Donal O’Donoghue

Thinking ahead – the need for early Advance Care Planning for people on haemodialysis: A qualitative interview study:

Background: There is a need to improve end-of-life care for people with end-stage kidney disease, particularly due to the increasingly elderly, frail and co-morbid end-stage kidney disease population. Timely, sensitive and individualised Advance Care Planning discussions are acceptable and beneficial for people with end-stage kidney disease and can help foster realistic hopes and goals. Aim: To explore the experiences of people with end-stage kidney disease regarding starting haemodialysis, its impact on quality of life and their preferences for future care and to explore the Advance Care Planning needs of this population and the timing of this support. Study design: Semi-structured qualitative interview study of people receiving haemodialysis. Interviews were analysed using thematic analysis. Recruitment ceased once data saturation was achieved. Setting/participants: A total of 20 patients at two UK National Health Service hospitals, purposively sampled by age, time on haemodialysis and symptom burden. Results: Themes emerged around: Looking Back, emotions of commencing haemodialysis; Current Experiences, illness and treatment burdens; and Looking Ahead, facing the realities. Challenges throughout the trajectory included getting information, communicating with staff and the ‘conveyor belt’ culture of haemodialysis units. Participants reported a lack of opportunity to discuss their future, particularly if their health deteriorated, and variable involvement in treatment decisions. However, discussion of these sensitive issues was more acceptable to some than others. Conclusion: Renal patients have considerable unmet Advance Care Planning needs. There is a need to normalise discussions about preferences and priorities in renal and haemodialysis units earlier in the disease trajectory. However, an individualised approach is essential – one size does not fit all.

Referral patterns to renal services: what has changed in the past 4 years?

BACKGROUND Awareness of chronic kidney disease (CKD) has been prompted by the publication of several large epidemiological studies since 2002. This has led to various initiatives for the early identification and management of CKD, including the introduction of automated glomerular filtration rate (GFR) reporting and renal indicators in the primary care quality and outcomes framework (QOF) since April 2006. These initiatives were intended to promote identification of CKD and have had an impact on referral patterns to renal services. The aim of this study was to understand the nature of this impact in a catchment population of 1.2 million people. METHODS Data were collected and recorded from all written referrals from primary care between 1 April 2004 and 31 March 2008. Referral patterns for each postcode sector were mapped using Microsoft MapPoint 2004. The effect of chance on referral patterns was modelled by using small area analysis techniques. The association between the CKD prevalence reported from QOF data and the estimated CKD prevalence was examined at post-code district level. RESULTS There were 1461 referrals in 2 years prior to the introduction of the initiatives and 2890 referrals in the 2 years post-introduction. The main reason for referral in both groups was impaired renal function or previously established renal disease. Reported comorbidity was similar between the groups. Mapping showed that there was wide heterogeneity in referral behaviour in the first 2 years of the study, which was less in the second period. Small area analysis suggested that the variation that led to the extremal quotients observed in both of the study periods was not due to random variation in referral pattern alone. There was no correlation between the reported CKD prevalence and the referral rates. CONCLUSION Referral patterns have changed between 1 April 2004 and 31 March 2008. The main findings were an increase in referral rate and in the age at referral without a significant change in reported comorbidity of the people referred. The main increase in referral rates was seen in more advanced CKD suggesting more targeted referral of patients with CKD to renal services.

Acute kidney injury in the community: why primary care has an important role.

There is mounting evidence that awareness of kidney function is central to the delivery of safe and clinically-effective care, in terms of preventing both cardiovascular events, and progression to established renal failure, with significant impacts on quality of life and healthcare expenditure.1,2 However, the staging of chronic kidney disease (CKD) has not been without controversy, and like all disease classifications has the potential to both structure and constrain the delivery of care.3,4 General practice has played a central role in the identification and management of CKD becoming a routine aspect of care delivery.1,5 Nevertheless, professional uncertainty remains on the merits of disclosure of the early stages of CKD, especially in older people.6 This is reflected in low levels of patient awareness of CKD, with discussions often limited to reassurance.6,7 In addition to maintenance of vascular health and prevention of progression of renal disease, another important reason to focus on the delivery of care for people with early stage CKD is its association with acute kidney injury (AKI). This is a syndrome which is common, harmful, and preventable.8,9 The term AKI is a shift away from the previous inconsistent use of the diagnosis of acute tubular necrosis and acute renal failure.8 Furthermore, the classification system highlights that AKI encompasses a spectrum of acute injury from minor changes in kidney function to acute failure requiring renal replacement therapy.8 This is important as it provides an opportunity to consider people at risk and identify people who may benefit from earlier intervention. It also takes into account the evidence that even small, reversible changes in kidney function (as …

Exploration of Chronic Kidney Disease Prevalence Estimates Using New Measures of Kidney Function in the Health Survey for England

Background Chronic kidney disease (CKD) diagnosis relies on glomerular filtration rate (eGFR) estimation, traditionally using the creatinine-based Modification of Diet in Renal Disease (MDRD) equation. The Chronic Kidney Disease Epidemiology Collaboration (CKDEPI) equation performs better in estimating eGFR and predicting mortality and CKD progression risk. Cystatin C is an alternative glomerular filtration marker less influenced by muscle mass. CKD risk stratification is improved by combining creatinine eGFR with cystatin C and urinary albumin to creatinine ratio (uACR). We aimed to identify the impact of introducing CKDEPI and cystatin C on the estimated prevalence and risk stratification of CKD in England and to describe prevalence and associations of cystatin C. Methods and Findings Cross sectional study of 5799 people in the nationally representative 2009 and 2010 Health Surveys for England. Primary outcome measures: prevalence of MDRD, CKDEPI and cystatin C-defined eGFR<60ml/min/1.73m2; prevalence of CKD biomarker combinations (creatinine, cystatin C, uACR). Using CKDEPI instead of MDRD reduced the prevalence of eGFR<60ml/min/1.73m2 from 6.0% (95% CI 5.4–6.6%) to 5.2% (4.7–5.8%) equivalent to around 340,000 fewer individuals in England. Those reclassified as not having CKD evidenced a lower risk profile. Prevalence of cystatin C eGFR<60ml/min/1.73m2 was 7.7% and independently associated with age, lack of qualifications, being an ex-smoker, BMI, hypertension, and albuminuria. Measuring cystatin C in the 3.9% people with CKDEPI-defined eGFR<60ml/min/1.73m2 without albuminuria (CKD Category G3a A1) reclassified about a third into a lower risk group with one of three biomarkers and two thirds into a group with two of three. Measuring cystatin C in the 6.7% people with CKDEPI eGFR >60ml/min/1.73m2 with albuminuria (CKD Category G1-2) reclassified almost a tenth into a higher risk group. Limitations Cross sectional study, single eGFR measure, no measured (‘true’) GFR. Conclusions Introducing the CKDEPI equation and targeted cystatin C measurement reduces estimated CKD prevalence and improves risk stratification.

The development and piloting of the REnal specific Advanced Communication Training (REACT) programme to improve Advance Care Planning for renal patients

Background: In recent years, the End-Stage Kidney Disease population has increased and is ever more frail, elderly and co-morbid. A care-focused approach needs to be incorporated alongside the disease focus, to identify those who are deteriorating and improve communication about preferences and future care. Yet many renal professionals feel unprepared for such discussions. Aim: To develop and pilot a REnal specific Advanced Communication Training (REACT) programme to address the needs of End-Stage Kidney Disease patients and renal professionals. Design: Two-part study: (1) development of the REnal specific Advanced Communication Training programme informed by multi-professional focus group and patient survey and (2) piloting of the programme. Setting/participants: The REnal specific Advanced Communication Training programme was piloted with 16 participants (9 renal nurses/health-care assistants and 7 renal consultants) in two UK teaching hospitals. Results: The focus group identified the need for better information about end-of-life phase, improved awareness of patient perspectives, skills to manage challenging discussions, ‘hands on’ practice in a safe environment and follow-up to discuss experiences. The patient survey demonstrated a need to improve communication about concerns, treatment plans and decisions. The developed REnal specific Advanced Communication Training programme was acceptable and feasible and was associated with a non-significant increase in confidence in communicating about end-of-life issues (pre-training: 6.6/10, 95% confidence interval: 5.7–7.4; post-training: 6.9/10, 95% confidence interval: 6.1–7.7, unpaired t-test – p = 0.56), maintained at 3 months. Conclusion: There is a need to improve end-of-life care for End-Stage Kidney Disease patients, to enable them to make informed decisions about future care. Challenges include prioritising communication training among service providers.

UK Renal Registry 11th Annual Report (December 2008): Chapter 12 Epidemiology of Methicillin Resistant Staphylococcus aureus bacteraemia amongst patients receiving Renal Replacement Therapy in England in 2007

From April 2007, all centres providing Renal Replacement Therapy in England were asked to provide additional data on patients with Methicillin Resistant Staphylococcus aureus (MRSA) bacteraemia using a secure web-based system. Data were recorded on modality of treatment and the type of vascular access in use at diagnosis and in the previous 28 days. From April 2007 until March 2008, 188 discrete episodes of MRSA bacteraemia were reported in patients receiving dialysis for established renal failure. Over the same period 4,448 MRSA bacteraemias were reported in England, indicating that 4.2% of all cases occurred in dialysis patients. Of the 188 episodes, additional data from the renal centres were available in 92 cases (49%). All patients with completed records were on haemodialysis at the time of the bacteraemia. Of those, 65/92 (70.7%) were using venous catheters, the majority tunnelled lines (n = 55, 59.8%), and 2 other cases had used venous catheters in the previous 28 days. The relative risk of MRSA bacteraemia was about 100 fold higher for a dialysis patient in comparison to the general population and 8 fold higher for a patient using a catheter in comparison to a fistula. The mean rate for all patients was 0.92_0.85 episodes/100 prevalent dialysis patients/year but the rate varied between renal centres with a range of 0–3.28. Using just haemodialysis patients as the denominator, the mean was 1.14_0.95 episodes/100 patients/year with a range of 0–3.93. Compared to previous Registry reports, absolute numbers of reported MRSA bacteraemias has fallen by approximately 62% from 2004. Many centres have substantially reduced the numbers of cases. Dialysis patients are at increased risk of MRSA bacteraemia; this is closely associated with the use of venous catheters. The rate of MRSA bacteraemia is falling substantially within the prevalent dialysis population, but with variation in performance between centres.

Quality achievement and disease prevalence in primary care predicts regional variation in renal replacement therapy (RRT) incidence: an ecological study

BACKGROUND Diabetes Meillitus (DM) and hypertension (HT) are important causes of end-stage renal disease (ESRD) and renal replacement therapy (RRT) is the standard active treatment. Financially, incentivized quality initiatives for primary care include pay-for-performance (P4P) in DM and HT. Our aim was to examine any effect of disease prevalence and P4P on RRT incidence and regional variation. METHODS The incidence of RRT, sex and ethnicity data and P4P disease register and achievement data were obtained for each NHS locality. We calculated correlation coefficients for P4P indicators since 2004/05 and socio-demographic data for these 152 localities. We then developed a regression model and regression coefficient (R(2)) to assess to what extent these variables might predict RRT incidence. RESULTS Many of the P4P indicators were weakly but highly significantly correlated with RRT incidence. The strongest correlation was 2004/05 for DM prevalence and 2006/07 for HT quality. DM prevalence and the percentage with blood pressure control in HT target (HT quality) were the most predictive in our regression model R(2) = 0.096 and R(2) = 0.085, respectively (P < 0.001). Combined they predicted a fifth of RRT incidence (R(2) = 0.2, P < 0.001) while ethnicity and deprivation a quarter (R(2) = 0.25, P < 0.001). Our final model contained proportion of population >75 years, DM prevalence, HT quality, ethnicity and deprivation index and predicted 40% of variation (R(2) = 0.4, P < 0.001). CONCLUSION Our findings add prevalence of DM and quality of HT management to the known predictors of variation in RRT, ethnicity and deprivation. They raise the possibility that interventions in primary care might influence later events in specialist care.

Preventing Acute Kidney Injury: a qualitative study exploring ‘sick day rules’ implementation in primary care

BackgroundIn response to growing demand for urgent care services there is a need to implement more effective strategies in primary care to support patients with complex care needs. Improving primary care management of kidney health through the implementation of ‘sick day rules’ (i.e. temporary cessation of medicines) to prevent Acute Kidney Injury (AKI) has the potential to address a major patient safety issue and reduce unplanned hospital admissions. The aim of this study is to examine processes that may enable or constrain the implementation of ‘sick day rules’ for AKI prevention into routine care delivery in primary care.MethodsForty semi-structured interviews were conducted with patients with stage 3 chronic kidney disease and purposefully sampled, general practitioners, practice nurses and community pharmacists who either had, or had not, implemented a ‘sick day rule’. Normalisation Process Theory was used as a framework for data collection and analysis.ResultsParticipants tended to express initial enthusiasm for sick day rules to prevent AKI, which fitted with the delivery of comprehensive care. However, interest tended to diminish with consideration of factors influencing their implementation. These included engagement within and across services; consistency of clinical message; and resources available for implementation. Participants identified that supporting patients with multiple conditions, particularly with chronic heart failure, made tailoring initiatives complex.ConclusionsImplementation of AKI initiatives into routine practice requires appropriate resourcing as well as training support for both patients and clinicians tailored at a local level to support system redesign.

Inpatient Coronary Angiography and Revascularisation following Non-ST-Elevation Acute Coronary Syndrome in Patients with Renal Impairment: A Cohort Study Using the Myocardial Ischaemia National Audit Project

Background International guidelines support an early invasive management strategy (including early coronary angiography and revascularisation) for non-ST-elevation acute coronary syndrome (NSTE-ACS) in patients with renal impairment. However, evidence from outside the UK suggests that this approach is underutilised. We aimed to describe practice within the NHS, and to determine whether the severity of renal dysfunction influenced the provision of angiography and modified the association between early revascularisation and survival. Methods We performed a cohort study, using multivariable logistic regression and propensity score analyses, of data from the Myocardial Ischaemia National Audit Project for patients presenting with NSTE-ACS to English or Welsh hospitals between 2008 and 2010. Findings Of 35 881 patients diagnosed with NSTE-ACS, eGFR of <60 ml/minute/1.73 m2 was present in 15 680 (43.7%). There was a stepwise decline in the odds of undergoing inpatient angiography with worsening renal dysfunction. Compared with an eGFR>90 ml/minute/1.73 m2, patients with an eGFR between 45–59 ml/minute/1.73 m2 were 33% less likely to undergo angiography (adjusted OR 0.67, 95% CI 0.55–0.81); those with an eGFR<30/minute/1.73 m2 had a 64% reduction in odds of undergoing angiography (adjusted OR 0.36, 95%CI 0.29–0.43). Of 16 646 patients who had inpatient coronary angiography, 58.5% underwent inpatient revascularisation. After adjusting for co-variables, inpatient revascularisation was associated with approximately a 30% reduction in death within 1 year compared with those managed medically after coronary angiography (adjusted OR 0.66, 95%CI 0.57–0.77), with no evidence of modification by renal function (p interaction = 0.744). Interpretation Early revascularisation may offer a similar survival benefit in patients with and without renal dysfunction, yet renal impairment is an important determinant of the provision of coronary angiography following NSTE-ACS. A randomised controlled trial is needed to evaluate the efficacy of an early invasive approach in patients with severe renal dysfunction to ensure that all patients who may benefit are offered this treatment option.

GOING UPSTREAM: THE IMPLICATION AND OPPORTUNITIES OF EARLY DETECTION

Chronic kidney disease (CKD) is common, harmful and treatable but has, until recently not been recognised in its early stages. The British National Health Service (NHS) provides a unique opportunity to study CKD because it is in effect a closed-managed care system. This single healthcare system for the United Kingdom is funded by the Government and paid for by general taxation. All UK citizens are registered with primary care physicians who control access to secondary care services. As a managed care system it should be able to offer integrated care across the whole patient pathway--allowing early identification of CKD, interventions to reduce risk and prompt management of complications. In reality, there are professional, organisational and institutional barriers to coordination and delivery of care in the NHS. The establishment of general-practice-based disease registers linked to a quality and outcomes framework in 2004 provides a basis for implementing the chronic disease model of care. The publication of the National Service Framework for renal services complemented by these changes in primary care has resulted in a paradigm shift from kidney disease being viewed as a secondary care condition to being a primary care priority as part of vascular control and management. In the first two years of the initiative, over 40% of the expected CKD stage 3 to 5 population has been registered in primary care. Kidney disease is now recognised as a public health problem in the United Kingdom, preventative strategies are being integrated into comprehensive vascular risk assessments and management programmes and kidney disease has become an NHS priority area.