Farida Hussain

Renal biopsies in children: current practice and audit of outcomes

BACKGROUND There is considerable variation in the way that children are prepared for and the techniques employed in a renal biopsy. There was national agreement between UK paediatric renal centres to review current practice and audit outcomes METHODS An initial questionnaire survey was undertaken and a 12-month prospective audit performed of renal biopsies against agreed standards for the number of needle passes, adequacy of biopsy material and complication rates. RESULTS Eleven of 13 centres participated. Information leaflets are sent pre-biopsy in five centres with only one using play preparation. Six of 11 routinely perform biopsies as day-case (DC) procedures and 6 use general anaesthesia (GA). Real-time ultrasound is the favoured method in eight centres. Biopsies are performed by nephrologists only in four centres, nephrologists with radiologists in five and radiology alone in two. Of 531 biopsies (352 native), 31% were performed as a DC with 49% being done under GA. The standard for the number of passes of native kidneys (<or=3 in 80%) was achieved in 86.4%, but the standard of <or=2 passes in 80% was achieved in only 73.4% of transplanted kidneys. Adequate tissue was obtained for diagnosis in 97.5% (standard >95%). The major complication rate was higher than the standard of <or=5% at 10.4%. There was no significant difference in complication rates when the biopsy was performed as a DC or inpatient procedure (P = 0.73) or when GA or sedation was used (P = 0.8). CONCLUSIONS The audit highlights significant variation in clinical practice with limited use of preparation materials and DC procedures. The results have stimulated constructive debate about preparation and indications for biopsy and training issues. The audit enables centres and individuals to monitor performance.

UK Renal Registry 11th Annual Report (December 2008): Chapter 13 Demography of the UK paediatric renal replacement therapy population.

Aims: To describe the demographics of the paediatric RRT population in the UK and analyse changes in demographics with time. Methods: Extraction and analysis of data from the UK paediatric Renal Registry. Results: The UK paediatric established renal failure (ERF) population in April 2008 was 875 patients. The prevalence under the age of 16 years was 55 per million age related population (pmp) and the incidence 7.92 pmp. The incidence and prevalence for South Asian and Other ethnic groups were 3 times that of the White and Black populations. Renal dysplasia was the most common cause of ERF accounting for 33% of prevalent cases. Diseases with autosomal recessive inheritance were more common in patients from ethnic minority groups. The spectrum of diseases seen has changed over a generation. Overall 5 year survival for children with ERF was 91.8%. Five year survival of infants starting dialysis was just 62%. Transplanted patients accounted for 74% of the current population. The proportion with grafts from living donors has steadily risen to 34%. Children from ethnic minority groups were less likely to have an allograft and living donation was less frequent in this population. For those on dialysis, 57% were receiving peritoneal dialysis. This was the main treatment modality for patients under 4 years of age. Conclusions: The paediatric ERF population continued to expand slowly. Incidence and prevalence rates were stable and similar to other developed nations. The high incidence in patients from ethnic minority groups will lead to a greater proportion of the population being from these groups in time. To maintain the high proportion of engrafted patients it will be necessary to encourage living donation in the ethnic minority population. The spectrum of diseases seen has already changed over a generation with the treatment of young children with diseases such as congenital nephrosis. The incidence of cystinosis causing ERF was reduced, probably reflecting better early treatment.

Standards for renal biopsies: comparison of inpatient and day care procedures.

Abstract. There are no national standards for the adequacy and complications of percutaneous renal biopsies. We developed local standards that have been used in a prospective audit of biopsies undertaken in a tertiary pediatric nephrology unit between January 1997 and December 2000. We compared outcomes of biopsies performed on inpatients with day care procedures. A total of 251 biopsies (113 transplant) were undertaken, 114 (46%) as day care procedures. Adequate tissue for diagnosis was obtained in 245 (97.6%), with a standard set at >95%. This was also achieved for a mean number of passes in native (<3 in 80%) and transplanted (<2 in 80%) kidneys. Eleven patients (4%) developed macroscopic hematuria (standard <5%) and none required transfusion. Delay in discharge occurred in 4 patients, and a further 4 returned to the ward post discharge. There was no significant difference in complication rates between inpatient and day care patients. Our local biopsy standards were met in this audit. Such standards could provide useful comparisons between units in national audit programs, as well as permitting the monitoring of individual performance as part of clinical governance. Day care procedures benefit the patient and family, as well as significantly reducing costs.

Chapter 5: Demography of the UK Paediatric Renal Replacement Therapy Population in 2009

Aims: To describe the demographics of the paediatric RRT population under the age of 16 years in the UK and to analyse changes in demography with time. Methods: Extraction and analysis of data from the UK Renal Registry (UKRR). Results: There were 751 children <16 years old with established renal failure (ERF) in the UK in December 2009. The reported prevalence under the age of 16 years was 65 per million age related population (pmarp) and the reported incidence 9.3 pmarp. The incidence and prevalence for South Asian patients was much higher than that of the White and Black populations. Of the patients for whom a primary renal diagnosis had been reported, renal dysplasia±reflux was the most common cause of ERF accounting for 34.0% of prevalent cases. There has been growth in treatment numbers in all paediatric renal centres between 1995 and 2010. Whilst the rate of transplantation within 90 days of commencing RRT has remained at around 25–30% of patients, the use of HD has increased by 4% at the expense of PD. Conclusions: The paediatric ERF population continued to expand with a slow increase in both incidence and prevalence rates. The high incidence in patients from ethnic minority groups will lead to a greater proportion of the population being from these groups in time. To maintain the high proportion of engrafted patients it will be necessary to encourage living donation in the ethnic minority population.

Appendix D: Methodology used for Analyses of PCT/ Local Authority Incidence and Prevalence Rates and of Standardised Ratios

The areas used were the 148 English primary care trusts (PCTs), the 4 English care trusts, the 22 Welsh local authorities, the 32 Scottish council areas and the 26 Northern Ireland district council areas – these different types of area are collectively called PCT/LAs here. In Northern Ireland, Scotland and Wales, the health authority boundaries align with the LAs and these areas have been included along with the English PCTs in the tables.

Appendix E: Additional Data Tables for 2008 new and existing patients

Abrdn 85 15 L Rfree 84 11 4 Airdrie 92 8 L St.G 62 18 20 Antrim 90 10 LWest 86 4 9 B Heart 84 14 2 Leeds 69 20 11 B QEH 73 23 4 Leic 79 10 12 Bangor 86 14 Liv Ain 98 2 Basldn 83 18 Liv RI 66 27 7 Belfast 84 12 4 M Hope 46 46 7 Bradfd 85 15 M RI 71 16 13 Brightn 66 33 1 Middlbr 80 13 8 Bristol 75 19 6 Newc 72 22 6 Camb 87 10 3 Newry 85 15 Cardff 78 15 7 Norwch 79 15 5 Carlis 74 23 3 Nottm 73 22 5 Carsh 85 14 1 Oxford 62 27 12 Chelms 73 27 Plymth 56 26 19 Clwyd 92 8 Ports 68 24 8 Colchr 100 Prestn 74 20 6 Covnt 74 19 6 Redng 70 25 5 Table E.1.2. Number of patients per treatment modality at 90 days

UK Renal Registry 11th Annual Report (December 2008): Appendix D Methodology used for analyses of PCT incidence and prevalence rates and of standardised ratios

The areas used were the 152 (English) Primary Care Trusts (PCTs), the 22 Welsh local health boards, the 32 Scottish council areas and the 26 Northern Ireland district council areas – these different types of area are collectively called PCTs here. Prior to 2007, only some of the boundaries of PCTs and Local Authorities (LAs) in England were similar. There were roughly twice as many PCTs as LAs and the registry reports published analyses by LA in the main report and prevalence rates by PCT as an appendix. In October 2006, the Office for National Statistics reduced the number of PCTs and re-aligned many of the PCT boundaries in England with those of Local Authorities. As a result, in the 2008 Report these analyses will be presented by PCT (not LA). For data for years before the boundaries changed, patients are allocated to the new PCTs as they are now. In Northern Ireland, Scotland and Wales, the Health Authority boundaries align with the LAs and these areas have been included along with the English PCTs in the tables.