Neil Ashman

Guidelines for the prevention and management of Mycobacterium tuberculosis infection and disease in adult patients with chronic kidney disease

Guidelines have been compiled by the Joint Tuberculosis Committee of the British Thoracic Society for the prevention and management of Mycobacterium tuberculosis infection and disease in patients with all grades of renal impairment.

Patient safety and estimation of renal function in patients prescribed new oral anticoagulants for stroke prevention in atrial fibrillation: a cross-sectional study

Objective In clinical trials of dabigatran and rivaroxaban for stroke prevention in atrial fibrillation (AF), drug eligibility and dosing were determined using the Cockcroft-Gault equation to estimate creatine clearance as a measure of renal function. This cross-sectional study aimed to compare whether using estimated glomerular filtration rate (eGFR) by the widely available and widely used Modified Diet in Renal Disease (MDRD) equation would alter prescribing or dosing of the renally excreted new oral anticoagulants. Participants Of 4712 patients with known AF within a general practitioner-registered population of 930u2005079 in east London, data were available enabling renal function to be calculated by both Cockcroft-Gault and MDRD methods in 4120 (87.4%). Results Of 4120 patients, 2706 were <80u2005years and 1414 were ≥80u2005years of age. Among those ≥80u2005years, 14.9% were ineligible for dabigatran according to Cockcroft-Gault equation but would have been judged eligible applying MDRD method. For those <80u2005years, 0.8% would have been incorrectly judged eligible for dabigatran and 5.3% would have received too high a dose. For rivaroxaban, 0.3% would have been incorrectly judged eligible for treatment and 13.5% would have received too high a dose. Conclusions Were the MDRD-derived eGFR to be used instead of Cockcroft-Gault in prescribing these new agents, many elderly patients with AF would either incorrectly become eligible for them or would receive too high a dose. Safety has not been established using the MDRD equation, a concern since the risk of major bleeding would be increased in patients with unsuspected renal impairment. Given the potentially widespread use of these agents, particularly in primary care, regulatory authorities and drug companies should alert UK doctors of the need to use the Cockcroft-Gault formula to calculate eligibility for and dosing of the new oral anticoagulants in elderly patients with AF and not rely on the MDRD-derived eGFR.

Allosensitization Rate of Male Patients Awaiting First Kidney Grafts After Leuko-Depleted Blood Transfusion

Background. Blood transfusions are generally avoided for potential renal transplant recipients due to risk of human leukocyte antigen (HLA) allosensitization. Despite the near universal use of erythropoiesis-stimulating agents, there are still occasions when patients require blood transfusions for reasons such as resistance to erythropoiesis-stimulating agents or cardiovascular instability. The risk of allosensitization in renal patients is believed to be lower with leuko-depleted blood. We sought to quantify the risk of blood transfusion per se in male renal patients on the transplant waiting list for their first kidney graft, using sensitive solid phase antibody detection. Method. Cross-sectional survey looking at the prevalence of HLA antibody detected using single antigen Luminex beads in male patients awaiting first renal transplantation. Results. One hundred sixteen male patients awaiting their first kidney transplant were identified on our waiting list. Seven of the 42 patients (16.7%) who received at least one unit of leuko-depleted blood developed HLA antibody (HLAab). Of the remaining 74 patients without a history of transfusion, 3 (4.1%) were found to have HLAab. All the antibodies identified were directed against class I antigens. A history of blood transfusion gave a relative risk of 4.1 of developing HLAab (P=0.02). Conclusion. Male patients awaiting their first organ transplant had a fourfold increased risk of developing HLA antibody if they had been previously transfused when compared with those who did not have a history of a transfusion. Transfusion even in the postleukodepletion era continues to pose a significant risk of sensitization.

A survey of stress, job satisfaction and burnout among haemodialysis staff.

BACKGROUNDnBurnout, psychological distress and job satisfaction experienced by healthcare workers in general are well documented in the literature; however, there is a paucity of research that focuses on the experiences of haemodialysis staff.nnnMETHODnThe study investigates burnout, psychological distress and job satisfaction in a sample of 50 haemodialysis staff from two units in one National Health Service (NHS) trust in London, England, using the Maslach Burnout Inventory (MBI), General Health Questionnaire (GHQ-12) and the Minnesota Satisfaction Questionnaire (MSQ).nnnRESULTSnThe majority of staff did not experience burnout or psychological distress and were satisfied with their jobs. However, some participants had low personal accomplishment and were dissatisfied with certain areas of their jobs. Age and length of haemodialysis experience were associated with burnout, job satisfaction and psychological distress.nnnCONCLUSIONSnOlder staff and staff with a greater length of service in haemodialysis have higher levels of burnout, psychological distress and job dissatisfaction.

Resolution of cast nephropathy following free light chain removal by haemodialysis in a patient with multiple myeloma: a case report

IntroductionAcute renal failure in multiple myeloma is most frequently caused by cast nephropathy, when excess monoclonal free light chains co-precipitate with Tamm-Horsfall protein in the distal nephron, causing tubular obstruction. The natural history of cast nephropathy after diagnosis is unknown. This report provides supporting histological evidence that, as serum free light chain concentrations fall, intratubular casts may resolve within weeks.Case presentationWe report the case of a 61-year-old Caucasian woman who presented with multiple myeloma and dialysis-dependent acute renal failure, with serum kappa free light chain concentrations of 15,700 mg/litre (normal range 3.3 to 19.4 mg/litre). Renal biopsy demonstrated cast nephropathy with waxy casts in distal tubules and collecting ducts. There was an interstitial inflammatory cell infiltrate with diffuse fibrosis and tubular atrophy. Following rehydration, chemotherapy and free light chain removal using high cut-off haemodialysis, free light chain concentrations fell to less than 5% of the starting level (500 mg/litre). A repeat renal biopsy 6 weeks after the first showed resolution of cast nephropathy.ConclusionThese observations indicate that cast nephropathy can quickly resolve on rapid reduction of monoclonal serum free light chains. This has important implications for the development of treatment strategies aimed at improving renal recovery rates for patients in this setting.

Inappropriately low aldosterone concentrations in adults with AIDS-related diarrhoea in Zambia: a study of response to fluid challenge

BackgroundChronic diarrhoea is one of the most debilitating consequences of HIV infection in sub-Saharan Africa and it carries a high mortality rate. We report unexpectedly low concentrations of circulating aldosterone in 12 patients (6 men, 6 women) in the University Teaching Hospital, Lusaka, who all had diarrhoea for over one month. Changes in serum electrolytes, blood pressure, Karnofsky score and serum aldosterone concentration were being monitored during a short study of responses to saline infusion (3 litres/24 h) over 72 hours.FindingsAt baseline, 9/12 (75%) of the patients were hyponatraemic, 10/11 (91%) were hypokalaemic, and 6/12 (50%) had undetectable aldosterone concentrations. Blood pressure and Karnofsky score rose and creatinine concentration fell in response to the infusion.ConclusionCirculating aldosterone concentrations were inappropriately low and complicate the profound electrolyte deficiencies resulting from chronic diarrhoea. Management of these deficiencies needs to be more aggressive than is currently practised and consideration should be given to a formal clinical trial of mineralocorticoid replacement in these severely ill patients. If the inappropriately low aldosterone reflects a general adrenal failure, it may explain a considerable proportion of the high mortality seen both before and after initiation of anti-retroviral therapy.

New ways of working; delivering better care for people with long-term conditions*

Abstract Background: The cost-effectiveness of the traditional outpatient model for specialist care provision is increasingly being questioned in view of the changing patient needs, workforce challenges and technological advances. Setting: This report summarises two RCGP London events showcasing new ways of delivering care for long-term conditions. Questions: What are the alternative approaches to the traditional outpatient model and do they have common themes? What are the challenges and opportunities of these new models of care? Methods: Presentation of examples of new ways of long-term condition care delivery and round-table facilitative discussion and reflection on the challenges and solutions around service re-design and implementation, the commissioning and funding of new models of care, the facilitation of system-wide learning and the collection of data for evaluation. Results: Different ways of delivering care for people with Chronic Kidney Disease (CKD) and Chronic Obstructive Pulmonary Disease (COPD) were presented. Most of the interventions included virtual clinics (during which patient care was reviewed by a specialist remotely without the need for a face-to-face consultation), improved communication between primary and secondary care clinicians, an element of referral triage/prioritisation, the use of trigger tools to identify people at risk of deterioration, patient education and a multi-disciplinary approach. Discussion-conclusions: Different models to the traditional outpatient long-term condition care are feasible and can result in improvements in the quality of care and staff satisfaction. However, such initiatives require careful planning, close collaboration between health care professionals and allocation of appropriate resources and training within primary care. There is also a need for systematic evaluation of such pilots to assess their cost-effectiveness and their acceptability to clinicians and patients. This requires systematic collection of population level data, agreement on the key outcomes for evaluation and a commitment of all stakeholders to sharing learning and resources to enable continuous improvement.

Aggression on haemodialysis units: a mixed method study

BACKGROUNDnAggression on haemodialysis units is a growing problem internationally that has received little research attention to date. Aggressive behaviour by patients or their relatives can compromise the safety and well-being of staff and other patients sharing a haemodialysis session.nnnOBJECTIVESnThe objectives of the study were twofold: First, to identify the prevalance and nature of aggression on haemodialysis units; and second, to investigate factors that contribute to aggressive behaviour on haemodialysis units.nnnDESIGN AND METHODSnA cross-sectional, sequential mixed method research design was adopted, with two research methods utilised. Incidents of aggressive behaviour were recorded over a 12-month period, using a renal version of the Staff Observation Aggression Scale. Six months after the incident data collection had commenced, semi-structured qualitative interviews were conducted with 29 multidisciplinary members of staff.nnnRESULTSnOver 12 months, 74 aggressive incidents were recorded. The majority of incidents involved verbal aggression, and the perpetrators were a minority of patients, relatives and staff. Two patients were responsible for 38% of all incidents; both patients had mental health problems. Distinct temporal patterns to the aggressive behaviour were observed according to the day of the week and time of day.nnnCONCLUSIONnThis study demonstrates that aggression is a significant problem on haemodialysis units, with verbal aggression most prevalent. The temporal patterns to aggression observed are related to the uniqueness of the haemodialysis setting, with a distinctly different treatment environment compared with other healthcare settings.

Magnetic resonance imaging with gadolinium enhancement in renal failure: a need for caution

A 36‐year‐old Asian man with von Hippel–Lindau syndrome was referred to the dermatology clinic in January 2005 with stiff fingers and ankles of 3 months’ duration. He had undergone bilateral nephrectomy for renal squamous cell carcinoma in 2002 and had started hemodialysis. Multiple cerebellar hemangiomata were resected in 1991, 2001, and 2003, and consequently he underwent multiple magnetic resonance imaging (MRI) scans with gadolinium‐based contrast agents whilst on hemodialysis. The serum creatinine level and calculated glomerular filtration rate (GFR) at the time of his first exposure to gadolinium were 584 µmol/L and 13.31 mL/min, respectively. The patient recalled his symptoms worsening dramatically immediately after he had undergone two MRI scans on a day on which he was not dialyzed.

Membranous nephropathy: a retrospective observational study of membranous nephropathy in north east and central London

BackgroundMembranous nephropathy (MN) is the leading cause of nephrotic syndrome in adults. MN is a clinically heterogeneous disease and it is difficult to accurately predict outcomes (including end stage renal failure) at presentation and whom to treat with potentially toxic therapies. We aimed to identify factors predicting outcome in MN in our cohort from two large tertiary London units by undertaking a retrospective data analysis of 148 biopsy-proven MN patients from North East and Central London between 1995 and 2015.MethodsReview of clinical and biochemistry databases.ResultsSurprisingly, patients that reached end stage renal failure (ESRF) had a less severe nephrosis compared to those that did not develop ESRF; serum albumin 33 g/L (3.3xa0g/dL) versus 24xa0g/L (2.4xa0g/dL), pxa0=xa00.002 and urinary protein creatinine ratio (uPCR) 550xa0mg/mmol (5500xa0mg/g) versus 902xa0mg/mmol (9020xa0mg/g), pxa0=xa00.0124. The correlation with ESRF was strongest with the presenting creatinine; 215xa0μmol/L (2.43xa0mg/dL) compared to 81xa0μmol/L (0.92xa0mg/dL), pxa0<xa00.0001. Patients presenting with creatinine of >120xa0μmol/L (1.36xa0mg/dL; corresponding to an eGFR of ≤60xa0ml/min in non-Black males) had an increased rate of ESRF and a faster decline. Other traditional risk factors for progression were not significantly associated with ESRF.Black patients presented with higher serum creatinine but no statistically significant difference in the estimated glomerular filtration rate, a higher rate of progression to ESRF and had a poorer response to treatment.ConclusionsThis ethnically diverse cohort does not demonstrate the traditional risk profile associated with development of ESRF. Thus, careful consideration of therapeutic options is crucial, as current risk modelling cannot accurately predict the risk of ESRF. Further studies are required to elucidate the role of antibodies and risk genes.