Renal Units Research Articles

Technique and outcomes of robotic-assisted retroperitoneal radical nephrectomy.

Robotic retroperitoneal partial nephrectomy (rRPN) has numerous advantages over transperitoneal surgery, including direct access to the renal hilum and posterior tumors, and avoidance of the peritoneal cavity in patients with a hostile abdomen. Although the use of the retroperitoneal approach has increased over the last decade, there is little literature on robotic retroperitoneal radical nephrectomy (rRRN), which has similar benefits over the transperitoneal approach. The aim of this study was to describe our technique for robotic retroperitoneal nephrectomy (rRN) and assess its feasibility and outcomes at a high-volume center. A retrospective review of patients who underwent some form of rRN [rRRN, robotic retroperitoneal simple nephrectomy (rRSN), or robotic retroperitoneal nephroureterectomy (rRNU)] at a single institution between 2013 and 2023. Patient characteristics, operative data, and postoperative complication rates were assessed. The technique for rRN was detailed. A total of 13 renal units in 12 patients were included for analysis (7 rRRN, 5 rRSN, 1 rRNU). Median patient age was 64.0 years, and median body mass index (BMI) was 36.0 kg/m2. Indications for retroperitoneal surgery were prior abdominal surgery in all patients, including three with bowel diversions, super morbid central obesity in two patients, and a large ventral hernia in one patient. Median operative time was 213 minutes and median estimated blood loss (EBL) was 85 cc. Median postoperative length of stay (LOS) was 3 days, and only one patient experienced a Clavien-Dindo grade ≥3 complication within 90 days of surgery. The retroperitoneal approach for robotic-assisted nephrectomy is feasible and associated with similar outcomes as the transperitoneal approach. This approach may prove beneficial in select patients with significant prior abdominal surgery including those who are morbidly obese.

Change in renal blood flow in response to intrarenal pressure alterations induced by ureteroscopy in an in-vivo porcine model.

High irrigation rates are commonly used during ureteroscopy and can increase intrarenal pressure (IRP) substantially. Concerns have been raised that elevated IRP may diminish renal blood flow (RBF) and perfusion of the kidney. Our objective was to investigate the real-time changes in RBF while increasing IRP during Ureteroscopy (URS) in an in-vivo porcine model. Four renal units in two porcine subjects were used in this study, three experimental units and one control. For the experimental units, RBF was measured by placing an ultrasonic flow cuff around the renal artery, while performing ureteroscopy in the same kidney using a prototype ureteroscope with a pressure sensor at its tip. Irrigation was cycled between two rates to achieve targeted IRPs of 30mmHg and 100mmHg. A control data set was obtained by placing the ultrasonic flow cuff on the contralateral renal artery while performing ipsilateral URS. At high IRP, RBF was reduced in all three experimental trials by 10-20% but not in the control trial. The percentage change in RBF due to alteration in IRP was internally consistent in each porcine renal unit and independent of slower systemic variation in RBF encountered in both the experimental and control units. RBF decreased 10-20% when IRP was increased from 30 to 100mmHg during ureteroscopy in an in-vivo porcine model. While this reduction in RBF is unlikely to have an appreciable effect on tissue oxygenation, it may impact heat-sink capacity in vulnerable regions of the kidney.

Renal vascular disparities among kidney donors presented at renal transplant unit- A single centre study

Renal vasculature has been reported to show anatomical variations, which may lead to surgical complications. The pattern of renal vascular variations in Pakistani population is not well reported. Thus, this study was designed to assess the renal vascularity among kidney donors and correlate with age, gender and site of vessels. A total of 223 healthy volunteers underwent evaluation for kidney donation at the Radiology Department, DOW University Hospital, Karachi, Pakistan from January 2020 to July 2022 were included. The assessment of renal vasculature was done on computed (CT) angiogram. Renal vascular variations were found in 112 (50.2%), 59.8% were seen in males and 40.2% in females. On right side 50% vascular anomalies were found followed by left side with 27% and 22% on both sides. The arterial variants included accessory renal artery seen in 76 (67.8%) individuals, out of which 13.2% had in upper polar, 26.3% in hilum, 36.8% in lower polar, while 23.7% of early branching was observed. Ten retro-aortic, fourteen accessory renal veins and six bifurcation renal veins, along with six early branching renal veins, were present. Patient who received donor nephrectomy, the outcomes of the operation were completely consistent with the results of the CTA. According to this study, Pakistani population have differences in their renal venous and arterial anatomy, which can significantly influence surgical procedures.

Evaluation of risk factors and clinical outcomes of acute respiratory failure from post renal transplant recipients: A five-year data of a single center

Acute Respiratory Failure (ARF) requiring Intensive Care Unit (ICU) admission is a common complication following renal transplant and is a diagnostic and therapeutic challenge. This study aimed to evaluate etiological factors and clinical outcomes of ARF following a renal transplant. This was a retrospective observational study. Data was recruited from last five –years’ records of Renal Transplant Unit of Dow University of Health Sciences, Karachi, Pakistan. Patients who developed ARF after renal transplantation whether requiring hospitalization (both in ICU or in ward) were included and their severity, etiologic diagnosis, and clinical outcomes were evaluated. During past five years (June 2017 till June 2023) a total of 450 kidney allografts were done and 35 patients (7.8%) developed ARF. Out of which 15 patients were shifted to the ICU. Mortality of female patients was higher as compared to males (26.1% versus 20.4%). Hypertension was found to be the most common comorbidity whereas glomerulonephritis was the most common cause of End Stage Renal Disease (ESRD). Acute rejection was observed in 20.89% (n = 94) of recipients. Bacterial pneumonia was the most common cause of ARF, one patient needed on mechanical ventilation whereas two patients were dialysis dependent survivors. ARF following renal transplant is associated with higher mortality and loss of graft function because of compromised immunity. Anti-bacterial prophylaxis and early intensive management appears to help in improving the outcome while integrating the graft function.

Preoperative Renal Parenchyma Volume as a Predictor of Kidney Function Following Nephrectomy of Complex Renal Masses

BackgroundThe von Hippel-Lindau disease (VHL) is a hereditary cancer syndrome with multifocal, bilateral cysts and solid tumors of the kidney. Surgical management may include multiple extirpative surgeries, which ultimately results in parenchymal volume loss and subsequent renal function decline. Recent studies have utilized parenchyma volume as an estimate of renal function prior to surgery for renal cell carcinoma; however, it is not yet validated for surgically altered kidneys with multifocal masses and complex cysts such as are present in VHL. ObjectiveWe sought to validate a magnetic resonance imaging (MRI)-based volumetric analysis with mercaptoacetyltriglycine (MAG-3) renogram and postoperative renal function. Design, setting, and participantsWe identified patients undergoing renal surgery at the National Cancer Institute from 2015 to 2020 with preoperative MRI. Renal tumors, cysts, and parenchyma of the operated kidney were segmented manually using ITK-SNAP software. Outcome measurements and statistical analysisSerum creatinine and urinalysis were assessed preoperatively, and at 3- and 12-mo follow-up time points. Estimated glomerular filtration rate (eGFR) was calculated using serum creatinine-based CKD-EPI 2021 equation. A statistical analysis was conducted on R Studio version 4.1.1. Results and limitationsPreoperative MRI scans of 113 VHL patients (56% male, median age 48 yr) were evaluated between 2015 and 2021. Twelve (10.6%) patients had a solitary kidney at the time of surgery; 59 (52%) patients had at least one previous partial nephrectomy on the renal unit. Patients had a median of three (interquartile range [IQR]: 2–5) tumors and five (IQR: 0–13) cysts per kidney on imaging. The median preoperative GFR was 70 ml/min/1.73 m2 (IQR: 58–89). Preoperative split renal function derived from MAG-3 studies and MRI split renal volume were significantly correlated (r = 0.848, p < 0.001). On the multivariable analysis, total preoperative parenchymal volume, solitary kidney, and preoperative eGFR were significant independent predictors of 12-mo eGFR. When only considering patients with two kidneys undergoing partial nephrectomy, preoperative parenchymal volume and eGFR remained significant predictors of 12-mo eGFR. ConclusionsA parenchyma volume analysis on preoperative MRI correlates well with renogram split function and can predict long-term renal function with added benefit of anatomic detail and ease of application. Patient summaryPrior to kidney surgery, it is important to understand the contribution of each kidney to overall kidney function. Nuclear medicine scans are currently used to measure split kidney function. We demonstrated that kidney volumes on preoperative magnetic resonance imaging can also be used to estimate split kidney function before surgery, while also providing essential details of tumor and kidney anatomy.

RGS1 mediates renal interstitial fibrosis through activation of the inflammatory response

Renal interstitial fibrosis (RIF) is considered as a common pathway for all patients with chronic kidney disease (CKD) to progress to end-stage kidney disease (ESRD). The basic pathological manifestation is the increase of matrix component in the tubular interstitium, while the injury of tubular epithelial cells in the renal interstitium and the excessive accumulation of matrix will eventually lead to tubular atrophy and obstruction, loss of effective renal units, and finally impaired renal filtration function. The relevant mechanism of RIF remains unclear. The present study will investigate the function and relevant mechanism of RGS1 in RIF. The RIF-related microarrays GSE22459 and GSE76882 were downloaded and analyzed. Renal parenchymal atrophic calyx tissues were collected from clinical RIF patients. Cellular inflammation, fibrosis and animal RIF models were constructed using Lipopolysaccharide (LPS), TGF-β1 and unilateral ureteral occlusion (UUO). HE and Masson staining were performed to detect morphological alterations of renal tissue samples. qRT-PCR, Western blot and ELISA were carried out to detect the expression of relevant genes/proteins. RGS1 is a gene co-differentially expressed by GSE22459 and GSE76882. RGS1 expression was elevated in renal tissues of RIF patients, cells and animal RIF models. Knockdown of RGS1 inhibited renal cell inflammatory response, fibrosis and renal fibrosis in RIF mice. Overexpression of RGS1 plays the opposite role. Knockdown of RGS1 inhibited the inflammatory response in the RIF cell and mouse model. Targeting RGS1 might be a potential therapeutic strategy for RIF treatment.

ThTP3.6 Patient-Reported Experience Measures: the impact of In-Person Surveys

Abstract Aims This study aimed to identify the impact of actively administering a survey to aid patients in completing patient-reported experience measure (PREM) surveys. We aimed to compare key domains' results to the national UK kidney PREM 2021 report and determine whether there is a difference between surveys administered by an in-person volunteer and self-administered surveys. Methods Our volunteers visited hospital renal and satellite dialysis units weekly from Aug to Oct 2022. All haemodialysis patients were offered to complete a 38-item survey covering 14 domains on their renal care experience using a 1-7 rating scale, 1 being the lowest rating and 7 the highest. We then compiled and compared our results to the 2021 report. Results 49 out of 82 patients completed the PREM survey. The completion rate increased from the previous year in hospital dialysis and satellite units. The patients’ experience domain score was lower than the 2021 report, with an average score of 5.66 compared to 6.24. A higher percentage of patients in our study (36.7%) reported never being asked about their emotions compared to 14.4% in 2021. This has led to a new referral pathway for seeking emotional counselling. Conclusions This year’s survey identified a felt need for emotional support and creation of a new referral pathway for the same. Administering surveys in person through volunteers increases patient engagement and receptiveness to engage, especially for patient groups that may have barriers such as language, disabilities and lack of access to technology.

SP3.11 Laparoscopic Donor Nephrectomy (LDN) Training in the UK. A National Re-Audit of the Trainee Experience

Abstract Purpose An Independent National-Trainee-Survey reported poor LDN training opportunities in the UK in 2014. It recommended LDN fellowships and LDN training as a part of the Transplant Curriculum. A Re-audit of the initial study was done to gauge improvement. Methods A short electronic survey was disseminated to surgical trainees via a web-based link (Survey-monkey) placed on the Herrick-Society forum and email/paper invitations to renal transplant units across the UK. Results 57 (53 in 2013) responses were received from the UK in 2022. Women in transplant training are still scarce OR 0.91 (0.40-2.06, p=0.49). 03% of units in the UK offer robotic-assisted LDN at present. In comparison to 2013, in 2022, 16%vs 20% of trainees were PGY1-3; 25% vs. 14% PGY 4-6; 17% vs. 18% post-residency training; 32 % vs. 31% IMG-non-training&amp;gt; 2 yr. transplant experience; 10%vs 09% IMG-non training &amp;lt; 2 yr. transplant experience (p=0.67). 92% vs. 91% of trainees reported that they had performed &amp;lt;01 LDN as primary-surgeon OR 0.87 (0.32-2.37, p=0.50). Only 33 % of trainees had been on a course for LDN. There was no correlation to seniority in training grade performing donor nephrectomies as a primary surgeon (p=0.76). There was no significant advantage to trainees on rotation (p=0.71) to service trainees (p=0.69) to perform LDN as primary surgeons. The likelihood of a trainee performing &amp;gt;01 LDN as a primary surgeon is &amp;lt;1 in 30 compared to &amp;lt; 1 in 25 (2013). Conclusions This study reports no improvement in training opportunities in LDN. The Trainers have yet to utilize the previous 2014 report to augment training opportunities in the UK.

Impact of Hemodialysis on Left Ventricular-Arterial Coupling in End-Stage Renal Disease Patients

Introduction: As a key determinant of cardiovascular performance, vascular-arterial coupling (VAC) has been reported to be a predictor of clinical outcomes in various clinical scenarios. However, few studies have explored how acute fluid removal during hemodialysis (HD) impacts the interaction between cardiac function and the arterial system. Methods: We recruited 317 HD patients from an established renal dialysis unit for this cross-sectional study and a total of 285 were included in the final analyses. We measured left ventricle end-systolic elastance (Ees), the effective arterial elastance (Ea), and VAC before and after HD using noninvasive echocardiographic measurements. We also compared echocardiographic and hemodynamic parameters in ventriculo-arterial coupling and ventriculo-arterial uncoupling patients. Results: HD significantly altered partial ventricular and vascular function parameters such as blood pressure, left ventricular end-diastolic volume, stroke volume, left ventricular ejection fraction, and systemic vascular resistance index. Ea increased following HD from 3.5 ± 1.4 to 4.2 ± 1.8 mm Hg/mL (p < 0.0001), Ees increased following HD from 7.9 ± 5.5 to 9.2 ± 6.9 mm Hg/mL (p = 0.04), whereas VAC did not markedly alter as a result of HD. Ventriculo-arterial uncoupling was found to be related to abnormal cardiac structure and worse systolic function. Conclusions: VAC obtained from echocardiography is likely to be load-independent and useful as a reliable index for stratifying the risk of cardiovascular diseases in HD patients. Further investigations on larger patient cohorts are needed to further validate our findings.

Environmental Impact of Nephrological Activity: How to Register, Evaluate and Audit?

While medical health professionals are trained to detect, treat, and comfort, they are not trained to consider the environmental impact of the services they provide. Healthcare contributes significantly to resource depletion and greenhouse gas emissions. Not only are healthcare institutions, whose mission is to protect and promote health, major polluters that use large amounts of energy and water, but the production, transport, use and disposal of medications and other medical consumables also leave considerable carbon footprints. In nephrology practice, dialysis programs have a particularly large carbon footprint with recurrent, per capita, resource consumption and waste generation profiles that are disproportionately high compared to other medical therapies. A close relationship between renal healthcare professionals and manufacturers is fundamental for the development of sustainable ecofriendly technologies, devices, and machines. Such collaboration is essential to reduce the environmental burden of renal therapies and maintain good quality of treatment. Renal units should register and evaluate their environmental performance and make an initial diagnosis of their environmental processes, to provide locally adapted recommendations for areas of additional improvement through environmental management programs. Regular auditing of these programs must be also performed aiming at continuous improvement with the setting of increasingly ambitious goals for reducing environmental burden of nephrology.

First analysis of the safety and efficacy of UGN-101 in the treatment of ureteral tumors

ObjectiveUGN-101 has been approved for the chemoablation of low-grade upper tract urothelial cancer (UTUC) involving the renal pelvis and calyces. Herein is the first reported cohort of patients with ureteral tumors treated with UGN-101. Patients and MethodsWe performed a retrospective review of patients treated with UGN-101 for UTUC at 15 high-volume academic and community centers focusing on outcomes of patients treated for ureteral disease. Patients received UGN-101 with either adjuvant or chemo-ablative intent. Response rates are reported for patients receiving chemo-ablative intent. Adverse outcomes were characterized with a focus on the rate of ureteral stenosis. ResultsIn a cohort of 132 patients and 136 renal units, 47 cases had tumor involvement of the ureter, with 12 cases of ureteral tumor only (8.8%) and 35 cases of ureteral plus renal pelvic tumors (25.7%). Of the 23 patients with ureteral involvement who received UGN-101 induction with chemo-ablative intent, the complete response was 47.8%, which did not differ significantly from outcomes in patients without ureteral involvement. Fourteen patients (37.8%) with ureteral tumors had significant ureteral stenosis at first post-treatment evaluation, however, when excluding those with pre-existing hydronephrosis or ureteral stenosis, only 5.4% of patients developed new clinically significant stenosis. ConclusionsUGN-101 appears to be safe and may have similar efficacy in treating low-grade urothelial carcinoma of the ureter as compared to renal pelvic tumors.

A quantitative analysis of voiding cystourethrogram features confirms the association between high-grade vesicoureteral reflux with male sex, younger age, and hydronephrosis.

Vesicoureteral reflux (VUR) is commonly diagnosed in the workup of urinary tract infections or hydronephrosis in children. Traditionally, VUR severity is graded subjectively based on voiding cystourethrogram (VCUG) imaging. Herein, we characterized the association between age, sex, and indication for VCUG, by employing standardized quantitative features. We included renal units with a high certainty in VUR grade (>80% consensus) from the qVUR model validation study at our institution between 2013 and 2019. We abstracted the following variables: age, sex, laterality, indication for VCUG, and qVUR parameters (tortuosity, ureter widths on VCUG). High-grade VUR was defined as grade 4 or 5 The association between each variable and VUR grade was assessed. A total of 443 patients (523 renal units) were included, consisting of a 48:52 male/female ratio. The median age at VCUG was 13 months. Younger age at VCUG (<6 months) was associated with greater odds of severe VUR (odds ratio [OR] 2.0), and there was a weak correlation between age and VUR grade (ρ=-0.17). Male sex was associated with increased odds of high-grade VUR (OR 2.7). VCUGs indicated for hydronephrosis were associated with high-grade VUR (OR 4.1) compared to those indicated for UTI only. Ureter tortuosity and width were significantly associated with each clinical variable and VUR severity. Male sex, younger age (<6 months), and history of hydronephrosis are associated with both high-grade VUR and standardized quantitative measures, including greater ureter tortuosity and increased ureteral width. This lends support to quantitative assessment to improve reliability in VUR grading.

Filling the Gap by Targeting the Gut: First Disease-Modifying Treatment Approved for IgA Nephropathy

This symposium took place during the 60th European Renal Association (ERA) Congress, held in Milan, Italy, and virtually. Bengt Fellström, Uppsala University, Sweden, described the relationship between IgA nephropathy (IgAN) and gastrointestinal mucosal reactivity. Fellström then outlined the history of Nefecon (Calliditas Therapeutics, Stockholm, Sweden, and STADA Arzneimittel, Bad Vilbel, Germany), which was developed based on the assumption that the gut plays a major role in the pathophysiology of the disease, and that there was a high unmet need for a well-tolerated and effective therapy. Nefecon was specifically designed to target the origins of IgAN. A Phase IIb clinical trial showed, for the first time, that 9 months of treatment with Nefecon was well-tolerated and effective in patients at risk of disease progression. Jonathan Barratt, University of Leicester, UK, and John Walls Renal Unit, Leicester General Hospital, UK, presented biomarker data supporting the efficacy data in clinical trials, and presented topline data from Part B of the Phase III NefIgArd trial. Specifically, the results demonstrated an average 5.05 mL/min/1.73 m2 estimated glomerular filtration rate (eGFR) treatment benefit in favour of Nefecon versus placebo over 2 years. This confirmed that the eGFR benefit of 9 months of active treatment with Nefecon was maintained during the observational follow-up. The eGFR benefit with Nefecon versus placebo was consistent regardless of baseline urine protein-creatinine ratio (UPCR). At 2 years, the 30% reduction in UPCR in the Nefecon versus placebo arm was similar to the percentage reduction at the end of the 9-month treatment period, plus 15 months follow-up off treatment. Patients treated with Nefecon experienced decreasing levels of proteinuria while on active treatment and for 3 months afterwards, suggesting a continued biologic effect. Barratt presented UK registry data showing that, despite being treated with the current standard of care for IgAN, three-quarters of adults and half of paediatric patients developed kidney failure or died within 20 years of disease onset. Barratt suggested a paradigm shift in the treatment approach for all patients with IgAN, who have a risk of developing kidney failure in their lifetime.

Allium® ureteral stent, a new player in the treatment of ureteral stenosis: a prospective cohort study

Introduction and objectivesUreteral stricture is a chronic condition that can result in the obstruction of urinary drainage from the affected renal unit, leading to loss of renal function. Treatment methods can be categorized into two main headings: endourological and reconstructive procedures. We aimed to investigate the efficacy and safety of the self-expandable Allium® ureteral stent, which has been used in the minimally invasive treatment of ureteral stenosis in recent years. Materials and methodsTwenty patients who were applied Allium® ureteral stent between 2017 and 2021 included in the study. The demographic and clinical characteristics of the patients, the details of the treatments applied to the patients, the perioperative and postoperative complications, the treatments applied for the complications and the findings in the follow-up were recorded and evaluated prospectively. ResultsEtiology included urolithiasis in 16 patients (80%), malignancy in 3 patients (15%), and a previous gynecological operation in 1 patient (5%). Stent obstruction was found to be the most common complication in 3 patients (15%). Stent migration was the second most common complication in 2 patients (10%). Our follow-up continues with 15 patients without stent-related complications and stent obstruction. The mean follow-up period was 28 ± 15.7 months. ConclusionsAllium ureteral stent is an effective and reliable method in the minimally invasive treatment of ureteral stricture with complications seen at acceptable rates and ease of treatment in the management of complications.

Mechanism of urosepsis: relationship between intrarenal pressures and pyelovenous backflow.

Ex vivo studies were performed on porcine renal models. Each ureter was cannulated with a 10-F dual-lumen ureteric catheter. A pressure-sensing wire was inserted through one lumen and with the sensor positioned in the renal pelvis for IRP measurement. Undiluted India ink stain was irrigated through the second lumen. Each renal unit was subjected to ink irrigation at target IRPs of 5 (control), 30, 60, 90, 120, 150, and 200 mmHg. Three renal units were subjected to each target IRP. After irrigation, each renal unit was processed by a uropathologist. Macroscopically, the amount of renal cortex stained by ink was calculated as a percentage of the total perimeter. Microscopically, presence of ink reflux into collecting ducts or distal convoluted tubules, and pressure-related features, was noted at each IRP. Signs of pressure, as represented by collecting duct dilatation, was first observed at 60 mmHg. Ink staining was consistently observed in the distal convoluted tubules at IRPs ≥60 mmHg, and all renal units above this pressure showed renal cortex involvement. At ≥90 mmHg, ink staining was observed in venous structures. At 200 mmHg, ink staining was observed in supportive tissue, venous tributaries in the sinus fat, peritubular capillaries, and glomerular capillaries. Using an ex vivo porcine model, pyelovenous backflow occurred at IRPs of ≥90 mmHg. Pyelotubular backflow occurred when irrigation IRPs were ≥60 mmHg. These findings have implications for the development of complications after flexible intrarenal surgery.

Laparoscopic resolution of Wünderlich syndrome as a primary treatment

Background: Spontaneous Retroperitoneal Hemorrhage, named Wünderlich Syndrome (WS) is usually managed by emergency surgeons with a conventional laparotomy. The aim is to report a patient with WS successfully treated by a laparoscopic approach avoiding open surgery. Methods: A 50-year-old female was diagnosed with WS hemodynamic instability and flank pain. After a normal CT scan that discarded visceral injuries and stabilized, the patient underwent a laparoscopic renal exploration. Results: Laparoscopic approach was as standard transperitoneal renal access. Fortunately, the hematoma was within Gerota fascia meaning a non-complex surgery. Due to the high R.E.N.A.L. score, it was necessary to complete a radical nephrectomy. Surgical time was 120 minutes without perioperative complications and the renal unit was retrieved using a Pfannenstiel incision. Estimate blood loss was not quantified. Finally, the hospital stay was 24 hrs. Conclusion: Laparoscopic approach could be performed in selected patients with WS especially when are hemodynamic stabilized with no visceral injury associated. Immediately treatment could facilitate the procedure because it avoids adherences or fibrosis due to hematoma. Experience in the laparoscopic approach is necessary.

A radiomics nomogram for preoperative prediction of nephron-sparing surgery in patients with bilateral Wilms tumor.

Bilateral Wilms tumor (BWT) is a relatively rare malignant renal tumor in children. Nephron-sparing surgery (NSS) is the preferred surgical approach for treating BWT, but lacks uniform surgical indications worldwide. This study aimed to summarize the clinical and imaging features of BWT children, establish a radiomics nomogram, and predict the feasibility of NSS for improving outcomes. A 12-year retrospective single-center review was conducted on clinical data and preoperative imaging features of BWT patients. The tumor kidneys were divided into NSS and non-NSS groups. Logistic regression analysis was performed to identify independent predictors and develop a prediction model of the feasibility of NSS in BWT patients. A radiomics nomogram was constructed and internally validated by the parametric bootstrapping method. A total of 58 BWT patients (115 renal units) were included in this study. After evaluations based on preoperative imaging and clinical data, 94 renal units underwent NSS with negative resection margins and were included in the NSS group, whereas 16 renal units with positive resection margins, macroscopic residual, or total nephrectomies were included in the non-NSS group. Tumor size [odds ratio (OR): 0.540, 95% confidence interval (CI): 0.308-0.945], relationship with the collecting system (OR: 0.013, 95% CI: 0.0004-0.370), and remaining renal parenchyma (RRP) proportion (OR: 71.23, 95% CI: 1.632-3108.8) were identified as independent predictors for NSS. A nomogram was constructed based on these factors, which demonstrated great consistency between the predicted and observed feasibility of NSS. The model presented with good discriminative ability [area under the curve (AUC), 0.982]. The decision curve analysis (DCA) revealed the clinical usefulness of the model. This study analyzed the clinical and preoperative imaging data of BWT patients and identified three independent predictors for the feasibility of NSS, including tumor size, relationship with the collecting system, and residual renal parenchyma proportion. The radiomics nomogram established in this study can provide individualized predictions to assist clinicians in making better decisions and improving patient outcomes.

Outcomes from the first dedicated diagnostic and interventional nephrology (DIN) service in a UK renal unit

Background: We report the clinical outcomes, operational and training model from the first diagnostic and interventional nephrology (DIN) department in a UK renal unit. Methods: Patient outcomes were evaluated for an array of diagnostic and therapeutic interventional procedures performed at the DIN unit, SDIN (the Sunderland Diagnostic and Intervention Unit), within the first year of its establishment. Data was retrospectively collected for the period beginning 1st October 2019 to 1st October 2020 for patients who underwent the following procedures: ultrasound guided renal biopsy, Tunnelled Dialysis Catheter (TDC) insertion and exchange, Peritoneal Dialysis (PD) catheter insertion/exchange, and Areteriovenous Fistula (AVF) Point of Care Ultrasound (POCUS). These figures were compared to the cohort from the one-year period pre-SDIN, between the 1st October 2018 and 31st September 2019. All results are expressed as mean and percentages unless otherwise specified. Results: Renal Biopsy: 104 biopsies were performed with an improvement in median waiting time from 12 to 7 days with 98.4% being diagnostic. Tunnelled Dialysis Catheters: 99 TDCs were inserted or exchanged with the catheters remaining in place for a mean duration of 156 days. We report an incidence of 2 infections per 1000 catheter days within the 90-day observation period. Peritoneal dialysis catheters: 16 PD catheters were inserted and they remained in place for an average of 153 days. Eleven (69%) catheters had no complications within the 28-day observation period, 3 (19%) catheters required manipulation. AVF POCUS: 279 AVF POCUS scans were performed during the SDIN period. The waiting time from referral to scan was reduced from a mean of 35 days to 2 days. Conclusions: A comprehensive DIN service leads to significant improvements in training, service and patient outcomes and would be an ideal model for wider adaptation across the UK renal units.

Correlation of ureteric jet angle (UJA) with vesicoureteral reflux grade and its assessment as a noninvasive diagnostic parameter to detect vesicoureteral reflux

BackgroundVesicoureteral reflux (VUR) is an essential urogenital entity affecting infants and younger children. Many patients present late with recurrent urinary tract infections (UTIs), which lead to chronic pyelonephritis, renal scarring, and end-stage renal disease (ESRD). This progression in disease adds to significant morbidity and mortality in the paediatric age group. Voiding cystourethrography (VCUG) is the investigation of choice which is an invasive procedure and is related to the risk of ionizing radiation and iodinated contrast administration. Ureteric jet angle (UJA) is a Doppler parameter that can be obtained by measuring the angle between the horizontal axis of the floor of the optimally distended bladder and the Doppler ureteric jet at the ureteral opening into the bladder. The study aimed (1) to investigate the correlation of UJA with VUR grade and (2) to assess the utility of UJA as a noninvasive diagnostic indicator to diagnose VUR as an alternative to VCUG.MethodAll paediatric patients with urinary complaints were evaluated by voiding cystourethrography (VCUG) for assessment of grades of VUR, followed by colour Doppler evaluation of ureteric jets. VCUG interpretations were made.UJA was calculated as the angle between the long axis of the colour Doppler jet and the horizontal axis of the floor of the optimally distended urinary bladder on colour Doppler examination. Ureteric jet angles were recorded on both sides irrespective of the presence of VUR, and data were analysed using SPSS. The correlation coefficient (r) with p value was calculated. The diagnostic efficacy of UJA (58° or more) to detect VUR was assessed by calculating sensitivity, specificity, PPV, NPV, positive LR and negative LR. The AUC was calculated to evaluate the diagnostic efficacy of UJA 58° or more to detect VUR.ResultsIn total, 34 (68 renal units) children (8 months–12 years), including 20 males (M) and 14 females (F), examined. The mean age was 4.96 ± 2.87 years for the total population, including 4.60 ± 2.02 years for boys and 5.47 ± 2.75 years for girls. Twenty-one patients (10 girls and 11 boys) showed VUR on MCUG. Eight patients showed high grades (grade III–V), including seven boys and a girl. The range of UJA in VUR-negative patients was 27–60° with a median angle of 42.03°. VUR-positive patients showed an angle range of 32–71°with a median angle of 62.13°. High-grade VUR was seen in 8 patients with an angle range of 59–84° and a median angle of 76.31°. A positive correlation (r = 0.81) was noted between UJA and VUR grading. The sensitivity and specificity of angle > 58° to detect VUR were 0.66 and 0.92 with PPV 0.93 and NPV 0.63. Yuden’s J value was 58°. The value for the area under the curve was 0.7.ConclusionsPositive linear correlation was seen between UJA and VUR grades with high specificity and positive predictive value. The Diagnostic Utility of UJA 58° as a screening method to detect severe VUR was acceptable and can be further studied with a larger sample size.

#4727 FLOZINATION: A ROLLING QUALITY IMPROVEMENT PROGRAMME

Abstract Background and Aims Sodium glucose linked transporter-2 inhibitors (SGLT2i) reduce renal and cardiovascular end points in people with chronic kidney disease (CKD), both with and without diabetes. Despite exciting data from the CREDENCE and DAPA-CKD trials, implementation of new evidence to every day clinical practice can be challenging. We present the results of a rolling quality improvement project regarding SGLT2i prescription. The aim of the project was to support clinicians in the evidence based prescribing of SGLT2i for CKD. Method Three renal units who share a single electronic clinical database agreed a joint protocol and staged implementation programme. These tertiary referral renal units cover a population of around 2.3 million people. The important timeline regarding SGLT2i licensing and interventions is shown in Figure 1. Interventions were as follows: 1. Identification of patients meeting the licensing criteria for prescription of canagliflozin for CKD with diabetes. 2. Addition of an alert to the electronic patient record. 3. SGLT2i protocol developed and advertised via poster in outpatient clinic sites. 4. Evaluation of clinician attitude to prescribing. 5. Measurement of number of patients meeting the licensing criteria for prescription of dapagliflozin for CKD with and without diabetes. Measurement of SGLT2i prescription was audited from the electronic record. Results In the first wave of the programme, 326 patients were identified as suitable under the initial licensing criteria for canagliflozin, and electronic alerts were added to the records of these patients. When measuring number of patients who may be suitable under the dapagliflozin licensing, there were 562 patients with diabetes and 5262 without diabetes. In a survey of clinician attitudes, 94% suggested they felt well equipped to prescribe SGLT2i. Prescribing of SGLT2i across time is shown in Figure 2. 1146 patients have been prescribed SGLT2i. Age was 64±13 years, and the majority were male (68%) with type 2 diabetes mellitus (61%). Most (73.6%) were treated with angiotensin converting enzyme inhibitor (ACEi) or angiotensin receptor blocker (ARB). More than half (54%) of patients live in areas with high levels of socio-economic deprivation (Scottish Index of Multiple Deprivation quintiles 1 or 2). Estimated glomerular filtration rate was 40.9±23.5ml/min/1.73 m2 and Kidney Failure Risk Equation (KFRE) 5 year risk of end stage kidney disease (ESKD) was 23.2±28.2%. In comparison with the general outpatient clinic population, the distribution of socioeconomic deprivation was similar, but a higher proportion were female (46%). Conclusion An iterative quality improvement project was designed around the evolving drug licensing of SGLT2i and capitalised on local strengths, including an effective and well used clinical electronic database shared across renal units. Clinicians have been supported in SGLT2i prescribing with highly visible clinical protocols, and electronic alerts to highlight candidate patients. A high level of SGLT2i prescribing has been achieved in a population at high risk of ESKD. Further interventions should focus on prescribing in groups where gaps have been identified – such as women and those without diabetes. Other units would be recommended to capitalise on existing strengths, exploit the use of clinical databases, and ensure protocols are inclusive and well-advertised in order to optimise evidence based treatment of CKD.