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Scottish Renal Association

ABSTRACT BOOKLET

Friday 11th November 2011

Saturday 12th November 2011

Hilton Strathclyde Hotel, Phoenix Crescent, BellshillML4 3JQ

Please try and recycle any conference papers after meeting

A1. Urinary steroid excretion is a significant independent predictor of proteinuria and left ventricular mass in patients with chronic kidney disease

Emily P McQuarrie 1,2, E Marie Freel 1, Patrick B Mark 1,2, Robert Fraser 1, Rajan K Patel 1,2, Henry G Dargie 3, John M C Connell 4, Alan G Jardine 1,2

1. BHF Glasgow Cardiovascular Research Centre, University of Glasgow, 126 University Place, GlasgowG12 8TA, UK.
2. Department of Renal Medicine, Western Infirmary, Dumbarton Road, Glasgow, G11 6NT, UK.
3. Department of Cardiology, Western Infirmary, Dumbarton Road, Glasgow, G11 6NT, UK.
4. School of Medicine, University of Dundee, DD1 9SY

Background: Blockade of the mineralocorticoid receptor (MR) in CKD reduces left ventricular mass index (LVMI) and proteinuria. The MR can be activated by aldosterone, cortisol and deoxycorticosterone. We aimed to assess the impact of mineralocorticoids on LVMI and proteinuria in patients with CKD.

Methods: 70 patients with CKD and 30 patients with essential hypertension (EH) were recruited. Patients underwent clinical phenotyping; biochemical assessment and 24h urinary collection for tetrahydroaldosterone (THAldo), tetrahydrodeoxycorticosterone (THDOC), cortisol metabolites (measured using gas chromatography-mass spectrometry); urinary electrolytes and protein (QP). LVMI was measured using cardiac magnetic resonance imaging. Factors which correlated significantly with LVMI and proteinuria were entered into linear regression models.

Results: In patients with CKD, significant predictors of LVMI were male gender, systolic blood pressure (SBP), QP, THAldo and THDOC excretion. Significant independent predictors on multivariate analysis were THDOC excretion, SBP and male gender. In EH no association was seen between THAldo or THDOC and LVMI; plasma aldosterone concentration was the only significant independent predictor of LVMI in patients with EH.

Significant univariate determinants of proteinuria in patients with CKD were THALDO and THDOC excretion, urinary sodium and SBP. Only THALDO excretion and SBP were significant multivariate determinants.

Conclusions: Using cardiac MRI to determine LVMI we have demonstrated THDOC is a novel independent predictor of LVMI in patients with CKD, differing from patients with EH. 24h THALDO excretion is an independent determinant of proteinuria in patients with CKD. These data emphasise the importance of MR activation in the pathogenesis of the adverse clinical phenotype in CKD.

Funding: MRC, Darlinda’s Charity for Renal Research

A2. Incidence of acute kidney injury amongst hospital in-patients

Callum Carruthers1, Emma Aitken1, Lewis Gall1, Lynne Kerr1, Amy Martin2, Ruta Zaliunate2 & David Kingsmore1

1 Department of Surgery, Western Infirmary, Glasgow

2 Department of Medicine, Western Infirmary Glasgow

Background: The incidence of acute kidney injury (AKI) is not well known1. Underreporting and variable definitions limit work in the existing literature2. Hospital in-patients are particularly vulnerable to “pre-renal” insults1,2. This audit aims to evaluate the true incidence of AKI in our population of hospitalised patients.

Methods: Retrospective data was collected for all 1,577 patients admitted to a University Teaching Hospital during a one month period (April 2011). Baseline, admission and peak creatinine was correlated with mortality and length of hospital admission. AKI was classified according to UK Renal Society Guidelines RIFLE criteria3. Results were analysed by age and admitting speciality. Data was analysed using SPSS v.15. Results are present as mean (SEM).

Results: Overall incidence of AKI (creatinine >1.5 x baseline) on admission was 4.6%, with 10.3% of patients developing AKI whilst in hospital. Patients with AKI were significantly older than those who did not (76.2+/-4y.o. vs. 59.6+/-2.1y.o.; p<0.001). Length of stay was longer with AKI on admission 11.5+/-1.6 days vs. 4.9 +/-1.2; p<0.001). Length of hospital stay was longer for patients who developed in hospital AKI (13.8+/-1.7days) vs. those patient admitted to hospital with AKI (9.8+/-1.5 days) (p<0.01). All cause mortality was higher in the admission AKI group and in-hospital AKI group compared to those with no AKI (18.8%, 20.2% and 3.8% respectively). Breakdown of AKI by speciality is outline in table 1 below:

Conclusion: AKI is common in patients admitted to hospital, and commonly develops de novo in hospitalised patients. Patients with AKI have higher mortality and increased length of hospital admission. Further work is required to evaluate the aetiology, early recognition and management, particularly of in-patient acquired AKI.

1. Cerda J et al (2008) Epidemiology of Acute Kidney Injury. Clin.J.Am.Soc.Nephrol. 3: 881-886
2. Chertow GM et al. (2005) Acute Kidney Injury, Mortality, Length of Stay, and Costs in Hospitalised Patients. J. Am.Soc.Neph 16: 3365-3370
3. Lewington A & Kanagasundaram A(2011). Acute Kidney Injury, UK Renal Society.

Conflict of interest: None

A3. Graft site candidiasis and fungal ureteric obstruction of a transplanted paediatric horse-shoe kidney: a case report

Aitken E., Kipgen D., Geddes, C., Murio, E., Shumeyko, V. Kingsmore, D.

Department of Renal Transplant, Western Infirmary, Glasgow

Background: We present an unusual case of graft site candidiasis presenting as fungal ureteric obstruction in the adult recipient of a paediatric horseshoe kidney.

Case report: A 42 year-old woman with end-stage renal failure was transplanted a paediatric (DBD) horseshoe kidney with duplex collecting system. The operative procedure was uncomplicated. Proximal donor aorta and IVC were oversewn and the distal ends anastomosed end-to-side to recipient external iliac artery and vein. The two donor ureters were spatulated, anastomosed together and implanted onto bladder with two pigtail stents. The initial post-operative course was uneventful. She was discharged home on day 10 with a serum creatinine of 140mg/dl.6 weeks later she represented with oliguria. Serum creatinine was 427mg/dl. Ultrasound revealed moderate hydronephrosis of the left moiety and a 8x4cm perinephric collection. Percutaenous nephrostomy was performed and the collection drained. 48 hours later she developed generalised urinary peritonitis, pyrexia and elevated inflammatory markers. CT abdomen with contrast via the nephrostomy confirmed free intra-abdominal fluid, with leakage of contrast from the renal pelvis, through a breach in the peritoneum, into the abdominal cavity. Failure to improve with broad-spectrum antibiotics necessitated laparotomy. There was gross hydronephrosis and hydroureter of both collecting systems. The ureters were filled with thick “cottage cheese like” material which solidified into ureteric casts. The ureters were irrigated and re-implanted and the peritoneum washed out. Candida albicans was isolated from peripheral blood, urine and ureteric casts. Antimicrobial cover was provided with Tazocin and fluconazole (4mg/kg/day). The patient’s condition transiently improved with anti-fungal treatment, however she again developed systemic sepsis and on day 13 (two months after transplantation), the decision was taken to undertake transplant nephrectomy.Macroscopically, the entire kidney capsule was covered in balls of white fungus. Microscopically, necrotising granulomatous inflammation was noted within the renal cortex, with fungal hyphae seen in both the renal pelvis and wall of the ureter. Post-transplant nephrectomy, the patient remained on amphotericin B for a total of 30 days and received twice daily bladder washouts. Her ongoing recovery was complicated by pulmonary thromboembolism, infected haematoma and septic shock necessitating a short admission to ICU. However she was eventually discharged after 6 weeks and has now made a complete recovery and is re-established on haemodialysis.

Discussion: Whilst opportunistic infections in immunosuppressed patients are commonplace, graft site candidiasis is rare affecting less than 1 in 1,000 renal transplants1. To our knowledge, there are only two other cases of fungal ureteric obstruction following renal transplantation2. In neither case was the infection donor derived. We postulate that in this case the abnormal anatomy of the donor kidney, predisposed to stagnation of the urine latent fungal infection reactivated in the immunosuppressed recipient.

References:

1Albano, L. et al (2009) Clinical Infectious Diseases 48(2), 194-202

2Ashish, A. et al (2009) Urology Journal6(2): 127-129

Conflict of interest: None

A4. Measurement of Protein:Creatinine Ratio in Acute Kidney Injury – is it useful?

J Bray, C Stirling. Renal Unit, Western Infirmary, Glasgow.

Renal textbooks report that increased urinary protein excretion common in acute kidney injury (AKI) but is characteristically less than 1g/day if the injury is due to acute tubular necrosis (ATN). However, there are very few studies quantifying proteinuria in patients with AKI, partly due to difficulties obtaining 24hr urine samples. However, as we now measure proteinuria by protein:creatinine ratio (PCR), we are able to quantify proteinuria in this setting more often. We present a case of a young man with AKI secondary to paracetamol toxicity. His urinary PCR was >1000mg/mmol on several occasions and he therefore went on to have a renal biopsy. This showed ATN and his PCR returned to normal on resolution of AKI.

Aim: The aim of this further study was to quantify proteinuria using PCR in patients with AKI requiring renal replacement therapy (RRT) and to examine whether PCR was a useful diagnostic or prognostic marker.

Methods: Patients presenting to the Renal Unit at Glasgow Royal Infirmary between 1st August 2007 and Jan 31st 2008 with AKI requiring RRT were studied. Baseline renal function prior to AKI was retrieved retrospectively in addition to patient age, gender and likely aetiology of AKI by review of the electronic patient record and casenotes. Data on PCR, albumin to creatinine ratio (ACR), serum creatinine (sCr), urine creatinine (uCr), urine volume was retrieved at the time of commencement of RRT. Outcome was determined at 6 months post commencement of RRT. Renal outcome was defined as either recovery to baseline, recovery but not to baseline or no renal recovery. Date of death was recorded if within 6 months of presentation of AKI.

Results: 45 patients were retrieved from the EPR during the 6 month period. 20 patients were excluded due to missing data as was 1 patient who had a transplant and 1 who had acute on chronic renal failure.

Median age at presentation was 71 years and 43% were female. 83% (19/23) had a diagnosis of presumed ATN after reviewing results, U/S and casenotes.

Median PCR at time of RRT was 240 mg/mmol and median ACR was 91 mg/mmol. 63% patients with ATN had a PCR>100mg/mmol and this group had a median PCR of 215mg/mmol.

40% patients died within 6 months of presentation of AKI and 3 patients were dialysis dependant when they died. 7 patients recovered renal function to baseline and 4 patients recovered with CKD at 6 months follow up.

There was no clear correlation between PCR at the time of initiation of dialysis and renal outcome or death, although the patient numbers were small.

Conclusions:Our study shows that proteinuria of >1g/day (as measured by PCR) occurs in the majority of patients with ATN requiring RRT and is contrary to information in current renal literature. A larger prospective analysis would be useful to examine whether PCR can predict renal diagnosis or prognosis in AKI. Our data also raises questions about whether there is additional glomerular pathology in patients with ATN to explain the degree of proteinuria.

NO FUNDING OR CONFLICT OF INTEREST

A5. Two cases of renal thrombotic microangiopathy occurring after beta interferon use for the management of multiple sclerosis

Iain Drummond1, Chris Bellamy2 John Neary1, Caroline Whitworth1, Morwenna Wood3

Renal Unit, Royal Infirmary of Edinburgh1, Pathology Department, Royal Infirmary of Edinburgh2, Renal Unit, QueenMargaretHospital, Dunfermline3

Introduction: Beta-interferon is commonly used in the management of multiple sclerosis and has been associated with a range of renal side-effects including proteinuria, nephrotic syndrome and interstitial nephritis. We describe 2 cases of renal thrombotic microangiopathy (TMA) occurring following its use for the treatment of multiple sclerosis.

Case 1: A 41-year-old female with a 6 year history of multiple sclerosis presented with a 5 month history of gradual deterioration in health. She had been using beta-interferon for 3 years. At admission, she was hypertensive and had evidence of renal impairment requiring renal replacement therapy and microangiopathic haemolytic anaemia (MAHA). Renal biopsy demonstrated thrombotic microangiopathy (TMA) with changes suggestive of incipient chronicity. Beta-interferon was stopped. She remained dialysis dependent for 4 months but has regained sufficient renal function to come off dialysis.

Case 2: A 54-year-old female with a 13 year history of multiple sclerosis presented with 1st generalised tonic-clonic seizure. She had been using beta-interferon for 6 years. At admission, she was markedly hypertensive and had evidence of significant renal impairment and MAHA. Renal biopsy demonstrated TMA with changes suggestive of chronicity. Retrospective review demonstrated that creatinine had first risen above baseline at least 3 months prior to presentation. Beta-interferon was stopped. She remains dialysis dependent 4 months following presentation.

Discussion: Although there is a well documented association between alpha interferon and TMA, there are only 2 clear cases of beta-interferon associated TMA described in the literature. The incipient chronicity noted in our cases demonstrates a requirement for carefully monitoring renal function in patients receiving interferon therapies.

A6. Study of the reliability of nitrite and leukocyte esterase dipstick tests in screening for urinary tract infections in renal transplant patients

Joanna Ting and Robert Mactier,Glasgow Renal and Transplant Unit, Western Infirmary, Glasgow, Scotland, UK, G11 6NT

Aim: This study was conducted to evaluate the use of nitrite and leukocyte esterase dipstick tests in screening for UTI in renal transplant patients and to evaluate if a midstream urine culture sample still needs to be sent to the microbiology laboratory in this patient group to exclude UTI.

Methods: Urinalysis and urine culture were performed prospectively in renal transplant patients attending 9 consecutive transplant clinic sessions. Patients were divided into 238 patients who were >3 months post-transplant (defined as “medical”) and 51 renal transplant patients who were <3 months post-operation (defined as “surgical”). 22 “medical” and 6 “surgical” patients were excluded from the study because the urine sample was contaminated or no urine sample was obtained. A trace or negative leukocyte esterase dipstick was considered as negative. A UTI was diagnosed if a positive urine culture with >105 organisms per ml was reported.

Results: The specificity and positive predictive value of combined leukocyte esterase and nitrite tests were 100% for “medical” renal transplant patients. The sensitivity of nitrite dipstick test was 0.00% in “surgical” renal transplant patients. The sensitivity of leukocyte esterase was 57.14% for “medical” and 66.67% for “surgical” patients.

Conclusion: Negative urine dipstick testing for leukocyte esterase and nitrites can be used to exclude UTI in “medical” renal transplant patients whilst positive nitrite and leukocyte esterase testing reliably diagnoses a UTI in “medical” renal transplant patients. Nitrite dipstick tests are not useful for screening for UTI in “surgical” transplant patients.

Conflicts of interest: The authors have no conflicts of interest.

A7. Living Life to the full on Home Haemodialysis

Chris Ridden, NHS Highland

Background: Home haemodialysis has been increasing in prominence in the U.K during the last few years and has been recognised by many experts to be a cost effective treatment option for people with end stage renal disease.

It was decided to expand the NHS Highland home haemodialysis programme in 2007 from 1patient to 6 patients in a 2 year pilot using existing equipment. Funding through a capital grant each year was used for home conversions to accommodate this equipment at a cost of up to £5000.00 per instillation.

67% of these patients were on the transplant list and 4 out of the original 6 patients did receive transplants there fore this became a costly element to the programme.

As we did not wish to exclude any patients which were on the transplant list from receiving home haemodialysis a solution had to be found.

A home haemodialysis patient transferred into the NHS Highland area and was given the first Nx Stage machine with cost of £150.00 for home conversion.

The Nx Stage machine is a small compact portable home haemodialysis machine which is designed for short daily treatments.

Summary: We have since purchased a further Nx Stage machine with a very generous donation form a French patient who briefly dialysed at Raigmore. The first patient to use this new machine had already researched its potential and had seen the benefits of its use. This patient has since decided to raise money to purchase a further 2 machines by holding charity events.

The first event was to canoe from FortWilliam to Inverness along the Caledonian Canal and dialyse on route via a generator in wild camp sites over 6 days.

A8. Patient self-management of Warfarin

SN Carole Burns, SCN Yvonne Grieve, NHS Fife renal service

Within the continually evolving Renal Speciality, patient choice and patient participation is more important than ever. Some patients embrace the opportunity to become involved with their care giving them a sense of ownership. Developing the self-management of Warfarin was aimed to allow the patient a sense of control within safe guidelines.

To achieve our aim, it was essential to chose suitable patients. These patients were then assessed using the mini mental state examination. A structured educational programme was followed ensuring a good understanding of Warfarin therapy and side effects. The patients were then allowed to self prescribe using a dose adjustment chart, closely supervised by the nursing staff who in turn informed the consultant of the results and dose changes. On the occasions where the INR was out with the target range an assessment was carried out and causes discussed. The trial was successfully completed with positive feedback from the patients.

A9. A unique patient journey towards home haemodialysis

Sean McCartney, (NHS Tayside)

No abstract received for printing.

A10.The prevalence of metabolic complications in stage 4 CKD patients attending a General Renal Clinic, a retrospective audit.