Home haemodialysis in Ireland.

BACKGROUND: Home haemodialysis (HHD) has the potential to impact positively on patient outcomes and health resource management. There has been rejuvenated international interest in HHD in recent years. AIM: We aimed to review the activity and outcomes of the Irish HHD Programme since inception (2009-16). DESIGN: Retrospective review. METHODS: Patient data were collected using the national electronic Renal Patient database (eMEDRenal version 3.2.1) and individual centre records. All data were recorded in a coded fashion on a Microsoft Excel Spread-sheet and analysed with Stata SE software. RESULTS: One hundred and one patients completed training and commenced HHD; a further fourty-five patients were assessed for HHD suitability but did not ultimately dialyse at home. Twenty patients switched to nocturnal HHD when this resource became available. The switch from conventional in-centre dialysis to HHD led to an increase in the mean weekly hours on haemodialysis (HD) and a reduction in medication burden for the majority of patients. The overall rate of arteriovenous fistula (AVF) as primary vascular access was 62%. Most HHD complications were related to access function or access-related infection. Over the 7-years, 29 HHD patients were transplanted and 9 patients died. No deaths resulted directly from a HHD complication or technical issue. CONCLUSIONS: Patient and technique survival rates compared favourably to published international reports. However, we identified several aspects that require attention. A small number of patients were receiving inadequate dialysis and require targeted education. Ongoing efforts to increase AVF and self-needling rates in HD units must continue. Psychosocial support is critical during the transition between dialysis modalities.

Serum D-dimer concentrations in nephrotic syndrome track with albuminuria, not estimated glomerular filtration rate.

BACKGROUND: The nephrotic syndrome is associated with an increased risk of venous and arterial thrombosis. There are little published data on the distribution, interpretation or determinants of serum D-dimer levels in patients with the nephrotic syndrome. We aimed to describe this relationship. METHODS: This was a cross-sectional study of 100 patients with the nephrotic syndrome. Multivariate linear regression was used to evaluate for independent predictors of elevated D-dimer levels. Patients were observed for a period of 2 years after the baseline measurement of D-dimer level to assess for subsequent clinically evident thrombosis. RESULTS: On univariate linear regression, D-dimer elevation was associated with age in years ß (95% CI) 0.02 (0.016, 0.03), log-transformed urinary protein:creatinine ratio in g/g 0.439 (0.32, 0.558) and inversely with serum albumin in g/l -0.05 (-0.073, -0.035) and estimated glomerular filtration rate (eGFR) in ml/min/1.73 m(2) -0.01 (-0.016, -0.003). On multivariate linear regression, age in years ß (95% CI) 0.019 (0.012, 0.026), serum albumin in g/l -0.023 (-0.043, -0.003), and log-transformed urinary protein:creatinine ratio in g/g 0.266 (0.124, 0.408) were independently associated with elevated D-dimer levels. CONCLUSION: D-dimer levels are commonly raised in the nephrotic syndrome in the absence of clinically evident thrombosis, and are independently associated with age, degree of proteinuria and serum albumin, but not with eGFR. Baseline levels of D-dimer did not predict subsequent episodes of clinically evident thrombosis after 2 years of follow-up.

Radiological features of progressive tumoral calcinosis in chronic renal failure.

We present the case of a young adult patient with chronic renal failure who developed painful subcutaneous nodules after failed renal transplant and recommencing dialysis. These nodules were juxta-articular in location and initially located over both shoulders. Radiological evaluation suggested tumoral calcinosis. The patient was placed on a strict dialysis and dietary regimen but was suboptimally compliant with same. The patient developed progressive disease with an increase in size and number of juxta-articular calcified soft-tissue masses. However, 6 months following a second renal transplant clinical and radiological follow up demonstrated marked resolution both in symptomatology and radiographic findings. We present the plain radiographic, CT and MRI findings which demonstrate the typical radiological features of tumoral calcinosis. We correlate these findings with clinical course and histological findings following surgical excision of one of these masses.

Poor uptake of reproductive health screening services by female renal transplant recipients.

Women with functioning renal transplants are a high-risk group for de novo malignancies and other gynaecological health problems. The objective of this study was to assess patients' awareness of gynaecological issues, and to assess uptake of cervical and breast cancer screening services. A structured questionnaire on family planning, menopausal issues and knowledge/use of cervical and breast cancer screening was administered to 64 female renal transplant recipients. 58 (91%) responded to the questionnaire. Mean age at first transplantation was 35 years (range 11 - 69). 84% were aware as to why they should have regular cervical smears. 15 (26%) had, however, never had a smear and only 9 (16%) were having yearly smears. 12 of 28 postmenopausal women entered the menopause under the age of 41 years, but only 5 of these had received Hormone Replacement Therapy. Breast self examination is practiced by 71%, but only 26% have had mammograms. These figures suggest that female renal transplant patients are not adequately screened for cervical and breast cancer. The results also indicate a need for further education regarding family planning issues and menopausal health concerns. We conclude that formal gynaecological review should be routinely available for women with renal transplants.

Subacute cutaneous lupus erythematosus and life-threatening hypokalaemic tetraparesis: a rare complication.

We describe a patient with lesions of subacute cutaneous lupus erythematosus associated with high titres of anti-Ro and anti-La antibodies who developed a rapidly progressive flaccid tetraparesis due to profound hypokalaemia. After investigation she was found to have distal renal tubular acidosis (dRTA) without pathological evidence of lupus nephritis. It is likely that her dRTA was a manifestation of associated Sjögren's syndrome, which had been otherwise asymptomatic. This is the first report of such a complication in the dermatological literature.

Epidemiology and control of vancomycin-resistant enterococci (VRE) in a renal unit.

This study reports an outbreak of infection and colonization caused by vancomycin-resistant enterococci (VRE) in the renal service of a large teaching hospital. The polymerase chain reaction and pulsed-field gel electrophoresis were used to study the epidemiology of 26/34 strains of vancomycin-resistant Enterococcus faecalis and Enterococcus faecium from the outbreak in comparison with five strains from other hospitals in Edinburgh and the Borders, and three from other wards in the Royal Infirmary. The study revealed a heterogeneous population of vancomycin-resistant E. faecalis. Over 60% of E. faecium isolates had matching pulsed-field gel electrophoresis patterns and all of these were of VanA phenotype. These results suggest that clonal spread of VanA phenotype E. faecium within and possibly between hospitals is the major vancomycin-resistant enterococcal problem in Edinburgh. Screening of patients and isolation of colonized and infected patients appear to have been successful in controlling the spread of VRE.

Change in nutritional status of patients on peritoneal dialysis.

OBJECTIVE: To document the prevalence of undernutrition/overnutrition in patients on peritoneal dialysis (PD) and to examine whether nutritional status (NS) changes with time on this form of dialysis. DESIGN: Retrospective observational study. Patients had been on PD >2 years. Data included age, gender, diagnosis, peritonitis rate, anthropometry and biochemistry. A classification system for NS was devised using BMI, TSF, MAMC and serum albumin. SETTING: Regional Peritoneal Dialysis Programme, University Teaching Hospital. PATIENTS: 82 patients were on PD on March 1994. A cohort of 28 patients remained on PD after 2 years and complete nutritional data was available for 23 of these patients (9 male, 14 female: mean age 58yrs). RESULTS: 65% of patients were classified as having an acceptable NS at the start of PD and 56% were classified as acceptable at the latest assessment. The prevalence of mild/moderate undernutrition both at the start of PD and at the latest assessment was 26% (different patients at each assessment). No patients were classified as severely undernourished. The prevalence of overnutrition at the start of PD was 9% and at the latest assessment was 17%. There was no statistically significant difference in NS between diabetics and non-diabetics nor between male and female patients although undernutrition was more frequently observed in males. Overnutrition increased with time in both genders but this did not reach statistical significance. There was no difference in initial NS between those who remained on PD and those who died. Change in NS was not related to peritonitis rate. CONCLUSION: Whereas this study has insufficient statistical power to avoid a Type II error it supports our clinical observation that NS does not substantially change with time in this population. There are, however, a small number of individuals who exhibit changes in NS. Given the difficulty in predicting change in NS with time, regular nutritional assessment is important to identify those who require more intensive dietetic intervention.

Patterns in acute referral to hospital.

This retrospective observational study aimed to assess factors affecting acute referral and subsequent admission to hospital by general practitioners. Data concerning 2,303 consecutive acute referrals to hospital from all GPs in a defined study area were collected over one month. Fund holding practices cared for 13% of the population referred 13% of all referrals resulting in 14% of admissions. Referral through the A&E resulted in significantly more patients being discharged upon initial assessment (p < 0.001). A telephone call accompanying referral dramatically increased the chance of hospital admission (p < 0.001). Referral to hospital was more likely the more socially deprived the patient (p < 0.001) but had no subsequent bearing on admission.

Cardiac involvement in Wegener's granulomatosis.

Wegener's granulomatosis is a systemic inflammatory disorder of unknown aetiology. The protean clinical presentations depend on the organ(s) involved and the degree of progression from a local to a systemic arteritis. The development of serological tests (antieutrophil cytoplasmic antibodies) allows easier diagnosis of a disease whose incidence is increasing. This is particularly helpful where the presentation is not classic--for example "overlap syndromes"--or where the disease presents early in a more localised form. This is true of cardiac involvement, which is traditionally believed to be rare, but may not be as uncommon as has hitherto been thought (< or = 44%). This involvement may be subclinical or the principal source of symptoms either in the form of localised disease or as part of a systemic illness. Pericarditis, arteritis, myocarditis, valvulitis, and arrhythmias are all recognised. Wegener's granulomatosis should therefore be considered in the differential diagnosis of any non-specific illness with cardiac involvement. This includes culture negative endocarditis, because Wegener's granulomatosis can produce systemic upset with mass lesions and vasculitis. Echocardiography and particularly transoesophageal echocardiography can easily identify and delineate cardiac and proximal aortic involvement and may also be used to assess response to treatment.

Signals from the oropharynx may contribute to the diuresis which occurs in man to drinking isotonic fluids.

The drinking of a variety of isotonic salt solutions provoked a short load-dependent diuretic response in man, similar in latency to that of a water diuresis and reaching its maximum 40-60 min from the start of drinking. Subjects differed in the threshold load at which the response became evident, and also in the magnitude of their responses. Changes in free water clearance matched the increases in urinary minute volume, with no significant change in either urinary sodium or potassium excretion. Changes in urinary pH and in ammonium excretion were similar to those described for a water diuresis. Drinking an isotonic solution of mannitol provoked a diuresis similar to that of the salt solutions. All subjects had diarrhoea after drinking the mannitol. Signals arising from the oropharynx might be partly responsible for eliciting the diuresis. The significantly smaller urinary responses to infusions of isotonic salt solutions directly into the stomach support this view. The absence of a significant response to 'sham drinking' appears inconsistent with this, but oropharyngeal signals may only have a priming role in man and interact with other signals to give the full response.