Tinzaparin for venous thromboembolism in patients with renal impairment: a single-centre, prospective pilot study.

BACKGROUND: Low molecular weight heparins (LMWH) are used extensively for prophylaxis and treatment of venous thromboembolism (VTE), bridging therapy for warfarin and standard of care in cancer-associated VTE (CA-VTE). Tinzaparin has the highest molecular weight of all LMWH and relies least on renal clearance to Cockcroft-Gault creatinine clearance (CrCl) of 20 mL/min. Previous pharmacological studies have demonstrated safety and effectiveness in elderly patients. Prospective clinical trials have confirmed these findings to CrCl 20 mL/min and in CA-VTE. We describe the pilot program developed at Concord Repatriation General Hospital for tinzaparin. AIMS: We aim to confirm the deliverability of tinzaparin in patients with renal insufficiency. METHODS: Twenty patients were established on tinzaparin as therapeutic anticoagulation with CrCl or CKD-EPI estimated glomerular filtration rate (eGFR) 20-50 mL/min with an indication for anticoagulation. Tinzaparin was given as a subcutaneous injection at 175 units/kg as a single daily dose, rounded to the nearest vial size. Tinzaparin anti-Xa levels were tested at Days 2, 7 and 14 (±1 day) and transition to oral anticoagulants were allowed at clinician discretion. RESULTS: No accumulation of tinzaparin was seen into Day 14. Two patients required dose-adjustment, five patients had bleeding complications (two major, three minor) and four patients died during follow-up, all attributable to patients' comorbidities. CrCl and body surface area-standardised CrCl were significantly correlated with tinzaparin anti-Xa level only on Day 2, and this effect was lost when patients with CrCl >50 mL/min were excluded. Data from our cohort confirm the deliverability of therapeutic tinzaparin in patients with CrCl or CKD-EPI eGFR 20-50 mL/min. Bleeding and death outcomes were also comparable to other trials using tinzaparin in CA-VTE. CONCLUSION: For patients with renal insufficiency, tinzaparin represents an attractive alternative anticoagulant with once-daily administration in a range of potential indications.

Attitudes of health professionals to using routinely collected clinical data for performance feedback and personalised professional development.

OBJECTIVES: To learn the attitudes of health professionals, health informaticians and information communication technology professionals to using data in electronic health records (eHRs) for performance feedback and professional development. DESIGN: Qualitative research in a co-design framework. Health professionals' perceptions of the accessibility of data in eHRs, and barriers to and enablers of using these data in performance feedback and professional development were explored in co-design workshops. Audio recordings of the workshops were transcribed, de-identified, and thematically analysed. SETTING, PARTICIPANTS: A total of nine co-design workshops were held in two major public hospitals in Sydney: three for nursing staff (ten participants), three for doctors (15 participants), and one each for information communication technology professionals (six participants), health informaticians (four participants), and allied health professionals (13 participants). MAIN OUTCOME MEASURES: Key themes related to attitudes of participants to the secondary use of eHR data for improving health care practice. RESULTS: Six themes emerged from the discussions in the workshops: enthusiasm for feeding back clinical data; formative rather than punitive use; peer comparison, benchmarking, and collaborative learning; data access and use; capturing complex clinical narratives; and system design challenges. Barriers to secondary use of eHR data included access to information, measuring performance on the basis of eHR data, and technical questions. CONCLUSIONS: Our findings will inform the development of programs designed to utilise routinely collected eHR data for performance feedback and professional development.

End-stage kidney disease in Fiji.

BACKGROUND: Chronic kidney disease is now a leading cause of death in Fiji. The country lacks even basic statistics about the incidence of end-stage kidney disease (ESKD) and presents significant challenges to conducting clinical research. AIM: To estimate the incidence and characteristics of ESKD in Fijian adults. METHODS: A retrospective cohort study was conducted of patients admitted to Colonial War Memorial Hospital in Suva, Fiji, in 2012. Suspected ESKD cases were identified from laboratory registers of renal function tests and confirmed through medical record review. Population data were from the Fijian Bureau of Statistics. RESULTS: Screening identified 1474 suspected ESKD cases. Following removal of 763 duplicates and cases with discrepant identifiers, 711 unique cases remained. An additional 552 cases met exclusion criteria, including acute kidney injury (247), failure to be admitted (131) and pre-existing ESKD diagnosis (103), leaving 159 cases of confirmed ESKD. Median age was 57 years (interquartile range 47-65). Crude and age-adjusted ESKD incidence rates were 753 per million population (pmp) (95% confidence interval (CI) 636-870) and 793 pmp (95% CI 669-916), respectively, rising to 938 pmp (95% CI 804-1072) if African-American correction was removed. Diabetic nephropathy was the most common cause of ESKD (65.4%). CONCLUSION: The incidence of ESKD in Fiji is high. This is a substantial public health problem that is likely impacting life expectancy and quality of life. Improving screening, detection and management of kidney disease should be given more prominence in programmes to address non-communicable diseases in Fiji and the Western Pacific.

Age-specific risk of renal graft loss from late acute rejection or non-compliance in the adolescent and young adult period.

AIMS: The aims of this study were to identify if an age-specific high-risk window for graft loss is present in Australia and New Zealand and identify the aetiology for such graft loss using the Australia and New Zealand Dialysis and Transplant Registry. METHODS: Retrospective cohort analysis of all renal transplants were performed in Australia and New Zealand during 1985-2010 in which the graft survived >3 months and the patient spent at least some time aged 10-30 years inclusive while the graft was functioning. Adjusted hazard ratio (aHR) for graft loss according to age, sex, race, cause of end-stage kidney disease, transition, era of transplantation, donor type and human leucocyte antigen mismatch were calculated using an extended Cox proportional hazards model for graft loss from any cause and graft loss from late acute rejection (LAR) or non-compliance. RESULTS: A total of 3289 grafts in 3048 recipients were included. A total of 757 grafts failed including 110 (15 %) from LAR or non-compliance. Age was strongly associated with graft loss from LAR or non-compliance (p < 0.001). Compared with age 10-12 years, the risk of graft loss from LAR or non-compliance was significantly increased from 16-24 years, peaking at 19-21 years (aHR 11.3, 95% confidence interval (CI) 1.5-84.3, p < 0.001). Indigenous race was associated with LAR or non-compliance (aHR 3.5, 95% CI 2.1-5.6) whereas paediatric-to-adult transition with a functioning transplant was not (aHR 1.2, 95% CI 0.4-3.5, p = 0.68). CONCLUSION: The high risk of graft loss during adolescence and young adulthood is primarily due to LAR or non-compliance. The elevated risk continues well into the 20s and is independent of paediatric-to-adult transition.

A survey of current procedural practices of Australian and New Zealand nephrologists.

The aim of this study was to describe the range and extent of current procedural practices of Nephrologists and trainees in Australia and New Zealand with a specific focus on renal biopsy. A web-based survey was constructed based on a 2009 pilot survey conducted by the authors. The survey was distributed by email. A total of 118 responses were received from 60 centers, including six pediatric centers; Nephrologists or trainees performed the following procedures: urine microscopy 36.4%; diagnostic ultrasound 10.2%; renal biopsy 93.2%; simple vascath insertion 64.4%; cuffed vascath insertion 22%; peritoneal catheter insertion 16.9%; fistula ultrasound 20.3%; and fistulography 5%. Trainees performed most renal biopsies (67.8% of respondents) and real-time ultrasound was the commonest technique (97%). The majority of respondents believe that renal biopsy is an essential skill for trainees (78.8%); 10-25 biopsies are required for trainee proficiency (59.3%); an online training module would assist in teaching renal biopsies (67.8%). Cuffed catheter insertion and fistulography were more often performed in nonmetropolitan than in metropolitan centers. Procedures are part of Australian and New Zealand Nephrology, including specialized procedures in a minority of centers. Vascular access procedures are more common in nonmetropolitan centers. Renal biopsy is an important skill, considered essential for trainees by most.

Incidence, treatment patterns and clinical outcomes associated with acute kidney injury in Fiji: a retrospective cohort study.

AIM: This study aims to describe the incidence and outcomes of acute kidney injury at Fiji's tertiary referral hospital. METHODS: A retrospective study of adults aged ≥ 18 years hospitalised at the Colonial War Memorial Hospital between 1 January and 30 June, 2015 was conducted. Acute kidney injury was defined using the 2012 Kidney Disease Improving Global Outcomes (KDIGO) guidelines by medical record review. RESULTS: One hundred ten (2.1%) of 5140 hospitalised patients met the diagnostic criteria for acute kidney injury. Fifty-two cases (47%) of acute kidney injury were stage 1, 11 (10%) cases were stage 2, and 47 (43%) cases were stage 3. Acute sepsis (n = 68) and dehydrating illness (n = 52) were the most common causes. Thirty-nine patients had urinalysis and 36 received imaging; none underwent kidney biopsy. Treatment included antibiotics (n = 91), intravenous fluids (n = 84) and vasopressors (n = 25). Twenty-one (19%) patients were treated with intermittent haemodialysis. Forty-seven patients (43%) with acute kidney injury died including 16 (76%) dialysed patients. Crude mortality at 7 days was 19 (40%). Of the 63 patients who survived their primary illness, 29 (46%) had a follow-up assessment at 3 months. CONCLUSION: In patients needing hospitalisation for acute kidney injury in Fiji, the most common causes were sepsis and dehydration. Mortality was high, in particular in those who received dialysis. Follow-up after acute kidney injury is incomplete.

Nationwide survey of adolescents and young adults with end-stage kidney disease.

AIM: To better understand the health-care needs of adolescents and young adults (AYA) with end-stage kidney disease (ESKD), we sought to describe the demographic characteristics of a national cohort. METHODS: Data were retrieved from the Australia and New Zealand Dialysis and Transplant Registry. We included all patients aged 15-25 years, living in Australia and receiving renal replacement therapy (RRT) on 31 December 2009. Data included race, aetiology of kidney disease, postal code, transition and migration history. RESULTS: A total of 495 AYA were receiving RRT in Australia giving a prevalence of 143 per million age-related population. Sixty-three per cent had a functioning transplant, 24% were receiving haemodialysis and 13% peritoneal dialysis. Median current age was 22 years (interquartile range (IQR) 19-24). The most prevalent cause of ESKD was glomerulonephritis (33%). The majority of patients lived in capital cities. Indigenous patients were more likely to live in more remote areas. Eighty-five per cent of patients were currently receiving care at an adult unit and 35% of these patients had transitioned from a paediatric unit since starting RRT. The median number of patients per adult unit was 5 (IQR 3-10). CONCLUSIONS: The majority of Australian AYA with ESKD are managed in adult units; however, the number at any one unit is low. As most live in the capital cities there may be an opportunity to establish centralized services designed to cater for the needs of AYA patients. However, the needs of patients living in more remote areas, including a significant proportion of Indigenous patients, may not be met by such a model.