British Journal of Renal Medicine - 2021

John Bradley, BJRM editor, writes a moving and personal tribute to Professor Donal O'Donoghue, who tragically lost his life earlier this year after becoming unwell with COVID-19. A consultant renal physician since 1992, Professor O'Donoghue worked for more than 30 years to improve the care of patients with kidney disease and held a number of roles in the field, including as the inaugural President of the British Renal Society, President of the Renal Association, the first National Director of Kidney Care at the Department of Health and Royal College of Physicians Registrar. He was a long-standing member of BJRM's editorial board, and will be sorely missed.

Granulomatosis with polyangiitis (GPA; also known as Wegener’s granulomatosis) is an uncommon multisystem disorder of unclear pathogenesis, which can be a rare cause of solitary cavitating lung lesions.

This article considers the case of a 46-year-old male who presented initially with fever, cough and right sided pleuritic chest pain, as well as a five year history of constitutional symptoms including night sweats and weight loss. A chest x-ray and subsequent CT thorax identified a 5.5cm cavitating chest lesion, which was initially considered to represent a primary lung cancer, and so the patient was referred for surgical excision. However, at the surgical pre-assessment a significant drop in renal function was noted. C-ANCA antibodies were found to be positive and kidney biopsy showed changes consistent with a diagnosis of GPA.

The authors describe the case in detail, including the investigations undertaken and the course of treatment given, and discuss the importance of achieving a correct diagnosis at the earliest possible stage, to save patients from unnecessary surgery and give the best treatment outcomes. Identifying and treating GPA earlier is a key factor in improving prognosis, they stress, and warn that if physicians don’t keep it at the back of their minds then it can be easily missed. Urine dip, consideration of a vasculitis screen and early kidney biopsy are the key to identifying this challenging presentation before multi-system involvement or end organ failure.

The National Kidney Federation (NKF) has been representing renal patients for over 40 years and is the only national charity run by kidney patients for kidney patients. The charity runs the only free UK Helpline (0800 169 09 36) dedicated solely to patients and families with kidney conditions. NKF are also the UK’s largest provider of kidney-related medical information leaflets, with a library of over 200 titles written by nephrologists in simple language for patients and carers. The NKF is now embarking on a national campaign to increase home dialysis in the UK. The campaign will focus on the disproportionate impact COVID-19 has had on patients who dialyse in a centre.

This article considers the clinical impact of routine screening for asymptomatic bacteriuria (ASB), which is common in the kidney transplant recipient (KTR) population, the incidence ranging from 17% to 51% between studies. The authors note that evidence for the benefits of antibiotic therapy for ASB in this patient population is conflicting. Several observational studies have reported a possible association between ASB and subsequent urinary tract infection (UTI), acute graft pyelonephritis, and allograft rejection, but an unblinded intervention study, which randomised patients with ASB to receive either systemic antibiotic therapy or no treatment, showed no evidence of benefit in the routine treatment of ASB in respect to prevention of transplant pyelonephritis and other secondary outcomes including lower urinary tract infection and graft dysfunction.

The clinical management of ASB in KTRs varies considerably and there are presently no UK national guidelines on this subject. In a Europe-wide survey of renal transplant physicians, 72% routinely screened for bacteriuria, 43% treated all episodes of ASB diagnosed within the first 6 months after kidney transplant, and 15% treated all episodes of ASB diagnosed at any time-point following transplantation. However, a 2018 Cochrane review of just two interventional studies concluded that there was insufficient evidence to support routine antimicrobial treatment of ASB for the prevention of UTI and graft dysfunction. Screening for ASB in KTRs may also increase the risk of antimicrobial resistance as a result of unnecessary antibiotic use, with one observational study demonstrating persistent ASB in 46% of KTRs despite antibiotic treatment, and 78% of treated KTRs going on to develop a UTI caused by a drug-resistant pathogen.

Non-attendance at outpatient appointments is an expensive and unnecessary burden to the NHS, with an estimated cost of over £1 billion annually. This article describes a quality improvement project designed to assess clinical characteristics of non-attenders at renal outpatient clinics, the effect of informing patients of the cost to services of missed appointments, and patient opinions on service improvement.

All missed clinic appointments from November 2017 to January 2019 inclusive were evaluated across four hospital sites (Dorset County Hospital, Poole General Hospital, Royal Bournemouth Hospital and Yeovil District Hospital) and two non-District General Hospital dialysis units (Poole Dialysis Unit and Yeovil Dialysis Unit) served by the Dorset Renal Service. Data on age, sex, appointment type (new or follow-up), pre-clinic renal function in non-dialysis patients where measured, location of clinic and travelling distance for non-attenders and cause of renal dysfunction if known were collected. A memo detailing the cost of missed clinic appointments was introduced into the clinic appointment letters in February 2018, with an assessment of missed appointments for a comparable 3-month period before (November 2017- January 2018) and after (November 2018-January 2019) introduction of the memo. Patient opinion on four options to reduce non-attendance was sought from circa 100 attendees and non-attenders (with a record of 3 or more missed appointments). Data was analysed using Chi Square, Fisher's exact test and Unpaired Student T tests.

A look at Kidney Care UK's work to ensure that it continues to provide kidney care patients in the UK with the most up-to-date information throughout the coronavirus pandemic.

Advances in medicine have led to improved survival into young adulthood of people with chronic kidney disease (CKD) and end-stage renal failure (ESRF). Consequently, the population of paediatric patients with CKD and ESRF who are on renal replacement therapy (RRT) transitioning to the adult nephrology service has progressively increased over the past decade. This small yet important group of people represents a significant investment of healthcare resources and organ donations.

Studies have shown that late adolescence and young adulthood is a period associated with an increased risk of graft loss. This increased risk is observed across both living and deceased donor transplant recipients and for all levels of HLA (human leukocyte antigen) mismatch. This is further evidenced by the recent UK Renal Registry data which showed that almost 1 in 10 young adults died by 5 years from the start of RRT with standard mortality ratio of 45.1. However, despite recognising these young adults as a vulnerable cohort of patients, there is a lack of good evidence for interventions that can improve outcomes.

This article describes a retrospective study that reviewed the outcomes of all young adults transitioned from paediatric to adult nephrology services over a 5-year period, and investigated the association between social deprivation status, medication frequency and compliance with renal outcomes.
Among the findings, the authors note that pill burden, poor medication adherence and clinic attendance were found to be associated with deterioration of both native and graft renal function.
They also stress that the study recognises that transition from the paediatric to the adult renal service is a high-risk period for young adults with chronic kidney disease, and that aggressive follow-up of clinic non-attendance, a consistent clinical team and promotion of self-care are required to help achieve the best outcomes.

Lead author Professor Martin Wilkie and co-authors Amjid Ali, Andy Henwood, Catherine Stannard, Claire Corps, Dela Idowu, Kirit Modi, Nick Selby, Ranjit Klare, Sonia Lee and Tracey Rose

This article summarises a webinar during which 150 patients and professionals discussed key questions around the practical aspects of working collaboratively together to improve kidney care.

The panel included individuals who had participated in improvement programmes in kidney care, as well as others with considerable experience in this area. The objective of the webinar was for patient partners and healthcare professionals (HCPs) to talk about what it feels like to work together in an improvement programme in kidney care and to understand the challenges, the successes and enablers to patient participation.

Questions considered in the article include: What are the most effective ways to involve people from a range of backgrounds?; What things should we consider when we are identifying potential patient roles?; How can we help patients gain the skills they don’t have so they can be more engaged and add value to the programme?; and What structures should we have to enable longer term support for patient partners?.

Dela Idowu, founder of Gift of Living Donation, also offers reflection on the webinar, which he sums up in three key words: change, to encourage involvement from patients from all communities – especially patients from BAME communities and those from a range of social backgrounds; collaboration, to work together with patients; and commitment to ensure that patient involvement is not just a buzz word.

After two years of engagement and discussions between the Renal Association (RA) and the British Renal Society (BRS), an overwhelming majority of the renal community have supported a merger of these two organisation to create the UK Kidney Association (UKKA). The transition reflects the evolving needs of the wider community and the centrality of multi-professional working in kidney care, enabling better support to all kidney professionals. 

The UKKA brings together, into one membership organisation, the 71-year history of the RA, including the professional and national delivery and the statutory data collection, analysis, research and reporting of the UK Renal Registry, with the multi-professional focus of the BRS and the knowledge, experience and research of the Affiliates and Special Interest Groups (SIGs).