Exploring young people's attitudes to HIV prevention medication (PrEP) in England: a qualitative study.

INTRODUCTION: Young people aged 18-24 years old are a key demographic target for eliminating HIV transmission globally. Pre-exposure prophylaxis (PrEP), a prevention medication, reduces HIV transmission. Despite good uptake by gay and bisexual men who have sex with men, hesitancy to use PrEP has been observed in other groups, such as young people and people from ethnic minority backgrounds. The aim of this study was to explore young people's perceptions and attitudes to using PrEP. DESIGN: A qualitative transcendental phenomenological design was used. PARTICIPANTS AND SETTING: A convenience sample of 24 young people aged between 18 and 24 years was recruited from England. METHODS: Semistructured interviews and graphical elicitation were used to collect data including questions about current experiences of HIV care, awareness of using PrEP and decision-making about accessing PrEP. Thematic and visual analyses were used to identify findings. RESULTS: Young people had good levels of knowledge about HIV but poor understanding of using PrEP. In this information vacuum, negative stigma and stereotypes about HIV and homosexuality were transferred to using PrEP, which were reinforced by cultural norms portrayed on social media, television and film-such as an association between using PrEP and being a promiscuous, white, gay male. In addition, young people from ethnic minority communities appeared to have negative attitudes to PrEP use, compared with ethnic majority counterparts. This meant these young people in our study were unable to make decisions about when and how to use PrEP. CONCLUSION: Findings indicate an information vacuum for young people regarding PrEP. A strength of the study is that theoretical data saturation was reached. A limitation of the study is participants were largely from Northern England, which has low prevalence of HIV. Further work is required to explore the information needs of young people in relation to PrEP.

Multiparametric Renal Magnetic Resonance Imaging for Prediction and Annual Monitoring of the Progression of Chronic Kidney Disease over Two Years.

BACKGROUND: Multiparametric renal Magnetic Resonance Imaging (MRI) provides a non-invasive method to assess kidney structure and function, but longitudinal studies are limited. METHODS: A total of 22 patients with CKD category G3-4 (estimated glomerular filtration rate (eGFR) 15-59 mL/min/1.73 m2) were recruited. Annual 3T multiparametric renal MRI scans were performed, comprising total kidney volume (TKV), longitudinal relaxation time (T1), apparent diffusion coefficient (ADC), Arterial Spin Labelling, and Blood Oxygen Level Dependent relaxation time (T2*), with 15 patients completing a Year 2 scan. CKD progression over 2 years was defined as eGFR_slope ≥ -5 mL/min/1.73 m2/year. RESULTS: At baseline, T1 was higher (cortex p = 0.05, medulla p = 0.03) and cortex perfusion lower (p = 0.015) in participants with subsequent progression versus stable eGFR. A significant decrease in TKV and ADC and an increase in cortex T1 occurred in progressors at Year 1 and Year 2, with a significant decrease in perfusion in progressors only at Year 2. The only decline in the stable group was a reduction in TKV. There was no significant change in cortex or medulla T2* at Year 1 or Year 2 for progressors or stable participants. CONCLUSION: Lower renal cortex perfusion and higher T1 in the cortex and medulla may predict CKD progression, while renal cortex T1, TKV, and ADC may be useful to monitor progression. This study provides pilot data for future large-scale studies.

Electronic alerts in acute kidney injury: why does evidence of benefit remain elusive?

PURPOSE OF REVIEW: Acute kidney injury (AKI) is a common syndrome characterized by a sudden reduction in kidney function. It is strongly associated with high mortality and longer, more expensive hospital stays. As AKI often presents silently, a lack of recognition can prevent recommended standards of care. Over the last decade or more, electronic alerts (eAlerts) for AKI have been studied and implemented to address this. This review will summarize the major randomized trials in this area. RECENT FINDINGS: A number of randomized trials now exist that study the effectiveness of AKI eAlerts in isolation or as part of more complex interventions. Varying results arise from differences in study design, healthcare system in which the eAlert is introduced, nature of alert, supporting interventions, implementation plan, stated aim (prevention or treatment of established AKI) and choice of outcome measures. SUMMARY: Current randomized trial evidence does not show any benefit of eAlerts on mortality. However, variously reported reductions in AKI incidence, AKI progression and AKI duration support a conclusion that strategies incorporating eAlerts can meaningfully benefit delivery of AKI care. Future work should consider how best eAlerts can be utilised, targeted and implemented.

Investigation of N,N,N-Trimethyl-L-alanyl-L-proline Betaine (TMAP) as a Biomarker of Kidney Function.

Glomerular filtration rate (GFR) is the most widely used tool for the measurement of kidney function, but endogenous biomarkers such as cystatin C and creatinine have limitations. A previous metabolomic study revealed N,N,N-trimethyl-L-alanyl-L-proline betaine (TMAP) to be reflective of kidney function. In this study, we developed a quantitative LCMS assay for the measurement of TMAP and evaluated TMAP as a biomarker of GFR. An assay to measure TMAP was developed using liquid chromatography-mass spectrometry. After validation of the method, we applied it to plasma samples from three distinct kidney disease patient cohorts: nondialysis chronic kidney disease (CKD) patients, patients receiving peritoneal and hemodialysis, and living kidney donors. We investigated whether TMAP was conserved in other mammalian and nonmammalian species, by analyzing plasma samples from Wistar rats with diet-induced CKD and searching for putative matches to the m/z for TMAP and its known fragments in the raw sample data repository "Metabolomics Workbench". The assay can measure plasma TMAP at a lower limit of quantitation (100 ng/mL) with an interday precision and accuracy of 12.8 and 12.1%, respectively. In all three patient cohorts, TMAP concentrations are significantly higher in patients with CKD than in controls with a normal GFR. Further, TMAP concentrations are also elevated in rats with CKD and TMAP is present in the sap produced from Acer saccharum trees. TMAP concentration is inversely related to GFR suggesting that it is a marker of kidney function. TMAP is present in nonmammalian species suggesting that it is part of a biologically conserved process.

Multiparametric MRI assessment of renal structure and function in acute kidney injury and renal recovery.

BACKGROUND: Acute kidney injury (AKI) is associated with a marked increase in mortality as well as subsequent chronic kidney disease (CKD) and end-stage kidney disease. We performed multiparametric magnetic resonance imaging (MRI) with the aim of identifying potential non-invasive MRI markers of renal pathophysiology in AKI and during recovery. METHODS: Nine participants underwent inpatient MRI scans at time of AKI; seven had follow-up scans at 3 months and 1 year following AKI. Multiparametric renal MRI assessed total kidney volume (TKV), renal perfusion using arterial spin labelling, T1 mapping and blood oxygen level-dependent (BOLD) R2* mapping. RESULTS: Serum creatinine concentration had recovered to baseline levels at 1-year post-AKI in all participants. At the time of AKI, participants had increased TKV, increased cortex/medulla T1 and reduced cortical perfusion compared with the expected ranges in healthy volunteers and people with CKD. TKV and T1 values decreased over time after AKI and returned to expected values in most but not all patients by 1 year. Cortical perfusion improved to a lesser extent and remained below the expected range in the majority of patients by 1-year post-AKI. BOLD R2* data showed a non-significant trend to increase over time post-AKI. CONCLUSIONS: We observed a substantial increase in TKV and T1 during AKI and a marked decrease in cortical perfusion. Despite biochemical recovery at 1-year post-AKI, MRI measures indicated persisting abnormalities in some patients. We propose that such patients may be more likely to have further AKI episodes or progress to CKD and further longitudinal studies are required to investigate this. .

Collapsing Glomerulopathy Affecting Native and Transplant Kidneys in Individuals with COVID-19.

Since the emergency of novel coronavirus COVID-19 (SARS-CoV-2) in December 2019, infections have spread rapidly across the world. The reported incidence of acute kidney injury (AKI) in the context of COVID-19 is variable, and its mechanism is not well understood. Data are emerging about possible mechanisms of AKI including virus-induced cytopathic effect and cytokine storm-induced injury. To date, there have been few reports of kidney biopsy findings in the context of AKI in COVID-19 infection. This article describes 2 cases of collapsing glomerulopathy, 1 in a native kidney and, for the first time, 1 in a kidney transplant. Both individuals were black, and both presented without significant respiratory compromise. Indeed, the 2 patients we describe remained systemically well for the majority of their inpatient stay, which would support the hypothesis that for these patients, AKI was caused by a cytopathic viral effect, rather than that of a cytokine storm or acute tubular necrosis caused by prolonged hypovolaemia or the effect of medication known to exacerbate AKI. Here, we report 2 cases of AKI with collapsing glomerulopathy in COVID-19, one of which is in a kidney transplant recipient, not previously described elsewhere.

Correction to: Phase-contrast magnetic resonance imaging to assess renal perfusion: a systematic review and statement paper.

The article Phase­contrast magnetic resonance imaging to assess renal perfusion: a systematic review and statement paper, written by Giulia Villa, Steffen Ringgaard, Ingo Hermann, Rebecca Noble, Paolo Brambilla, Dinah S. Khatir, Frank G. Zöllner, Susan T. Francis, Nicholas M. Selby, Andrea Remuzzi and Anna Caroli, was originally published electronically on the publisher's internet portal on 17 August 2019 without open access.

Long-Term Outcomes in Patients with Acute Kidney Injury.

The long-term sequelae of AKI have received increasing attention so that its associations with a number of adverse outcomes, including higher mortality and development of CKD, are now widely appreciated. These associations take on particular importance when considering the high incidence of AKI, with a lack of proven interventions and uncertainties around optimal care provision meaning that the long-term sequelae of AKI present a major unmet clinical need. In this review, we examine the published data that inform our current understanding of long-term outcomes following AKI and discuss potential knowledge gaps, covering long-term mortality, CKD, progression to ESKD, proteinuria, cardiovascular events, recurrent AKI, and hospital readmission.

Phase-contrast magnetic resonance imaging to assess renal perfusion: a systematic review and statement paper.

OBJECTIVE: Phase-contrast magnetic resonance imaging (PC-MRI) is a non-invasive method used to compute blood flow velocity and volume. This systematic review aims to discuss the current status of renal PC-MRI and provide practical recommendations which could inform future clinical studies and its adoption in clinical practice. METHODOLOGY: A comprehensive search of all the PC-MRI studies in human healthy subjects or patients related to the kidneys was performed. RESULTS: A total of 39 studies were included in which PC-MRI was used to measure renal blood flow (RBF) alongside other derivative hemodynamic parameters. PC-MRI generally showed good correlation with gold standard methods of RBF measurement, both in vitro and in vivo, and good reproducibility. Despite PC-MRI not being routinely used in clinical practice, there are several clinical studies showing its potential to support diagnosis and monitoring of renal diseases, in particular renovascular disease, chronic kidney disease and autosomal dominant polycystic kidney disease. DISCUSSION: Renal PC-MRI shows promise as a non-invasive technique to reliably measure RBF, both in healthy volunteers and in patients with renal disease. Future multicentric studies are needed to provide definitive normative ranges and to demonstrate the clinical potential of PC-MRI, likely as part of a multi-parametric renal MRI protocol.

The 'Nifty Fifty': medical student ward work guide.

BACKGROUND: Final-year medical students have many timetabled clinical and academic commitments. Independent ward time is an opportunity for students to experience situated learning; however, there are a number of barriers to participation. We aimed to identify barriers to independent ward work and provide a tool to maximise learning opportunities and encourage multidisciplinary learning. We created the booklet: Nifty Fifty: Ways to Avoid Being a Trip Hazard on the Wards using anecdotal and personal experience to guide curriculum-orientated learning. METHODS: Students undertaking attachments on medical wards at Queen's Medical Centre in Nottingham, UK, were provided with a small printed handbook of 50 suggested activities to participate in when on a ward. Feedback was collected at the beginning, middle and end of the attachment, with the handbook distributed following a mid-attachment questionnaire. This feedback was compared with that of a control group. Quantitative data were subsequently analysed. We created the booklet: Nifty Fifty … using anecdotal and personal experience to guide curriculum-orientated learning RESULTS: Post-intervention feedback showed an improvement in the frequency of ward attendance, a reduction in the perceived barriers to independent ward work and an increase in the perceived usefulness of ward attendance. Students who received the handbook reported an improvement in confidence in self-directed ward work compared with the control group. DISCUSSION: We have demonstrated that a simple handbook may assist in the facilitation of independent ward work for final-year medical students, with widespread improvements in measured outcomes. Our project was limited by size, but we believe that its positive results could be scaled up.

Evaluating a process of academic detailing in primary care: an educational programme for acute kidney injury.

BACKGROUND: Primary care has a significant role in AKI management: two-thirds of AKI originates in the community. Through academic detailing (an evidence-based educational approach) we aimed to implement and measure the effect of a primary care-based education programme based around academic detailing and peer-reviewed audit. METHODS: The education programme took place across a large clinical commissioning group (CCG) consisting of 55 primary care practices. All 55 practices participated in large group teaching sessions, 25 practices participated in academic detailing and 28 of the remaining 30 practices performed internal AKI audit. Over a 12 month period, an educational programme was delivered consisting of large group teaching sessions followed by either academic detailing sessions or self-directed AKI audit activity. Academic detailing sessions consisted of a short presentation by a consultant nephrologist followed by discussion of cases. Qualitative feedback was collected from all participants at peer review sessions. Web-based, CCG-wide questionnaires assessed baseline and post-intervention knowledge levels. RESULTS: Nine hundred ninety-six individuals completed the questionnaires (556 at baseline, 440 at 1 yr., 288 participated in both). Exposure to AKI teaching, self-reported awareness and confidence levels were higher in the second questionnaire. There was a significant increase in the percentage of correct answers before and after the intervention (55.6 ± 21% versus 87.5 ± 20%, p < 0.001). Improvements were also seen in practices that did not participate in academic detailing. 92.9% of participants in the academic detailing sessions ranked their usefulness as high, but half of participants expressed some anxiety about discussion of cases in front of peers. CONCLUSION: Primary care education can improve knowledge and awareness of AKI. Small group teaching with involvement of a nephrologist was popular, although there were mixed responses to group discussion of real cases. Academic detailing did not appear more effective than other educational formats.