Jyoti Baharani

Uraemic Pruritus: Relief of Itching by Gabapentin and Pregabalin

Background: Pruritus (skin irritation or itching) is common in patients with chronic kidney disease (CKD) stages 4 and 5. It is associated with disrupted sleep, reduced quality of life, depression and increased mortality. A video of a patient describing the symptoms is at vimeo.com/49458473. Methods: We used gabapentin or pregabalin in 71 consecutive patients, 82% male. 25 had CKD stage 4 or 5, median eGFR = 17, range 9-30; 40 were on haemodialysis; 6 on peritoneal dialysis. Median itch severity score out of 10 = 8, range 6-10; median duration of itching = 6 months, range 0.5-240. Serum calcium ≤2.60 mmol/l (≤10.4 mg/dl) in 87% patients, phosphate ≤1.8 mmol/l (≤5.6 mg/dl) in 75%. 63% had used antihistamines and not gained relief. Starting dose of gabapentin 100 mg after dialysis or daily. Patients intolerant of gabapentin were offered pregabalin, starting dose 25 mg after dialysis or daily. Results: Gabapentin relieved itching in 47 patients (66%). A video of a patient describing the effect is at vimeo.com/49455976. 26 patients (37%) suffered side effects from gabapentin. Of 21 patients who stopped gabapentin due to side effects, 16 started pregabalin. Pregabalin relieved itching in 13 patients (81%). In total, gabapentin or pregabalin relieved itching in 60 patients (85%), median follow-up 2 months (range 1-8 months). Median itch severity out of 10 reduced from 8 to 1. Conclusions: Gabapentin or pregabalin relieved itching in 85% of 71 consecutively treated CKD patients. Patients should be advised about side effects and the drug initiated at a low dose. Patients intolerant of gabapentin may tolerate pregabalin.

Short and long-term outcome of patients with severe acute kidney injury requiring renal replacement therapy

BACKGROUND Severe acute kidney injury (AKI) occurs in 2-7% of all hospital admissions and is an independent poor prognostic marker. Nevertheless, information on the long-term outcome of AKI and the factors influencing this is limited. AIM To describe the short- and long-term outcome of patients requiring renal replacement therapy (RRT) for severe AKI and to examine factors affecting patient survival and renal recovery. DESIGN AND METHODS Single centre retrospective analysis of 481 consecutive patients over a period of 39 months. FOLLOW-UP 12 months. PRIMARY AND SECONDARY OUTCOMES overall mortality and RRT dependency at 30 days, 90 days and 1 year. RESULTS Survival at 30 days, 90 days and 1 year was 54.4, 47.2 and 37.6%, respectively. RRT independency at 30 days, 90 days and 1 year was 35.2, 27.2 and 25.8%, respectively. Of those RRT independent at 90 days, 55% had ongoing chronic kidney disease. There were two distinct groups of patients: Group A (haemofiltration in ITU) and Group B (intermittent haemodialysis in the renal unit). Patient survival was worse in Group A while RRT independence was higher. Independent predictors of survival included renal cause of AKI and lower CI score in Group A and renal or post-renal cause of AKI, younger age and the absence of malignancy in Group B. Independent predictors of renal recovery included the presence of sepsis in Group A and pre- or post-renal cause of AKI in Group B. CONCLUSIONS The short- and long-term survival outcome of severe AKI requiring RRT remains poor. Among those who survive, a significant number either continue to require RRT or have residual renal impairment necessitating ongoing follow-up.

Does community-wide chronic kidney disease management improve patient outcomes?

BACKGROUND The number of patients starting renal replacement therapy (RRT) is increasing in England, as it is worldwide. Improvements in the management of chronic kidney disease (CKD) across communities to alter this trend are a public health priority. We have prospectively studied changes in the incidence and modality of treatment for end-stage renal disease following the introduction of a CKD management programme in the West Midlands region of England. METHODS Nephrology service to approximately 700 000 adult population of mixed ethnicity in urban and suburban areas, many with social deprivation. The programme was introduced in stages between 2003 and 2006 and comprised primary care education and financial incentives, personal clinical reports written directly to patients following every consultation, routine laboratory estimated glomerular filtration rate (eGFR) reporting, eGFR graph surveillance to identify and monitor patients at risk, multidisciplinary pre-RRT care and conservative care. Prevalent patients: 10 552 with CKD and 8509 without CKD with diabetes. OUTCOMES access to nephrology care, trends in RRT incidence and starting modality, place of death without RRT. Incident count was adjusted for changes in the local adult population recorded in national censuses. RESULTS Ninety-one per cent of patients aged ≥75 years with incident CKD stage 5 were known to a nephrologist. The population-adjusted incident RRT rate peaked in 2005 and then declined; the proportion starting with transplant, peritoneal dialysis or haemodialysis by arterio-venous fistula increased to 63% by 2012 (P = 0.001 versus 2005). Fifty-two per cent of patients receiving planned conservative care without dialysis died out of hospital. CONCLUSIONS Following the introduction of a community-wide systematic CKD management programme, the population-adjusted incidence of RRT reduced, modality of initiation of RRT improved and a majority of patients receiving planned conservative care without dialysis died out of hospital.

Earlier intervention for acute kidney injury: evaluation of an outreach service and a long-term follow-up

BACKGROUND There have been few studies of earlier systematic intervention to reduce the impact of acute kidney injury (AKI). In 2009, we piloted an AKI outreach service with a before and after study, and we report on the study and its longer-term follow-up. METHODS AKI patients were identified using a laboratory delta check for creatinine of 75%. In the 4-week before phase patients received standard care. In a consecutive 7-week after phase an outreach team of nephrology doctors and nurses reviewed all alerts twice daily, 5 days a week. The primary clinical team caring for the patient was called to be given advice on AKI care. RESULTS There were 157 and 251 patients in the before and after groups, respectively, who were comparable in their characteristics. The mean age was 70 years in both groups and ∼ 80% of each group were admitted to the hospital. In the after group, the Outreach telephone call was successful in 88%, at a median of 14 h. Substantial numbers of recommendations were made, largely related to fluid balance, investigations and medication use. Survival showed an immediate non-significant improvement in the after group, but converged at about 4 years. CONCLUSION Outreach shows potential to improve outcomes in AKI. In order to achieve this it seems likely that at least a five-day per week service will be needed to assist good renal and general medical care for this vulnerable group.

Organ Trafficking for Live Donor Kidney Transplantation in Indoasians Resident in the West Midlands: High Activity and Poor Outcomes

Introduction. Some Indoasian (IA) patients with established renal failure travel abroad for commercial kidney transplantation. We compared the 1-year outcomes of IA patients from one UK region who received overseas transplants with IA patients receiving local living donor (LD) kidney transplantation, deceased donor (DD) transplantation, and dialysis. Methods. Between 1996 and 2006, 40 adults were transplanted overseas; 38 were IA, and follow-up data were available on 36 patients. Forty IA patients received LD transplants, and 156 patients received DD transplants locally. A cohort of 120 prospective dialysis patients was also used as a comparator group. Results. In the overseas cohort, 20 patients (56%) were not active in the UK transplant waiting list at the time of kidney transplantation overseas. One-year graft survival was 87%, and 1-year patient survival was 83%. Composite graft and patient survival was 69.5% at 1 year. In the local LD transplant recipients, patient survival was 97.5% (39 of 40; P=0.03), and graft survival was 97.5% (39 of 40; P=0.06). Composite graft and patient survival was 95% (P=0.003). In the overseas group, 42% had major infections compared with 15% in the local group (P=0.02). One-year graft survival for DD transplant was 84.6% (132 of 156), and 1-year patient survival was 93% (145 of 156; P=NS and P=0.06, respectively). In the dialysis group, 1-year patient survival was 96.7% (116 of 120; P=0.001). Conclusion. IA patients who choose to travel overseas for kidney transplantation have poor clinical outcomes and should be counseled accordingly.

End-of-life decision making: withdrawing from dialysis: a 12-year retrospective single centre experience from the UK

Aim Withdrawal from dialysis is a common mode of death in patients undergoing dialysis. Anecdotally most patients have a physician-directed dialysis withdrawal (DW) following an acute medical precipitant, rather than a patient-narrated planned withdrawal as part of a collaborative end-of-life care plan. We report a 12-year retrospective experience of patients undergoing dialysis who died following DW, and suggest clinical parameters which can be used to identify patients who are able to direct their end-of-life care process. Methods Retrospective 12-year review of inhouse electronic and paper records. Results 867 patients undergoing dialysis died during the study period. 93 patients died from DW. 9 (10%) patients electively withdrew in the absence of an acute medical precipitant and 84(90%) withdrew from dialysis for medical reasons. Patients who chose to withdraw were 10 years younger at dialysis initiation and withdrawal, had greater reported sessional difficulties/intolerances (p<0.05), greater general deterioration in terms of comorbidity and physical dependency during the course of dialysis (p<0.05), were more likely to rehabilitate following an acute medical precipitant, and were more likely to reside in their own home on DW (p<0.05). All had decision-making capacity compared with 35(42%) patients who had dialysis withdrawn for medical reasons (p<0.05). Conclusions Comorbidity, physical dependence, dialysis tolerance, cognitive decline, rehabilitation post an acute medical precipitant and, place of residence are parameters which differentiate between patients who choose to withdraw from dialysis and those who have dialysis withdrawn for medical reasons. These parameters can be used to identify terminal patients on dialysis who are able to be directive in their end-of-life advanced care planning.

Acute Kidney Outreach to Reduce Deterioration and Death (AKORDD) trial: the protocol for a large pilot study

Introduction Acute kidney injury (AKI) contributes to morbidity and mortality, and its care is often suboptimal and/or delayed. The Acute Kidney Outreach to Reduce Deterioration and Death (AKORDD) study is a large pilot testing provision of early specialist advice, to improve outcomes for patients with AKI. Methods and analysis This before and after study will test an Outreach service for adult patients with AKI, identified using the national algorithm. During the 2-month before phase, AKI outcomes (30-day mortality, need for dialysis or AKI stage deterioration) will be observed in the intervention and control hospitals and their respective community areas; no interventions will be delivered. Patients will receive good standard care. During the 5-month after phase, the intervention will be delivered to patients with AKI in the intervention hospital and its area. Patients with AKI in the control hospital and its area will continue to have good standard care only. Patients already on dialysis and at end of life will be excluded. The interventions will be initially delivered via a phone call, with or without a visit to the primary clinician, aiming at rapidly establishing the aetiology, correcting reversible causes and conducting further appropriate investigation. Surviving stage 3 patients will be followed-up in an AKI clinic. We will conduct qualitative research using focus group-based discussions with primary and secondary care clinicians during the early and late phases of the trial. This will help break down potential barriers and improve care delivery. Ethics and dissemination Patients will be contacted about the study allowing them to ‘opt out’. The work of an Outreach team, guided by AKI alerts and delivering timely advice to clinicians, may improve outcomes. If the results suggest that benefits are delivered by an AKI Outreach team, this study will lead to a full cluster randomised trial. Trial registration number NCT02398682: Pre-results.

Timing of acute kidney injury — does it matter? A single-centre experience from the United Kingdom

BACKGROUND Acute kidney injury (AKI) requiring renal replacement therapy (RRT) is associated with high mortality and long-term dependence on RRT. However, there is limited information about the difference in outcome between patients who develop AKI in the community (c-AKI), and those who develop AKI in hospital (h-AKI). AIM Identify differences in short- and long-term outcomes between patients admitted with c-AKI and h-AKI who require intermittent haemodialysis, and to identify factors that predict poor outcome. DESIGN & METHODS Single-centre, retrospective analysis of 306 patients with AKI who received intermittent haemodialysis between 2009 and 2011. FOLLOW-UP six months. Primary endpoints: patient and renal survival. Secondary endpoints: time on dialysis, length of hospital stay, and admission to the intensive care unit (ICU). RESULTS Survival for patients in the h-AKI group was significantly lower, at 42.9% (compared to 72%). They had a significantly longer length of stay. However, at 6-month follow-up, the survival benefit of the c-AKI group was no longer significant. Patients with h-AKI were more likely to be dialysis independent at discharge and six months although this result did not reach statistical significance. Independent predictors of survival to discharge within the entire group included: renal/post-renal causes of AKI, younger age, pre-existing diabetes, and c-AKI. The only independent predictor for RRT dependence at discharge and six months was pre-existing chronic kidney disease. CONCLUSIONS h-AKI is associated with high mortality and longer hospital stays during the acute admission. However, h-AKI patients who survive are more likely to be independent of RRT at discharge and follow-up.

Haemodialysis in the Octogenarian: More Than a Decade of Experience from a Single UK Centre

Background. To assess factors affecting survival in an octogenarian cohort commencing haemodialysis (HD) and describe outcomes associated with prolonged survival. Materials and Methods. We retrospectively analysed 11 years of data (1 January 2000–31 December 2010) from patients aged ≥ 80 years starting HD at a teaching hospital in the United Kingdom. Data was collected on patient demographics, aetiology of renal failure, indication and duration of HD, access type at first dialysis, Charlson comorbidity index score, and cause of death. Results. Data from 139 eligible patients was included for analysis (85 male, 54 female (1.54 : 1)). The mean age was years and 90% of this cohort were Caucasian. Thirty percent (42/139) of the cohort died within 90 days of starting dialysis. For those who survived >90 days the mean (median) duration of HD was 871.8 (805) days. Long-term survival was more common in females and those who first dialysed through an AVF. Conclusions. There is a significant early mortality risk in octogenarians commencing HD. For individuals who survive beyond the initial 90 days, the majority have a good long-term survival and our results are better than previously published UK data. Long-term survival was more common in female patients and those starting HD using an AVF.

UK organisation of access care

National UK audits show that 73% of patients start renal replacement therapy (RRT) with haemodialysis (HD). However, 59% of those start HD on non-permanent access in the form of a tunnelled line (TL) or a non-tunnelled line (NTL), 40% on an arteriovenous fistula (AVF) and 1% on an arteriovenous graft (AVG). After 3 months, the number of patients dialysing on AVF was only 41%. Late referrals, within 90 days of starting dialysis to the renal service, occur in one-fifth of all incident HD patients. Referral to a surgeon was an important determinant of mode of access at first dialysis. However, referral to a surgeon occurred in 67% of patients who were known to the nephrologist for over a year and in 46% of patients who were known to nephrology less than a year but more than 90 days. Best practice tariffs of the National Health Service (NHS) payment by results program have set a target of 75% of prevalent HD occurring via an AVF or AVG in 2011/2012, rising to 85% in 2013/2014. We suggest that this target is best achieved by increasing timely referral to a surgeon for creation of access before HD is needed.