A stepped wedge cluster randomized trial of graphical surveillance of kidney function data to reduce late presentation for kidney replacement therapy.

Late presentation for kidney replacement therapy (KRT) is an important cause of avoidable morbidity and mortality. Here, we evaluated the effect of a complex intervention of graphical estimated glomerular filtration rate (eGFR) surveillance across 15% of the United Kingdom population on the rate of late presentation using data routinely collected by the United Kingdom Renal Registry. A stepped wedge cluster randomized trial was established across 19 sites with eGFR graphs generated from all routine blood tests (community and hospital) across the population served by each site. Graphs were reviewed by trained laboratory or clinical staff and high-risk graphs reported to family doctors. Due to delays outside the control of clinicians and researchers few laboratories activated the intervention in their randomly assigned time period, so the trial was converted to a quasi-experimental design. We studied 6,100 kidney failure events at 20 laboratories served by 17 main kidney units. A total of 63,981 graphs were sent out. After adjustment for calendar time there was no significant reduction in the rate of presentation during the intervention period. Therefore, implementation of eGFR graph surveillance did not reduce the rate of late presentation for KRT after adjustment for secular trends. Thus, graphical surveillance is an intervention aimed at reducing late presentation, but more evidence is required before adoption of this strategy can be recommended.

Subgroup analysis of the ASPirin in Reducing Events in the Elderly randomized clinical trial suggests aspirin did not improve outcomes in older adults with chronic kidney disease.

The role of aspirin for primary prevention in older adults with chronic kidney disease (CKD) is unclear. Therefore, post hoc analysis of the randomized controlled trial ASPirin in Reducing Events in the Elderly (ASPREE) was undertaken comparing 100 mg of enteric-coated aspirin daily against matching placebo. Participants were community dwelling adults aged 70 years and older in Australia, 65 years and older in the United States, all free of a history of dementia or cardiovascular disease and of any disease expected to lead to death within five years. CKD was defined as present at baseline if either eGFR under 60mL/min/1.73m2 or urine albumin to creatinine ratio 3 mg/mmol or more. In 4758 participants with and 13004 without CKD, the rates of a composite endpoint (dementia, persistent physical disability or death), major adverse cardiovascular events and clinically significant bleeding in the CKD participants were almost double those without CKD. Aspirin's effects as estimated by hazard ratios were generally similar between CKD and non-CKD groups for dementia, persistent physical disability or death, major adverse cardiovascular events and clinically significant bleeding. Thus, in our analysis aspirin did not improve outcomes in older people while increasing the risk of bleeding, with mostly consistent effects in participants with and without CKD.

An ontological approach to identifying cases of chronic kidney disease from routine primary care data: a cross-sectional study.

BACKGROUND: Accurately identifying cases of chronic kidney disease (CKD) from primary care data facilitates the management of patients, and is vital for surveillance and research purposes. Ontologies provide a systematic and transparent basis for clinical case definition and can be used to identify clinical codes relevant to all aspects of CKD care and its diagnosis. METHODS: We used routinely collected primary care data from the Royal College of General Practitioners Research and Surveillance Centre. A domain ontology was created and presented in Ontology Web Language (OWL). The identification and staging of CKD was then carried out using two parallel approaches: (1) clinical coding consistent with a diagnosis of CKD; (2) laboratory-confirmed CKD, based on estimated glomerular filtration rate (eGFR) or the presence of proteinuria. RESULTS: The study cohort comprised of 1.2 million individuals aged 18 years and over. 78,153 (6.4%) of the population had CKD on the basis of an eGFR of < 60 mL/min/1.73m2, and a further 7366 (0.6%) individuals were identified as having CKD due to proteinuria. 19,504 (1.6%) individuals without laboratory-confirmed CKD had a clinical code consistent with the diagnosis. In addition, a subset of codes allowed for 1348 (0.1%) individuals receiving renal replacement therapy to be identified. CONCLUSIONS: Finding cases of CKD from primary care data using an ontological approach may have greater sensitivity than less comprehensive methods, particularly for identifying those receiving renal replacement therapy or with CKD stages 1 or 2. However, the possibility of inaccurate coding may limit the specificity of this method.

Longitudinal study of changing psychological outcomes following the Victorian Black Saturday bushfires.

OBJECTIVES: To map the changing prevalence and predictors of psychological outcomes in affected communities 5 years following the Black Saturday bushfires in Victoria. METHOD: Follow-up assessment of longitudinal cohort study in high, medium and non-affected communities in Victoria, Australia. Participants included 1017 respondents (Wave 1) interviewed via telephone and web-based survey between December 2011 and January 2013, and 735 (76.1%) eligible participants were retested between July and November 2014 (Wave 2). The survey included measures of fire-related and subsequent stressful events, probable posttraumatic stress disorder, major depressive episode, alcohol use and severe distress. RESULTS: There were reduced rates of fire-related posttraumatic stress disorder (8.7% vs 12.1%), general posttraumatic stress disorder (14.7% vs 18.2%), major depressive episode (9.0% vs 10.9%) and serious mental illness (5.4% vs 7.8%). Rates of resilience increased over time (81.8% vs 77.1%), and problem alcohol use remained high across Wave 1 (22.1%) and Wave 2 (21.4%). The most robust predictor of later development of fire-related posttraumatic stress disorder (odds ratio: 2.11; 95% confidence interval: [1.22, 3.65]), general posttraumatic stress disorder (odds ratio: 3.15; 95% confidence interval: [1.98, 5.02]), major depressive episode (odds ratio: 2.86; 95% confidence interval: [1.74, 4.70]), serious mental illness (odds ratio: 2.67; 95% confidence interval: [0.57, 1.72]) or diminished resilience (odds ratio: 2.01; 95% confidence interval: [1.32, 3.05]) was extent of recent life stressors. CONCLUSION: Although rates of mental health problems diminished over time, they remained higher than national levels. Findings suggest that policy-makers need to recognize that the mental health consequences of disasters can persist for many years after the event and need to allocate resources towards those who are most at risk as a result of substantive losses and ongoing life stressors.

A programme to spread eGFR graph surveillance for the early identification, support and treatment of people with progressive chronic kidney disease (ASSIST-CKD): protocol for the stepped wedge implementation and evaluation of an intervention to reduce late presentation for renal replacement therapy.

BACKGROUND: Patients who start renal replacement therapy (RRT) for End-Stage Kidney Disease (ESKD) without having had timely access to specialist renal services have poor outcomes. At one NHS Trust in England, a community-wide CKD management system has led to a decline in the incident rate of RRT and the lowest percentage of patients presenting within 90 days of starting RRT in the UK. We describe the protocol for a quality improvement project to scale up and evaluate this innovation. METHODS: The intervention is based upon an off-line database that integrates laboratory results from blood samples taken in all settings stored under different identifying labels relating to the same patient. Graphs of estimated glomerular filtration rate (eGFR) over time are generated for patients <65 years with an incoming eGFR <50 ml/min/1.73 m2 and patients >65 years with an incoming eGFR <40 ml/min/1.73 m2. Graphs where kidney function is deteriorating are flagged by a laboratory scientist and details sent to the primary care doctor (GP) with a prompt that further action may be needed. We will evaluate the impact of implementing this intervention across a large population served by a number of UK renal centres using a mixed methods approach. We are following a stepped-wedge design. The order of implementation among participating centres will be randomly allocated. Implementation will proceed with unidirectional steps from control group to intervention group until all centres are generating graphs of eGFR over time. The primary outcome for the quantitative evaluation is the proportion of patients referred to specialist renal services within 90 days of commencing RRT, using data collected routinely by the UK Renal Registry. The qualitative evaluation will investigate facilitators and barriers to adoption and spread of the intervention. It will include: semi-structured interviews with laboratory staff, renal centre staff and service commissioners; an online survey of GPs receiving the intervention; and focus groups of primary care staff. DISCUSSION: Late presentation to nephrology for patients with ESKD is a source of potentially avoidable harm. This protocol describes a robust quantitative and qualitative evaluation of a quality improvement intervention to reduce late presentation and improve the outcomes for patients with ESKD.

The Relationship between Serum Sodium Concentration and Albuminuria: A Retrospective Cohort Study.

BACKGROUND: Lowering dietary salt intake reduces albuminuria, an early marker of renal damage and a sensitive predictor of adverse cardiovascular outcomes. The mechanisms underlying this effect are uncertain but small changes in serum sodium concentration may be important: this retrospective cohort study investigated the hypothesis that higher serum sodium concentration is a risk factor for albuminuria (defined as a urine albumin:creatinine ratio [UACR], ≥3 mg/mmol). METHODS: Primary care data from the Royal College of General Practitioners Research and Surveillance Centre were used to identify 47,294 individuals with a UACR result available between April 2010 and March 2015, and no known albuminuria prior to this. Exclusion criteria were missing or abnormal serum sodium concentration at baseline (<135 or >146 mmol/L); age <18 years; diabetes mellitus; decompensated liver disease; heart failure; and stage 5 chronic kidney disease. RESULTS: After adjustment for known risk factors, there was a significant "U-shaped" relationship between serum sodium concentration and albuminuria. The lowest risk was associated with a serum sodium of 138-140 mmol/L. In comparison, the risk of albuminuria was 18% higher with a serum sodium of 135-137 mmol/L and 19% higher with a serum sodium of 144-146 mmol/L. There was no association between serum sodium concentration and blood pressure. CONCLUSION: The finding of a positive association between higher serum sodium concentration and albuminuria is in support of the hypothesis, but the inverse relationship between serum sodium concentration and albuminuria at lower concentrations warrants further explanation.

Audit-based education lowers systolic blood pressure in chronic kidney disease: the Quality Improvement in CKD (QICKD) trial results.

Strict control of systolic blood pressure is known to slow progression of chronic kidney disease (CKD). Here we compared audit-based education (ABE) to guidelines and prompts or usual practice in lowering systolic blood pressure in people with CKD. This 2-year cluster randomized trial included 93 volunteer general practices randomized into three arms with 30 ABE practices, 32 with guidelines and prompts, and 31 usual practices. An intervention effect on the primary outcome, systolic blood pressure, was calculated using a multilevel model to predict changes after the intervention. The prevalence of CKD was 7.29% (41,183 of 565,016 patients) with all cardiovascular comorbidities more common in those with CKD. Our models showed that the systolic blood pressure was significantly lowered by 2.41 mm Hg (CI 0.59-4.29 mm Hg), in the ABE practices with an odds ratio of achieving at least a 5 mm Hg reduction in systolic blood pressure of 1.24 (CI 1.05-1.45). Practices exposed to guidelines and prompts produced no significant change compared to usual practice. Male gender, ABE, ischemic heart disease, and congestive heart failure were independently associated with a greater lowering of systolic blood pressure but the converse applied to hypertension and age over 75 years. There were no reports of harm. Thus, individuals receiving ABE are more likely to achieve a lower blood pressure than those receiving only usual practice. The findings should be interpreted with caution due to the wide confidence intervals.

Predicting the prevalence of chronic kidney disease in the English population: a cross-sectional study.

BACKGROUND: There is concern that not all cases of chronic kidney disease (CKD) are known to general practitioners, leading to an underestimate of its true prevalence. We carried out this study to develop a model to predict the prevalence of CKD using a large English primary care dataset which includes previously undiagnosed cases of CKD. METHODS: Cross-sectional analysis of data from the Quality Improvement in CKD trial, a representative sample of 743 935 adults in England aged 18 and over. We created multivariable logistic regression models to identify important predictive factors. RESULTS: A prevalence of 6.76% was recorded in our sample, compared to a national prevalence of 4.3%. Increasing age, female gender and cardiovascular disease were associated with a significantly increased prevalence of CKD (p < 0.001 for all). Age had a complex association with CKD. Cardiovascular disease was a stronger predictive factor in younger than in older patients. For example, hypertension has an odds ratio of 2.02 amongst patients above average and an odds ratio of 3.91 amongst patients below average age. CONCLUSION: In England many cases of CKD remain undiagnosed. It is possible to use the results of this study to identify areas with high levels of undiagnosed CKD and groups at particular risk of having CKD. TRIAL REGISTRATION: Current Controlled Trials ISRCTN: ISRCTN56023731. Note that this study reports the results of a cross-sectional analysis of data from this trial.

Association of anaemia in primary care patients with chronic kidney disease: cross sectional study of quality improvement in chronic kidney disease (QICKD) trial data.

BACKGROUND: Anaemia is a known risk factor for cardiovascular disease and treating anaemia in chronic kidney disease (CKD) may improve outcomes. However, little is known about the scope to improve primary care management of anaemia in CKD. METHODS: An observational study (N = 1,099,292) with a nationally representative sample using anonymised routine primary care data from 127 Quality Improvement in CKD trial practices (ISRCTN5631023731). We explored variables associated with anaemia in CKD: eGFR, haemoglobin (Hb), mean corpuscular volume (MCV), iron status, cardiovascular comorbidities, and use of therapy which associated with gastrointestinal bleeding, oral iron and deprivation score. We developed a linear regression model to identify variables amenable to improved primary care management. RESULTS: The prevalence of Stage 3-5 CKD was 6.76%. Hb was lower in CKD (13.2 g/dl) than without (13.7 g/dl). 22.2% of people with CKD had World Health Organization defined anaemia; 8.6% had Hb ≤ 11 g/dl; 3% Hb ≤ 10 g/dl; and 1% Hb ≤ 9 g/dl. Normocytic anaemia was present in 80.5% with Hb ≤ 11; 72.7% with Hb ≤ 10 g/dl; and 67.6% with Hb ≤ 9 g/dl; microcytic anaemia in 13.4% with Hb ≤ 11 g/dl; 20.8% with Hb ≤ 10 g/dl; and 24.9% where Hb ≤ 9 g/dl. 82.7% of people with microcytic and 58.8% with normocytic anaemia (Hb ≤ 11 g/dl) had a low ferritin (<100 ug/mL). Hypertension (67.2% vs. 54%) and diabetes (30.7% vs. 15.4%) were more prevalent in CKD and anaemia; 61% had been prescribed aspirin; 73% non-steroidal anti-inflammatory drugs (NSAIDs); 14.1% warfarin 12.4% clopidogrel; and 53.1% aspirin and NSAID. 56.3% of people with CKD and anaemia had been prescribed oral iron. The main limitations of the study are that routine data are inevitably incomplete and definitions of anaemia have not been standardised. CONCLUSIONS: Medication review is needed in people with CKD and anaemia prior to considering erythropoietin or parenteral iron. Iron stores may be depleted in over >60% of people with normocytic anaemia. Prescribing oral iron has not corrected anaemia.

Association of chronic kidney disease (CKD) and failure to monitor renal function with adverse outcomes in people with diabetes: a primary care cohort study.

BACKGROUND: Chronic kidney disease (CKD) is a known risk factor for cardiovascular events and all-cause mortality. We investigate the relationship between CKD stage, proteinuria, hypertension and these adverse outcomes in the people with diabetes. We also study the outcomes of people who did not have monitoring of renal function. METHODS: A cohort of people with type 1 and 2 diabetes (N = 35,502) from the Quality Improvement in Chronic Kidney Disease (QICKD) cluster randomised trial was followed up over 2.5 years. A composite of all-cause mortality, cardiovascular events, and end stage renal failure comprised the outcome measure. A multilevel logistic regression model was used to determine correlates with this outcome. Known cardiovascular and renal risk factors were adjusted for. RESULTS: Proteinuria and reduced estimated glomerular filtration rate (eGFR) were independently associated with adverse outcomes in people with diabetes. People with an eGFR < 60 ml/min, proteinuria, and hypertension have the greatest odds ratio (OR) of adverse outcome; 1.58 (95% CI 1.36-1.83). Renal function was not monitored in 4460 (12.6%) people. Unmonitored renal function was associated with adverse events; OR 1.35 (95% CI 1.13-1.63) in people with hypertension and OR 1.32 (95% CI 1.07-1.64) in those without. CONCLUSIONS: Proteinuria, eGFR < 60 ml/min, and failure to monitor renal function are associated with cardiovascular and renal events and mortality in people with diabetes.

Beyond Bushfires: Community, Resilience and Recovery - a longitudinal mixed method study of the medium to long term impacts of bushfires on mental health and social connectedness.

BACKGROUND: Natural disasters represent an increasing threat both in terms of incidence and severity as a result of climate change. Although much is known about individual responses to disasters, much less is known about the social and contextual response and how this interacts with individual trajectories in terms of mental health, wellbeing and social connectedness. The 2009 bushfires in Victoria, Australia caused much loss of life, property destruction, and community disturbance. In order to progress future preparedness, response and recovery, it is crucial to measure and understand the impact of disasters at both individual and community levels. METHODS/DESIGN: This study aims to profile the range of mental health, wellbeing and social impacts of the Victorian 2009 bushfires over time using multiple methodologies and involving multiple community partners. A diversity of communities including bushfire affected and unaffected will be involved in the study and will include current and former residents (at the time of the Feb 2009 fires). Participants will be surveyed in 2012, 2014 and, funding permitting, in 2016 to map the predictors and outcomes of mental health, wellbeing and social functioning. Ongoing community visits, as well as interviews and focus group discussions in 2013 and 2014, will provide both contextual information and evidence of changing individual and community experiences in the medium to long term post disaster. The study will include adults, adolescents and children over the age of 5. DISCUSSION: Conducting the study over five years and focussing on the role of social networks will provide new insights into the interplay between individual and community factors and their influence on recovery from natural disaster over time. The study findings will thereby expand understanding of long term disaster recovery needs for individuals and communities.

Step-Wise Management of Anemia in Patients With Chronic Kidney Disease in Primary Care: Qualitative Study.

INTRODUCTION: Anemia is common in chronic kidney disease (CKD) and is associated with increased cardiovascular risk and reduced quality of life, but is often sub-optimally managed. Most patients are managed in primary care alongside other comorbidities. Interventions to improve the management of anemia in CKD in this setting are needed. METHODS: We conducted a qualitative study to evaluate how an audit-based education (ABE) intervention might improve the management of anemia in CKD. We explored outcomes that would be relevant to practitioners and patients, that exposed variation of practice from National Institute for Health and Care Excellence (NICE) guidelines, and whether the intervention was feasible and acceptable. RESULTS: Practitioners (n = 5 groups) and patients (n = 7) from 4 London general practices participated in discussions. Practitioners welcomed the evidence-based step-wise intervention. However, prescribing erythropoiesis-stimulating agents (ESAs) was felt to be outside of their scope of practice. There was a gap between NICE guidance and clinical practice in primary care. Iron studies were not well understood and anemia management was often conservative or delayed. Patients were often unaware of having CKD, and were more concerned about their other comorbidities, but largely trusted their GPs to manage them appropriately. CONCLUSIONS: The first steps of the intervention were welcomed by practitioners, but they expressed concerns about independently prescribing ESAs. Renal physicians and GPs could develop shared care protocols for ESA use in primary care. There is scope to improve awareness of renal anemia, and enhance knowledge of guideline recommendations; and our intervention should be modified accordingly.

Investigating the effectiveness of oral ketamine on pain, mood and quality of life in treatment resistant chronic pain.

Introduction: Chronic pain is defined as pain lasting longer than 3 months. This often causes persistent emotional distress and functional disability that is refractory to conventional treatments. Emerging evidence suggests that oral Ketamine therapy may have a specific role in managing treatment-resistant chronic pain. This study aimed to assess the effectiveness of oral ketamine within a tertiary chronic pain management clinic. Methods: This study was a clinic-based retrospective descriptive study of 79 patients with a broad range of chronic pain diagnoses and treated with oral ketamine over a period up to 12 years. Changes in pain, mood and quality of life (QoL) were assessed using a numerical pain severity score, the Brief Pain Inventory (BPI), the Public Health Questionnaire (PHQ-9) and American Chronic Pain Association Quality of Life (QoL) scale. Results: 73 patients were accessible for follow-up (mean daily dose and treatment duration were 193.84 mg and 22.6 months respectively). Pain scores decreased (p < 0.0001) on both numerical scores (41.6% decrease) and BPI scoring (mean decrease 2.61). Mood improved (p < 0.0001) across both PHQ-9 and BPI measurements. Patients also reported less difficulty with daily activities and improved QoL. The most common adverse reaction was drowsiness (21.9%), with 30.1% reporting no adverse reactions from Ketamine. Discussion: This work adds to the growing body of evidence that under the supervision of a pain specialist, oral ketamine therapy may be a safe, tolerable and effective treatment for chronic pain conditions which have not responded to other management options. Further research is required to produce a more accurate understanding of its chronic use. Key message: This real-world study shows that patients being treated with oral ketamine for chronic pain report decreased severity of pain, improved mood and increased quality of life across all conditions.

Aspirin to target arterial events in chronic kidney disease (ATTACK): study protocol for a multicentre, prospective, randomised, open-label, blinded endpoint, parallel group trial of low-dose aspirin vs. standard care for the primary prevention of cardiovascular disease in people with chronic kidney disease.

BACKGROUND: Chronic kidney disease (CKD) is a very common long-term condition and powerful risk factor for cardiovascular disease (CVD). Low-dose aspirin is of proven benefit in the secondary prevention of myocardial infarction (MI) and stroke in people with pre-existing CVD. However, in people without CVD, the rates of MI and stroke are much lower, and the benefits of aspirin in the primary prevention of CVD are largely balanced by an increased risk of bleeding. People with CKD are at greatly increased risk of CVD and so the absolute benefits of aspirin are likely to be greater than in lower-risk groups, even if the relative benefits are the same. Post hoc evidence suggests the relative benefits may be greater in the CKD population but the risk of bleeding may also be higher. A definitive study of aspirin for primary prevention in this high-risk group, recommended by the National Institute for Health and Care Excellence (NICE) in 2014, has never been conducted. The question has global significance given the rising burden of CKD worldwide and the low cost of aspirin. METHODS: ATTACK is a pragmatic multicentre, prospective, randomised, open-label, blinded endpoint adjudication superiority trial of aspirin 75 mg daily vs. standard care for the primary prevention of CVD in 25,210 people aged 18 years and over with CKD recruited from UK Primary Care. Participants aged 18 years and over with CKD (GFR category G1-G4) will be identified in Primary Care and followed up using routinely collected data and annual questionnaires for an average of 5 years. The primary outcome is the time to first major vascular event (composite of non-fatal MI, non-fatal stroke and cardiovascular death [excluding confirmed intracranial haemorrhage and other fatal cardiovascular haemorrhage]). Deaths from other causes (including fatal bleeding) will be treated as competing events. The study will continue until 1827 major vascular events have occurred. The principal safety outcome is major intracranial and extracranial bleeding; this is hypothesised to be increased in those randomised to take aspirin. The key consideration is then whether and to what extent the benefits of aspirin from the expected reduction in CVD events exceed the risks of major bleeding. DISCUSSION: This will be the first definitive trial of aspirin for primary CVD prevention in CKD patients. The research will be of great interest to clinicians, guideline groups and policy-makers, in the UK and globally, particularly given the high and rising prevalence of CKD that is driven by population ageing and epidemics of obesity and diabetes. The low cost of aspirin means that a positive result would be of relevance to low- and middle-income countries and the impact in the developed world less diluted by any inequalities in health care access. TRIAL REGISTRATION: ISRCTN: ISRCTN40920200 . EudraCT: 2018-000644-26 . CLINICALTRIALS: gov: NCT03796156.

Changes in bone mineral parameters, vitamin D metabolites, and PTH measurements with varying chronic kidney disease stages.

Vitamin D deficiency is associated with an increased risk of many diseases (skeletal and nonskeletal). Emerging data also associate high concentrations of serum parathyroid hormone (PTH) with morbidity and increased mortality in patients both with and without known chronic kidney disease (CKD). Understanding the relationship between vitamin D and PTH and the determinants of PTH is therefore important. We performed a cross-sectional study of 203 patients with varying stages of CKD randomly recruited from the Renal Unit database at our institution. Detailed case review was performed, and samples of fasting blood were taken for biochemical analyses. We measured standard biochemistry, 25-hydroxyvitamin D (25-OHD), 1,25-OHD, and three PTH measurements [1-84 PTH, total PTH, and derived N-terminal truncated, 7-84 PTH (cPTH)]. Vitamin D deficiency was high, with 86% of patients having 25-OHD levels below 30 ng/ml. Estimated glomerular filtration rate (eGFR) was not associated with 25-OHD levels, whereas 1,25-OHD was lower in those with CKD stage 5 versus stage 4, who were not treated with vitamin D metabolites (18 vs. 65 pg/ml, respectively; P < 0.05). All three PTH measurements increased with worsening eGFR, with this finding being more pronounced in those patients who were not treated with vitamin D metabolites. The slope of the regression line of cPTH on eGFR tended to be steeper, -0.90, compared to -0.81 for total PTH and -0.80 for 1-84 PTH (P = 0.06). The ratio of total PTH to cPTH did decrease significantly through the range of CKD stages (P = 0.03). The determinants of PTH were similar for all three PTH measurements, with eGFR having a strong inverse relationship, with weaker relationships for 25-OHD and ionized calcium on multivariate analyses. We confirm that there is a complex relationship between 25-OHD, eGFR, and PTH. Total PTH, 1-84 PTH, and cPTH increase with increasing CKD stages, with a relatively greater increase in cPTH, although the clinical significance of this finding remains uncertain. The three PTH measurements had similar correlations with the biochemical and clinical variables studied, suggesting that either total PTH or 1-84 PTH can be used in clinical practice when evaluating vitamin D and PTH status.

Creatinine fluctuation has a greater effect than the formula to estimate glomerular filtration rate on the prevalence of chronic kidney disease.

BACKGROUND/AIMS: Cases of chronic kidney disease (CKD) are defined by the estimated glomerular filtration rate (eGFR), calculated using the Modified Diet in Renal Disease (MDRD) or, more recently, the CKD Epidemiology Collaboration (CKD-EPI) formula. This study set out to promote a systematic approach to reporting CKD prevalence. DESIGN, SETTING, PARTICIPANTS AND MEASUREMENTS: The study explores the impact of the way in which eGFR is calculated on the prevalence of CKD. We took into account whether including (1) ethnicity, (2) using a single eGFR, (3) using more than 1 eGFR value or (4) using the CKD-EPI formula affected the estimates of prevalence. SAMPLE: Of 930,997 registered patients, 36% (332,891) have their eGFR defined (63% of those aged 50-74 years, 81% >75 years). RESULTS: The prevalence of stage 3-5 CKD is 5.41% (n = 50,331). (1) Not including ethnicity data the prevalence would be 5.49%, (2) just using the latest eGFR 6.4%, (3) excluding intermediary values 5.55% and (4) using the CKD-EPI equation 4.8%. All changes in eGFR (t test) and the proportion with CKD (χ(2) test) were significant (p < 0.001). Using serum-creatinine-calculated eGFR instead of laboratory data reduced the prevalence of stage 3-5 CKD by around 0.01%. Sixty-six percent of people with stage 3-5 disease have cardiovascular disease and 4.0% significant proteinuria using the MDRD formula; the corresponding figures using CKD-EPI are 74 and 4.6%. CONCLUSIONS: A standardised approach to reporting case finding would allow a better comparison of prevalence estimates. Using a single eGFR tends to inflate the reported prevalence of CKD by ignoring creatinine fluctuation; this effect is greater than the difference between MDRD and CKD-EPI.

Confidence and quality in managing CKD compared with other cardiovascular diseases and diabetes mellitus: a linked study of questionnaire and routine primary care data.

BACKGROUND: Much of chronic disease is managed in primary care and chronic kidney disease (CKD) is a recent addition. We are conducting a cluster randomised study of quality improvement interventions in CKD (QICKD) - Clinical Trials Registration: ISRCTN56023731. CKD registers have a lower than expected prevalence and an initial focus group study suggested variable levels of confidence in managing CKD. Our objective is to compare practitioner confidence and achievement of quality indicators for CKD with hypertension and diabetes. METHOD: We validated a new questionnaire to test confidence. We compared confidence with achievement of pay-for-performance indicators (P4P) and implementation of evidence-based guidance. We achieved a 74% (148/201) response rate. RESULTS: 87% (n = 128) of respondents are confident in managing hypertension (HT) compared with 59% (n = 87) in managing HT in CKD (HT+CKD); and with 61% (n = 90) in HT, CKD and diabetes (CKD+HT+DM). 85.2% (P4P) and 62.5% (National targets) of patients with hypertension are at target; in patients with HT and CKD 65.1% and 53.3%; in patients with HT, CKD and DM 67.8% and 29.6%. Confidence in managing proteinuria in CKD is low (42%, n = 62). 87% of respondents knew BP treatment thresholds in CKD, but only 53% when proteinuria is factored in. Male GPs, younger (< 35 yrs), and older (> 54 yrs) clinicians are more confident than females and 35 to 54 year olds in managing CKD. 84% of patients with hypertension treated with angiotensin modulating drugs achieve achieved P4P targets compared to 67% of patients with CKD. CONCLUSIONS: Practitioners are less likely to achieve management targets where their confidence is low.

Managing Access by Generating Improvements in Cannulation: A national quality improvement project.

Cannulation is essential for haemodialysis with arteriovenous access, but also damages the arteriovenous access making it prone to failure, is associated with complications and affects patients' experiences of haemodialysis. Managing Access by Generating Improvements in Cannulation is a national UK quality improvement project, designed to improve cannulation practice in the United Kingdom, ensuring it reflects current needling recommendations. It uses a simple quality improvement method, the Model for Improvement, to structure improvement to cannulation practice. It assists units in the practical implementation of the British Renal Society and Vascular Access Society of Britain and Ireland needling recommendations, ensuring actual cannulation practice reflects what is defined as best practice in cannulation. An eLearning package and awareness materials have been developed, to assist units in changing their cannulation practice. The Kidney Quality Improvement Partnership provides a structure for Managing Access by Generating Improvements in Cannulation that promotes development and dissemination. It is hoped that Managing Access by Generating Improvements in Cannulation will raise an understanding about the cannulation of arteriovenous access and change behaviours and beliefs around correct cannulation practice, to ensure longevity of this lifeline.

Broadening Options for Long-term Dialysis in the Elderly (BOLDE): differences in quality of life on peritoneal dialysis compared to haemodialysis for older patients.

BACKGROUND: Health-related quality of life (QOL) is an important outcome for older people who are often on dialysis for life. Little is, however, known about differences in QOL on haemodialysis (HD) and peritoneal dialysis (PD) in older age groups. Randomising patients to either modality to assess outcomes is not feasible. METHODS: In this cross-sectional, multi-centred study we conducted QOL assessments (Short Form-12 Mental and Physical Component Summary scales, Hospital Anxiety and Depression Scale and Illness Intrusiveness Ratings Scale) in 140 people (aged 65 years or older) on PD and HD. RESULTS: The groups were similar in age, gender, time on dialysis, ethnicity, Index of Deprivation (based on postcode), dialysis adequacy, cognitive function (Mini-Mental State Exam and Trail-Making Test B), nutritional status (Subjective Global Assessment) and social networks. There was a higher comorbidity score in the HD group. Regression analyses were undertaken to ascertain which variables significantly influence each QOL assessment. All were influenced by symptom count highlighting that the patient's perception of their symptoms is a critical determinant of their mental and physical well being. Modality was found to be an independent predictor of illness intrusion with greater intrusion felt in those on HD. CONCLUSIONS: Overall, in two closely matched demographic groups of older dialysis patients, QOL was similar, if not better, in those on PD. This study strongly supports offering PD to all suitable older people.

Chronic kidney disease in adults: assessment and management.

Chronic kidney disease (CKD) is a common condition associated with significant amenable morbidity and mortality, primarily related to the substantially increased risk of cardiovascular disease (CVD) in this population. Early detection of people with CKD is important so that treatment can be initiated to prevent or delay kidney disease progression, reduce or prevent the development of complications, and reduce the risk of CVD. Classification of CKD by the estimated glomerular filtration rate and urine albumin to creatinine ratio identifies those at greatest risk of adverse outcomes. This concise guideline highlights the key recommendations of the National Institute for Health and Care Excellence guideline Chronic kidney disease in adults: assessment and management: Clinical guideline [CG182], published in July 2014. It focuses on recommendations most relevant to secondary care physicians.