Comment: Staying home
John Bradley
pp 3-3
Empowering patients to make an informed choice of treatment modality is a key element of predialysis care. A recent single-centre UK study highlighted the importance of good information provision and predialysis education to patients choosing self-care therapies. Providing accurate, up-to-date information can be challenging when techniques and survival rates are continually improving, and data are necessarily based on cohorts rather than individuals.
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Patient safety in the renal context
Kate Beaumont and Donal J O’Donoghue
pp 4-6
Before looking at patient safety in the renal context, it is important to understand what we mean by ‘patient safety’. There are many definitions; perhaps the simplest is from NHS Education for Scotland, which defines it as ‘freedom from healthcare-associated, preventable harm’. However, the next two questions are: ‘what is harm?’ and ‘what is preventable?’ Both are slightly more complex. To maintain or improve patient safety, error has to be prevented, recovered or, at least, minimised. Error can be defined as the result of choosing the wrong plan to achieve an aim, or not initiating or completing the right plan as intended. Errors are unintentional and should not be confused with violations, negligence or recklessness. However, Charles Vincent suggests that it is harm reduction that we should focus on if we are to improve patient safety; it is after all what patients most care about. A pragmatic interpretation of harm according to Vincent is anything that you would not want to happen to you or your relatives while receiving care.
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Anaemia in CKD: the KDIGO 2012 guidelines
Ahsan Syed and Sunil Bhandari
pp 7-9
Chronic kidney disease (CKD) affects between 6–8% of the UK adult population. It is associated with a high prevalence of cardiovascular disease and is a large economic burden. Anaemia in CKD affects patients early during its course and gets progressively worse as a result of both iron and erythropoietin deficiencies. Anaemia is also prevalent in those on renal replacement therapy, such as dialysis patients and transplant recipients with chronic graft dysfunction. The incidence of anaemia in predialysis patients can range from 9–67%, increasing with declining estimated glomerular filtration rate (eGFR). Early management of CKD-related anaemia can lead to an improvement in the patient’s overall prognosis. Despite the lack of high-quality randomised controlled trials (RCTs) on this subject, there have been numerous guidelines from across the globe published over the past five years.
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ERA-EDTA Congress 2013
Kirstin Knight
pp 10-11
The 2013 European Renal Association–European Dialysis and Transplant Association (ERAEDTA) Congress marked the organisation’s golden anniversary. A total of 7,660 attendees descended on Istanbul in May for four days of teaching, discussion and debate. The Congress opened with a press conference where academics called for increased public awareness of chronic kidney disease (CKD). President of the ERA-EDTA Professor Raymond Vanholder picked up a theme from the previous year’s Congress, highlighting again that kidney disease is ‘the forgotten illness’, despite links with co-morbidities such as hypertension, diabetes and heart disease. Nowhere is this topic more pertinent than in Turkey, where it is estimated that one in every six adults is affected by the disease. Professor Gu¨ltekin Su¨leymanlar, Congress President, agreed that CKD is a major public health problem that receives far less attention than it deserves: 500 million people are estimated to suffer from CKD worldwide, with over two million patients on dialysis or receiving a transplant. This last figure is expected to double in the coming decade. When the societal burden – high disability and mortality rates, decreased quality of life and highcost renal replacement therapies – is considered, it becomes clear that this is a problem that extends far beyond the renal sphere.
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Severe hyponatraemia following renal transplant artery angioplasty
Michael Spencer Chapman, Andrew Hall and Aine Burns
pp 12-14
Transplant renal artery stenosis (TRAS) is a common complication of transplantation, with an incidence of 1–23%.1–3 It is often found during investigation of transplant dysfunction, but may be suspected in the context of post-transplantation hypertension, flash pulmonary oedema and fluid overload. It may lead to graft loss, but is frequently curable by percutaneous transluminal angioplasty (PTA). Though generally a safe procedure, TRAS angioplasty has potential complications that should be considered. We report a case of severe symptomatic hyponatraemia following balloon angioplasty of TRAS. A 72-year-old Nigerian gentleman with a history of end-stage renal failure of uncertain cause with bilateral small kidneys, hypertension, benign prostatic hypertrophy and colonic angiodysplasia underwent cadaveric renal transplantation from a marginal donor. He had received haemodialysis for the six years preceding transplantation. The kidney was from a 1:1:1 mismatched 72-year-old heartbeating donor who had a history of type 2 diabetes, hypertension and previous hepatitis B infection. Surgery was straightforward, with no intraoperative hypotension or other surgical complications, and the cold ischaemic time was six hours.
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What I tell my patients about having an arteriovenous fistula made for haemodialysis
Jeremy S Crane
pp 15-17
As your native kidney function deteriorates, it is necessary to find something to replace the role of the kidneys – this is known as ‘renal replacement therapy’. The best solution is to have a kidney transplant, but if this is not an option, or if you are on the waiting list for a transplant, dialysis is necessary. This can be peritoneal dialysis or, more commonly, haemodialysis. In haemodialysis, blood is removed from the bloodstream and passed through a dialysis machine. This acts like an artificial kidney, removing impurities that have built up and returning ‘clean’ blood back into the body. To do this, there needs to be one of three types of entry route, or ‘vascular access’, into the bloodstream: an arteriovenous fistula, a graft or a central venous catheter. A fistula is the preferred means of vascular access and the thrust of this article. However, patient preference is very important and has a large influence on the choice of access.
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Cardiovascular disease in renal patients
Lisa E Crowley and Christopher W McIntyre
pp 19-22
It is well recognised that patients with chronic kidney disease (CKD) are at increased risk of cardiovascular morbidity and mortality. This increased risk is present from early on in the CKD continuum.1 Although the ‘traditional’ cardiac risk factors are common in CKD patients, outcomes in this group are disproportionately worse than in the general population and this excess of cardiovascular disease (CVD) cannot be fully explained by their presence. The underlying pathology of CVD changes with the progression of renal disease. In early CKD, thrombotic occlusive large vessel disease leading to acute myocardial infarction is more common. By contrast, patients with end-stage renal failure (ESRF) requiring dialysis are prone to microvascular disease. They suffer recurrent ischaemic insults that do not result in tissue necrosis but that lead, over time, to adverse functional and structural effects on vital end-organs. These patients are especially prone to heart failure and sudden cardiac death.
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Policy matters: Quality and safety first
Donal J O’Donghue
pp 23-23
The publication of A promise to learn – a commitment to act, the Berwick Report,1puts safety squarely at the centre of the NHS. Don Berwick states, ‘Very occasionally at the root of harm do lie willful reckless behaviours or neglect that cannot be tolerated’. However, he goes on to say, ‘Acting on rare and outlying behaviours and on exceptional cases of poor performance – though necessary, will not create an overall far safer and better NHS’. Berwick’s refusal to blame NHS staff reminds me of an aphorism much loved by Sir Bruce Keogh, Medical Director of NHS England, ‘There are no bad soldiers, only bad officers’. The people doing the job, along with those receiving care, are best placed to make improvements. Berwick recognises this. The report emphasises four fundamental principles. These are: quality and safety must be placed above all else; patients and carers must be empowered and heard; staff should be developed and supported; and there should be thorough and unequivocal transparency.
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Peritoneal dialysis – a patient’s perspective
Lionel Miles and Pearl Pai
pp 24-26
At the age of 56, I decided to take early retirement from a managerial job. My wife and I lived in an old house in the country with a large garden, and we enjoyed two or three foreign holidays each year. I enjoyed DIY and looking after my garden, and kept very active with these and other interests. My problems began around 1996, when I was 61 years old. A blood test result indicated that I suffered from chronic kidney disease. I was told that my kidney function was likely to decline and that dialysis would become necessary. I was concerned about the severe limitations dialysis might mean for me and my lifestyle, and so I told the kidney specialist that there was no way I was going to have dialysis. Towards the later part of 1997, I began to feel tired and nauseous. I realised that I was no longer able to walk to my village shop for the paper, and things came to a head when we went on holiday and I did not have the strength to go up some steps. I went downhill rapidly and became increasingly weak. My wife pressed me to accept dialysis.
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Living kidney donation – a district general hospital perspective
Andrew K Coutinho and Brian Camilleri
pp 28-31
Renal transplantation is the definitive treatment for end-stage renal disease in those fit to undergo the procedure. Living donation provides better patient and allograft survival compared with deceased donor transplantation, especially when the live donor transplant is performed before the onset of dialysis. The recipient receives a graft with a negligible ischaemic time, while there is also a reduced rate of graft rejection and a prolongation of the graft and recipient survival. The procedure has psychological benefits for the donor in knowing that they have received a thorough medical and surgical evaluation before the operation, and that the donation will immensely benefit the recipient. There are financial implications for the healthcare delivery system, as dialysis is more expensive in the long term than transplantation. As living donation has many benefits over a cadaveric graft, we conducted a single-centre retrospective study to assess the living donation process in our hospital. We looked at the factors influencing the duration of assessments that led to a successful donation, and those that prevented the process from being completed.
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