Acute interstitial nephritis following SARS-CoV-2 virus vaccination.

A number of reports have described new onset or relapse of existing glomerular disease after severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) vaccination. More and more of these cases continue to emerge, and the European Medicines Agency (EMA) has recently launched an in-depth investigation to ascertain the true frequency of such renal side effects. In comparison, acute interstitial nephritis after SARS-CoV-2 vaccination has only been described in 1 solitary case. Here, we describe a case of acute kidney injury due to biopsy-proven acute interstitial nephritis soon after SARS-CoV-2 vaccination with the Astra-Zeneca vaccine. The patient responded well to steroids, although he required temporary renal replacement therapy. A thorough medical history failed to elucidate any plausible explanation or trigger other than the preceding vaccination. We acknowledge the possibility that other factors could have triggered acute interstitial nephritis in the case described here. Similar uncertainty exists regarding glomerular disease reported in conjunction with SARS-CoV-2 vaccination. However, we note that acute interstitial nephritis associated with vaccination has been described before the pandemic, and we therefore feel that a link is possible. We suggest that nephrologists should be vigilant when they see cases of unexplained acute interstitial nephritis. A history of preceding SARS-CoV-2 vaccination should be explored, and cases should be reported within national systems of pharmacovigilance.

Implementation of a frailty screening programme and Geriatric Assessment Service in a nephrology centre: a quality improvement project.

INTRODUCTION: The aims of this quality improvement project were to: (1) proactively identify people living with frailty and CKD; (2) introduce a practical assessment, using the principles of the comprehensive geriatric assessment (CGA), for people living with frailty and chronic kidney disease (CKD) able to identify problems; and (3) introduce person-centred management plans for people living with frailty and CKD. METHODS: A frailty screening programme, using the Clinical Frailty Scale (CFS), was introduced in September 2018. A Geriatric Assessment (GA) was offered to patients with CFS ≥ 5 and non-dialysis- or dialysis-dependent CKD. Renal Frailty Multidisciplinary Team (MDT) meetings were established to discuss needs identified and implement a person-centred management plan. RESULTS: A total of 450 outpatients were screened using the CFS. One hundred and fifty patients (33%) were screened as frail. Each point increase in the CFS score was independently associated with a hospitalisation hazard ratio of 1.35 (95% CI 1.20-1.53) and a mortality hazard ratio of 2.15 (95% CI 1.63-2.85). Thirty-five patients received a GA and were discussed at a MDT meeting. Patients experienced a median of 5.0 (IQR 3.0) problems, with 34 (97%) patients experiencing at least three problems. CONCLUSIONS: This quality improvement project details an approach to the implementation of a frailty screening programme and GA service within a nephrology centre. Patients living with frailty and CKD at risk of adverse outcomes can be identified using the CFS. Furthermore, a GA can be used to identify problems and implement a person-centred management plan that aims to improve outcomes for this vulnerable group of patients.

Let food be thy medicine and medicine be thy food?

Ensuring adequate nutrition in children with chronic kidney disease whilst avoiding hyperkalaemia can be a difficult balance to achieve. Pre-treatment of feeds, whether milk, formula or enteral nutrition, with sodium polystyrene sulfonate (SPS) is practiced in some paediatric centres internationally. Such treatments are purported to avoid the potentially serious complications of direct administration of SPS, such as intestinal necrosis, aspiration pneumonitis and metabolic alkalosis to name but a few. Although described some 45 years ago, this study by Palma et al. is only the second retrospective study to describe the clinical consequence of pre-treating feeds with SPS with the majority of earlier studies describing only the in vitro effects of this method. Whilst effective in reducing serum potassium, the authors justifiably highlight the high incidence of complications, such as hypokalaemia (31.6%) and hypernatraemia (26.3%). We have further highlighted this with a summary of the available literature on this subject demonstrating the gross alterations of the electrolyte composition of feeds following SPS pre-treatment and clinical complications in its application. We heartily agree and support the conclusion by Palma et al. that where this therapy is practiced, close monitoring of electrolytes is essential and much more work is needed to identify those patient cohorts for which this can indeed be considered a safe and effective intervention.

Thrice-Weekly Nocturnal In-Centre Haemodiafiltration: A 2-Year Experience.

BACKGROUND: Adequate control of plasma phosphate without phosphate binders is difficult to achieve on a thrice-weekly haemodialysis schedule. The use of quotidian nocturnal dialysis is effective but not practical in the in-centre setting. This quality improvement project was set up as an exercise allowing the evaluation of small-solute clearance by combining convection with extended-hour dialysis in a thrice-weekly hospital setting. METHODS: A single-centred, prospective analysis of patients' electronic records was performed from August 2012 to July 2014. The duration of haemodiafiltration was increased from a median of 4.5 to 8 h. Dialysis adequacy, biochemical parameters and medications were reviewed on a monthly basis. A reduction in plasma phosphate was anticipated, so all phosphate binders were stopped. RESULTS: Since inception, 14 patients have participated with over 2,000 sessions of dialysis. The pre-dialysis phosphate level fell from a mean of 1.52 ± 0.4 to 1.06 ± 0.1 mmol/l (p < 0.05). The average binder intake of 3.26 ± 2.6 tablets was eliminated. A normal plasma phosphate range has been maintained with increased dietary phosphate intake and no requirement for intradialytic phosphate supplementation. CONCLUSION: Phosphate control can be achieved without the need for binders or supplementation on a thrice-weekly in-centre haemodiafiltration program.

Socio-economic status influences chronic kidney disease prevalence in primary care: a community-based cross-sectional analysis.

BACKGROUND: Primary care chronic kidney disease (CKD) registers report widely varying prevalence within the UK. We examined the effects of laboratory ascertainment and adjusting for practice-level variables on the variation in CKD prevalence. We carried out an Ayrshire-wide laboratory database analysis of primary care practices (PCPs). METHODS: We analysed 54 PCPs with 313 639 registered patients aged ≥ 18. All patients with a low estimated glomerular filtration rate (<60 mL/min/1.73 m(2)) had their serum creatinine values extracted from 1st January 2009 to 31st March 2012. Individuals with CKD stage 3-5 were identified with an algorithm that confirmed chronicity. These data were linked to PCP attributes from Information Services Division, Scotland. Using laboratory-ascertained CKD prevalence, we examined whether adjusting for practice-level factors [socio-economic status (SES), rurality and patients to general practitioner ratio (PGR)] and patient-level factors (age, gender) explained some of the observed variation among PCPs. Individual and combined hierarchical multilinear regression models were used. RESULTS: Eighteen thousand two hundred and eighty-five (5.8%) had CKD stage 3-5 on 31 March 2011. SES, rurality and PGR predicted 39% (F(3,50) = 12.37, P < 0.001) of the variation in prevalence with SES exerting the most influence (25%). With the stepwise addition of explanatory variables, variation between practices fell from 3.9-fold using PCP register prevalence to laboratory ascertained (3.1-fold variation), with age and gender adjustment (further fall to 2.1-fold), and lastly to 1.8-fold variation with adjustment for SES. Funnel plots using these adjustments reduced the number of outliers outside of 3 SD from 15 to 7 to 6, and outliers between 2 and 3 SD by 16 to 13 to 5. CONCLUSIONS: Laboratory ascertainment is practicable, reduces variation and facilitates benchmarking. PCP attributes other than age and gender impact on prevalence. Over a third of variation in CKD prevalence among PCPs can be explained by rurality, PGR and especially SES even after age and gender stratification.