37.5 months (IQR
9.8-40.2). Baseline SBP was 151 29 mmHg and fell to 147 21 mmHg over followup (p<0.02). DBP was 77 16 mmHg at baseline and fell to 75 11 mmHg at followup, (p<0.03). Cholesterol fell over follow up from 4.9 at baseline to 4.6 over follow-up
(p<0.02).
56% (55) of patients were on statin therapy at the time of MR scanning, increasing to
96% (99) patients during follow-up. 63% (62) were on anti-platelet therapy at
diagnosis increasing to 86% (85) patients during follow-up. 24% (24) were on an
ACE inhibitor with a further 5% (5) on an angiotensin receptor antagonist.
Rate of progression was slow (median 2.2ml/min/yr) and 28% showed no
progression. Median CRP and mean cholesterol were the only 2 variables with an
independent effect on the rate of progression (p<0.001 and p=0.012). There was a
significant difference in survival between unilateral versus bilateral disease for the
combined end-point of death or dialysis (p=0.02). Baseline ECC was lower in the
bilateral group (p=0.027) but there was no significant difference in rate of progression
between the 2 groups.
Conclusion
Our data suggests that rate of progression of renal failure in this population is slow. Outcome
is worse in bilateral disease. This is likely to be due to their worse baseline renal function.
The high CRP might suggest that inflammation contributes to progression in these patients.
Adequate blood pressure control was achieved despite a low intervention rate. We keenly
await the results of the ASTRAL trial to guide us towards the best management of this
population.
Description of pattern of myocardial damage in dialysis patients using cardiac
magnetic resonance imaging with late gadolinium hyperenhancement
P.B. Mark, N. Johnston, T. Martin, T. Steedman, J. Foster, R.S.C. Rodger, B.
Groenning, H.J. Dargie, A.G. Jardine
Background - Premature cardiovascular disease remains the commonest cause of
death for patients with end stage renal failure requiring dialysis. One factor associated
with adverse outcome is the development of uraemic cardiomyopathy, which has been
described in echocardiographic studies to present in approximately 90% of dialysis
patients at the initiation of dialysis therapy. The technique of using cardiac magnetic
resonance imaging (CMR) with gadolinium hyperenhancement has been validated to
demonstrate previous myocardial damage due to myocardial infarction and has been
shown to demonstrate abnormal myocardium in cardiomyopathies.
Methods - We undertook a study to describe patterns of myocardial damage in
potential renal transplant recipients on dialysis. 42 male and 17 female patients
(median(range) age =52(27-70)), underwent cardiac magnetic resonance imaging. LV
dimensions were evaluated by cinematographic (TrueFISP) breath-hold sequence
using a Siemens Sonata 1.5T system. Further images were acquired 10 minutes after
injection of 0.2 mmol/kg gadolinium-DTPA using a breath-hold segmented turbo
FLASH inversion-recovery sequence. The images were assessed by a single observer
for mass and function, and a further 2 observers for pattern of gadolinium
hyperenhancement.
Results - All patients completed the study (mean age 51.8, SD9.6, 71.2%Male). 16
patients (27.1%) had evidence of gadolinium uptake suggestive of previous
myocardial damage. 11(18.6%) of these patients had dense subendocardial
hyperenhancement suggestive of previous myocardial infarction. 6(10.2%) patients
had a more diffuse, less intense uptake of gadolinium, without dominant
subendocardial involvement. This pattern has not previously described and these
findings suggest that this pattern may be unique to cardiomyopathy found in advanced
renal failure. These groups were not mutually exclusive and 3 patients had both
findings. All patients (6) who had positive gadolinium uptake who had coronary
angiography had coronary artery disease.
Presence of late gadolinium uptake correlated with a history of diabetes mellitus(R=
0.36 p<0.05), ejection fraction (R=0.36, p<0.01), end diastolic volume (0.3, p<0.01)
and left ventricular hypertrophy(R=0.28, p<0.05).
Conclusion - Abnormalities in uptake of late gadolinium are present in nearly 30% of
potential renal transplant recipients, suggesting a high incidence if previous
myocardial damage. The patterns of myocardial uptake of gadolinium in patients on
dialysis may be different from those previously described in other patient groups,
suggestive of a alternative process contributing to uraemic cardiomyopathy other than
conventional large vessel coronary artery disease, although the two may coexist.
Further studies on larger numbers of patients including coronary angiography will be
necessary to further describe this finding.
Hepatitis B Vaccination in Dialysis Patients in Grampian
Mohamed Shanavas, David Walbaum, Nick Fluck
Renal Unit, Dept of Medicine & Therapeutics, Aberdeen Royal Infirmary, AB25 2ZD
Introduction: Vaccination against hepatitis B is recommended for all patients prior to
commencement of renal replacement therapy. A 3-dose vaccination protocol is
advised with antibody testing thereafter. Those who develop an adequate antibody
response should receive a booster every 5 years. Non-responders should be
revaccinated.
Local practice is to send an information sheet from the general nephrology clinic to
the patient’s GP, advising vaccination for patients with advanced renal failure.
Methods: We audited all dialysis patients under the care of Aberdeen Renal Unit in
June 2003. Details of immunisation were obtained by contacting patients’ general
practice. Antibody levels were obtained from the hospital database.
Results: A total of 185 patients were receiving dialysis at the time of the audit: 145
hospital HD, 32 PD and 8 home HD.
Overall 32% had been immunised according to the recommended protocol with a
further 9% completing 3 doses of vaccine by an irregular schedule. 28% of patients
had no record of vaccination being performed.
Of the hospital HD patients, 55 (38%) had completed vaccination and 81 (56%) had
incomplete or no vaccination. For PD patients 16 (50%) had completed vaccination
and 11 (34%) had not. Of the 8 home HD patients there were 4 (50%) in each group.
Of the 75 patients receiving 3 doses of vaccine, 29 (39%) had a post-vaccination
antibody check. Of these patients 8 (28%) failed to respond, with antibody titre
<10IU/L.
Vaccination Received
3 doses as per schedule
3 doses not by schedule
2 doses only
1 dose only
No documented vaccination
Recently commenced vaccination
Initial Ab titre >10 IU/L
No. of patients
59
16
28
17
51
8
6
%
32
9
15
9
28
4
3
Discussion: Current practice for hepatitis vaccination in Aberdeen Renal Unit is not
achieving recommended standards. Only 41% of patients have completed a
vaccination course, and 28% have no record of being immunised.
Despite full vaccination, 28% of those tested failed to respond.
The introduction of a low-clearance clinic, including pre-dialysis patients on the
Renal Unit database, should allow improved hepatitis B vaccination.
Conflict of interest: none
Funding: none
A feasibility study of exercise during hospital haemodialysis
Matthew Torkington, Maureen MacRae, Sue Robertson, Alison Almond, Chris Isles
Renal Unit, Dumfries and Galloway Royal Infirmary, Dumfries, DG1 4AP
Background – Dialysis patients experience a reduced exercise capacity when compared
to sedentary age and sexed matched people from the general population. A growing body
of evidence, mainly from America, shows that renal patients benefit from exercise and
that this can safely be performed during dialysis.
Objective – To determine the feasibility of exercise during hospital haemodialysis.
Patients – All hospital haemodialysis patients in Dumfries were invited to join a thrice
weekly cycling program for eight weeks during July and August 2003, supervised by a
physiotherapist. Exercise sessions were conducted during the first two hours of dialysis
and consisted of a warm up, followed by sub-maximal exercise and cool down.
Resistance and time were increased according to the level of perceived exertion using the
Borg scale, aiming to achieve a level between 13 and 15 (somewhat hard to hard).
Main outcome measures – The primary outcome measure was the number of patients
who were still exercising at the end of the eight week program. Secondary outcome
measures included the distance covered during a 6 minute shuttle walk test, haemoglobin,
body mass index, urea reduction ratio, nutritional status and nine domains of quality of
life using the SF-36 questionnaire.
Results – Four patients were ineligible: 2 died, 1 moved to another centre and 1
transferred to peritoneal dialysis. Twenty two of the remaining 45 (49%) began the
program. Eight (18%) were not interested and 15 (33%) had medical or physical
problems that prevented them from taking part. Those who exercised were younger (58 v
76 years) and had fewer comorbitities (1.3 v 2.1) than patients who did not exercise.
18/22 (82%) completed more than half the exercise sessions and 17 patients (38% of
those eligible) were still cycling at the end of the eight week period. 16 patients who
were assessed before and after exercise showed an average increase in the distance
walked during a 10 meter shuttle walking test of 78 meters, with no change in
haemoglobin, body mass index, urea reduction ratio or nutritional status. There were
improvements in 8 of the 9 domains of the SF-36 questionnaire, though none achieved
statistical significance (a result of the small sample size). 16/22 patients felt they had
benefited from the program and 22/22 patients said that the program should continue.
Conclusions – Just over a third of an unselected haemodialysis population may be
suitable and appear to benefit from an eight week dialysis cycling program. The success
of the program is likely to reflect the presence during each dialysis session of a
physiotherapist. It remains to be seen whether patients who complete an initial eight
week program can sustain dialysis exercise during the medium to long term.
Outcome of Central Tunnelled Haemodialysis Catheters.
Renal Unit, Monklands Hospital, Airdrie, Lanarkshire.
H Oun, I Shilliday, M Hand, W Smith.
Purpose: To assess the outcome of tunnelled central catheters in patients on
haemodialysis.
Materials and methods: Over a 3 year period 160 tunnelled haemodialysis catheters
were placed in 143 patients (from December 1999 to December 2002). Data were
analysed for catheter survival, infection rate, blood flow, URR, haemoglobin, serum
albumin, C reactive protein, morbidity and mortality.
Results: Ninety-eight (61%) patients had tunnelled catheters as the first mode of
access for haemodialysis, 26(16.5%) because of a-v fistula failure, 25(15.5%) due to
previous tunnelled catheter failure and 11(7%) due to peritoneal dialysis failure.
Eighty- four % of catheters were placed in jugular veins, 74 % in the right and 11% in
the left. Sixty % of catheters were functioning at 6 months, and up to 40% were still
working at 12 months. There were no immediate complications apart from two
patients with haemorrhage who required blood transfusion. There were 82 episodes of
infection diagnosed in 60(42%) patients and the cumulative infection rate was 2.7 per
1000 catheter days. Fifty-four (66%) of theses episodes were bacteraemia, 23(28%)
exit sit infection, and 5(6%) tunnel infection incidents. Sixty (73%) of the infection
episodes were caused by staphylococci and 18(22%) episodes were due to gram
negative organisms. Two patients developed infective endocarditis, one had an
epidural abscess and discitis and two patients had severe sepsis syndrome. Twentythree (14%) patients had poor blood flow and required recurrent thrombolytic
treatment. The average URR was 66%, however 45(31%) patients had a URR less
than 65%. Haemoglobin was above 10 g/dl in only 71(55.5%) patients. Average C
reactive protein was 44 mg/l and 95(67%) patients had a C reactive protein above 10
mg/l. During this follow up period, 23(16%) patients died; 6(20%) died from catheter
related infection and 11(8%) had dialysis withdrawn.
Conclusion: A significant number of patients with end-stage renal disease are
dialysed with central tunnelled catheters as the primary mode of vascular access.
Catheters failure and infection remain the main complications. Most patients have
long term tunnelled lines due to restrictions on a-v fistula creation as a result of
inadequate vascular access facilities. Improving the vascular access service must be
given a higher priority.
Systematic review of treatment interventions for depression in chronic dialysis
patients
K.S.Rabindranath1, A.M.MacLeod1, P.Roderick2, J.Butler3, S.Wallace4, C.Daly1
1
Department of Medicine and Therapeutics, Polwarth Building, University of
Aberdeen, Foresterhill, Aberdeen, AB25 2ZD, 2 Department of Public Health
Medicine, Southampton University, Southampton, 3 Department of Psychiatry, Royal
South Hants Hospital, Southampton, SO14 0YG and 4 Health Services Research Unit,
University of Aberdeen, Foresterhill, Aberdeen, AB25 2ZD
Introduction: Depression is the most common psychological problem in patients
undergoing chronic dialysis. Dialysis patients who are depressed have higher rates of
hospitalisation and complications such as peritonitis; poorer compliance with
treatment and increased mortality. Depressed dialysis patients are more likely to
commit suicide.
Objectives: To evaluate the effectiveness of psychosocial treatment interventions for
depression in patients on dialysis for end-stage renal disease (ESRD).
Methods: We undertook a systematic review of randomised controlled trials (RCTs)
which compared psychosocial treatment interventions for depression with placebo or
no additional treatment in chronic dialysis patients. Clinical outcomes assessed were,
change in depression score, number of depressed patients, quality of life, mortality,
number of withdrawals from dialysis and antidepressant treatment. A comprehensive
search strategy was employed including - MEDLINE, EMBASE, Cochrane Database
of Systematic Reviews, Database of Reviews of Effectiveness and PsycInfo.
Identified potential RCTs were assessed for inclusion independently by two
reviewers. Data concerning trial methodological quality and relevant clinical
outcomes were extracted and where appropriate entered into RevMan for metaanalysis.
Results: Twenty-five potential RCTs were identified. Six fulfilled our inclusion
criteria although they assessed the effects of the interventions on the dialysis
population as a whole, and not only in depressed dialysis patients. Three studies
which assessed exercise therapy, showed a reduction in the number of depressed
patients (Relative Risk Reduction 0.33, 95% CI- 0.14 to 0.79). One study showed that
a social work intervention reduced the mean Beck depression Inventory scores (Mean
Difference= –3.96, 95% CI = -5.31 to -2.61), another study showed a non-significant
reduction in mean Depression Score (Centre for epidemiological Scales) (Mean
Difference= –2.30, 95% CI = -5.34 to 0.74) was achieved though strategic selfpresentation skills
Conclusions: Exercise therapy may help both treat and prevent depression in the
chronic dialysis population. Further methodologically sound RCTs are required to
confirm this finding and to adequately determine the role of other psychosocial
interventions in the treatment of depression in this group of patients.
Vernon MA, Hiemstra TF, Ingram S, Whitworth CE
Department of Renal Medicine, Royal Infirmary of Edinburgh, Little France,
Edinburgh
‘A Case of Post Stent Mycotic Aneurysm of the Renal Artery in a Woman With Renal
Impairment’
We describe a case of a 76 year old female patient with dialysis requiring end stage
renal failure secondary to bilateral renovascular disease. Access for haemodialysis
was achieved with a left femoral line. 11 days after commencing haemodialysis a left
renal artery stent was inserted. This resulted in sufficient improvement in renal
function to become dialysis independent. However, it was complicated by the
development of a mycotic aneurysm of the stented vessel. MRSA was cultured from
blood. Surgical intervention was deemed to carry an unacceptably high risk. Medical
management with intravenous antibiotics was continued and the patient died. We
describe the first known case of mycotic aneurysm of a renal artery complicating stent
placement.