Kidney Units Research Articles

Preparing for responsive management versus preparing for renal dialysis in multimorbid older people with advanced chronic kidney disease (Prepare for Kidney Care): Study protocol for a randomised controlled trial.

BackgroundChronic kidney disease (CKD) prevalence is steadily increasing, in part due to increased multimorbidity in our aging global population. When progression to kidney failure cannot be avoided, people need unbiased information to inform decisions about whether to start dialysis, if or when indicated, or continue with holistic person-centred care without dialysis (conservative kidney management). Comparisons suggest that while there may be some survival benefit from dialysis over conservative kidney management, in people aged 80 years and over, or with multiple health problems or frailty, this may be at the expense of quality of life, hospitalisations, symptom burden and preferred place of death. Prepare for Kidney Care aims to compare preparation for a renal dialysis pathway with preparation for a conservative kidney management pathway, in relation to quantity and quality of life in multimorbid, frail, older people with advanced CKD.MethodsThis is a two-arm, superiority, parallel group, non-blinded, individual-level, multi-centre, pragmatic trial, set in United Kingdom National Health Service (NHS) kidney units. Patients with advanced CKD (estimated glomerular filtration rate < 15 mL/min/1.73 m2, not due to acute kidney injury) who are (a) 80 years of age and over regardless of frailty or multimorbidity, or (b) 65–79 years of age if they are frail or multimorbid, are randomised 1:1 to ‘prepare for responsive management’, a protocolised form of conservative kidney management, or ‘prepare for renal dialysis’. An integrated QuinteT Recruitment Intervention is included. The primary outcome is mean total number of quality-adjusted life years during an average follow-up of 3 years. The primary analysis is a modified intention-to-treat including all participants contributing at least one quality of life measurement. Secondary outcomes include survival, patient-reported outcomes, physical functioning, relative/carer reported outcomes and qualitative assessments of treatment arm acceptability. Cost-effectiveness is estimated from (i) NHS and personal social services and (ii) societal perspectives.DiscussionThis randomised study is designed to provide high-quality evidence for frail, multimorbid, older patients with advanced CKD choosing between preparing for dialysis or conservative kidney management, and healthcare professionals and policy makers planning the related services.Trial registrationISRCTN, ISRCTN17133653 (https://doi.org/10.1186/ISRCTN17133653). Registered 31 May 2017.

A national survey of current rehabilitation service provisions for people living with chronic kidney disease in the UK: implications for policy and practice

BackgroundNational guidance recognises the key role of rehabilitation in improving outcomes for people living with chronic kidney disease. Implementation of this guidance is reliant upon an adequate and skilled rehabilitation workforce. Data relating to this is currently lacking within the UK. This survey aimed to identify variations and good practices in kidney physiotherapy (PT), occupational therapy (OT) and clinical exercise physiologist (CEP) provision; and to understand barriers to implementation.MethodsAn online survey was sent to all 87 UK kidney units between June 2022 and January 2023. Data was collected on the provision of therapy services, barriers to service provision and responses to the COVID-19 pandemic. The quantitative survey was analysed using descriptive statistics. Free-text responses were explored using reflexive thematic analysis.ResultsForty-five units (52%) responded. Seventeen (38%) units reported having a PT and 15 (33%) an OT with a specialist kidney role; one unit (7%) had access to a CEP. Thirty units (67%) offered inpatient therapy services, ten (22%) outpatient therapy clinics, six (13%) intradialytic exercise, six (13%) symptom management and three (7%) outpatient rehabilitation. Qualitative data revealed lack of money/funding and time (both n = 35, 85% and n = 34, 83% respectively) were the main barriers to delivering kidney-specific therapy. Responders saw an increase in the complexity of their caseload, a reduction in staffing levels and consequently, service provision during the COVID-19 pandemic. Exemplars of innovative service delivery, including hybrid digital and remote services, were viewed as positive responses to the COVID-19 pandemic.ConclusionDespite clear evidence of the benefits of rehabilitation, across the UK, there remains limited and variable access to kidney-specific therapy services. Equitable access to kidney-specific rehabilitation services is urgently required to support people to ‘live well’ with kidney disease.

#1011 Clinical characteristics and outcomes of C3 glomerulopathy and immune complex MPGN from the UK National Registry of Rare Kidney Diseases (RaDaR)

Abstract Background and Aims Primary membranoproliferative glomerulonephritis (MPGN), is a rare kidney disorder which can be further divided into immune-complex MPGN (IC-MPGN) and C3 glomerulopathy (C3G) based on relative complement and immunoglobulin staining on biopsy specimens. There is limited literature on the natural history and long-term outcomes of this disorder. The aims of this study were to: Method Adult and paediatric patients with diagnostic biopsy reports that could be classified or reclassified as C3G or IC-MPGN within RaDaR were included. RaDaR contains data on MPGN patients from kidney units across the UK, with automated collection of retrospective and prospective laboratory data. Follow-up time was from diagnosis, defined by biopsy date, until KF, death or last available test result. Kidney failure was defined as initiation of dialysis, kidney transplantation or sustained eGFR ≤15 mL/min/1.73 m2 for ≥4 weeks. Annualized rate of eGFR loss (eGFR slope) was calculated for the first 24 months and over full duration of follow-up. A linear mixed model was used to estimate each patient's intercept and slope of eGFR using a minimum of four observations. Analyses of time to KF were conducted using Kaplan–Meier estimates with log-rank tests for comparisons and Cox regression. The latter was used to investigate the association of early (within 24 months of diagnosis) changes in urine protein:creatinine ratio (UPCR), eGFR and eGFR slope with KF events over maximum of 20 years. Results Our cohort included 135 patients with C3G and 152 patients with IC-MPGN diagnosed between 1987 and 2020. At the time of diagnosis 153/287 (53%) of the cohort were paediatric (&amp;lt;18 years old). Both groups had significant proteinuria at baseline (Table 1). Median eGFR was 70 mL/min/1.73 m2 (IQR 30-92) and 58 mL/min/1.73 m2 (IQR 40-110) for C3G and IC-MPGN respectively. Median time to KF was 9.3 years for C3G and 12 years for IC-MPGN but the difference was not statistically significant (p = 0.31). KF was significantly associated with changes in UPCR between 0-12 months and 6-12 months (HRs adjusted for eGFR) (Fig. 1). Similarly, a 50 mg/mmol reduction in time-averaged UPCR between 0-12 months and 6-12 months was also strongly associated with a lower risk of KF (HR adjusted for eGFR [95% Confidence Interval] 0.66 [0.53-0.83] and 0.71 [0.59-0.85] respectively). Both annualized 24 month eGFR slope, and percentage change in eGFR at 24 months were also significantly associated with KF events (Fig. 1). Conclusion We present one of largest studies describing the demographics, clinical characteristics, and long-term outcomes of 287 UK patients with IC-MPGN and C3G. Consistent with other studies we found no statistically significant difference in time to KF for C3G and IC-MPGN patients. We also demonstrate the value of short-term changes in proteinuria and eGFR (within 24 months of biopsy diagnosis), for predicting long-term risk of kidney failure.

#901 Natural history of idiopathic nephrotic syndrome: the UK National RaDaR Idiopathic Nephrotic Syndrome Cohort

Abstract Background and Aims Idiopathic nephrotic syndrome (INS) is an important class of proteinuric renal disease leading to kidney failure (KF). Here we describe the natural history of INS and congenital nephrotic syndrome (NS) using the UK National Registry of Rare Kidney Diseases Idiopathic Nephrotic Syndrome (RaDaR-INS) Cohort, including retrospective and prospective data from 4610 patients with NS not attributable to glomerulonephritis or systemic disorders recruited from 107 adult and paediatric kidney units across the UK since 2010. Method Participant eligibility of RaDaR-INS Cohort patients included ≥12 months observation from disease onset and no KF (CKD stage 5 or on renal replacement therapy) at or prior to disease onset. Disease onset date was defined as first database occurrence of kidney biopsy, primary diagnosis or protein-creatinine ratio (PCR) ≥1.5 g/g. Participants were sub-categorized into those with a genetic diagnosis (INS-genetic), biopsy-proven FSGS (FSGS-biopsy), biopsy–proven minimal change disease (MCD-biopsy) and those with no genetic or biopsy-proven diagnosis (INS-no genetic or biopsy diagnosis). Participants with a biopsy-proven MCD diagnosis and a subsequent biopsy proven FSGS diagnosis were included in both MCD-biopsy and FSGS-biopsy categories and formed a category of their own (MCD progressing to FSGS). Longitudinal proteinuria, assessed as time-average protein-to-creatinine ratio (TA-PCR), and eGFR slope were calculated over the full duration of follow-up or until KF. Kidney survival was calculated from disease onset to event (KF or death) and censored at last follow-up. Results Of the 4066 patients meeting eligibility, median age at disease onset was 28 years (IQR 6-51), with children (&amp;lt;18 yrs) representing 39% of the study population. Median proteinuria was 6.4 g/g (IQR 3.1-10.8; n = 923), while mean eGFR was 118 mL/min/1.73 m2 (SD 49; n = 240) and 69 mL/min/1.73 m2 (SD 34; n = 906) for children and adults, respectively. Median follow-up duration was 8.2 yrs (IQR 4.3-13.1) with KF/death events occurring in 30% of patients. Mean TA-PCR was greater in children than adults (5.0 g/g (SD 13.9) vs. 1.9 g/g (SD 2.5), as was annual rate of loss of eGFR (−7.4 mL/min/1.73 m2 (SD 21.8) vs. −3.1 mL/min/1.73 m2 (SD 10.2)). Characteristics at disease onset and clinical outcomes of the INS cohort sub-categories are presented in Fig. 1. Kaplan Meier survival plots of each sub-category, and further divided into children and adults, illustrate the poor survival probability for patients with FSGS, particularly INS-genetic patients who are predominantly diagnosed in childhood (Fig. 2). While INS with no genetic or biopsy diagnosis presenting in childhood exhibits disease course and outcomes similar to MCD-biopsy patients, those diagnosed in adulthood have a more rapid disease course similar to FSGS-biopsy patients. Conclusion The RaDaR-INS cohort represents a large study population with lengthy follow-up data. These analyses illustrate the difference in disease progression and survival rates for INS patients with different causes or histological descriptions, highlighting in particular an unmet need for effective treatments for patients with nephrotic syndrome and FSGS.

Insights into Kidney Dysplasia in Duplex Kidneys: From Radiologic Diagnosis to Histopathologic Understanding.

Duplex kidney is a urinary tract anomaly commonly associated with a wide range of primary and secondary parenchymal structural abnormalities. We present a unique comparison of US and MRI findings with histopathology following partial resection of duplex kidneys due to nephropathy. We examined a group of 21 children with duplex kidneys who were qualified for heminephrectomy (24 kidney units (KU)). All patients underwent US and MRI prior to the surgery. The imaging results were compared with histopathologic findings. In 21/24 KU, dysplastic changes were found on histopathology, including all with obstructive nephropathy and 7/10 specimens with refluxing uropathy. The loss of corticomedullary differentiation on US and increased signal on T2-weighted images (T2WI) on MRI were the imaging findings that best correlated with fibrosis. In children with megaureter, there were no statistical differences in histopathological findings between primary megaureter, megaureter with ureterocele, and megaureter with ectopia (p > 0.05). The extent of dysplasia of the affected pole correlated negatively with residual function in MRI. Kidney dysplasia and inflammation in the kidney with obstructive nephropathy are the most important histopathologic findings of this study. US is a valuable screening tool, and MRI enables morphologic and functional assessments of the nephropathy in duplex kidneys.

A Multinational, Multicenter Study Mapping Models of Kidney Supportive Care Practice

IntroductionKidney supportive care (KSC) integrates kidney and palliative care to improve quality of life for people with chronic kidney disease. Despite increasing interest and global advocacy to integrate KSC into kidney care, evidence to guide optimal care delivery is limited. MethodsThis observational cross-sectional study used an online survey to describe current KSC models in Australia, Aotearoa-New Zealand and the United Kingdom (UK). ResultsBetween April and December 2022, 114 units responded (response rate 67%), with 66% having a dedicated KSC service (UK 74%, Australia 58%, New Zealand 67%). Many different healthcare professionals worked in KSC services with diversity in clinical resources and activities between units and across countries. Overall, funding for KSC services was low, with a median full time equivalent per unit (standardised per 100 people receiving haemodialysis) of 0.51 (interquartile range 0.17-1.05) and 4 units provided a service without allocated funding. The scope of KSC service was wide-ranging and prioritised activities included symptom management, psychological support, complex future treatment planning and discussion, and care coordination. There were no significant differences between countries in terms of location of care provision, frequency of review, referral patterns or discharge rates, but there was variation described within countries. ConclusionModels of KSC vary markedly across kidney units and between countries. Despite this variation there was consistency in terms of clinical priorities which were person-centred and focused on physical and psychosocial wellbeing. Further research is required to evaluate the effectiveness of KSC provision, alongside improved funding methods to ensure sustainable and equitable KSC delivery.

A stepped wedge cluster randomized trial of graphical surveillance of kidney function data to reduce late presentation for kidney replacement therapy

Late presentation for kidney replacement therapy (KRT) is an important cause of avoidable morbidity and mortality. Here, we evaluated the effect of a complex intervention of graphical estimated glomerular filtration rate (eGFR) surveillance across 15% of the United Kingdom population on the rate of late presentation using data routinely collected by the United Kingdom Renal Registry. A stepped wedge cluster randomized trial was established across 19 sites with eGFR graphs generated from all routine blood tests (community and hospital) across the population served by each site. Graphs were reviewed by trained laboratory or clinical staff and high-risk graphs reported to family doctors. Due to delays outside the control of clinicians and researchers few laboratories activated the intervention in their randomly assigned time period, so the trial was converted to a quasi-experimental design. We studied 6,100 kidney failure events at 20 laboratories served by 17 main kidney units. A total of 63,981 graphs were sent out. After adjustment for calendar time there was no significant reduction in the rate of presentation during the intervention period. Therefore, implementation of eGFR graph surveillance did not reduce the rate of late presentation for KRT after adjustment for secular trends. Thus, graphical surveillance is an intervention aimed at reducing late presentation, but more evidence is required before adoption of this strategy can be recommended.

First prospective clinical assessment of the ILY® robotic flexible ureteroscopy platform.

To present the initial prospective clinical assessment of the ILY® robotic ureteroscopy manipulator platform, focusing on its safety and effectiveness. Data gathered from 31 kidney units which underwent elective robotic flexible ureteroscopy (FURS) for renal stone management utilizing the ILY® robotic system. Patient demographics, stone characteristics, surgical durations, perioperative and post-operative complications, and follow-up parameters were collected. Our primary outcome was evaluating the efficacy and safety of the ILY® robotic ureteroscopy for treating kidney stones. Therefore, we analyzed complication rates, surgical durations, and the stone-free rate during follow-up. Our cohort consisted of 29 patients, presenting with 45 stones with a median volume of 736.22 mm3. The median operation time was 85 min, accompanied by 3 min for robot draping, 3.5 min for robot docking, 48 min of console operation, and lasing time of 36.75 min. Post operative stay for all patients was 1 day, while complications were observed in 9.68% of cases. Notably, all complications were classified as CVD (Clavien-Dindo) class 1 due to pain requiring emergency department visit. The stone-free rate achieved was 93.55%, and none of the patient required reoperation for the treated stone. In the first prospective clinical experience of the ILY® robotic FURS, we demonstrated its efficacy and safety. To further investigate its clinical practical value, additional investigations are warranted, including direct comparative analyses with manual flexible ureteroscopy techniques.

Comparison of Treatment Methods of Primary Obstructive Megaureter

BACKGROUND: Primary megaureter (PM) is a common congenital uropathy. In this study, we compared the results of treatment options for primary megaureter with obstruction in UVJ.&#x0D; METHODS: The files of all patients who underwent open surgery and had a double J (JJ) ureteral stent for treating primary obstructive megaureter in our institution between 2010 and 2023 were evaluated retrospectively. The demographic information of the patients, the results of imaging tests before and after the surgery, early and late complications after the treatment, and the length of stay in the hospital were recorded. The results of both treatment methods were compared statistically.&#x0D; RESULTS: A total of 23 patients and 26 kidney units over 13 years were retrospectively analyzed. Eighteen patients were male (78%); 5 were girls (22%). Ureteral tapering and ureteroneocystostomy (UNC) were performed with open surgery in 8 patients, while JJ stent was placed in 12 patients primarily by cystoscopy. In the urinary system ultrasonography (USS) performed at an average of 3 months after the treatment, hydronephrosis grades were observed to regress in 25 units. All patients recovered after surgery and there was no significant difference between the two treatment methods (p&gt; 0.05).&#x0D; CONCLUSION: In the treatment of primary obstructive megaureter (POM), endoscopic JJ stenting is as effective as ureteral reimplantation with open surgery. It may be considered more valuable due to the shorter hospital stay

140 Five Year Single-Unit Experience and Outcomes of Renal Decompression for Ureteral Obstruction: A Retrospective Analysis of 102 Kidney Units

Abstract Aim Renal decompression following ureteral obstruction is a common urological emergency. Malignant obstruction patients often have poor life-expectancy, and the impact of decompression on survival is questionable [1]. We herein review outcomes of ureteral obstruction management in a single unit. Method Records of nephrostomy requests in Ysbyty Gwynedd between January 2017 and December 2021 were retrospectively reviewed. Information on patient demographics, primary pathology, performance status (PS), change in renal function and outcomes were recorded. Results Over 60 months, 102 nephrostomies were performed. Benign obstructions constituted 30.4% (n = 31) of cases. Of 71 cancer cases, 9 were re-insertions due to complications. Cancer group was associated with high and early deaths (11.3%, 64.5% and 85.5% at 3, 12 and 60 months, respectively) with only 1 in 5 kidney units illustrating improvement in renal function following decompression. All cancer patients were frail, with performance status of 2 (63%) and 3 (37%). Following nephrostomy insertion, 69.3% of kidney units developed urinary infection and/or sepsis requiring treatment. Only about 1 in 2 (53%) cancer patients received further oncological treatment (chemo- and /or radiotherapy). Though ante grade ureteric stenting was attempted in 23 kidney units following nephrostomy insertion for cancer, only 21 were successful and 2 of those blocked within 14 days. Conclusions Decompression of malignant ureteral obstruction may not improve survival and can involve multiple interventions with quality-of-life implication. Hence, the decision to decompress should not be the default and would therefore need to be individualized, adopting a multidisciplinary approach.

Ethical Challenges Opposing Health Care Professionals Working at Artificial Kidney Units of Ain Shams University Hospitals and a Proposed Guide to Deal with Them

Abstract Background Treatment for end-stage kidney disease is a major economic challenge and a public health concern worldwide. Renal-replacement therapy poses several practical and ethical dilemmas of global relevance for patients, clinicians, and policy makers. Aim The aim of the present work was to highlight ethical challenges encountered by health care professionals working at Artificial kidney units of Ain Shams University hospitals which may oppose their practice and lead to malpractice. In addition, outlining an ethical guide; in a trial to metigate some of these challenges, and ameliorate the practical environment to minimise malpractice issues. Method The present study is a descriptive cross-sectional study that was held on health care professionals (physicians and nurses) working at the Artificial Kidney Units of (El Demerdash and Ain Shams specialized University hospitals). Results More than half of the physicians (57.9%) agreed that all patients admitted to kidney units should sign a legal informed consent, while 78.9% of physicians admitted that not all patients could give a legal informed consent. Nearly all physicians (94.7%) endorsed that the clinician should provide the patient with all needed information; then, the patient decides freely based on his priorities and values. 57.9% of the physicians and 48.3% of the nurses negated any discussion about patients’ private information within the earshot of others. The vast majority of physicians (92.1%) and nurses (83.9%) were completely convinced of the right of any patient -in need- to have an equal access to any form of treatment. Most of the physicians (71.5%) and 90.3% of nurses were convinced that beneficence and non-maleficence are not two opposing ethical concepts. Conclusions The current study clarified that significant proportion of physicians and nurses were aware of the universally recognized ethical principles which are essential part of clinical practice in nephrology. The present study found that some healthcare professionals reported encountering a number of ethical issues when dealing with patients. Recommendations The growing public and professional discourse about ethical issues in nephrology creates an atmosphere in which the special issues in End Stage Renal Disease treatment can be addressed openly. As some healthcare providers in this study reported some ethical issues when dealing with hemodialysis patients, thus, there is a need for ongoing education of ethics to ensure the optimal approach to patient care. It is recommended to follow our guideline proposal in order to help health care professionals in dealing with the confronted ethical challenges.

The role of mini-PCNL as primary approach for the treatment of pediatric kidney stones in a high-income country. Ten-year single-center report.

To describe our experience in the use of percutaneous nephrolithotomy (PCNL) as a primary treatment for paediatric kidney stones and to highlight its benefits. The design was retrospective and observational. All the children treated for kidney stones from 2011 to 2021 were included. The population was divided into Group A (PCNL) and Group B (retrograde intrarenal surgery, RIRS). The outcomes were stone-free rate (SFR), the rate of procedures per patient, the rate of failure and the rate of complications. Twenty-eight patients with 33 kidney units were included. Eighteen of them (64%) were males. The median age was 10 (IQR 6.8-13) years. Forty-seven procedures were performed. Twenty-four of them (51%) were mini-PCNL. Group A included 17 patients (61%). Group A presented a higher SFR (p = 0.007) and a lower number of procedures (p < 0.001). RIRS failed in five cases (45%) because of non-compliant ureter. Two urinary tract infections (UTI) were reported after PCNL and four UTIs after RIRS (p = 0.121). No major complications were reported. Mini-PCNL should be suggested as a primary approach for pediatric kidney stones. This technique presented a better effectiveness with a reduced number of procedures when compared to RIRS.

#3057 OUTCOMES IN SRNS (FSGS) PATIENTS IN THE UK RADAR IDIOPATHIC NEPHROTIC SYNDROME REGISTRY AND THEIR RELATIONSHIP WITH TIME-AVERAGED PROTEINURIA

Abstract Background and Aims Idiopathic Steroid Resistant Nephrotic Syndrome, SRNS (incorporating FSGS) is an important cause of proteinuric renal disease leading to kidney failure. Here we describe the outcomes of SRNS using the UK National Registry of Rare Kidney Diseases Idiopathic Nephrotic Syndrome (RaDaR-INS) Cohort, including retrospective and prospective data from 4274 patients with nephrotic syndrome (NS) not attributable to glomerulonephritis or systemic disorders, recruited from 107 adult and paediatric kidney units across the UK since 2010. In patients with FSGS, severity of proteinuria at onset and during follow up is associated with renal failure. In this study, we tested for associations between defined proteinuria endpoints with both eGFR slope and renal survival, in children and adults. Method Participants included those with renal biopsy diagnosis of FSGS or minimal change disease (MCD), or monogenic NS. Patients with no proteinuria measurement ≥1.0 g/g &amp;gt;6 months after disease onset were excluded as likely fully steroid-sensitive. Patients with kidney failure (KF) (CKD stage 5 or on renal replacement therapy) at or prior to first proteinuria measurement after baseline were excluded. Disease onset was defined as time of renal biopsy; primary renal diagnosis (PRD) date if no biopsy date recorded, and first proteinuria ≥1 g/g if neither biopsy/PRD date was available. Baseline was defined as first proteinuria ≥1 g/g &amp;gt;6 months after disease onset. Kaplan-Meier methods were used to analyze renal survival, defined as absence of KF or death with survival time calculated from baseline to last follow up. eGFR slope was measured from 6 months after baseline for the duration of follow up. Results Of 612 MCD and FSGS patients meeting eligibility, median time from disease onset to baseline was 1.2 years (IQR 0.6-4.4). Median baseline age was 38 years (IQR 21–56) with paediatric patients representing 21% of the study population. Median proteinuria at baseline was 3.4 g/g (IQR 1.9-6.2), while mean eGFR was 89 mL/min/1.73 m2 (SD 39). Mean rate of loss of eGFR over follow-up was 4.4mL/min/1.73 m2/year (SD 10.9). Complete proteinuria remission (CR) and FSGS partial remission (FPR) were defined as shown in Table 1 using values of time-averaged proteinuria (TA-PU) over months 6–24 from baseline. For patients achieving CR or FPR, the rate of loss of eGFR was slower (Table 1), with a higher probability of survival from KF/death (Table 1 &amp; Figure 1), than patients failing to achieve CR or FPR. Conclusion This is a study of proteinuria and outcomes in a population of patients with FSGS or steroid-resistant MCD. We regard the latter group as likely also to have FSGS. In this population of patients with overt proteinuria, achieving partial or complete remission of proteinuria is associated with slower disease progression and reduced risk of KF/death.

The effect of a novel, digital physical activity and emotional well-being intervention on health-related quality of life in people with chronic kidney disease: trial design and baseline data from a multicentre prospective, wait-list randomised controlled trial (kidney BEAM)

BackgroundPhysical activity and emotional self-management has the potential to enhance health-related quality of life (HRQoL), but few people with chronic kidney disease (CKD) have access to resources and support. The Kidney BEAM trial aims to evaluate whether an evidence-based physical activity and emotional wellbeing self-management programme (Kidney BEAM) leads to improvements in HRQoL in people with CKD.MethodsThis was a prospective, multicentre, randomised waitlist-controlled trial, with health economic analysis and nested qualitative studies. In total, three hundred and four adults with established CKD were recruited from 11 UK kidney units. Participants were randomly assigned to the intervention (Kidney BEAM) or a wait list control group (1:1). The primary outcome was the between-group difference in Kidney Disease Quality of Life (KDQoL) mental component summary score (MCS) at 12 weeks. Secondary outcomes included the KDQoL physical component summary score, kidney-specific scores, fatigue, life participation, depression and anxiety, physical function, clinical chemistry, healthcare utilisation and harms. All outcomes were measured at baseline and 12 weeks, with long-term HRQoL and adherence also collected at six months follow-up. A nested qualitative study explored experience and impact of using Kidney BEAM.Results340 participants were randomised to Kidney BEAM (n = 173) and waiting list (n = 167) groups. There were 96 (55%) and 89 (53%) males in the intervention and waiting list groups respectively, and the mean (SD) age was 53 (14) years in both groups. Ethnicity, body mass, CKD stage, and history of diabetes and hypertension were comparable across groups. The mean (SD) of the MCS was similar in both groups, 44.7 (10.8) and 45.9 (10.6) in the intervention and waiting list groups respectively.ConclusionResults from this trial will establish whether the Kidney BEAM self management programme is a cost-effective method of enhancing mental and physical wellbeing of people with CKD.Trial RegistrationNCT04872933. Registered 5th May 2021.

Mpox Perceptions and Vaccine Advocacy among the Healthcare Workers of Solid Organ Transplant Centers: A Multicenter, Cross-Sectional Survey in Saudi Arabia.

In response to the global Mpox outbreaks, this survey aimed to assess the knowledge, perceptions, and advocacy of Mpox vaccines among solid organ transplant healthcare workers (HCWs) in Saudi Arabia. A cross-sectional survey was conducted among solid organ transplant HCWs in Saudi Arabia from 15 August to 5 September 2022. A total of 199 responses were received from participants primarily working in the kidney (54.8%) and liver (14.6%) transplant units. The survey found that most participants were aware of the 2022 Mpox outbreak, but the majority were more concerned about COVID-19 than Mpox. While the majority of participants thought laboratory personnel and HCWs in direct contact with Mpox patients should receive the vaccine, less than 60% believed that all HCWs should be vaccinated. Additionally, over half of the participants lacked knowledge of animal-human transmission of the virus. The results highlight the need for increased education on Mpox among transplant HCWs in Saudi Arabia, particularly regarding the virus's transmission dynamics and vaccines. This education is crucial to improve HCWs' understanding of this emerging disease, especially given their vulnerability during the COVID-19 pandemic.

Bench surgery with autotransplantation for bilateral Wilms tumor-A feasible technique for renal sinus invasion.

Bilateral Wilms tumor (BWT) with renal sinus invasion requires extremely difficult surgical care. This study presents an alternative strategy for tumor removal while at the same time preserving the renal parenchyma. In total, 9 cases of synchronous BWT were admitted to our hospital between May 2016 to Aug 2020. We retrospectively reviewed the clinical data, surgical technique, and functional and oncological outcomes of these cases. The 9 cases included 3 males and 6 females, with a median age of 12months at surgery (range 7-40). A total of 14 kidney units had renal sinus invasion (77.8%), whereas multifocal neoplasms were observed in 7 units (38.9%). The local stage distribution revealed 1 kidney with stage I, 10 kidneys with stage II, and 7 kidneys with stage III. Nephron-sparing surgery was performed on 15 kidney units (83.3%), among which 13 (72.2%) underwent bench surgery with autotransplantation (BS-AT), whereas 2 (11.1%) were subjected to tumor enucleation in vivo. Urinary leakage was the most prevalent postoperative complication. We observed negative margins. During the mean follow-up of 28.4 months, 2 patients (22.2%) succumbed from sepsis and renal failure, respectively, whereas the other 7 (77.8%) survived without recurrence. Survivors experienced an estimated glomerular filtration rate of 81 ± 15.4 ml/(min × 1.73 m2). The endpoint renal volume of 9 renal units receiving BS-AT significantly increased (P = 0.02). In summary, the surgical management of bilateral Wilms tumor requires meticulous operative approach and technique. Besides, BS-AT provides a viable alternative to nephron-sparing surgery for BWT patients with renal sinus invasion.

A Safe and Effective Two-Step Tract Dilation Technique in Totally Ultrasound-Guided Percutaneous Nephrolithotomy.

To evaluate the safety and the efficacy of a radiation-free 2-step tract dilation technique in totally ultrasound-guided percutaneous nephrolithotomy (PCNL). From Oct 2018 to Mar 2020, we prospectively and consecutively enrolled 18 patients with 19 kidney units with urolithiasis. The nephrostomy tract was established by the following four steps: 1) ultrasound-guided renal puncture, 2) first-stage serial dilation to 16 Fr with Amplatz dilators, 3) check and adjustment of the partially dilated tract with a ureteroscope, 4) second-stage dilation with a 24-Fr balloon dilator. The median age was 62.0 [IQR 11.0] years, and 11 (61.1%) were male. The median stone size was 3.3 [3.6] cm2, and stone laterality was almost equal over both sides. Successful tract establishment on the first attempt without fluoroscopy was achieved in 18 (94.7%) operations. The median tract establishment time was 10.4 [4.9] mins, and the median operation time was 67.0 [52.2] mins. The median hemoglobin drop was 1.0 [1.1] g/dL, and none required blood transfusion. Three (15.8%) developed fever. Pleural injury occurred in two (10.5%) operations (both had supracostal puncture), and one required drainage with pigtail. Stone-free status was achieved in 15 (77.8%) operations at 3 months postoperatively. Herein we present a radiation-free 2-step tract dilation technique, which is characterized by ureteroscopic check of the partially dilated tract in between the first dilation with serial fascial dilators and the second dilation with balloon. Our data suggest that it is a safe and effective method.

Shared decision-making and planning end-of-life care for patients with end-stage kidney disease: a protocol for developing and testing a complex intervention

BackgroundInternationally, it has been stressed that advance care planning integrated within kidney services can lead to more patients being involved in decisions for end-of-life care. In Denmark, there is no systematic approach to advance care planning and end-of-life care interventions within kidney services. A shared decision-making intervention for planning end-of-life care may support more effective treatment management between patients with end-stage kidney disease, their relatives and the health professionals. The purpose of this research is to find evidence to design a shared decision-making intervention and test its acceptability to patients with end-stage kidney disease, their relatives, and health professionals in Danish kidney services.MethodsThis research project will be conducted from November 2020 to November 2023 and is structured according to the UK Medical Research Council framework for complex intervention design and evaluation research. The development phase research includes mixed method surveys. First, a systematic literature review synthesising primary empirical evidence of patient-involvement interventions for patients with end-stage kidney disease making end-of-life care decisions will be conducted. Second, interview methods will be carried out with patients with end-stage kidney disease, relatives, and health professionals to identify experiences of involvement in decision-making and decisional needs when planning end-of-life care. Findings will inform the co-design of the shared decision-making intervention using an iterative process with our multiple-stakeholder steering committee. A pilot test across five kidney units assessing if the shared decision-making intervention is acceptable and feasible to patients, relatives, and health professionals providing services to support delivery of care in kidney services.DiscussionThis research will provide evidence informing the content and design of a shared decision-making intervention supporting patient-professional planning of end-of-life care for patients with end-stage kidney disease, and assessing its acceptability and feasibility when integrated within Danish kidney units. This research is the first step to innovating the involvement of patients in end-of-life care planning with kidney professionals.

Mini-track, mini-nephroscopy, mini-ultrasonic probe percutaneous nephrolithotomy and its initial clinical application

BackgroundTo assess the outcome of the mini-track, mini-nephroscopy, mini ultrasonic probe percutaneous nephrolithotomy for upper ureteral and kidney stones.MethodsWe collected data of 53 patients (55 kidney units) who underwent mini-track, mini-nephroscopy, mini-ultrasonic probe percutaneous nephrolithotomy between September 2020 and March 2021. The study included single and upper ureteral stones from 12 kidneys, multiple stones from 28 kidneys, and staghorn stones from 15 kidneys.ResultsThe mean operative duration was 50.6 min, ranging from 15 to 200 min, whereas the mean lithotripsy and stone removal time was 17.2 min (3–45 min). Moreover, the mean postoperative length of stay was 4.0 days (1–7 days). Besides, the stone-free rate (SFR) of discharge was 89.1% (49/55). The mean hemoglobin drop was 15.3 mg/dL, ranging 1–32 mg/dL. Out of the total cases, only 4 of them displayed minor complications. The outcomes of < 40 mm versus ≥ 40 mm calculi were compared by performing subgroup analysis. The results demonstrated a longer operation duration (65.2 vs. 40.2 min), higher complication rate (13.0% vs. 3.3%), and lower SFR in the ≥ 40 mm calculi subgroup.ConclusionsIn summary, mini-track, mini-nephroscopy, mini-ultrasonic probe percutaneous nephrolithotomy is an effective and safe method to treat patients with upper ureteral and kidney calculi. This is especially significant for the stone size of 20–40 mm, demonstrating excellent SFR and a lower complication rate.

Regional variation in tolvaptan prescribing across England: national data and retrospective evaluation from an expert centre.

Tolvaptan, a vasopressin V2 receptor antagonist, was approved in 2015 by the UK National Institute for Health and Care Excellence for use in patients with autosomal dominant polycystic kidney disease (ADPKD) and rapid disease progression. Simultaneous guidance was issued by the UK Kidney Association (UKKA) to facilitate national implementation. Data on tolvaptan prescribing in England was obtained through the National Health Service (NHS) Digital, a national survey of all 77 adult kidney units, and the implementation of UKKA guidance was evaluated at an expert PKD centre. A regional variation of up to 4-fold for tolvaptan prescribing in England was found. Despite most kidney units following UKKA guidance, centre-based estimates of eligible or treated patient numbers were highly variable. Retrospective evaluation at an expert PKD centre revealed that in a cohort demonstrating rapid estimated glomerular filtration rate (eGFR) decline, 14% would not be eligible for tolvaptan by Mayo imaging classification and more than half (57%) would not be eligible by Predicting Renal Outcome in Polycystic Kidney Disease score. The 3-year discontinuation rate was higher than expected (56%), the majority (70%) due to aquaretic symptoms. In patients taking tolvaptan for at least 2years, 81% showed a reduction in the rate of eGFR decline compared with baseline, with earlier disease associated with positive treatment response. Real-world data have revealed a much higher regional variation in tolvaptan prescribing for ADPKD in England than expected. We propose further investigation into the factors responsible for this variation.