A comparison between serial changes in left ventricular mass in renal transplant recipients compared to patients on dialysis therapy using cardiac magnetic resonance imaging.
RajanK Patel1, Patrick B Mark1, Nicola Johnston2, Henry J Dargie2, Alan G Jardine1
1. Renal Unit, Western Infirmary, Glasgow
2. Department of Cardiology, Western Infirmary, Glasgow
Background
Patients with end stage renal failure (ESRD), requiring dialysis and transplantation, have an increased risk of cardiovascular (CV) disease. Left ventricular hypertrophy (LVH) is a risk factor for CV events and death in ESRD. Renal transplantation has been associated with echocardiographic regression of LVH and reduction in CV risk. However, echocardiography has been shown to overestimate LV mass in ESRD patients. Cardiac magnetic resonance (CMR) provides more detailed, volume independent, measures of cardiac structure. We studied changes in LV mass measured by CMR after renal transplantation.
Methods
Nineteen transplanted patients and 19 patients on the renal transplant waiting list underwent CMR on two separate occasions. Patients who had received a renal transplant underwent CMR scanning at least 6 months after their transplant. CMR was performed on a 1.5T scanner with LV mass index (LVMI) was calculated from short axis cines of the LV in end systole and diastole and corrected for body surface area. Change in LVMI was expressed as percentage change over time. Patients with CV events between scans (e.g. acute coronary syndrome, myocardial infarction) were excluded. All transplant patients had good renal function (Cr<150μmol/l).
Results
There was no significant difference in age, sex, blood pressure, LVMI, ACE/AIIR antagonism, between transplant patients and non-transplanted at the time of baseline CMR scan. There was no significant change in LVMI in patients who underwent renal transplantation and those who remained on dialysis (transplanted mean +6.14%/year, SD 12.8 vs. dialysis -2.58%/year SD 17.9 respectively; p=0.09). There were no significant changes in end diastolic volumes (transplanted median -1.19%/year, IQR -11.2,+5.4
vs. dialysis -1.64%/y; -14.5,+7.53; p=0.78) or end systolic volumes (transplanted median -5.67; IQR-13.7,+6.1 vs. dialysis -0.71 ;-30.6,+15.1;p=0.72) between the groups.
Conclusion
In this small pilot study using CMR to accurately assess LV mass, renal transplantation was not associated with a significant effect on LVMI when compared to patients who remain on the transplant waiting list. Possible explanations include previous reported improvements described with echocardiography being artefactual, small sample size, or possible post-transplant hypertension secondary to immunosuppressant therapy.
Funding: British Heart Foundation and Darlinda’s charity for Renal Research
Conflict of interest: None
Mycophenolate Mofetil Induced Villous Atrophy, Enteric Hyperoxaluria and Renal Transplant Oxalate Nephropathy
Doyle M, Pall A, Laurie M, Walsh S, Lang S & Fleming S.
Departments of Renal Medicine & Pathology, NinewellsHospital & MedicalSchool, Dundee
A 44-year-old man with end stage renal disease due to branchio-oto-renal syndrome received a live related renal transplant. Maintenance immunosuppression regimen was tacrolimus, mycophenolate mofetil (MMF) and prednisolone. Five months post-transplant he developed frequent and loose bowel movements. The dose of MMF was reduced pending further investigations of GI tract. However this was followed by an acute decline in allograft function with transplant biopsy confirming an acute cellular rejection. This was treated with pulse methylprednisolone resulting in improvement but not a return to baseline serum creatinine. A repeat renal biopsy was therefore performed which although confirmed complete resolution of the rejection also revealed significant oxalate crystal deposition within the tubules. Hyperoxaluria was confirmed by urinary oxalate excretion of 1.49 mmol/day. An upper GI endoscopy was performed and duodenal biopsies confirmed villous atrophy. This was thought most likely to be drug-induced. MMF was discontinued. Within 3 weeks his diarrhoea had stopped and his weight improved. Six weeks after stopping the MMF urinary excretion of oxalate reduced to within normal range at 0.32 mmol/day. Progress was complicated by a further episode of more severe acute cellular rejection that proved to be steroid–resistant requiring treatment with ATG. Transplant biopsies at this stage were able to show there was no further oxalate crystal deposition. Subsequently he has remained well with stable allograft function. Repeat duodenal biopsies after 3 months confirmed complete resolution of the villous atrophy.
MMF-associated villous atrophy is recognised although as far as we are aware not previously been reported to be complicated by secondary enteric hyperoxaluria and transplant oxalate nephropathy.
EBV status and the risk of PTLD
Vik Selvarajah, Alison Almond, Sue Robertson, Chris Isles
Renal Unit, Dumfries and Galloway Royal Infirmary, Dumfries, DG1 4AP
Renal transplantation prolongs survival and improves quality of life for most patients who require renal replacement therapy. Complications include cardiovascular disease, opportunistic infections and tumours. Ebstein Barr virus (EBV), cytomegalovirus (CMV) and varicella zoster virus (VZV) can all cause serious illnesses in transplanted patients. The spectrum of illness caused by EBV ranges from an acute infectious mononucleosis-like illness to a highly malignant B cell tumour. We previously reported a patient who developed this particular complication after her second transplant in whom long term remission has been achieved by reduction in immunosuppression and the use of rituximab, a monoclonal antibody with activity against B lymphocytes. We have since undertaken a survey of the Scottish Renal Transplant Pool in order to ascertain the proportion who might be at risk of PTLD in the event that they receive a kidney from an EBV positive donor or become infected by EBV following transplantation. The results of this survey will be presented at the meeting.
An Audit of Patient Satisfaction in the Renal Transplant Clinic Setting
Shona Methven, Jamie Traynor, Stuart Rodger, Western Infirmary, Glasgow
Background and Aims
Patients’ satisfaction in the outpatient clinic experience is dictated by a number of factors; waiting times, the facilities in the outpatient department and length and quality of the consultation itself. We present data regarding the experiences of renal transplant recipients attending the outpatient clinic in a single setting.
Methods
A questionnaire was distributed to all return patients attending a renal transplant clinic in the Western Infirmary, Glasgow for 4 consecutive weeks in May 2006. Two changes in routine practise were proposed; patients were offered a container to bring a urine sample to clinic and to have venepuncture performed while waiting to see the doctor. The audit cycle was then repeated in May 2007. The patients completed the questionnaire independently and anonymously during the visit.
Results
Demographic data: The mean age of respondents was 47.25 years and 40% were male. In the 2006 cohort 44% of respondents were employed, in 2007 this fell to 30%. The percentage of patients with transplants within the last year had risen concurrently from 15 to 22%. Patients attend the clinic frequently with 90% of 2007 respondents attending every three monthly or less. 32% are attending at least monthly. In the 2006 cohort 68% of patients used private transport and 74% reported travelling time >30 minutes. In 2007 private transport had fallen to 58% and 80% reported travelling time of >30 minutes.
Waiting times: Short waiting times were reported at the reception desk and for using the toilet to provide a urine sample; both cycles showed average wait <5 minutes for greater than 80% of patients. Waiting time was longer for seeing the nurse with >10 minutes waiting time being reported by 43% in the 2006 cohort and 51%in 2007, and seeing the doctor, with >10 minutes being reported by 82% and 81% respectively. There was significant improvement in waiting time to have venepuncture performed; patients waiting >10 minutes fell from 90% to 22%. This followed the change in procedure.
Areas for improvement: Identified as waiting time for seeing the nurse, seeing the doctor and venepuncture. These were the same areas where waiting times >10 minutes were common. Venepuncture was still identified as a priority despite objective improvement. In 2007 fewer patients felt waiting time to see the doctor needed to be reduced.
Patients reported high overall patient satisfaction with a mean of 88% and a median of 90%. There is support for both bringing a urine sample to clinic and having venepuncture performed while waiting to see the doctor.
Conclusion
Overall patient satisfaction is high. However a number of areas for improvement have been identified. It will require input from all members of the multi-disciplinary team to achieve these improvements.
A Scottish Electronic Renal Patient Record (SERPR) - Proposal
Keith Simpson1, Colin Geddes2, Neil Turner3
1 Renal unit, Glasgow Royal Infirmary, G4 0SF
2 Renal unit, Western Infirmary Glasgow. G11 6NT
3 Renal unit, Royal Infirmary of Edinburgh.EH16 4SU
The benefits of electronic patient records (EPRs) are widely recognised but seldom achieved (1,2). Renal units are different. For more than forty years the specialty has used fast configurable databases from which highly tuned systems have been developed. They contribute to the care of patients and to unit organisation, measurement of resource use, training, quality improvement and research (3,4).
Most renal units have developed their own database built with common software tools eg Proton® (5). This has resulted in cherished systems that reflect local practice and promote local knowledge and expertise. It has also unfortunately caused much duplication of effort, required specific training schemes in each hospital and produced few transferable IT skills. Further we are not able to benefit from economies of scale in the provision of fast well-supported lab links, fault tolerance, the adoption of international standards or the reuse of modules to solve ubiquitous problems. First generation renal systems had to provide basic patient registration, results reporting and clinic scheduling. These functions can now be devolved to dedicated administrative systems and our task in nephrology should be to design tools that address complex clinical problems, make good safe practice the norm and encourage excellence.
A recent survey of UK renal units has produced a comprehensive list of functions currently enjoyed by renal EPRs (6) and a wish list for future systems including basic decision support, predictive modelling, access to literature and high quality pictures. Most of these functions exist in embryonic form in one of the current Scottish renal EPRs. The Inverness and Aberdeen units have recently produced details specifications so it is clear that we know what we want and given the tools, know how to get there.
The Glasgow adult renal units (WIG & GRI) are being reorganised and new ambulatory care units will open soon. A new computer system will be necessary and the units at RHSC, Monklands, Crosshouse and Dumfries will be partners in this EPR. If all renal units in Scotland collaborate quickly, we could grab the opportunity and develop a national specification which would be introduced first in the west of Scotland and would be adopted by others as soon as possible. The project would be run under the auspices of the Scottish Renal Association by a group with the necessary interest and skills and with at least one person from each parent renal unit.
A SERPR would greatly simplify the running of the Scottish Renal Registry but its main function must be to support our routine clinical work.
If the project is approved by the annual business meeting of the SRA, a working group will be formed and we will arrange an early meeting with the clinical IT lead for Scotland prior to discussion with NHS Scotland and NHS Boards.
References.
1) Littlejohns P, Wyatt JC, Garvican L.
Evaluating computerised health information systems: hard lessons still to be learnt.
BMJ 2003; 326(7394): 860
2) Timm SJ, Rundall TG, Vogt TM, Hsu J.
Kaiser Permanente's experience of implementing an electronic medical record: a qualitative study.
BMJ 2005; 331(7528): 1313-13
3) Simpson K, Gordon M.
The anatomy of a clinical information system.
BMJ 1998; 316(7145); 1655-1658
4) Will EJ, Richardson D, Tolman C, Bartlett C.
Development and exploitation of a clinical decision support system for the management of renal anaemia.
Nephrol Dial Transplant 2007; 22 Suppl 4: iv31-iv36
5) The Scottish Renal Registry website
6)Stribling B.
Service Implementation - Do Once and Share Renal Action Team 2005.
The Community Prevalence of low eGFR: the Scottish Heart Health Study and the British Regional Heart Study
Keith McCullough1, Corri Black 2 and Gordon Prescott 2 on behalf of the Aberdeen Renal Research Group.
1 Renal Unit, Aberdeen Royal Infirmary; 2 Public Health, University of Aberdeen
Introduction:Our understanding of the prevalence of low eGFR in unselected community populations is based on published studies carried out overseas, the most widely quoted being NHANES III in the U.S.(1); no prevalence study based on an unselected screened community sample has been reported in the U.K.
Aims:We sought data from 2 large historical heart cohort studies carried out in the U.K., in which participants underwent measurement of serum creatinine as part of the baseline examination, to explore the prevalence and associated co-morbidity of low eGFR.
Methods:Data was supplied by the British Regional Heart Study (BRHS) and Scottish Heart Health Study (SHHS) teams in London and Dundee. The BRHS surveyed 7735 men aged 40 to 59 years, randomly selected from the registers of one general practice in each of 24 towns across England, Wales and Scotland between 1978 and 1980; response rate was 78%(2). The SHHS/ WHO Monica Study surveyed 13067 men and women aged 25 to 70 years (87% aged 40 – 59 years) across 25 districts of Scotland, selected by random sampling from General Practice registers between1984 and 1987; response rate was 72%(3).
Creatinine values were standardised to reference methods using method-specific slope and intercept equations for the assay types used, then converted into eGFR using the re-expressed version of the 4-variable MDRD equation for use with zero-biased assays. Standardised prevalence rates were based on 1981 Census figures.
Results:Valid eGFRs were available for 7689 (99.4%) BRHS and 11704 (89.6%) SHHS participants. In both surveys eGFR was normally distributed; in the SHHS the normal distribution for women was shifted towards lower levels. In both surveys, amongst those with eGFR below 60, eGFR was ≥ 45 in over 90%. Based on those aged 40 to 59 years with valid eGFR, adjusted prevalence rates (95%C.I.) for eGFR < 60 and eGFR < 45 respectively were: 411 per 10000 (366 – 455) and 35 per 10000 (21 – 48) for British men; 282 per 10000 (238 – 326) and 39 per 10000 (22 – 56) for Scottish men; 851 per 10000 (755 – 928) and 59 per 10000 (38 – 81) for Scottish women. For eGFR < 60, strong cross-sectional associations with hypertension, coronary artery and stroke disease were demonstrated, but not with diabetes and deprivation score.
Conclusion:The prevalence rates appear higher than in the U.S. study for this age group (1.8%) (1), even allowing for error in the creatinine standardisation methodology. This could be related to the relatively high rate of vascular disease in the U.K. at the time. The degree to which low eGFR alone at a single time point predicts progressive Chronic Kidney Disease is uncertain.
(1) Coresh J, Astor BC, Greene T, Eknoyan G, Levey AS. Prevalence of chronic kidney disease and decreased kidney function in the adult US population: Third National Health and Nutrition Examination Survey. Am.J.Kidney Dis. 2003 Jan;41(1):1-12.
(2) Shaper AG, Pocock SJ, Walker M, Cohen NM, Wale CJ, Thomson AG. British Regional Heart Study: cardiovascular risk factors in middle-aged men in 24 towns. Br.Med.J.(Clin.Res.Ed) 1981 Jul 18;283(6285):179-186.
(3) Smith WC, Crombie IK, Tavendale R, Irving JM, Kenicer MB, Tunstall Pedoe H. The Scottish Heart Health Study: objectives and development of methods. Health.Bull.(Edinb) 1987 Jul;45(4):211-217.
The changes in patients attending the renal clinic since the introduction of the UK CKD guidelines.
Kathryn Dunne1, Krish Gunesh 2, Darryl O’Brien 2, Colin C Geddes 1
Renal Unit, Western Infirmary Glasgow, Faculty of Medicine, University of Glasgow.
Introduction: The UK CKD guidelines and laboratory eGFR reporting were introduced in April 2006 with the main aim of improving the identification and management of cardiovascular risk of patients with eGFR<60ml/min/1.73m2. Furthermore, the guidelines recommend that the majority of patients with CKD 3 without proteinuria do not require referral to nephrology clinics. The aim of this study was to quantify the change in number, demographic and clinical features of new patients attending renal clinic before and after introduction of the UK CKD guideline.
Method: All new patients attending the Western Infirmary Renal clinic in 4 time periods (second 6 months of 2003, 2004, 2005, 2006) were identified from the electronic patient record. Age, sex, CKD stage, blood pressure (BP), urine protein:creatinine ratio (uPCR), haemoglobin, serum phosphate, and the proportion on aspirin, statins and ACE inhibitors at time of first clinic attendance were compared.
Results: Analysing the trend inthe four 6 month periods of 2003, 2004, 2005, 2006, the introduction of the CKD guidelines in April 2006 was associated with an abrupt rise in absolute number (186, 204, 223 and 378 respectively), mean age (57.9, 58.9, 61.1, and 66.6 year) and proportion of females (45.7%, 47.5%, 44.4% and 57.1%). The majority of the increase was explained by the number of patients with stage 3 (70, 86, 80 and 201) and stage 4 (48, 51, 64 and 115) CKD. In patients with stage 3 CKD mean systolic BP at presentation across the four year periods was 148, 146, 149 and 146 mmHg, median uPCR was 26, 26, 26 and 17mg/mmol, the proportion of patients on Aspirin was 21.1%, 39.8%, 41.3% and 41.9%, the proportion of patients on a statin was 23.9%, 38.6%, 43.8% and 51.7% and the proportion of patients on ACE inhibitors or ARBs was 28%, 38.6%, 32.5% and 44.3%. In new patients with stage 4 CKD mean systolic BP was 153, 149, 152 and 151 mmHg, median uPCR was 45, 60, 58 and 31mg/mmol, the proportion of patients on Aspirin was 35.4%, 33.3%, 46.1% and 33.9%, the proportion of patients on a statin 47.9%, 41.2%, 49.2% and 41.7% and the proportion of patients on ACE inhibitors or ARBs was 33.3%, 29.4%, 20% and 40%.
Conclusion:
The data show that the introduction of the UK CKD guidelines in April 2006 was associated with an abrupt 58.9% increase in new patients seen in the renal clinic and that the majority of the increase was explained by patients with stage 3 and 4 CKD. The median uPCR of patients with CKD 3 was, surprisingly, lower in 2006. There was evidence of increasing effort to reduce cardiovascular risk in patients with CKD in primary care before referral but no improvement in blood pressure at presentation.