Wednesday, 30 September 2009

Bedtime reading: BMJ launch CKD e-learning package with NICE

BMJ have launched a CKD e-learning package with NICE. Why don’t you have a go on the interactive cases and see how you get on?

Tuesday, 29 September 2009

Recorded CKD prevalence continues to rise

The Quality and Outcomes Framework data for 2008/09 was published on 29 September and is available at . The data shows that over 4% of adults in England are now recognised to have chronic kidney disease and are on primary care CKD registers. That’s a 10% increase in recorded CKD prevalence between 2007/08 and 2008/09. Depending on the estimated prevalence used however up to 55% of people with stage 3-5 kidney disease have not yet been identified and when you look at blood pressure achieved, taking into account the unidentified population and exception reporting there is still a lot to do to reduce the vascular and progressive kidney disease risk in our populations. The variance between practices – in every PCT area, remains high and can be used in local planning to target education and support.

Monday, 28 September 2009

Q & A: Taking frequency & length of HD sessions into account

Q: Given what appears to be growing evidence that longer hours/more frequent HD produces better clinical and general quality of life outcomes, would you think it reasonable, even in the current financial situation, for patient and their representatives . to ask for this to be taken into account when planning the capacity of new units? Dr Simon Jenkins, North West Region KPA

A: Dear Simon, I think that it’s important that patient and their advocates continue to articulate the needs of service users. I am firmly of the opinion that high quality is value for money and what’s more usually costs less than if services are chaotic and inefficient. Doing the right thing at the right time, every time drives up quality, drives up safety, drives down complications and drives down costs.

Having said that, there are clear logistical issues with regard to extending hours and frequency for hospital based haemodialysis. What isn’t in doubt is that home based haemodialysis can be precisely tailored to the needs of the individual and definitely costs considerably less than hospital based haemodialysis. There are barriers to home haemodialysis – funds in the “wrong” budgets, cultural barriers, difficulties in supporting people who have become institutionalised to regain their confidence and manage their own conditions. Several units have overcome these barriers and home dialysis is growing in Manchester, in Derby and at Guys Hospital. I think efforts to question why units are not at 5, 10, 12 or 15% home haemodialysis should be a standing item on Network and renal unit/KPA agendas. In South Island New Zealand all patients are on home dialysis (some peritoneal dialysis of course).

If we can optimize modality of dialysis for the population by offering more choice, I am sure that would increase the numbers of people on both home haemodialysis and peritoneal dialysis – that in turn would free up capacity within hospital and satellite units They could then run with some leeway to offer dialysis away from base, more flexibility in changing slots or providing longer hours and for those that would benefit (eg those that find the long break really difficult because of fluid issues), 4 or even 5 times dialysis a week, could be accommodated.

The fiscal situation means that the “do nothing” option is untenable, the “lets cut back a little” option is also untenable so we have to transform NHS services and use the £100 billion plus to deliver real quality. Home dialysis offers quality for those who choose this option and costs less than hospital based therapy. Improving quality at the same time as reducing cost is possible .

I firmly believe we can do that but don’t minimise the challenges and difficulties that we will have along the way. Individuals like you, who sit on network groups, play a vital role in ensuring that those who are less advantaged continue to receive increasingly high quality of care

Wednesday, 23 September 2009

BNF advice on drug doses adjustments in CKD

The British National Formulary has revised its guidance on drug dose adjustments in Chronic Kidney Disease. For most drugs, for most patients over 18 years of age of average build and height, the eGFR (derived from the modification of diet in renal disease formula) can be used to determine dosage adjustments in place of creatinine clearance. Exceptions include potentially toxic drugs with a small safety margin, and patients at both extremes of weight. The BNF have replaced its references to creatinine clearance with eGFR where applicable and revamped its Appendix 3 to include a table grading renal function according to eGFR. Why don’t you try your hand at the case study?

Monday, 21 September 2009

Better quality of life in Essex

Better quality of life is the goal of Essex County Council and its Health Overview and Scrutiny Committee is determined to ensure that includes people with kidney disease. Scrutiny’s hard hitting report on dialysis services in Essex lays out an ambitious agenda for improvement and identifies some key areas where action is needed – home haemodialysis, transport and parking, dialysis away from home and the importance of social care. This is the first report I am aware of by a Health Overview and Scrutiny Committee focussing on dialysis services but where there is local cause for concern or kidney care is in need of improvement, I expect we will see more aimed at improving provision and support for people with kidney disease.

Tuesday, 15 September 2009

Q & A: Single sex areas - hospital dialysis

Q: Dear Dr O'Donoghue, we are currently being advised by our Trust management team that we will soon be required to adhere to the single sex areas rule, which has been decreed by the Department of Health. As you can imagine, this was met with horror; finding dialysis slots for all patients can be hard enough, without having to think of that too. Hospital transport would also be an issue, as patients may be grouped on dialysis shifts for geographical area not gender!

We think that our patients would not feel the need or like this as the social aspect of mixing with others, especially for younger patients is important to them. We understand that the idea in principle may be better for sick, underdressed inpatinets and would welcome your thoughts on its application to fairly well, fully clothed outpatients. Thank you. Kind regards, Nicky Moncrieff (Renal Nurse Specialist, Addenbrookes Hospital, Cambridge).

A: Dear Nicky, thank you for your question, it is something that is being raised by several renal units. The existing guidance on the Department of Health website actually uses dialysis as an example where common sense needs to prevail. To quote directly "Staff in these areas will need to make decisions on a day-to-day basis. For instance, in a renal dialysis unit, if all patients are well-established on treatment, wear their own clothes and have formed personal friendships, mixing may be a good thing. By contrast, a new dialysis patient, with a femoral catheter, and wearing a hospital gown, should be able to expect a much higher degree of privacy." I do hope this is helpful. Kind regards Donal.

Monday, 14 September 2009

Renal NSF update September 2009

The NSF update for September 2009 is available here

Thursday, 10 September 2009

Q & A: Could you explain the good, medium and low eGFRs and what they mean?

Q: My transplanted kidney is now in its 15th year and as far as my blood figures show it is still doing fine. My eGFR is 42 if that is anything to go by. I am coming up to my 87th birthday. could you put in the next Kidney Life some information on the eGFR to explain to members (readers) the good, medium and low eGFRs and what they mean? Best wishes,
Frank Wood

A: Congratulations Frank, on your upcoming 87th birthday and the 15th year anniversary of your kidney transplant. Your experience of receiving a transplant in your early 70s and continuing to live a long and productive life will be a great inspiration to others with kidney disease. Thanks for your question about eGFR and what it means. eGFR stands for estimated Glomerular Filtration Rate. Glomerular Filtration Rate is now widely recognised as the best measure of kidney function. It can be estimated from the level of creatinine in the blood and since a normal GFR in a young adult is about a hundred mils per minute, the eGFR can be thought of as percentage kidney function. Talking about eGFR as percentage kidney function has been a useful way to demystify kidney disease for doctors, nurses and patients. However, eGFR isn’t a perfect measure of kidney function, it has several limitations and a single figure will never tell you everything you need to know about an individual’s kidney or transplant function.

Each kidney is made up of about 1 million nephrons. The nephrons do the work of the kidney – getting rid of waste products, controlling and adjusting the blood chemistry and producing the metabolic messengers vitamin D and erythropoietin that keep our bones and blood healthy. Nephrons do this by filtering the blood through tiny specialised blood vessels called glomeruli and then fine tuning what the body needs to retain or be eliminated along the tubules which make up the rest of the nephron. Filtration of blood across these filters is therefore the first and most important stage of cleansing the blood of impurities. This is called Glomerular Filtration Rate or GFR. The GFR can be directly measured by using radioactive isotopes or by infusing certain inert chemicals into the bloodstream. This is sometimes done to very precisely measure kidney function in people offering kidneys for live donation. Such tests are not practical in routine clinical practice for day to day assessment of kidney function. Fortunately, GFR can be estimated from serum creatinine which is easily measured. Creatinine has been used to give an idea of kidney function for many years. Creatinine, used alone, is an insensitive marker of kidney function, up to 50% of kidney function can be lost before the serum creatinine concentration rises above the normal range. Estimated GFR is a better measure of kidney function that serum creatinine. Since 2006, every laboratory in the UK has calculated a standardised eGFR using a formula based on sex, ethnicity, age and serum creatinine.

Routine reporting of eGFR was one of the recommendations of the National Service Framework for Renal Services. It has allowed early identification of kidney disease in literally millions of people. Early investigation and treatment of kidney problems has become a core part of general practice.

All people with kidney disease are now entitled to a care plan designed around their individual needs to keep kidney function as good as possible for as long as possible and to reduce cardiovascular risk. We are already starting to see improvements in blood pressure control in general practice and earlier referral to the multi professional kidney team to support individuals in making decisions about transplantation and dialysis when replacement therapy is needed. The eGFR is also the way chronic kidney disease is staged and monitored over time. Staging and monitoring also requires assessment of proteinuria by measurement of the albumin creatinine ratio, or ACR, in the urine. Proteins in the urine, of which albumin is the main protein, indicate a higher risk of progressive kidney disease and of cardiovascular risk.

Thankfully, protein in the urine can be treated by certain drugs including the ACE inhibitors and ARB class of blood pressure drugs. So regular, accurate assessment of eGFR and ACR are absolutely essential for people with kidney disease. The eGFR tells GPs when specialist kidney referral is needed – when the eGFR falls below 30 mls per minute. It helps the patients, nurses and doctors in getting the timing of transplantation before dialysis right (at 15 mls per minute or below) and/or in the preparation for dialysis such as when to operate to create a fistula for haemodialysis. Looking at an individual’s eGFR over time tells you if the kidney function is stable, improving or declining – it acts as a trigger for further evaluation and changes in treatment as well as providing a window on the future. But eGFR doesn’t tell you everything and used alone can be misleading.

The eGFR needs to be interpreted cautiously at the extremes of age and extremes of body mass, it can be interfered with by some drugs, it is not always helpful in the acute situation and the accuracy of the equation used hasn’t been proven in all ethnic minority groups and clinical situations including transplantation. It is not a perfect measure of kidney function, rather it provides a guide.

Even eating a meal before the measurement can affect the reported level. There are equations for using children but the routine laboratory based equation is not suitable for people under the age of 18 years. It’s of no value in people receiving dialysis. Hence the need to look at more than one thing to get the right answers – the ABC of kidney disease is know your: A ACR – albumin creatinine ratio in the urine; B blood pressure – aim for perfect blood pressure control; C creatinine for the eGFR = percentage kidney function

The introduction of eGFR into the National Health Service has helped demystify kidney disease. It has promoted the understanding of kidney disease by doctors and nurses. I would encourage all people with kidney disease, or at risk of kidney disease, to know their eGFR and to keep track of how it is changing. Your eGFR should be discussed as part of your care planning. People with kidney disease and the healthcare professionals who care for them need to speak the same language – so you need to know your eGFR, your ACR and your blood pressure.

published in Kidney Life, Autumn issue 2009

Bedtime reading: What do I need to know about proteinuria? Information for patients

The Department of Health have produced a leaflet for the public to explain proteinuria.

The leaflet aimed at patients explains the meaning of proteinuria, cases, signs and tests to determine proteinuria. It also covers how to manage diabetes and blood pressure with proteinuria. This is part of a pack of information on proteinuria testing. Information sheets for GPs and labs have been published on the Department of Health website.

Monday, 7 September 2009

Going Green

The NHS faces a major challenge – no, not just the £20 billion that needs to be saved because of the fiscal crisis but the need to reduce the carbon footprint of healthcare.

The health sector is responding by signing up to the bold new climate change campaign 10:10. Ten NHS organisations plus the BMJ Group have committed to cutting their carbon emissions by 10% in 2010 from a 2009 base year. The target is challenging but by no means impossible for many organisations. The NHS ten include one Strategic Health Authority, several large acute teaching hospitals, two PCTs, a mental health trust, and a GP Surgery.

Green Nephrology is leading the way, Dr Andrew Connor took up his new post as "Green Nephrology Fellow" at the Campaign for Greener Healthcare on 1 September. Andrew is a specialist trainee in kidney medicine and is generously funded by NHS Kidney Care. Over the next year, he will be exploring the environmental impacts of kidney care and working with NHS staff and patients to improve practice in kidney units. Andrew has an ambitious programme of work and is supported by both the British Renal Society and the Renal Association who co-Hosted a Green Nephrology Summit earlier in the year. Given the water, electricity, dialysis consumables and amount of drugs used in Kidney care, let alone the travelling back and forth to renal units, it’s likely that kidney services can make a big contribution.

The Royal Cornwall Hospital Renal Unit has already begun a comprehensive green project and I was delighted to learn that Simeon Edwards and the team have been shortlisted for a Health Service Journal award this year . Their action plan includes energy saving in lighting and heating, greener pharmaceuticals and consumables , water reduction, managing transport to reduce carbon emissions at the same time as improving patient transport quality in addition to reducing, better management and increased recycling of waste . Everyone in the unit, patients included are playing their part. I am sure that we will all want to wish Simeon and colleagues good luck for the award. There is lots we can learn from the Cornwall team - perhaps the most import thing being - a thousand mile journey begins with the first step.

Less of the same is not the answer; we need to transform clinical services to sustain healthcare. The waste water reclamation initiative at Kent and Canterbury and the Chronic Kidney Disease electronic advisory service at Bradford are examples of different ways of doing things; both save money and save carbon. For a capital investment of £14,000 Kent and Canterbury Hospital have made an annual saving of £8000 and shown a 38% reduction in mains water usage. Well done Steve Milne.

Looking to the future, every kidney unit is going to be asking green questions, Green Nephrology and Andrew Connor’s work will help the kidney community and provide answers for some of these questions. The actions are for all of us.