Friday, 21 April 2017

Disappointment at proposed chnages to chronic kidney disease quality standards

Here we quote a news item from the British Kidney Patients Association

We regularly work with the National Institute of Health and social Care Excellence (NICE) to add the perspective and views of kidney patients into their work. In 2011, the first ever CKD Quality Standards were produced, outlining markers of good quality for kidney care, including support for the patient’s mental as well as physical well-being, and recommending that a care planning discussion about treatment is held between the patient and doctor or nurse.

In 2017, NICE is reviewing the standards and have just put forward a proposal (external link). We're surprised to see that most of the standards have been removed and while we are all in favour of simplification we do not believe that removing the need for psycho-social support, or for a care planning discussion is the right thing to do for kidney patients.

We have made it clear that we want some of the previous standards to be retained and have worked closely with our colleagues in the Renal Association, British Renal Society, Renal Psychology Group and the renal services Clinical Reference group and they have also expressed these concerns in their responses to NICE.

We believe that people should be given information that’s appropriate for their kidney disease, and that the way in which they will be cared for should be documented and agreed with them. This standard should therefore remain. Furthermore we would like the standard recommending that “People with kidney failure have access to psychosocial support (which may include support with personal, family, financial, employment and/or social needs)” to be retained. Through our own work we fund much of this type of vital support for patients, yet NICE states that “the previous recommended quality standards are no longer considered national priorities for improvement but may still be useful at a local level”. This gives a disappointing and inaccurate message that these are not important for kidney patients. Something we know just simply isn’t true.

Tuesday, 18 April 2017

Antidepressants, Exercise, and Dialysis Patients

Having chronic kidney failure and being on dialysis is definitely depressing. But efforts to get these patients on antidepressants often fail, according to research published online in the Clinical Journal of the American Society of Nephrology.

Of 101 patients followed for ≤12 months, 39 met criteria for depression (Patient Health Questionnaire 9 score ≥10 on one or more assessments). These 39 patients had depression on 147 of 373 (39%) monthly assessments. At 103 of these 147 (70%) assessments, patients were receiving antidepressant therapy, and at 51 of 70 (70%) assessments, patients did not accept nurses’ recommendations to intensify treatment. At 44 assessments, patients with depression were not receiving antidepressant therapy, and in 40 (91%) instances, they did not accept recommendations to start treatment. The primary reason that patients refused the recommendations was attribution of their depression to an acute event, chronic illness, or dialysis (57%). In 11 of 18 (61%) instances in which patients accepted the recommendation, renal providers were unwilling to provide treatment.

Patients on chronic hemodialysis with depression are frequently not interested in modifying or initiating antidepressant treatment, commonly attributing their depression to a recent acute event, chronic illness, or dialysis. Renal providers are often unwilling to modify or initiate antidepressant therapy. Future efforts to improve depression management will need to address these patients- and provider-level obstacles to providing such care.

Interestingly, a second paper appeared in the very next issue of the journal, saying lower physical activity and depression are associated with hospitalization and shorter survival in CKD !

Physical activity or exercise training helps improve muscle strength and physical and mental function, including benefits on depressive symptoms, which affects at least 20%–30% of patients receiving maintenance hemodialysis (MD). Depression contributes to low quality of life and restricted living among patients with CKD. Thus, exercise can be an interesting intervention to reduce depression and hospitalization and improve quality of life in these patients. Physical activity is defined as any bodily movement produced by skeletal muscles that results in energy expenditure.

Overall, is exercise beneficial to patients with CKD? The answer is yes. Both physical activity and exercise are associated with improved outcomes in these patients. Although a limited number of studies have been reported, all differing by protocol, they show that aerobic and resistance training can improve physical functioning, quality of life, depressive symptoms, survival, or hospitalization

Monday, 23 January 2017

UK National Chronic Kidney Disease Audit Results

The first ever National CKD audit produced worrying results for the UK. With 1 in 20 adults having CKD and often no symptoms until it is too late, those at higher risk eg patients with diabetes and high blood pressure, regular blood and and urine tests should be done, and at least annually if not more often. But the recently released National CKD audit found that on average only 54% of people with diabetes have the relevant urine tests, compared to 86% that have blood tests. In some other groups, including those with high blood pressure, it’s less than 30%.

This makes the chance of identifying patients with problems a bit variable to put it mildly. Further findings showed that whilst over 80% of those who have CKD had had a blood test in the previous year, only 31% had a repeat urine test. For people without diabetes, urine testing rates dropped to less than 15%. This is despite recommendations that effort should be focused on regular review. The report authors also urged GPs to review how they record the fact a patient has CKD on their systems as almost a third of confirmed CKD cases were not given the right coding and 1 in 10 people who were coded as having CKD did not have it.

You can read the full report at the Healthcare Quality Improvement Partnership.

For our American readers, GP is short for General Practitioner, the free medical providers available to all UK residents. The vast majority of UK medical care is provided free by the state's National Health Service.

Saturday, 21 January 2017

Kidney dialysis treatment negatively impacts heart function says MRI study

The world’s first MRI study of the effect of kidney disease on heart function shows that the necessary dialysis treatments for those with kidney failure can cause heart damage.

Recent research conducted by the University of Nottingham used magnetic resonance imaging to study the stress placed on patients’ hearts while they underwent kidney dialysis. The study compared the effects of two different types of dialysis on the heart—hemodialysis and hemodiafiltration.

They noted the amount of blood pumped per minute by the left ventricle, as well as how efficiently the muscle could contract, as well as blood flow into the coronary artery, and found that cardiac function suffered while the patient underwent both forms of dialysis, with some recovery after the treatment.

Professor of Nephrology at the University of Nottingham, Maarten Taal, summarized their findings, noting that “All patients showed some degree of left ventricular dysfunction and blood flow to the small capillaries in the heart muscle decreased significantly during both types of treatment.” While the sample size tested was small, 100% of patients’ cardiac function was negatively impacted by the dialysis treatments, raising concern.

But for many patients, dialysis is not something they can casually say no thanks to. That causes even greater problems. More research is required so that doctors can treat chronic kidney disease by dialysis without causing heart problems.

A summary of this report can be read here

Wednesday, 21 December 2016

Kidney transplanted in place of spleen

A child who has been on dialysis since birth due to a rare kidney problem and malformed blood vessels has had her spleen removed and a kidney transplanted in the space created. This is reported as a new and innovative technique in the an Italian newspaper, Tonino (let google translate it for you), UK's Daily Mail and many others world wide.

The operation is described as an immediate success as the six year old Italian girl's new kidney started functioning immediately