Comment: Doctors' orders
John Bradley
pp 3-3
Most patients discharged home are taking more drugs than when they came into hospital.1 In a prospective study of 1,155 patients aged over 65 who were discharged from hospital, the prevalence of polypharmacy, defined as the concomitant use of five or more medications, rose from 51.9% at admission to 67.0% at discharge.2 Being discharged on more than five different medications is more likely if patients have chronic kidney disease (CKD), or a diagnosis of congestive heart failure, coronary artery disease, hypertension, diabetes mellitus, atrial fibrillation, or chronic obstructive pulmonary disease. Patients with a combination of CKD and diabetes, or CKD and heart failure, were taking an average of eight drugs on discharge.3 The most commonly prescribed drugs at discharge are antithrombotic agents, drugs for dyspepsia, diuretics, angiotensin antagonists, beta-blockers, lipid-modifying agents and drugs to lower blood glucose.
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Calciphylaxis: an update on the pathogenesis and management
Robert W Adams and Paul Mead
pp 4-8
Calcific uraemic arteriolopathy (calciphylaxis) is a condition with a grave prognosis: 60–80% mortality, usually within six to 12 months of diagnosis. It is common among, but not exclusive to, chronic renal failure patients, affecting around 1% of dialysis dependent patients. Although it was first described in 1898 and experimental models have been available since the 1960s, its aetiology is poorly understood, the therapeutic armamentarium is limited and, due to discrepancy among the available literature of case reports and series, little progress has been made in delineating efficacious therapeutic strategies. We describe a 60-year-old Caucasian woman on peritoneal dialysis (PD) following a failed kidney transplant who was diagnosed with calciphylaxis and who, after just four months, had complete resolution of her lesions. We attribute the success to the potency of a regimen consisting of three-times weekly haemodialysis (HD) followed by intravenous (IV) sodium thiosulphate – the fulcrum around which any successful therapeutic regimen should be based, for its ability to mediate and reverse underlying metabolic aberrances. The achievement is more profound given the multiple complicating factors, including contemporaneous and persistent transfusion-dependent severe anaemia (secondary to known red cell aplasia), ipsilateral deep vein thrombosis (DVT) and malnutrition requiring nasogastric feeding with two consequent episodes of refeeding syndrome, necessitating electrolyte supplementation.
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Polypharmacy and non-adherence to prescribed medicines in CKD
Gus McKillop and Jane Joy
pp 9-11
Patients with chronic kidney disease (CKD) are often required to take multiple long-term medicines to manage disease progression and complications, as well as to treat co-morbidities such as diabetes, hypertension and cardiovascular risk. This paper describes the results of quantitative data from a mixed methodology study conducted in 2012. There are few studies in the literature that examine non-adherence with prescribed medicines in patients with CKD who are not on renal replacement therapy. For this study, polypharmacy is defined as the prescription of more than five different oral medicines. Systematic reviews of interventions to improve adherence have shown little evidence of important outcomes.
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British Renal Society
Simon Ball
pp 11-11
is a great pleasure writing my first column as the new British Renal Society (BRS) President. I hope to represent the whole community in a way that continues to focus the BRS on how the multiprofessional team delivers the best possible care to patients with kidney disease.
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Overcoming the technical challenges of implementing a nocturnal haemodialysis programme
Elizabeth J Lindley and Sandip Mitra
pp 12-14
The 2012 report from the Renal Registry showed that the proportion of haemodialysis (HD) patients in the UK who are on home HD has risen gradually from 2.4% in 2006 to 3.9% in 2011. Although encouraging, this is far from the target of 15% suggested by the National Institute for Health and Care Excellence (NICE). The growth of shared care through local and regional initiatives, such as ‘Closing the Gap’, means that more patients are now capable of operating a dialysis machine. But not all of them choose to become fully independent. If nocturnal HD (NHD) is available, the benefits it offers could provide the incentive for patients to take the final step from self-care in the unit to dialysis at home. NHD means that patients can dramatically increase their treatment time without feeling that dialysis has taken over their life. The benefits of this include minimal restrictions on diet and fluid intake, fewer medications, increased energy levels with less ‘dialysis hangover’, and freedom to continue education, work or caring during the day. As well as improving quality of life, NHD has been shown to achieve five-year survival rates comparable to those in patients who received a transplant from a deceased donor. NHD also provides the best chance of conceiving a child for female HD patients.
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What I tell my patients about the Registry for Rare Kidney Diseases
Moin Saleem
pp 15-18
Rare diseases are common. There are several thousand conditions overall, and it has been estimated that 5–10% of the population suffer from a rare disease. However, these are often complex in nature, as well as difficult to understand and treat, so the Renal Association has introduced a rare disease strategy, at the centre of which sits the Registry for Rare Kidney Diseases (RaDaR). You have been diagnosed with a disease that is described as ‘rare’. A rare disease is defined as having such a low incidence (rate of occurence) that it cannot be effectively managed on experience drawn from one, or even a few, medical centres. Most doctors are unlikely to have much experience of it, and will rely heavily on external information to offer advice or treatment. The problem is amplified because good-quality clinical and scientific information is difficult to capture, or may not exist. Many rare diseases are complex and have genetic or metabolic causes. Treatment is less likely to be developed and tested than in more common disorders.
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NKF
Timothy F Statham
pp 18-18
Most people would agree that publicity for organ donation is a good thing, especially when you learn that some parts of our community lag far behind the rest in signing up to the organ donor register. Black, Asian and other minority ethnic groups are a prime example. Those groups are four times more likely to suffer renal failure, yet four times less likely to sign up to the register.
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Policy matters: Future Hospital: prospect for less acute kidney injury
Donal O'Donoghue
pp 19-19
In the past decade, there have been many changes in clinical care – the needs and aspirations of the population have changed; advances in technology, understanding of disease processes and interactions between diseases have increased options available to patients and evolved the way we deliver healthcare. These demographic and technological shifts, coupled with the rising cost of care and recent global financial crisis, are major drivers for changes in policy and practice of healthcare.
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Identifying and managing depression on an HD unit
Lucy E Holloway and Michael K Almond
pp 20-25
The lifetime prevalence of depression among the whole population is 16.2%; prevalence of depression among long-term dialysis patients is thought to be as high as 46%. Depression is the most common psychiatric problem among patients with end-stage renal disease (ESRD), especially those on haemodialysis (HD). The World Health Organization describes depression as ‘a common mental disorder that presents with depressed mood, loss of interest or pleasure, feelings of guilt or low self-worth, disturbed sleep or appetite, low energy and poor concentration’. Patients typically present with both cognitive symptoms, such as memory loss and motor retardation, and somatic symptoms, such as fatigue, headaches and digestive disturbance.
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A partnership approach to transplant preparation: involving children, young people and their families
Cara Davis, Kirsty Ryninks, Alena Cliss and Sue Dolby
pp 26-29
This article aims to describe patient- and parent/carer-reported experience of the renal transplant preparation programme (RTPP) offered at Bristol Royal Hospital for Children (BRHC). The Department of Health stipulates that the effective involvement of patients and their carers in developing, commissioning, delivering and evaluating UK healthcare services is essential to ensure improvements in standards of care that reflect the preferences and needs of patients, their families and their carers. The National Service Framework for Renal Services emphasises that provision of high-quality information in partnership with children, young people and their carers is key to enabling informed decision-making. This sentiment is echoed by the call to action in the editorial of the Spring 2012 issue of this journal.
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Kidney Research UK
Claire White
pp 29-29
PIVOTAL is a new clinical trial, led by Professor Iain Macdougall, chair of the Anaemia Clinical Study Group, which aims to recruit 2,080 patients across more than 40 UK sites. By investigating two different regimens for administering intravenous (IV) iron to incident haemodialysis patients – a ‘proactive’ high-dose regimen and a ‘reactive’ low-dose regimen – the PIVOTAL study will provide informative data to help address the clinical equipoise regarding the possible benefits or harm of using more liberal amounts of IV iron.
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Far infrared therapy for arteriovenous fistulas
Timothy Shipley, Debbie Sweeney, Iain Moore, Sean Fenwick, Hatem Mansy and Saeed Ahmed
pp 30-31
Reliable, safe and effective vascular access is the Achilles’ heel of haemodialysis (HD). It is widely accepted that a functioning arteriovenous fistula (AVF) is the best form of access for HD; this is reflected in the fact that there will be a future target of 85% for the number of prevalent patients dialysing via an AVF in UK HD units. When compared with AV grafts and dialysis catheters, AVFs are associated with a lower infection rate and, therefore, reduced patient morbidity, mortality and length of stay in hospital. Dialysis adequacy is also superior via an AVF, leading to improved patient well-being and quality of life. For these reasons, it is highly desirable that a patient already has a functioning AVF established when they start HD. Equally, it is vital that these AVFs are well maintained and continue to function efficiently throughout a patient’s time on HD.
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