Mick Kumwenda

Renal Association Clinical Practice Guideline on vascular access for haemodialysis.

Vascular access remains a key component of haemodialysis. The ideal vascular access should provide safe and effective therapy by enabling the removal and return of blood via an extracorporeal circuit. Vascular access should be easy to use, reliable and have minimal risk to the individual receiving haemodialysis. However, the provision of good quality access, whilst it is a fundamental aspect of the treatment of haemodialysis patients, remains difficult to achieve. Native access, in particular arteriovenous fistulae, requires prior planning yet has a high primary failure rate. Arteriovenous grafts utilising replacement of synthetic or biological material in conjunction with native vessels again require planning and surgical expertise yet have a high demand to maintain them and a high rate of complications. Venous catheters (both tunnelled and non-tunnelled) are in common usage both as temporary access and in a smaller number of patients as the only form of access that is available, yet offer inferior therapy. Vascular access via central venous catheters provides poorer solute clearance related to the limited achieved blood flow and also a higher rate of complications. This guideline updates the section on vascular access in the haemodialysis module of the 4th edition of the RA guidelines published on-line at www.renal.org in 2007. These guideline recommendations are based on a literature review from relevant publications in journals cited on MEDLINE, PubMed and UpToDate up to 1st May 2010. The modified GRADE system has been adopted by the Renal Association Clinical Practice Guidelines Committee and has been used to grade the recommendations in all of the modules in the 5th edition of the Renal Association guidelines. It explicitly describes both the strength of the recommendations and the quality of the underlying evidence, with the aim of maximising applicability to standard clinical practice [1–4]. The modified GRADE system grades level of expert recommendation as ‘strong’ (Grade 1) or ‘weak’

Nandrolone Decanoate as Anabolic Therapy in Chronic Kidney Disease: A Randomized Phase II Dose-Finding Study

Background/Aims: In patients with chronic kidney disease (CKD) receiving adequate erythropoietin therapy, the ideal dose of nandrolone decanoate (ND) to enhance muscle mass is not known. Methods: In this phase II dose-finding study, 54 patients with CKD stage 5 were randomized to either low, medium or high doses of ND (50, 100 or 200 mg/week for 24 weeks, respectively, in males; doses halved in females), while 7 patients acted as non-randomized controls. The primary outcome measure was appendicular lean mass (ALM) by dual-energy X-ray absorptiometry. Fluid overload (hydration of the fat-free mass) and indicators of physical functioning were secondary measures. Harms were also recorded. Data were analysed using Quade’s (1967) non-parametric analysis of covariance. Results: ND increased ALM in a dose-responsive manner (change scores = 0.3 ± 0.3 vs. 0.8 ± 0.3 vs. 1.5 ± 0.5 vs. 2.1 ± 0.4 kg, control vs. low vs. medium vs. high dose groups, respectively, p < 0.001) with no increases in fluid overload but no consistent effect on physical functioning. The highest dose of ND (100 mg/week) was intolerable in females because of virilizing effects. Conclusion: If goals of future studies are to improve body composition, dosing of ND up to 200 mg/week in males and 50 mg/week in females should be investigated. However, to realize improvements in physical functioning, future phase III trials of ND may require additional interventions such as exercise training.

Summary of the 5th Edition of the Renal Association Clinical Practice Guidelines (2009-2012)

Robert Mactier, Simon Davies, Chris Dudley, Paul Harden, Colin Jones, Suren Kanagasundaram, Andrew Lewington, Donald Richardson, Maarten Taal, Peter Andrews Richard Baker, Cormac Breen, Neill Duncan, Ken Farrington, Richard Fluck, Colin Geddes, David Goldsmith, Nic Hoenich, Stephen Holt, Alan Jardine, Sarah Jenkins, Mick Kumwenda, Elizabeth Lindley, Mark MacGregor, Ashraf Mikhail, Edward Sharples, Badi Shrestha, Rajesh Shrivastava, Simon Steddon, Graham Warwick, Martin Wilkie, Graham Woodrow, Mark Wright

Survey of permanent central venous catheters for haemodialysis in the UK

BACKGROUND Venous catheter haemodialysis may be necessary in some patients without arterio venous fistulae on dialysis for end-stage renal failure. We conducted a survey to compare management of these catheters in different units in the UK. METHODS Postal questionnaires were sent to nurses in charge of 81 renal units in the UK for a twelve month study period in 1994 to find out the type of catheter used, catheter after insertion care, the rate and management of exit site infections, and bacteraemia. RESULTS (1) Total number of questionnaires returned 66 (81.5%). (2) 63.6% of renal units used double lumen Permcath catheters, 16.7% single lumen (Francis/Kimal, Gambro or Vascath), 10.6% use both double and single lumen catheters and 9.1% of renal units only use temporary polyurethane catheters. (3) Catheter exit site aseptic dressing technique was used in 84.8% of renal units, clean technique in 15.2%. 66.8% change dressings at each dialysis session, 22.7% weekly. The majority of renal units (63.6%) had one nurse to change the dressing, used Betadine as a cleaning agent and Mepore to cover the exit site. (4) 75.8% did not know the exact incidence of episodes of sepsis and/or exit site infections. Flucloxacillin was the antibiotic of choice for each catheter related sepsis episode. CONCLUSION During this study period most renal units used Permcaths as first choice for long term catheter dialysis, the after insertion care of which varied. The number of episodes of sepsis was unknown. We suggest UK collection of data for all long term catheters and related problems for audit purposes.

UK Renal Registry 18th Annual Report 2015

The UK Renal Registry (UKRR) continues to provide a national source of NHS healthcare data on patients dependent on renal replacement therapy (RRT) across the four nations. Using electronic reporting and substantial integration across the 71 adult and 13 paediatric renal centres independent audit and analysis of dialysis and transplant activity and care across the UK is provided. The UKRR is part of the UK Renal Association and is funded directly by participating renal centres through an annual capitation fee per patient per annum, currently £19 or 0.01% of annual RRT running costs. The UKRR remains relatively unique amongst renal registries in publishing both centre-specific analyses of indicators of quality of care, such as haemoglobin and also ageadjusted survival statistics for each renal centre [1].

UK Renal Registry 18th Annual Report: Chapter 11 2014 Multisite Dialysis Access Audit in England, Northern Ireland and Wales and 2013 PD One Year Follow-up: National and Centre-specific Analyses.

Introduction: Dialysis access should be timely, minimise complications and maintain functionality. Good functional access is required for renal replacement therapy (RRT) to be successful. The aim of the combined vascular and peritoneal dialysis access audit was to examine practice patterns with respect to dialysis access and highlight variations in practice between renal centres. Methods: The UK Renal Registry collected centre-specific information on vascular and peritoneal access outcome measures including patient demographics, dialysis access type (at start of dialysis and three months after start of dialysis), surgical assessment and access functionality. The combined access audit covered incident haemodialysis (HD) and peritoneal dialysis (PD) patients in 2012 from England, Northern Ireland and Wales. Centres who had reported data on incident PD patients for the previous audit in 2011 were additionally asked to provide one year follow up data for this group. Results: Fifty-one centres in England, Wales and Northern Ireland (representing 82% of all centres) returned data on first access from 3,720 incident HD patients and 1,018 incident PD patients. A strong relationship was seen between surgical assessment and the likelihood of starting HD with an arteriovenous fistula (AVF). Type of first access was related to the length of time known to renal services with higher numbers of AVFs and PD catheters used in patients known to renal services for at least one year. Three month and one year outcomes of HD and PD access were poorly reported. Conclusions: This audit provides information on important patient related outcome measures with the potential to lead to an improvement in access provision. This represents an important advance, however data collection remains suboptimal. There is wide practice variation across the England, Wales and Northern Ireland in provision of both HD and PD access which requires further exploration.

UK Renal Registry 17th Annual Report: Appendix B Definitions and Analysis Criteria

The take-on population is defined as all patients over 18 who started renal replacement therapy (RRT) at UK renal centres and did not have a recovery lasting more than 90 days within 90 days of starting RRT. The treatment timeline is used to define take-on patients as follows. If a patient has timeline entries from more than one centre then these are all combined and sorted by date. Then, the first treatment entry gives the first date of when they received RRT. This is defined as a ‘start date’. However, in the following situations there is evidence that the patient was already receiving RRT before this ‘start date’ and these people are not classed as takeon patients:

UK Renal Registry 15th Annual Report: Appendix A The UK Renal Registry Statement of Purpose

1. Executive summary 2. Introduction 3. Statement of intent 4. Relationships of the UK Renal Registry 5. The role of the UK Renal Registry for patients 6. The role of the UK Renal Registry for nephrologists 7. The role of the UK Renal Registry for Trust managers 8. The role of the UK Renal Registry for commissioning agencies 9. The role of the UK Renal Registry in national quality assurance schemes 10. References and websites

Chapter 10 Multisite Dialysis Access Audit in England, Northern Ireland and Wales and 2015 Peritoneal

This article is licensed under the Creative Commons AttributionNonCommercial-NoDerivatives 4.0 International License (CC BYNC-ND) (http://www.karger.com/Services/OpenAccessLicense). Usage and distribution for commercial purposes as well as any distribution of modified material requires written permission. Barnaby Hole UK Renal Registry, Southmead Hospital, Southmead Road, Bristol, BS10 5NB, UK Email: renalregistry@renalregistry.nhs.uk Nephron 2018;139(suppl1):253–272

UK Renal Registry 19th Annual Report: Appendix I Acronyms and Abbreviations used in the Annual Report

AAB Academic Affairs Board (Renal Association) ACE (inhibitor) Angiotensin converting enzyme (inhibitor) AKI Acute kidney injury ANZDATA Australia and New Zealand Dialysis and Transplant Registry APD Automated peritoneal dialysis ADPKD Autosomal dominant polycystic kidney disease APKD Adult polycystic kidney disease ATTOM Access to transplant and transplant outcome measures ATTOMic Access to transplant and transplant outcome measures in children AV Arteriovenous AVF Arteriovenous fistula AVG Arteriovenous graft BAPN British Association of Paediatric Nephrology BCG Bromocresol green BCP Bromocresol purple Bicarb Bicarbonate BMD Bone mineral disease BMI Body mass index BP Blood pressure BSI Blood stream infection BTS British Transplant Society Ca Calcium CAB Clinical Affairs Board (Renal Association) CABG Coronary artery bypass grafting CAPD Continuous ambulatory peritoneal dialysis CCG Clinical Commissioning Group CCL Clinical Computing Limited CCPD Cycling peritoneal dialysis CDI Clostridium difficile infection Chol Cholesterol CHr Target reticulocyte Hb content CI Confidence interval CICR Cumulative incidence competing risk CIF Cumulative incidence function CK Creatine kinase CKD Chronic kidney disease CKD-EPI Chronic kidney disease epidemiology collaboration CK-MB Creatine kinase isoenzyme MB CKD-MBD Chronic kidney diseasemineral bone disorder COPD Chronic obstructive pulmonary disease