Comment: Planning ahead
John Bradley
pp 3-3
Life expectancy at birth, for infants born in England and Wales between 2010 and 2012, was 79.1 years for males and 82.9 years for females. For men aged 65, life expectancy increased from 17.6 years in 2006–08, to 18.5 years in 2010–12. For females of the same age, life expectancy increased from 20.3 to 21.1 years over the same period. In 2011, 9.2 million people living in England and Wales were aged 65 and over. This was an increase of almost one million from 2001, when 8.3 million were 65 and above. In 2011, more than half of those aged 65 reported having a long-term health problem or disability, which limited their daily activities.
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Planning for the future: developing an advance care plan for patients with end-stage renal disease
Laura Clipsham, Caroline Cooke, Graham Warwick and Coral Graham
pp 4-7
Patients with end-stage renal disease (ESRD) have an unpredictable disease trajectory, with a marked increase in symptoms and health related concerns in the last year of life. Typically, a gradual deterioration in functional status occurs, punctuated by periods of ill health and multiple hospital admissions. The role of end-of-life care discussions and advance care planning (ACP) needs to be considered before a patient becomes too frail or their mental capacity becomes compromised. ACP explores patients’ understanding of their illness, considers priorities and wishes for care, facilitates continuity of care and can avoid unwanted and unnecessary hospital admissions. Here, we discuss how a patient-held advance care plan, which can be shared with both primary and secondary care, was developed to improve end-of-life planning.
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Statin-induced myopathy mimicking Guillain-Barré syndrome, in a transplant patient taking doxycycline
Frances Dowen, Christopher Christou and Paul Mead
pp 7-8
A 71-year-old male with a history of autosomal dominant adult polycystic kidney disease, necessitating cadaveric renal transplant in 1991 (cytomegalovirus [CMV] donor negative to recipient positive) and subsequent bilateral open native nephrectomy in 2012, attended the renal clinic with general malaise and weakness. He was normally independent, active and self-caring. Six days before admission, he had been prescribed a one-week course of doxycycline for a lower respiratory tract infection. His drug history included doxycyline 100 mg, bisoprolol 5 mg, Adcal D3® (ProStrakan), domperidone 10 mg, finasteride 5 mg, prednisolone 5 mg, lansoprazole 30 mg, furosemide 40 mg and simvastatin 40 mg, all once-daily, ciclosporin 100 mg twice daily and paracetamol 1 g four times daily. His baseline renal function was stable, with creatinine levels of 130 µmol/l, and his trough ciclosporin level was raised from 150 ng/ml at baseline to 231 ng/ml.
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Vancomycin therapy in patients on high-flux HD: a single-centre experience
Phillippa K Bailey and Rommel Ravanan
pp 8-9
Vancomycin is a glycopeptide antibiotic used to treat serious infections with gram-positive bacteria that are resistant to other antibiotics. Patients receiving haemodialysis (HD) via central venous catheters are at an increased risk of gram-positive bacterial infections. Strains of staphylococci and enterococci resistant or only partially sensitive to vancomcyin have developed; therefore, appropriate controlled use of vancomycin is essential.
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Tacrolimus-induced neutropenia following renal transplantation: a case report
Ons Charfi, Emna Gaies, Issam Salouage, Mohamed Lakhal and Anis Klouz
pp 12-13
Tacrolimus is an effective immunosuppressant used in renal transplantation. It provides excellent graft and patient survival and is associated with a low incidence of acute rejection. It has many side effects, the most common being chronic allograft nephropathy, diabetes mellitus, arterial hypertension and neurotoxicity. Haematological side effects seem to be rare and their aetiology is still unclear. However, a causal association between tacrolimus and these haematological side effects is difficult to prove because renal transplant patients are subject to many other treatments to prevent rejection and infections. Here, we report a case of a tacrolimus-induced severe neutropenia in a kidney transplant patient.
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What I tell my patients about exercise
Alice C Smith and James O Burton
pp 15-18
Physical inactivity is now recognised as the developed world’s biggest health problem, and the prescription of exercise for the treatment of chronic disease is, thankfully, becoming more established. Unfortunately, kidney patients have been rather neglected in this regard compared with some other clinical services, such as those for heart and lung disease. At the moment, very few UK renal units offer any kind of exercise advice or support for their patients. However, recently, there has been quite a lot more research into the role of exercise in the management of kidney disease, and we are beginning to see that it can be very beneficial indeed. We need to do more studies to find out the best exercise regimes for kidney patients and to discover the best ways of helping people take up an exercise habit and stick to it. But, in the meantime, we hope that the following advice will be helpful.
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How seven-day working will affect kidney services
Donal O'Donoghue
pp 19-19
Sir David Nicholson, former Chief Executive of NHS England, is often quoted as saying that changes to our health system, and particularly the need to save over £20 billion, are ‘so massive that you could see them from Mars’. The reforms have certainly been a seismic organisational shift for the Department of Health, Public Health England and the Care Quality Commission. However, the public, our patients and frontline staff have been more concerned about quality failures, sustaining services and cuts in local authority social care budgets. Now that the new structures are bedding in, we are going to see these agendas converge to drive large-scale changes that will affect us all. The headlines often mention reconfiguration – where things are done and which hospital services will close – but equally important is how things are done and how they will be done differently in the future; both are changing. Sir Bruce Keogh, Medical Director of NHS England, said that specialist services should be brought together as much as possible, be provided across no more than 15–30 sites in England and that the shift to seven-day services is well under way. So, what will this mean for kidney units and kidney care?
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Update: Renal Association Patient Safety Project
Paul B Rylance
pp 21-22
Patient safety is an obligatory priority for all renal unit healthcare professionals. The Renal Association Patient Safety Project has been running for over six years and is now developing into a multiprofessional project in collaboration with the British Renal Society (BRS) and the Association of Renal Technologists (ART).
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Fistula refusal: a qualitative study exploring decisions against fistula access
Jennifer Hare, Mark Forshaw and Sarah Grogan
pp 23-29
Haemodialysis (HD) requires the individual to have well-functioning vascular access (VA); an arterio-venous fistula (AVF) is considered the best and most reliable access for HD. It is the preferred method because it provides the best long-term VA with the fewest complications. When an individual is medically unsuitable for an AVF, an arteriovenous graft (AVG) may be used. Alternatively, if an individual begins emergency HD or there is insufficient time to establish mature VA (AVF/AVG), a line (central venous catheter [CVC]) may be used. Lines are considered the least desirable VA, due to their associations with increased morbidity and mortality compared with a fistula or graft.
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Why are patients disappearing from dietetic services?
Andrew Morris, Clive Liles and Carolyn Roskell
pp 30-31
‘It’s like dietitians only see people disappearing on them,’ declared a service user during a recent dietetic renal service evaluation, funded by the National Institute of Health Research (NIHR). To clarify, they offered an explanation as to why they feel people do not engage with us healthcare professionals: the delivery of essential dietary information may not be very useful. Describing their experience of receiving advice, one patient proclaimed, ‘Have I suddenly become a child, a naughty child? I'm an adult, I make free choices, and I’ll deal with them.’ This perspective is potentially the tip of an iceberg; each year, non-attendance costs the NHS £360 million and of this, it is not known how much can be attributed to patients’ negative perceptions of healthcare professionals.
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