• Trends in variceal bleeding: A single centre experience from 2006-2013

      Grant, C; Kemp, D; Austin, Andrew (2014-06)
      Introduction Over the last decade, the numbers of patients presenting with chronic liver disease has risen. During this period the approach to the treatment of variceal bleeding has undergone important changes both internationally (adoption of early TIPSS in high risk cases), and locally with the development of a 24 h endoscopy service (2006), movement to single site hospital with enlarged intensive care capacity (2009), adoption of the DanisTM stent (2009) and a shift to carvedilol as the primary agent for prophylaxis (2013). We reviewed all episodes of variceal bleeding in the last 8 years to describe patient outcomes. Methods All episodes of bleeding from oesophageal varices managed in the Liver Unit at Royal Derby Hospital from 2005 to mid 2013 were identified from clinical coding data - population served approx. 650,000. A retrospective review of the patient records identified the aetiology and severity of liver disease, morbidity, mortality, endoscopy findings and episodes of rebleeding. Results Each year between 17 and 31 patients presented with variceal bleeding. 5 day mortality fluctuated between 3-22% whereas 30 day mortality fell steadily from a peak in 2006 of 41% to 5% in 2012 (Figure 1). The reduction in mortality was in Child's B/C cirrhosis. Interestingly, the proportion of episodes in Child's A cirrhosis increased from 2009 onwards (7% of all bleeding episodes in 2009 to above 30% in 2013). 30 day mortality rates for Child's A did not improve but remained lower than for those with Child's B/C cirrhosis (mean 9.8% compared to 22.8% (2009-2013)). From 2007, there was a fall in frequency of rebleeding from 35% to below 10% in 2013. Only 3 high risk patients underwent an early TIPSS procedure, all after 2012. (Figure presented) Conclusion Variceal bleeding rates have remained surprisingly constant over 8 years despite the rise in admissions with chronic liver disease. Outcomes for acute variceal bleeding have improved which is likely the result of several organisational changes. Notably, rebleeding rates and 30 day mortality decreased even before the adoption of early TIPSS.
    • Troponin T for the detection of dialysis-induced myocardial stunning in hemodialysis patients.

      Breidthardt, Tobias; Burton, James; Odudu, Aghogho; Eldehni, Mohamed; Jefferies, Helen; McIntyre, Christopher (2012-08)
      BACKGROUND AND OBJECTIVES: Circulating troponin T levels are frequently elevated in patients undergoing long-term dialysis. The pathophysiology underlying these elevations is controversial. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS: In 70 prevalent hemodialysis (HD) patients, HD-induced myocardial stunning was assessed echocardiographically at baseline and after 12 months. Nineteen patients were not available for the follow-up analysis. The extent to which predialysis troponin T was associated with the occurrence of HD-induced myocardial stunning was assessed as the primary endpoint. RESULTS: The median troponin T level in this hemodialysis cohort was 0.06 ng/ml (interquartile range, 0.02-0.10). At baseline, 64% of patients experienced myocardial stunning. These patients showed significantly higher troponin T levels than patients without stunning (0.08 ng/ml [0.05-0.12] versus 0.02 ng/ml [0.01-0.05]). Troponin T levels were significantly correlated to measures of myocardial stunning severity (number of affected segments: r=0.42; change in ejection fraction from beginning of dialysis to end of dialysis: r=-0.45). In receiver-operating characteristic analyses, predialytic troponin T achieved an area under the curve of 0.82 for the detection of myocardial stunning. In multivariable analysis, only ultrafiltration volume (odds ratio, 4.38 for every additional liter) and troponin T (odds ratio, 9.33 for every additional 0.1 ng/ml) were independently associated with myocardial stunning. After 12 months, nine patients had newly developed myocardial stunning and showed a significant increase in troponin T over baseline (0.03 ng/ml at baseline versus 0.05 ng/ml at year 1). CONCLUSIONS: Troponin T levels in HD patients are associated with the presence and severity of HD-induced myocardial stunning.
    • Troublesome belching with fetor odour.

      Rashid, Farhan; Singh, Rajeev; Cole, Andrew; Iftikhar, Syed (2010-03)
    • U.K. guidelines on the management of variceal haemorrhage in cirrhotic patients.

      Austin, Andrew (2015-11)
      These updated guidelines on the management of variceal haemorrhage have been commissioned by the Clinical Services and Standards Committee (CSSC) of the British Society of Gastroenterology (BSG) under the auspices of the liver section of the BSG. The original guidelines which this document supersedes were written in 2000 and have undergone extensive revision by 13 members of the Guidelines Development Group (GDG). The GDG comprises elected members of the BSG liver section, representation from British Association for the Study of the Liver (BASL) and Liver QuEST, a nursing representative and a patient representative. The quality of evidence and grading of recommendations was appraised using the AGREE II tool.The nature of variceal haemorrhage in cirrhotic patients with its complex range of complications makes rigid guidelines inappropriate. These guidelines deal specifically with the management of varices in patients with cirrhosis under the following subheadings: (1) primary prophylaxis; (2) acute variceal haemorrhage; (3) secondary prophylaxis of variceal haemorrhage; and (4) gastric varices. They are not designed to deal with (1) the management of the underlying liver disease; (2) the management of variceal haemorrhage in children; or (3) variceal haemorrhage from other aetiological conditions.
    • UK Renal Registry 12th Annual Report (December 2009): chapter 12: epidemiology of methicillin resistant Staphylococcus aureus bacteraemia amongst patients receiving dialysis for established renal failure in England in 2008: a joint report from the UK Renal Registry and the Health Protection Agency.

      Fluck, Richard (2010)
      BACKGROUND: From April 2007, all centres providing renal replacement therapy in England were asked to provide additional data on patients with Methicillin Resistant Staphylococcus aureus (MRSA) bacteraemia using a secure web based system established to capture data for the mandatory surveillance of MRSA bacteremia. RESULTS: From April 2008 until March 2009 171 discrete episodes of MRSA bacteraemia were identified from the Health Protection Agency database as being potentially associated with patients in established renal failure (ERF) requiring dialysis. Of 171 records, 18 records were rejected by renal centres as not being associated with patients on dialysis or as being duplicates of other records. Following data validation by centres, 139 patients had vascular access documented (no episodes of bacteraemia were recorded amongst patients receiving peritoneal dialysis). Of these patients, 30.2% were utilising an arteriovenous fistula or graft and 69.8% were dialysing on a nontunnelled or tunnelled venous catheter. Two of the patients on arteriovenous fistulae had used venous catheters in the prior 28 days. Eleven patients had more than one episode in the year and accounted for 30 (20%) of the episodes of MRSA bacteraemia. Overall there was a reduction of 22% in episodes from the previous year. The median centre-specific rate of MRSA bacteraemia was 0.64 (range 0-3.49) episodes per 100 haemodialysis patients per year, and 0.55 (range 0-2.89) episodes per 100 dialysis (haemodialysis and peritoneal dialysis combined) patients per year. CONCLUSIONS: The rate of MRSA bacteraemia in patients requiring long term dialysis continues to fall within the prevalent dialysis population in England, but there is still marked variation in centrespecific rates.
    • UK Renal Registry 16th annual report: chapter 15 epidemiology of reported infections amongst patients receiving dialysis for established renal Failure in England from May 2011 to April 2012: a joint report from Public Health England and the UK renal registry.

      Crowley, Lisa; Fluck, Richard (2013)
      INTRODUCTION: Infection remains one of the leading causes of mortality in established renal failure patients receiving renal replacement therapy (RRT). Since 2007, centres providing RRT in England have been asked to provide additional data on patients with methicillin resistant Staphylococcus aureus (MRSA) bacteraemia. Since 2011, the option to provide data on methicillin sensitive Stapylococcus aureus (MSSA) and Escherichia coli bacteraemia, as well as Clostridium difficile infection has also been available. METHODS: Data were submitted to Public Health England by laboratories via HCAI-DCS including whether the patients were receiving dialysis. Individual renal centres then confirmed the record either directly via the database or after being contacted. Data were collected for the period of the 1st May 2011 to the 30th April 2012. RESULTS: There were 49 episodes of MRSA bacteraemia, an overall rate of 0.22 per 100 dialysis patients per year, representing a further year on year fall in MRSA rate. There were a higher number of MSSA episodes, 322 in total, with an overall rate of 1.15 per 100 dialysis patients per year. The number of episodes and overall rate of E. coli and C. difficile were 284 and 0.92 per 100 prevalent dialysis patients per year and 172 and 0.61 per 100 prevalent dialysis patients per year respectively. In each infection type the presence of a central venous catheter appeared to correlate with an elevated risk. CONCLUSIONS: Data are presented from one year of infections reported to PHE. The rate of MRSA bacteraemia episodes in England continues to fall. There was a higher rate of MSSA infections amongst renal dialysis patients. Findings from the first year of E. coli and C. difficile data collection are also reported. Future cycles will give us a further idea of the trend in incidences of these infections.
    • The UK-PBC risk scores: Derivation and validation of a scoring system for long-term prediction of end-stage liver disease in primary biliary cholangitis

      Palejwala, Altaf; Maiden, Jane; Damant, Rose (2016-03)
      The biochemical response to ursodeoxycholic acid (UDCA)--so-called "treatment response"--strongly predicts long-term outcome in primary biliary cholangitis (PBC). Several long-term prognostic models based solely on the treatment response have been developed that are widely used to risk stratify PBC patients and guide their management. However, they do not take other prognostic variables into account, such as the stage of the liver disease. We sought to improve existing long-term prognostic models of PBC using data from the UK-PBC Research Cohort. We performed Cox's proportional hazards regression analysis of diverse explanatory variables in a derivation cohort of 1,916 UDCA-treated participants. We used nonautomatic backward selection to derive the best-fitting Cox model, from which we derived a multivariable fractional polynomial model. We combined linear predictors and baseline survivor functions in equations to score the risk of a liver transplant or liver-related death occurring within 5, 10, or 15 years. We validated these risk scores in an independent cohort of 1,249 UDCA-treated participants. The best-fitting model consisted of the baseline albumin and platelet count, as well as the bilirubin, transaminases, and alkaline phosphatase, after 12 months of UDCA. In the validation cohort, the 5-, 10-, and 15-year risk scores were highly accurate (areas under the curve: >0.90).
    • An uncommon cause of panniculitis

      King, T; Rabindranathnambi, Rangarajan; Van Schalkwyk, Gerhard (2017-12)
    • Understanding the scale of non-adherence with haemodialysis

      White, Kelly; Fluck, Richard (2017-01)
      Non-adherence significantly impacts patient care and outcomes, and has been associated with increased mortality. In this article, Kelly White and Richard Fluck discuss the results of a recent study into why dialysis sessions were either shortened or cancelled at their unit, and highlight the importance of achieving complete dialysis with every single prescribed session.
    • United Kingdom Survey of Culture-Negative Peritonitis and Dialysate Sampling Practice.

      Leung, Janson; Salmon, Laura; Coomer, K; Yazdani, F; Turner, Jake (2016-01)
      Peritonitis is a major cause of technique failure in peritoneal dialysis (PD) and accurate diagnosis ensures successful management and avoids unnecessary antibiotic exposure. United Kingdom (UK) registry data on peritonitis rates are not routinely reported. We conducted an electronic survey amongst senior PD nurses and microbiologists to obtain information about PD effluent sampling and processing practices in the UK. The survey was completed by 53 of 79 centres (67% response rate). The median annual culture-negative rate was 15% (range 5 - 38%). The main findings were wide variation in reported sampling volumes and processing methods that may in part explain the variation in culture-negative rates. Adherence to guidelines might reduce culture-negative rates informed by reporting data into national registries.
    • An unusual case of sepsis: Liver abscess masquerading as pneumonia

      Kozhippally, Mohandas; Sivaraman, Subash (2017)
      A 63-year-old woman presented with fever, tachycardia and tachypnoea, with right sided chest and hypochondrial pain. Chest radiograph showed right basal consolidation and she was treated for community acquired pneumonia with intravenous antibiotics. Subsequent clinical deterioration in presence of a previous history of complicated diverticulitis, persistent right hypochondrial pain and deranged liver function tests prompted further investigations that confirmed presence of a large pyogenic liver abscess. Following appropriate antibiotic treatment and image guided drainage of the abscess, the patient made a complete recovery. This case illustrates the importance of considering a subdiaphragmatic source of sepsis even in the presence of chest radiographic abnormalities, when a patient fails to respond to initial treatment for pneumonia.
    • Update on drugs to treat diabetes.

      Game, Frances (2012-05)
      Diabetes is a common disease worldwide with a multitude of complications and high mortality. Moreover, its prevalence is increasing and many of our patients will have diabetes. We have known for almost 50 years that patients with diabetes undergo surgical procedures at a higher rate than patients who do not have the condition and that they spend 45% longer in a hospital bed than patients with diabetes admitted to a medical ward.
    • An updated overview of diabetic nephropathy: Diagnosis, prognosis, treatment goals and latest guidelines.

      Selby, Nicholas; Taal, Maarten (2020-04)
      Diabetic nephropathy (DN) is a major healthcare challenge. It occurs in up to 50% of those living with diabetes, is a major cause of end-stage kidney disease (ESKD) that requires treatment with dialysis or renal transplantation, and is associated with significantly increased cardiovascular morbidity and mortality. DN is a clinical syndrome characterized by persistent albuminuria and a progressive decline in renal function, but it is increasingly recognized that the presentation and clinical course of kidney disease in diabetes is heterogeneous. The term diabetic kidney disease (DKD) is now commonly used to encompass the spectrum of people with diabetes who have either albuminuria or reductions in renal function. In this article, the clinical presentation and approach to diagnosis of DKD will be discussed, as will its prognosis. The general principles of management of DKD will also be reviewed with reference to current international guidelines.
    • Use of electronic results reporting to diagnose and monitor AKI in hospitalized patients.

      Selby, Nicholas; Crowley, Lisa; Fluck, Richard; Kolhe, Nitin; McIntyre, Christopher (2012-04)
      BACKGROUND AND OBJECTIVES: Many patients with AKI are cared for by bnon-nephrologists. This can result in variable standards of care that contribute to poor outcomes. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS: To improve AKI recognition, a real-time, hospital-wide, electronic reporting system was designed based on current Acute Kidney Injury Network criteria. This system allowed prospective data collection on AKI incidence and outcomes such as mortality rate, length of hospital stay, and renal recovery. The setting was a 1139-bed teaching hospital with a tertiary referral nephrology unit. RESULTS: An electronic reporting system was successfully introduced into clinical practice (false positive rate, 1.7%; false negative rate, 0.2%). The results showed that there were 3202 AKI episodes in 2619 patients during the 9-month study period (5.4% of hospital admissions). The in-hospital mortality rate was 23.8% and increased with more severe AKI (16.1% for stage 1 AKI versus 36.1% for stage 3) (P<0.001). More severe AKI was associated with longer length of hospital stay for stage 1 (8 days; interquartile range, 13) versus 11 days for stage 3 (interquartile range, 16) (P<0.001) and reduced chance of renal recovery (80.0% in stage 1 AKI versus 58.8% in stage 3) (P<0.001). Utility of the Acute Kidney Injury Network criteria was reduced in those with pre-existing CKD. CONCLUSIONS: AKI is common in hospitalized patients and is associated with very poor outcomes. The successful implementation of electronic alert systems to aid early recognition of AKI across all acute specialties is one strategy that may help raise standards of care.
    • Use of online conductivity monitoring to study sodium mass balance in chronic haemodialysis patients: prospects for treatment individualisation.

      Odudu, Aghogho; Lambie, Stewart; Taal, Maarten; Fluck, Richard; McIntyre, Christopher (2011-07)
      BACKGROUND: Failure to achieve isonatric haemodialysis (HD) drives an expansion of extracellular volume leading to increased interdialytic weight gain (IDWG). This may be a causative factor in the development of HD-induced cardiac injury. We examined total and diffusive sodium mass balance during HD. METHODS: 24 chronic HD patients using a fixed 140 mmol/l sodium concentration were studied over 4 weeks. Dialysate and plasma conductivity and ionic mass balance (IMB) were recorded. IMB estimates total ionic transfer across the membrane. RESULTS: Mean total IMB was 338 mmol indicating net sodium removal. Intrapatient variability was less than interpatient variability (coefficient of variation = 42 vs. 26%, respectively). The diffusive component of ionic mass balance (IMB(diff)) was 97 ± 18 mmol approximating 29% (±22-36) of total sodium removal. IMB(diff) also correlated with both plasma conductivity and predialysis plasma sodium (r(2) = 0.82 and 0.6, respectively; p < 0.0001) as well as the reduction in plasma conductivity and plasma sodium during HD (r(2) = 0.7 and 0.5, respectively; p < 0.0001). CONCLUSION: HD against a fixed dialysate sodium concentration of 140 mmol/l results in a wide range of sodium removal with a mean of 29% removed by diffusion. Online conductivity monitoring can be utilized as part of a variety of strategies to enable the delivery of individualised and isonatric HD. Further study is required to explore the utility of such strategies which may be crucial in reducing IDWG and HD-induced cardiac injury.
    • Validation of a Core Patient-Reported Outcome Measure for Fatigue in Patients Receiving Hemodialysis: The SONG-HD Fatigue Instrument

      Fluck, Richard (2020-11)
      Background and objectives: Fatigue is a very common and debilitating symptom and identified by patients as a critically important core outcome to be included in all trials involving patients receiving hemodialysis. A valid, standardized measure for fatigue is needed to yield meaningful and relevant evidence about this outcome. This study validated a core patient-reported outcome measure for fatigue in hemodialysis. Design, setting, participants, & measurements: A longitudinal cohort study was conducted to assess the validity and reliability of a new fatigue measure (Standardized Outcomes in Nephrology-Hemodialysis Fatigue [SONG-HD Fatigue]). Eligible and consenting patients completed the measure at three time points: baseline, a week later, and 12 days following the second time point. Cronbach α and intraclass correlation coefficient were calculated to assess internal consistency, and Spearman rho was used to assess convergent validity. Confirmatory factor analysis was also conducted. Hemodialysis units in the United Kingdom, Australia, and Romania participated in this study. Adult patients aged 18 years and over who were English speaking and receiving maintenance hemodialysis were eligible to participate. Standardized Outcomes in Nephrology-Hemodialysis, the Visual Analog Scale for fatigue, the 12-Item Short Form Survey, and Functional Assessment of Chronic Illness Therapy-Fatigue were used. Results: In total, 485 participants completed the study across the United Kingdom, Australia, and Romania. Psychometric assessment demonstrated that Standardized Outcomes in Nephrology-Hemodialysis is internally consistent (Cronbach α =0.81-0.86) and stable over a 1-week period (intraclass correlation coefficient =0.68-0.74). The measure demonstrated convergence with Functional Assessment of Chronic Illness Therapy-Fatigue and had moderate correlations with other measures that assessed related but not the same concept (the 12-Item Short Form Survey and the Visual Analog Scale). Confirmatory factor analysis supported the one-factor model. Conclusions: SONG-HD Fatigue seems to be a reliable and valid measure to be used in trials involving patients receiving hemodialysis.
    • Variations in access to and reimbursement for continuous glucose monitoring systems for people living with Type 1 diabetes across England.

      Wilmot, Emma (2018-06)
      Since the introduction of real-time continuous glucose monitoring (CGM) systems more than 15 years ago and, more recently, flash glucose monitoring (Flash-GM), clinical studies have observed reductions in HbA1c , independent of insulin delivery method, with decreasing time spent in hypoglycaemia [1] and reduction in glycaemic variability [2]. CGM can improve quality of life and reduce diabetes-related distress [3], including fear of hypoglycaemia [4,5]. Despite these benefits, CGM has yet to be fully implemented as part of the standard of care for people living with Type 1 diabetes in England, and there is considerable variation in how it is funded through local payer organizations.
    • Vascular Access Special Interest Group: a Multiprofessional Initiative

      Fielding, Catherine (2016)
      In December 2015, the British Renal Society Vascular Access Specialist Interest Group (BRS VA SIG) was formed. Its purpose is to identify and promote best practice in vascular access care across the UK, and encourage consistency between services. Catherine Fielding, Suzanne Glover and Mick Kumwenda discuss the group's active and forthcoming projects.