Department Of Renal Medicine Research Articles

Safety and effectiveness of direct oral anticoagulants in patients with nephrotic syndrome: a report of 21 cases

BackgroundNephrotic syndrome (NS) is associated with increased risk of thromboembolic events (TE) adding to the morbidity and mortality. International guidelines recommend prophylactic anticoagulation in patients with NS and high risk of TE, but no studies have identified the optimal type of anticoagulation in NS. We aimed to assess the effectiveness and safety of direct oral anticoagulant (DOAC) by analyzing the thromboembolic and bleeding events in NS patients prescribed DOAC as primary prophylaxis to prevent TE or as treatment for TE occurring in relation to NS.MethodsWe performed a single-center, retrospective study including patients with NS, a plasma albumin less than 25 g/L and prophylactic anticoagulation treatment with DOAC at the Department of Renal Medicine at Aarhus University Hospital, Denmark from July 2016 to June 2021. Patients treated with DOAC as thromboprophylaxis for other indications than NS were excluded. Baseline characteristics and outcomes, including TE, bleeding and other adverse effects associated with DOAC were obtained from medical records.ResultsWe identified 268 patients treated with DOAC of which 21 patients with NS were included in the study. Nineteen patients were prescribed DOAC as thromboprophylaxis and two patients received DOAC due to previous TE, which was considered associated with the NS. The type of DOAC prescribed was apixaban (n = 10) and rivaroxaban (n = 11). No patients experienced TE during DOAC treatment, while five patients had a minor bleeding episode. Patients who experienced bleeding episodes were older (median 62 vs 51 years), more often female (80%) and had been on DOAC for a longer period (204 days vs 47 days). Neither the HAS-BLED score nor GN-risk-score predicted the risk of minor bleedings in this population.ConclusionsIn this case series, no new TE and only minor bleeding complications were observed among adult NS patients treated with DOAC.

Urinary metabolic profile and stone composition in kidney stone formers with and without heart disease

ObjectiveKidney stone disease seems to be associated with an increased risk of incident cardiovascular outcomes; the aim of this study is to identify differences in 24-h urine excretory profiles and stone composition among stone formers with and without cardiovascular disease (CVD).MethodsData from patients attending the Department of Renal Medicine’s metabolic stone clinic from 1995 to 2012 were reviewed. The sample was divided according to the presence or absence of CVD (myocardial infarction, angina, coronary revascularization, or surgery for calcified heart valves). Univariable and multivariable regression models, adjusted for age, sex, BMI, hypertension, diabetes, eGFR, plasma bicarbonate and potential renal acid load of foods were used to investigate differences across groups.Results1826 patients had available data for 24-h urine analysis. Among these, 108 (5.9%) had a history of CVD. Those with CVD were older, have higher prevalence of hypertension and diabetes and lower eGFR. Univariable analysis showed that patients with CVD had significantly lower 24-h urinary excretions for citrate (2.4 vs 2.6 mmol/24 h, p = 0.04), magnesium (3.9 vs 4.2 mmol/24 h, p = 0.03) and urinary pH (6.1 vs 6.2, p = 0.02). After adjustment for confounders, differences in urinary citrate and magnesium excretions remained significant. No differences in the probability of stone formation or stone compositions were found.ConclusionsStoneformers with CVD have lower renal alkali excretion, possibly suggesting higheracid retention in stone formers with cardiovascular comorbidities. Randomizedclinical trials including medications and a controlled diet design are neededto confirm the results presented here.Graphic abstract

Using Patient-Reported Outcome Measures (PROMs) to promote quality of care and safety in the management of patients with Advanced Chronic Kidney disease (PRO-trACK project): a mixed-methods project protocol

IntroductionAdvanced chronic kidney disease (CKD) has a major effect on the quality of life and health status of patients and requires accurate and responsive management. The use of electronic patient-reported...

Use of patient-reported outcomes in outpatient settings as a means of patient involvement and self-management support – a qualitative study of the patient perspective

Rationale, aims and objectives Patient-reported outcomes (PRO) is being implemented in clinical practice across different healthcare settings with various purposes. Involving the patients in reporting outcomes may increase their attention to symptoms and thereby support their self-management. The aim of the present study was to describe patients’ experiences with a web-based PRO system where patients fill in a PRO questionnaire at home or in the outpatient clinic prior to a consultation. Moreover, the study aimed to explore how PRO influenced the interaction between patients and clinicians during the consultation.Methods Through participant observations of nine consultations and 12 semi-structured interviews with patients after the consultation this interpretive description study explored patients’ experiences with the PRO system. The PRO included self-assessment on health-related quality of life, symptoms, and well-being. Patients who visited the outpatient clinic at Department of Renal Medicine at Aarhus University Hospital in the Central Denmark Region in February and March 2014 and in March and August 2015 were invited to participate. We used a convenience sampling approach to recruit patients who had completed at least two PRO questionnaires.Results The analysis revealed rudiments of PRO in clinical practice leading to an increased understanding of their chronic disease, patient-centred communication and an additional focus on psychosocial problems. However, the very application of PRO in the outpatient clinic and the patient attitudes were substantial and crucial barriers for PRO as a method to achieve patient involvement and self-management.Conclusion The use of PRO in outpatient consultations may support patients' self-management by a) impelling patient-centred communication in the consultation, b) legitimising talk about psychosocial problems, and c) increasing the patients' understanding of their disease. Yet, applying PRO into clinical practice does not automatically involve the patients and support their self-management. We suggest supplementary clinical initiatives to strengthen the patient involving benefits of PRO.

Transcranial Direct Current Stimulation as a Treatment for Depression in the Hemodialysis Setting

Received July 27, 2015; revised November 8, 2015; accepted November 19, 2015. From School of Psychiatry, University of New South Wales, Sydney, Australia (AB, CKL, SBH); NSW Institute of Psychiatry, Westmead, Australia (AB); Department of Psychiatry, St George Hospital, Kogarah, Australia (AB, CKL, SH); Department of Renal Medicine, St George Hospital, Kogarah, Australia (IK); Black Dog Institute, Sydney, Australia (CKL,DM, SBH); Faculty ofMedicine, University ofNewSouth Wales, Sydney, Australia (IK); Prince of Wales Hospital, Randwick, Australia (AB). Send correspondence and reprint requests to Alison Bautovich, M.B.B.S., B.Sc. (Med), School of Psychiatry, University of New SouthWales, Black Dog Institute Building, Hospital Road, Randwick NSW 2031, Australia; e-mail: a.bautovich@unsw.edu.au Crown Copyright & 2016 Published by Elsevier Inc. on behalf of The Academy of Psychosomatic Medicine. All rights reserved. Introduction

The Impact of Dialysis-Dependent Acute Kidney Injury on Mortality in Myeloma: Findings from England Hospital Episode Statistics Data

e114 PO-059 The Impact of Dialysis-Dependent Acute Kidney Injury on Mortality in Myeloma: Findings from England Hospital Episode Statistics Data M. Cook, F. Evison, J. Sangha, P. Yadav, S. Aung, D. Ray, A. Sharif, J. Pinney, M. Drayson, P. Cockwell Department of Haematology, University Hospital Birmingham, Birmingham, UK; School of Infection and Immunity, University of Birmingham, Birmingham, UK; Department of Informatics, University Hospital Birmingham, Birmingham, UK; Department of Renal Medicine, University Hospital Birmingham, Birmingham, UK

Expiration: inspiration ratio as a prognostic factor in systemic AL amyloidosis

e114 PO-059 The Impact of Dialysis-Dependent Acute Kidney Injury on Mortality in Myeloma: Findings from England Hospital Episode Statistics Data M. Cook, F. Evison, J. Sangha, P. Yadav, S. Aung, D. Ray, A. Sharif, J. Pinney, M. Drayson, P. Cockwell Department of Haematology, University Hospital Birmingham, Birmingham, UK; School of Infection and Immunity, University of Birmingham, Birmingham, UK; Department of Informatics, University Hospital Birmingham, Birmingham, UK; Department of Renal Medicine, University Hospital Birmingham, Birmingham, UK

Does Augmented Creatinine Clearance Accurately Reflect Glomerular Hyperfiltration in Critical Illness?

Adult Critical Care Unit and Department of Renal Medicine and Transplantation, The Royal London Hospital, Barts Health NHS Trust, London, United Kingdom Dr. Prowle consulted for Gambro AB, is employed by Barts Health NHS Trust, and lectured for Gambro AB and Alere. His institution received grant support from Bart and the London Charity.

Cardiovascular disease in patients with chronic kidney disease

Department of Renal Medicine, Auckland City Hospital and Department of Medicine, Auckland University, Auckland, New Zealand; Department of Renal Medicine, Sir Charles Gairdner Hospital, Perth, Western Australia, Department of Nephrology, Austin Health, Department of Medicine, University of Melbourne, Melbourne, The George Institute for Global Health, The University of Sydney, Sydney, New South Wales, Australia; Department of Clinical Pharmacology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands; and Department of Nephrology, Hypertension, and Strokology, Kyushu University Hospital, Kyushu, Japan

AB0478 Anca associated vasculitis presenting with anterior ischemic optic neuropathy

BackgroundAnterior Ischemic Optic Neuritis (AION) is caused by arteritic and non arteritic factors. Giant Cell Arteritis is one of the well-recognised causes of arteritic AION. AION is a rare but...

The Effect of Sea Buckthorn Supplement on Oral Health, Inflammation, and DNA Damage in Hemodialysis Patients: A Double-Blinded, Randomized Crossover Study

Chronic kidney disease is associated with inflammation, oxidative stress, malnutrition, poor oral health, and mouth dryness. The objective of this study was to evaluate effects of sea buckthorn oil (SBO) extract, which is rich in vitamins, phytochemicals, and polyunsaturated fatty acids, on oxidative stress, saliva production, and inflammation in hemodialysis patients. This was a randomized, double-blinded, and placebo-controlled crossover study (2 × 8 weeks, 4-week washout). The study subjects were hemodialysis patients (n = 45) recruited from the Department of Renal Medicine at Karolinska University Hospital in Stockholm. The patients received 4 capsules per day, each containing 500 mg of SBO or placebo, for 8 weeks. They were then crossed over to the other treatment after a 4-week washout period. Salivary gland biopsies, saliva, and blood samples were collected before and after each treatment period. Main outcomes were DNA breaks and oxidative DNA lesions in minor accessory salivary glands, salivary flow rates, and inflammation markers in blood (high-sensitivity C-reactive protein, antitrypsin, orosomucoid in plasma, leukocytes in blood). Blood markers including creatinine, urea in plasma, and hemoglobin in blood were investigated. The results showed no significant changes in DNA breaks, oxidative DNA lesions, salivary flow rates, or inflammation after SBO supplementation. However, plasma levels of phosphate and sodium increased and plasma levels of iron decreased. In conclusion, SBO supplementation as performed in this study did not protect against oxidative stress, nor improve oral health or inflammation status in hemodialysis patients.

Coronary Angiitis and Cardiac Arrest in Antineutrophil Cytoplasmic-Antibody Associated Systemic Vasculitis

A 58-year-old man was admitted with a 6-week history of fever, lethargy, arthralgia, and dyspnea on exertion. He had no prior illness or cardiovascular risk factors, and with the exception of a pyrexia, his physical examination was unremarkable. Investigations were performed, including blood and urine cultures and a connective tissue screen. He was subsequently discharged with a view to an early outpatient review when he collapsed at home with cardiac arrest. The initial rhythm was ventricular fibrillation, which was successfully cardioverted. His postarrest electrocardiogram revealed transient right bundle-branch block and his plasma troponin I concentration was raised at 8.5 μg/L. His renal function was normal, but markers of …

Diagnosis, prevention and treatment of haemodialysis catheter-related bloodstream infections (CRBSI): a position statement of European Renal Best Practice (ERBP).

Nephrology Section, Department of Internal Medicine, University Hospital, Gent, Belgium, Nephrology, Dialysis and Intensive Care Unit, Lapeyronie University Hospital, Montpellier, France, Department of Renal Medicine, Royal Derby Hospital, Derby, UK, Nephrology, Cliniques Universitaires Saint-Luc, Universite Catholique de Louvain, Brussels, Belgium, Nephrology Department, Consorcio Hospital General Universitario, Valencia, Spain and Vascular Surgery, Department of Surgery, Maastricht University Medical Center, Maastricht, the Netherlands

Catheter-related blood stream infections (CRBSI): a European view

Nephrology Section, Department of Internal Medicine, University Hospital, Gent, Belgium, Nephrology, Dialysis and Intensive Care Unit, Lapeyronie University Hospital, Montpellier, France, Department of Renal Medicine, Royal Derby Hospital, Derby, UK, Nephrology, Cliniques Universitaires Saint-Luc, Universite Catholique de Louvain, Brussels, Belgium, Nephrology Department, Consorcio Hospital General Universitario, Valencia, Spain and Vascular Surgery, Department of Surgery, Maastricht University Medical Center, Maastricht, The Netherlands

New biomarkers of acute kidney injury: Promise for the future but beware the lure of novelty*

Department of Renal Medicine; Newcastle upon Tyne Hospitals; NHS Foundation Trust; Newcastle Upon Tyne, United Kingdom The author has not disclosed any potential conflicts of interest.

KIDNEY TRANSPLANTATION, A UNIQUE CURE FOR SEVERE LEFT VENTRICULAR DYSFUNCTION

Department of Renal Medicine, Hull and East Yorkshire Hospitals NHS Trust and Hull York Medical School, Kingston upon Hull, UK

Molecular characterization of two patients with severe LCAT deficiency

Cardiovascular Research Group, University of Manchester, Manchester Royal Infirmary, Manchester, UK, Department of Internal Medicine, University of Genoa, Genoa, Italy, Department of Renal Medicine, University of Manchester, Manchester Royal Infirmary, Manchester, UK, Department of Pharmacological Sciences, University of Milan, Milan and Department of Biomedical Sciences, University of Modena, Italy

Epoetin trials: randomised controlled trials don't always mimic observational data

The medical management of stage 3 and 4 chronic kidney disease (CKD) attempts to both slow the rate of progression towards dialysis and prevent the development of secondary complications associated with worsening uraemia. Clinicians attempt to achieve this by targeting blood pressure, lipids, calciumphosphate imbalance (mineral metabolism) and anaemia. Over the past 20 years, there has been a wealth of publications reporting on the associations between uraemic anaemia and the development of left ventricular dilatation and left ventricular hypertrophy (LVH) [1–4], reduced quality of life [5,6] and mortality rates [7], both in the CKD non-dialysis and dialysis populations. In the pre-epoetin era, Silberberg reported an association between the degree of anaemia and LVH and differential mortality rates in dialysis patients in the late 1980s [8]. These findings were extended by Foley and Parfrey et al. [9,10] in a number of publications describing the association of anaemia with LVH, congestive heart failure and mortality. Levin et al. [1–3] extended those observations to patients with varying degrees of renal dysfunction, demonstrating increasing prevalence of LVH, dilatation and heart failure as kidney function declines. In addition, numerous other authors have described the association of haemoglobin and outcomes in CKD populations, prior to dialysis, on dialysis and even post-transplant [11]. Given the biological plausibility that anaemia impacts cardiac structure and function, and outcomes, as well as large amount of observational data that suggested a ‘cause and effect’ between the presence of uraemic anaemia and cardiomyopathy, a series of interventional trials were undertaken. Commencing in the late 1990s, a range of themes were applied to clinical trials to examine different hypotheses: ‘early’ vs ‘late’ correction of anaemia and ‘lower’ vs ‘higher’ haemoglobin levels in both ‘pre-dialysis’ and ‘dialysis’ populations. Two published trials have examined whether prevention of anaemia could reduce or reverse the development of LVH in the non-dialysis CKD population, maintaining appropriate attention to other modifiable risk factors. Despite maintaining haemoglobin higher than 120 g/l in the active group and allowing for a progressive decline in haemoglobin in the control group (90–100 g/l), there was no statistical difference in the left ventricular mass between the groups after 2 years [12,13]. Of note, both studies found relative stability of haemoglobin in the control group, despite previous observations which would have suggested decline. Within the context of the trial, a number of parameters were attended to: blood pressure control, mineral metabolism balance and iron status. The findings suggest that even at relatively advanced stages of renal dysfunction, multiple clinical parameters within the context of a trial may cancel out the impact of anaemia on LVH. An editorial by Strippoli and Craig [14], of the Cochrane Renal Group, referred to this as a potential example of the Hawthorn effect, where patients in trials tend to do well. Nonetheless, it is important to note that in the observational studies, no treatment interventions were undertaken. The observations were undertaken in an unselected population, either in the pre-epoetin era, or prior to the acceptance of multiple risk factor intervention in CKD. Thus the randomized controlled trials have included a group of patients who are different from those on whom the original observations were made. In this edition of NDT, Macdougall and co-investigators [15] applied a different model to pre-dialysis anaemic patients, whereby the control group’s haemoglobin concentration was allowed to decline to lower levels (90 g/l), but were subsequently rescued to the same haemoglobin concentration as the active group. They too were unable to demonstrate Correspondence and offprint requests to: Dr Simon D. Roger, MD, FRACP, Department of Renal Medicine, Gosford Hospital, Gosford 2250, Australia. Email: sroger@nsccah.health.nsw.gov.au

Has potassium been prematurely discarded as a contributing factor to the development of uraemic neuropathy?

Sobell Department of Neurophysiology, Institute of Neurology and Department of Clinical Neurophysiology, National Hospital for Neurology and Neurosurgery, London, Department of Renal Medicine, St Mary’s Hospital, London, UK, Department of Clinical Neurophysiology, Glostrup Hospital, University of Copenhagen, Glostrup, Denmark, Prince of Wales Medical Research Institute, University of New South Wales and the Institute of Neurological Sciences, Prince of Wales Hospital, Sydney, Australia

Pattern of Peritoneal Permeability in Continuous Ambulatory Peritoneal Dialysis Patients in Brunei

Peritoneal permeability may be dissimilar in different populations. The present study identified the pattern of peritoneal permeability in continuous ambulatory dialysis (CAPD) patients treated at the Department of Renal Medicine, RIPAS Hospital, Brunei Darussalam. Data were collected from patients on CAPD in 2001 (n = 65). Four children were excluded from the study. The remaining 61 patients underwent a 4-hour peritoneal equilibration test (PET) as prescribed by Twardowski et al. For those patients, adequacy of dialysis (Kt/V) was estimated. A retrospective analysis of the peritoneal membrane characteristics of those CAPD patients was also conducted. The membrane characteristics were compared with the urea clearance results. Of the 61 patients, 40 were non diabetic, and 21 (34.43%) were diabetic. More than half of our patients (55.74%) had membranes classified as high-average, followed by low-average (22.95%), high (18.03%), and low (3.28%). When the patient population was grouped separately into non diabetic and diabetic patients, peritoneal permeability differed between the groups (p = 0.000585). No relationship was observed between weekly Kt/V and transport characteristics in the group with diabetes (p = 0.219306), the group without diabetes (p = 0.74179), or the entire patient population (p = 0.376832) We conclude that peritoneal permeability among Bruneian CAPD patients is probably different from that among patients from other regions of Asia (more than half of our Bruneian patients had a peritoneal membrane classified as high average). We believe that the observed difference may be related to a difference in ethnicity. In general, patients with diabetes have a highly permeable membrane. Adequacy of dialysis had no correlation to PET results in our study. A larger prospective study is required to confirm our findings.