Radiation and body mass index, are your overweight patients more at risk? astudy looking at radiation doses during intervention for renal tract calculi (2020)

Type of publication:
Conference abstract

Author(s):
Lefroy R.; Johnson A.; McCrea J.; *Dunk S.; *Elves A.

Citation:
British Journal of Surgery; Jun 2020; vol. 107 ; p. 226-227

Abstract:
Aim: Renal tract stones are more common in overweight individuals as part of metabolic syndrome. Modern fluoroscopic devices used during ureteroscopy adjust exposure, providing high imaging quality. Consequently, total radiation doses in this group is increased compared to patients with lower BMIs. Patients with obesity and stone disease will potentially be exposed to more radiation, increasing the risk of developing malignancy. We assessed the radiation doses that our stone population received during fluoroscopic ureteroscopic procedures and how this varied with BMI.
Method(s): 62 consecutive patients undergoing fluoroscopic ureteroscopic laser procedures were identified between March and August 2018, ten of these were uretorenoscopies and were therefore excluded from analysis. Radiation exposure was corrected for dose/unit time and BMI was defined by criteria set by NHS Choices.
Result(s): There was significant association between BMI and radiation exposure as measured does/unit time. The exposure for those with the highest BMI was up to four times that of the lowest BMI.
Conclusion(s): Fluoroscopy in patients with high BMI should seek to limit radiation exposure. This could be achieved by use of snap imaging and ureteroscopy under direct vision where appropriate. Consideration of radiation exposure should be given within the consent process especially when compared to alternative therapies.

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Emotional distress and adjustment in patients with end-stage kidney disease: A qualitative exploration of patient experience in four hospital trusts in the West Midlands, UK (2020)

Type of publication:
Journal article

Author(s):
Sein K.; Damery S.; Combes G.; Baharani J.; *Nicholas J.

Citation:
PLoS ONE; Nov 2020; vol. 15 (no. 11)

Abstract:
Objectives To explore patient perceptions and experiences of mild-to-moderate emotional distress and the support offered by kidney units to patients with end-stage kidney disease. Methods In-depth, semi-structured qualitative interviews with patients (n = 46) being treated for endstage kidney disease in four hospital Trusts, with data analysed thematically. Results Patients described multiple sources of distress and talked about the substantial burden that emotional challenges raised for their ability to manage their condition and develop coping strategies. Many patients did not feel it appropriate to disclose their emotional issues to staff on the kidney unit, due to a perceived lack of time for staff to deal with such issues, or a perception that staff lacked the necessary skills to provide resolution. Five themes were identified from the patient interviews, broadly related to patients’ experience of distress, and the support offered by the kidney unit: I) the emotional burden that distress placed on patients; ii) patients’ relationship with the treatment for their condition; iii) strategies for coping and adjustment; iv) patient-staff interactions and the support offered by the kidney unit, and v) the mediating impact of the treatment environment on patient experience of distress and their ability to raise emotional issues with staff. Conclusions Many patients felt unprepared for the likelihood of experiencing emotional issues as part of their condition, for which pre-dialysis education could help in managing expectations, along with support to help patients to develop appropriate coping strategies and adjustments. These findings demonstrate the importance of recognising patient distress and ensuring that talking about distress becomes normalised for patients with end-stage kidney disease.

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Metabolic stone screening – can education improve adherence to national guidelines? (2020)

Type of publication:
Journal article

Author(s):
Ravindraanandan M.; *Jayawardena P.

Citation:
Journal of Endoluminal Endourology; Jan 2020; vol. 3 (no. 1)

Abstract:
Nephrolithiasis is a common urological disease affecting approximately 13% of the global population. Identifying a preventable cause during follow-up for stone formation is a necessary factor in reducing recurrence. The majority of kidney stones are comprised of calcium, with oxalate and phosphate compounds accounting for approximately 80% of stone formers. Serum analysis can be used to identify the levels of calcium in the blood, excluding metabolic causes for stones. Current NICE guidelines recommend performing a metabolic screen during an acute admission. Adherence to these guidelines from clinicians can be poor. We aim to see whether education can improve serum metabolic requests from clinicians in the UK. Method A case-control study was performed in a single rural district general hospital in the UK. Patients who presented with renal colic were analyzed retrospectively for four months, looking at serum metabolic screen requests. Two months of education was then delivered to acute departments, with a further prospective study performed following this for six months. Outcomes were then compared between both groups to see if there was an improvement in serum requests following the delivery of local education. Results A total of 124 patients were included in our study. 50 patients were analyzed in cohort A over a 4-month period. Complete serum analysis was performed on 22% (n=11) of patients. Incomplete serum analysis was performed on 58% (n-29) of patients with uric acid being missed on all of them. 10 patients had no metabolic serum analysis performed at all, with 1 patient having a previous history of stones. A total of 74 patients were analyzed in cohort B over a 6-month period. This was following the 2 months of departmental education given by urologists. Complete serum analysis was performed on 24% (n=18) of patients. Incomplete serum analysis was performed on 55% (n=41) of patients with uric acid being missed from all of them. The remaining 21% of patients (n=15) had no metabolic serum screen performed at all. There was no significant difference seen between both cohorts after comparing metabolic serum requests before and after department education for 2 months (p=0.7287). Conclusion Improving adherence to clinical guidelines for metabolic screening has proved difficult with departmental teaching alone, with very little improvement achieved. Nevertheless, formal face-to-face education is advocated to reinforce knowledge in junior doctors managing renal stones.

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‘You have got a foreign body in there’: Renal transplantation, unexpected mild-to-moderate distress and patients’ support needs: A qualitative study (2020)

Type of publication:
Journal article

Author(s):
Jones J.; Damery S.; Combes G.; Allen K.; *Nicholas J. ; Baharani J.

Citation:
BMJ Open; Mar 2020; vol. 10 (no. 3)

Abstract:
Objective: To explore why transplant patients experience unexpected mild-to-moderate distress and what support they may need.
Design: Qualitative study using individual in-depth interviews. Setting Four National Health Service (NHS) Trusts in the Midlands, UK. Participants Fifteen renal transplant patients meeting the criteria for mild-to-moderate distress from their responses to emotion thermometers. Main outcome measures Identification of the reasons for distress and support options acceptable to renal transplant patients.
Results: Three themes were interpreted from the data: I am living with a “foreign body” inside me’, why am I distressed?’ and different patients want different support’. Following their transplant, participants felt that they should be happy and content, but this was often not the case. They described a range of feelings about their transplant, such as uncertainty about the lifespan of their new kidney, fear of transplant failure or fear of the donor having health conditions that may transfer to them. A few experienced survivors’ guilt when others they had met at the dialysis unit had not received a transplant or because someone had died to enable them to receive the transplant. No longer having regular contact with the renal unit made participants feel isolated. Some participants did not initially attribute the source of their distress to their transplant. Participants’ preferred support for their distress and their preferences about who should deliver it varied from peer support to seeing a psychologist.
Conclusions: Raising the issue of post-transplant mild-to-moderate distress with patients and encouraging them to think about and plan coping strategies pretransplant may prove beneficial for the patient and healthcare provider. Patients should be able to choose from a variety of support options.

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Home haemodialysis: barriers and stepping stones (2019)

Type of publication:
Journal article

Author(s):
*Nair, Sunita; *Kanbar, Ammar; Bajo, Maria

Citation:
Journal of Kidney Care; Sep 2019; vol. 4 (no. 5); p. 240-245

Abstract:
Despite national recommendations and well-chronicled benefits for extended hours home haemodialysis, uptake remains poor. The issues surrounding this are multifactorial. There are barriers to uptake at all levels of care—patient, clinician and commissioning. This article looks at some of those barriers and addresses them.

How can we make renal medicine careers more appealing to UK trainees? (2019)

Type of publication:
Journal article

Author(s):
Karangizi A.H.K.; Chanouzas D.; Foggensteiner L.; *Mahdi A.

Citation:
Clinical Kidney Journal; Feb 2019; vol. 12 (no. 5); p. 756-759

Abstract:
Background: There is a global decline in interest in careers in renal medicine. This is concerning given the increasing global burden of kidney disease. Previous studies in the USA and Australia have identified factors such as a poor work-life balance, lack of role models and the challenging nature of the speciality as possible reasons behind recruitment struggles. This study aimed to identify factors associated with declining interest among trainees in the UK.
Method(s): We conducted a survey of 150 National Health Service Foundation trainees (interns) and Core Medical Trainees in Health Education West Midlands. Participants completed a 14-part paper-based questionnaire capturing data on trainee demographics, medical school and postgraduate exposure to renal medicine and perceptions of a career in renal medicine.
Result(s): There was limited early clinical exposure to renal medicine both in terms of time spent in the speciality and perceived exposure to the range of domains of the speciality. Trainees perceived the speciality as complex with a heavy workload. Very few trainees considered the speciality to be lifestyle oriented. There was also disinterest in taking on the associated general medicine commitments of the training programme. Job experience and identification of role models increased the likelihood of consideration of the speciality.
Conclusion(s): This survey has identified key areas to drive interest in the speciality, including early engagement, enthusiastic supervision and increased training flexibility. Urgent attention is required to address these areas and make renal medicine careers more appealing.

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MON-112 Home Haemodialysis (HHD) with low dialysate volume (LDV) – The green benefit (2019)

Type of publication:
Conference abstract

Author(s):
*Nair, S.; Gautier J.

Citation:
Kidney International Reports; Jul 2019; vol. 4 (no. 7), S350

Abstract:
Introduction: Man-made greenhouse gas emissions have impacted climate changes significantly. This has
adversely affected human health presently and has serious implications for future generations. Healthcare
industry itself contributes towards these carbon footprints. In England, 3.2% of the total CO2 emissions are accounted for by the healthcare industry alone producing 18 million tons CO2eq emissions. National Health Services (NHS) England CO2 emissions exceeds the total emissions from all aircraft departing from Heathrow, the largest European airport. Dialysis patient care accounts for 62.5% of the carbon footprint of a renal service. In UK, the prevalence rate of dialysis patients is 440 patients per million population, that is 25,261 haemodialysis (HD) patients in 2016. 1256 patients received dialysis at home. In-centre HD undertaking dialysis 4 hours 3 times/week, consumes more than 55,000 Litres of water/patient/year and contributes 3,818 kgCO2eq to the carbon footprint. A LDV system may have less emissions compared to traditional machines.
Method(s): This footprint is influenced more by frequency of treatments rather than duration. On average in Europe, patients using NxStage System One (NSO) dialyse 5.7 times for 2.6 hours/week with 24.3 Litres of dialysate/session to deliver a 2.61 stdKt/V. Based on manufacturers data, we calculated fluids volume, weight and energy required with NSO and we compared with requirements to deliver 3 times/week HD or the same clearance with traditional machines (3.5 times/week to deliver a 2.6 stdKt/V in the same patient).
Result(s): Reduced water usage NSO with PureFlow allows to prepare dialysate in-situ. It includes deionization technology and converts 1 Litre source water to 1 Litre of ultrapure dialysate as against traditional osmosis water systems which have a conversion rate of around 50%. Frequent therapy as above utilizes 7377 Litres of source water/year, only 13% of the 56,160 Litres of water used in centre HD and 12% of the 59,717 Litres of water required to deliver the same clearance with a traditional system. Low shipping volume of dialysate concentrates Fluids is the main contributor to shipping volumes in dialysis supplies. PureFlow system allows a minimal shipping volume of 422 Litres of concentrate including buffer per patient-year vs. 702-780 Litres of acid concentrate (dilution 1/43 or 1/35) in conventional HD or 819-910 Liters to deliver the same clearance as with NSO. PureFlow concentrate equals 1.5ton and 0.8m3 per patient-year. Conventional therapy equals 0.9-1.1 ton and 1.4-1.7 m3 (dilution 1/43 or 1/35) of acid concentrate. Delivering the same clearance with a traditional system equals 1.0-1.2 ton and 1.6-2.0 m3. Less energy consumption NSO with PureFlow utilizes 8.2-10.7 kwh to deliver 6 sessions/week. This is 28% less than 29.6-52.9 kwh to deliver 3 sessions/week with a traditional system. If one includes the energy used for water treatment which amounts to 32.5-63.2 kwh/week without heat disinfection, PureFlow usage is less than 20% of this.
Conclusion(s): Despite increased frequency, HHD with LDV is a much greener option for dialysis patients and significantly reduces the carbon footprint. Such systems are the order of the day where one is constantly looking for effective greener options in delivering treatments for our patients.

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The prevalence of mild moderate distress in patients with end-stage renal disease: Results from a patient survey using the emotion thermometers in four hospital Trusts in the West Midlands, UK (2019)

Type of publication:
Journal article

Author(s):
Damery S.; Sein K.; Combes G.; Brown C.; *Nicholas J. ; Baharani J.

Citation:
BMJ Open; May 2019; vol. 9 (no. 5), e027982

Abstract:
Objectives To assess the prevalence of mild-To-moderate distress in patients with end-stage renal disease (ESRD) and determine the association between distress and patient characteristics. Design Cross-sectional survey using emotion thermometer and distress thermometer problem list. Setting Renal units in four hospital Trusts in the West Midlands, UK. Participants Adult patients with stage 5 chronic kidney disease who were: (1) On prerenal replacement therapy. (2) On dialysis for less than 2 years. (3) On dialysis for 2 years or more (4) With a functioning transplant. Outcomes The prevalence of mild-To-moderate distress, and the incidence of distress thermometer problems and patient support needs. Results In total, 1040/3730 surveys were returned (27.9%). A third of survey respondents met the criteria for mild-To-moderate distress (n=346; 33.3%). Prevalence was highest in patients on dialysis for 2 years or more (n=109/300; 36.3%) and lowest in transplant patients (n=118/404; 29.2%). Prevalence was significantly higher in younger versus older patients (chi 2 =14.33; p=0.0008), in women versus men (chi 2 =6.63; p=0.01) and in black and minority ethnic patients versus
patients of white ethnicity (chi 2 =10.36; p=0.013). Over 40% of patients (n=141) reported needing support. More than 95% of patients reported physical problems and 91.9% reported at least one emotional problem. Conclusions Mild-To-moderate distress is common in patients with ESRD, and there may be substantial unmet support needs. Regular screening could help identify patients whose distress may otherwise remain undetected. Further research into differences in distress prevalence over time and at specific transitional points
across the renal disease pathway is needed, as is work to determine how best to support patients requiring help.

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Variable clinical presentations of renal cyst and diabetes (RCAD) syndrome in two patients (2019)

Type of publication:
Conference abstract

Author(s):
*Al-Salihi A.; *Kandaswamy L.; *Qamar S.; *Rangan S.; *Moulik P.; *Singh P.K.

Citation:
Diabetic Medicine; Mar 2019; vol. 36 ; p. 86

Abstract:
Maturity onset diabetes of the young Type 5 (MODY 5), known as RCAD syndrome, results from mutations in the hepatocyte nuclear factor 1-beta (HNF1B), most commonly 17q12 deletion. We present two patients with this syndrome: Patient 1: A 31 year old male presented with symptomatic hyperglycaemia. He was diagnosed with diabetes three months previously and had been treated with a sulphonylurea. His past medical history included deranged liver function tests (LFT), azoospermia and a single functioning dysplastic kidney. He had a family history of diabetes in first-degree relatives. Genetic tests confirmed HNF1B heterozygous whole gene deletion. Patient 2: A 34 year old male with diabetes diagnosed two years previously was referred for his
complex medical background. He had a history of renal problems (renal agenesis on right and cysts on left), gout and deranged LFT. His glycaemic control was adequate on Linagliptin monotherapy. Despite the absence of relevant family history, he has been referred for genetic testing.
Discussion(s): RCAD syndrome comprises 2% of all cases of MODY and features renal cysts and diabetes alongside a spectrum of other conditions such as renal dysplasia/hypoplasia/agenesis, reproductive tract anomalies, psychiatric problems, deranged LFTs and other metabolic abnormalities in various combinations. Genetic mutations can be inherited or sporadic. Absence of family history and variability in clinical manifestations can lead to delayed recognition.
Conclusion(s): Patients with RCAD syndrome can present with a varied combination of clinical features. Clinical suspicion, irrespective of family history, is key to diagnosis and management.

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