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Publication Haemodialysis open day: supporting pre-dialysis patients towards haemodialysis(University Hospitals Birmingham NHS Foundation Trust, 2025-06-10) Lucas, Benjamin; Phillips, Juliette; Small, Judy; Attukunnel, Alex; Watkins, Mel; Carden, Sioban; Wallace, Natalie; University Hospitals Birmingham NHS Foundation Trust; The Nursing and Midwifery Council; Renal; Nursing and Midwifery Registered; Admin and Clerical; Lucas, Benjamin; Phillips, Juliette; Attukunnel, Alex; Watkins, Melai; Carden, Siobhan; Wallace, NatalieThe Haemodialysis open day program was developed to support patients who have opted for haemodialysis after receiving CKD education. Feedback was used as method to determine if this program had helped pre dialysis patients in their transition to haemodialysis. NICE guidelines recommend that people with CKD including their family are given education and information that suits their modality choice. A haemodialysis satellite centre was used as the venue for the open day.Publication Evaluation of the effect of cooled haEmodialysis on cognitive function in patients suffering with end-stage Kidney Disease (E-CHECKED): feasibility randomised control trial protocol.(BioMed Central, 2020-09-30) Dasgupta, Indranil; Odudu, Aghogho; Baharani, Jyoti; Fergusson, Niall; Griffiths, Helen; Harrison, John; Maruff, Paul; Thomas, G Neil; Woodhall, Gavin; Youseff, Samir; Tadros, George; Renal medicine; Elderly care; Medical and Dental; Dasgupta, Indranil; Baharani, Jyoti; Fergusson, NiallBackground: Cognitive impairment is common in haemodialysis (HD) patients and is associated independently with depression and mortality. This association is poorly understood, and no intervention is proven to slow cognitive decline. There is evidence that cooler dialysis fluid (dialysate) may slow white matter changes in the brain, but no study has investigated the effect of cooler dialysate on cognition. This study addresses whether cooler dialysate can prevent the decline in cognition and improve quality of life (QOL) in HD patients. Methods: This is a multi-site prospective randomised, double-blinded feasibility trial. Setting: Four HD units in the UK. Participants and interventions: Ninety HD patients randomised (1:1) to standard care (dialysate temperature 36.5 °C) or intervention (dialysate temperature 35 °C) for 12 months. Primary outcome measure: Change in cognition using the Montreal Cognitive Assessment (MoCA). Secondary outcome measures: Recruitment and attrition rates, reasons for non-recruitment, frequency of intradialytic hypotension, depressive symptom scores, patient and carers burden, a detailed computerised cognitive test and QOL assessments. Analysis: mixed method approach, utilising measurement of cognition, questionnaires, physiological measurements and semi-structured interviews. Discussion: The results of this feasibility trial will inform the design of a future adequately powered substantive trial investigating the effect of dialysate cooling on prevention and/or slowing in cognitive decline in patients undergoing haemodialysis using a computerised battery of neuro-cognitive tests. The main hypothesis that would be tested in this future trial is that patients treated with regular conventional haemodialysis will have a lesser decline in cognitive function and a better quality of life over 1 year by using cooler dialysis fluid at 35 °C, versus a standard dialysis fluid temperature of 36.5 °C. This also should reflect in improvements in their abilities for activities of daily living and therefore reduce carers' burden. If successful, the treatment could be universally applied at no extra cost. Trial registration: ClinicalTrials.gov NCT03645733 . Registered retrospectively on 24 August 2018.Publication Exercise programme to improve quality of life for patients with end-stage kidney disease receiving haemodialysis: the PEDAL RCT.(NIHR Journals Library, 2021-06) Greenwood, Sharlene A; Koufaki, Pelagia; Macdonald, Jamie H; Bulley, Catherine; Bhandari, Sunil; Burton, James O; Dasgupta, Indranil; Farrington, Kenneth; Ford, Ian; Kalra, Philip A; Kumwenda, Mick; Macdougall, Iain C; Messow, Claudia-Martina; Mitra, Sandip; Reid, Chante; Smith, Alice C; Taal, Maarten W; Thomson, Peter C; Wheeler, David C; White, Claire; Yaqoob, Magdi; Mercer, Thomas H; Renal medicine; Medical and Dental; Dasgupta, IndranilBackground: Whether or not clinically implementable exercise interventions in haemodialysis patients improve quality of life remains unknown. Objectives: The PEDAL (PrEscription of intraDialytic exercise to improve quAlity of Life in patients with chronic kidney disease) trial evaluated the clinical effectiveness and cost-effectiveness of a 6-month intradialytic exercise programme on quality of life compared with usual care for haemodialysis patients. Design: We conducted a prospective, multicentre randomised controlled trial of haemodialysis patients from five haemodialysis centres in the UK and randomly assigned them (1 : 1) using a web-based system to (1) intradialytic exercise training plus usual-care maintenance haemodialysis or (2) usual-care maintenance haemodialysis. Setting: The setting was five dialysis units across the UK from 2015 to 2019. Participants: The participants were adult patients with end-stage kidney disease who had been receiving haemodialysis therapy for > 1 year. Interventions: Participants were randomised to receive usual-care maintenance haemodialysis or usual-care maintenance haemodialysis plus intradialytic exercise training. Main outcome measures: The primary outcome of the study was change in Kidney Disease Quality of Life Short Form, version 1.3, physical component summary score (from baseline to 6 months). Cost-effectiveness was determined using health economic analysis and the EuroQol-5 Dimensions, five-level version. Additional secondary outcomes included quality of life (Kidney Disease Quality of Life Short Form, version 1.3, generic multi-item and burden of kidney disease scales), functional capacity (sit-to-stand 60 and 10-metre Timed Up and Go tests), physiological measures (peak oxygen uptake and arterial stiffness), habitual physical activity levels (measured by the International Physical Activity Questionnaire and Duke Activity Status Index), fear of falling (measured by the Tinetti Falls Efficacy Scale), anthropometric measures (body mass index and waist circumference), clinical measures (including medication use, resting blood pressure, routine biochemistry, hospitalisations) and harms associated with intervention. A nested qualitative study was conducted. Results: We randomised 379 participants; 335 patients completed baseline assessments and 243 patients (intervention, n = 127; control, n = 116) completed 6-month assessments. The mean difference in change in physical component summary score from baseline to 6 months between the intervention group and control group was 2.4 arbitrary units (95% confidence interval -0.1 to 4.8 arbitrary units; p = 0.055). Participants in the intervention group had poor compliance (49%) and very poor adherence (18%) to the exercise prescription. The cost of delivering the intervention ranged from £463 to £848 per participant per year. The number of participants with harms was similar in the intervention (n = 69) and control (n = 56) groups. Limitations: Participants could not be blinded to the intervention; however, outcome assessors were blinded to group allocation. Conclusions: On trial completion the primary outcome (Kidney Disease Quality of Life Short Form, version 1.3, physical component summary score) was not statistically improved compared with usual care. The findings suggest that implementation of an intradialytic cycling programme is not an effective intervention to enhance health-related quality of life, as delivered to this cohort of deconditioned patients receiving haemodialysis. Future work: The benefits of longer interventions, including progressive resistance training, should be confirmed even if extradialytic delivery is required. Future studies also need to evaluate whether or not there are subgroups of patients who may benefit from this type of intervention, and whether or not there is scope to optimise the exercise intervention to improve compliance and clinical effectiveness. Trial registration: Current Controlled Trials ISRCTN83508514.Publication Emotional distress and adjustment in patients with end-stage kidney disease: A qualitative exploration of patient experience in four hospital trusts in the West Midlands, UK.(Public Library of Science, 2020-11-05) Sein, Kim; Damery, Sarah; Baharani, Jyoti; Nicholas, Johann; Combes, Gill; Renal medicine; Medical and Dental; Baharani, JyotiObjectives: To explore patient perceptions and experiences of mild-to-moderate emotional distress and the support offered by kidney units to patients with end-stage kidney disease. Methods: In-depth, semi-structured qualitative interviews with patients (n = 46) being treated for end-stage kidney disease in four hospital Trusts, with data analysed thematically. Results: Patients described multiple sources of distress and talked about the substantial burden that emotional challenges raised for their ability to manage their condition and develop coping strategies. Many patients did not feel it appropriate to disclose their emotional issues to staff on the kidney unit, due to a perceived lack of time for staff to deal with such issues, or a perception that staff lacked the necessary skills to provide resolution. Five themes were identified from the patient interviews, broadly related to patients' experience of distress, and the support offered by the kidney unit: i) the emotional burden that distress placed on patients; ii) patients' relationship with the treatment for their condition; iii) strategies for coping and adjustment; iv) patient-staff interactions and the support offered by the kidney unit, and v) the mediating impact of the treatment environment on patient experience of distress and their ability to raise emotional issues with staff. Conclusions: Many patients felt unprepared for the likelihood of experiencing emotional issues as part of their condition, for which pre-dialysis education could help in managing expectations, along with support to help patients to develop appropriate coping strategies and adjustments. These findings demonstrate the importance of recognising patient distress and ensuring that talking about distress becomes normalised for patients with end-stage kidney disease.Publication Early renal function trajectories, cytomegalovirus serostatus and long-term graft outcomes in kidney transplant recipients.(BioMed Central, 2021-03-20) Law, Jonathan P; Borrows, Richard; McNulty, David; Sharif, Adnan; Ferro, Charles J; Renal Medicine; Nephrology; Research and Development; Medical and Dental; Law, Jonathan; Borrows, Richard; Sharif, Adnan; Ferro, Charles; McNulty, DavidBackground: Improved recognition of factors influencing graft survival has led to better short-term kidney transplant outcomes. However, efforts to prevent long-term graft decline and improve graft survival have seen more modest improvements. The adoption of electronic health records has enabled better recording and identification of donor-recipient factors through the use of modern statistical techniques. We have previously shown in a prevalent renal transplant population that episodes of rapid deterioration are associated with graft loss. Methods: Estimated glomerular filtration rates (eGFR) between 3 and 27 months after transplantation were collected from 310 kidney transplant recipients. We utilised a Bayesian approach to estimate the most likely eGFR trajectory as a smooth curve from an average of 10,000 Monte Carlo samples. The probability of having an episode of rapid deterioration (decline greater than 5 ml/min/1.73 m2 per year in any 1-month period) was calculated. Graft loss and mortality data was collected over a median follow-up period of 8 years. Factors associated with having an episode of rapid deterioration and associations with long-term graft loss were explored. Results: In multivariable Cox Proportional Hazard analysis, a probability greater than 0.8 of rapid deterioration was associated with long-term death-censored graft loss (Hazard ratio 2.17; 95% Confidence intervals [CI] 1.04-4.55). In separate multivariable logistic regression models, cytomegalovirus (CMV) serostatus donor positive to recipient positive (Odds ratio [OR] 3.82; 95%CI 1.63-8.97), CMV donor positive (OR 2.06; 95%CI 1.15-3.68), and CMV recipient positive (OR 2.03; 95%CI 1.14-3.60) were associated with having a greater than 0.8 probability of an episode of rapid deterioration. Conclusions: Early episodes of rapid deterioration are associated with long-term death-censored graft loss and are associated with cytomegalovirus seropositivity. Further study is required to better manage these potentially modifiable risks factors and improve long-term graft survival.Publication Dialysis and end of life: an analysis of advance care planning and patient outcomes.(Elsevier, 2020-03) Khiroya, Heena; Miller, Sonia; Baharani, Jyoti; Renal Medicine; Medical and Dental; Baharani, JyotiNo abstract availablePublication Acute kidney injury in patients admitted with COVID-19 in a south Birmingham trust.(Elsevier, 2021-03) Jham, Seema; Shafiq, Taimoor; Loverre, Francesco; Edwards, Josh; Fahy, Megan; Harper, Lorraine; Baharani, Jyoti; Eddington, Helen; Renal Medicine; Medical and Dental; Jham, Seema; Harper, Lorraine; Baharani, JyotiNo abstract availablePublication Acute kidney injury calculated using admission serum creatinine underestimates 30-day and 1-year mortality after acute stroke.(Oxford University Press, 2019-05-10) Arnold, Julia; Sims, Don; Gill, Paramjit; Cockwell, Paul; Ferro, Charles; Renal Medicine; Medical and Dental; Cockwell, Paul; Ferro, CharlesBackground: Acute kidney injury (AKI) diagnosis requires ascertainment of change from a known baseline. Although pre-admission serum creatinine (SCr) is recommended, to date, all studies of AKI in acute stroke have used the first SCr on admission. Methods: All patients admitted with an acute stroke to an emergency hospital were recruited. We compared use of pre-admission SCr with admission SCr to diagnose AKI. Regression analyses were used to identify risk factors for 30-day and 1-year mortality, respectively. Results: A total of 1354 patients were recruited from December 2012 to September 2015. Incidence of AKI was 18.7 and 19.9% using pre-admission SCr and admission SCr, respectively. Diagnosis of AKI was associated with significantly increased 30-day and 1-year mortality. Diagnosis of AKI using pre-admission SCr had a stronger relationship with both 30-day and 1-year mortality. In 443 patients with a pre-admission SCr and at least two SCr during admission, AKI diagnosed using pre-admission SCr had a stronger relationship than AKI diagnosed using admission SCr with 30-day mortality [odds ratio (OR) = 2.64; 95% confidence interval (CI) 1.36-5.12; P = 0.004 versus OR = 2.10; 95% CI 1.09-4.03; P = 0.026] and 1-year mortality [hazard ratio (HR) = 1.90, 95% CI 1.32-2.76; P = 0.001 versus HR = 1.47; 95% CI 1.01-2.15; P = 0.046] in fully adjusted models. Conclusions: AKI after stroke is common and is associated with increased 30-day and 1-year mortality. Using first SCr on admission gives a comparable AKI incidence to pre-admission SCr, but underestimates 30-day and 1-year mortality risk.Publication Assessing bone mineralisation in children with chronic kidney disease: what clinical and research tools are available?(Springer International, 2019-06-25) Lalayiannis, A D; Crabtree, N J; Fewtrell, M; Biassoni, L; Milford, D V; Ferro, C J; Shroff, R; Renal medicine; Medical and Dental; Ferro, CharlesMineral and bone disorder in chronic kidney disease (CKD-MBD) is a triad of biochemical imbalances of calcium, phosphate, parathyroid hormone and vitamin D, bone abnormalities and soft tissue calcification. Maintaining optimal bone health in children with CKD is important to prevent long-term complications, such as fractures, to optimise growth and possibly also to prevent extra-osseous calcification, especially vascular calcification. In this review, we discuss normal bone mineralisation, the pathophysiology of dysregulated homeostasis leading to mineralisation defects in CKD and its clinical consequences. Bone mineralisation is best assessed on bone histology and histomorphometry, but given the rarity with which this is performed, we present an overview of the tools available to clinicians to assess bone mineral density, including serum biomarkers and imaging such as dual-energy X-ray absorptiometry and peripheral quantitative computed tomography. We discuss key studies that have used these techniques, their advantages and disadvantages in childhood CKD and their relationship to biomarkers and bone histomorphometry. Finally, we present recommendations from relevant guidelines-Kidney Disease Improving Global Outcomes and the International Society of Clinical Densitometry-on the use of imaging, biomarkers and bone biopsy in assessing bone mineral density. Given low-level evidence from most paediatric studies, bone imaging and histology remain largely research tools, and current clinical management is guided by serum calcium, phosphate, PTH, vitamin D and alkaline phosphatase levels only.Publication Acute kidney injury is more common in men than women after accounting for socioeconomic status, ethnicity, alcohol intake and smoking history.(BioMed Central, 2021-04-08) Loutradis, Charalampos; Pickup, Luke; Law, Jonathan P; Dasgupta, Indranil; Townend, Jonathan N; Cockwell, Paul; Sharif, Adnan; Sarafidis, Pantelis; Ferro, Charles J; Renal medicine; Cardiology; Medical and Dental; Law, Jonathan; Dasgupta, Indranil; Cockwell, Paul; Sharif, Adnan; Ferro, Charles; Townend, JonathanBackground: The association of several comorbidities, including diabetes mellitus, hypertension, cardiovascular disease, heart failure and chronic kidney or liver disease, with acute kidney injury (AKI) is well established. Evidence on the effect of sex and socioeconomic factors are scarce. This study was designed to examine the association of sex and socioeconomic factors with AKI and AKI-related mortality and further to evaluate the additional relationship with other possible risk factors for AKI occurrence. Methods: We included 3534 patients (1878 males with mean age 61.1 ± 17.7 and 1656 females 1656 with mean age 60.3 ± 20.0 years) admitted to Queen Elizabeth or Heartlands Hospitals, Birmingham, between October 2013 and January 2016. Patients were prospectively followed-up for a median 47.70 [IQR, 18.20] months. Study-endpoints were incidence of AKI, based on KDIGO-AKI Guidelines, and all-cause mortality. Data acquisition was automated, and information on mortality was collected from the Hospital Episode Statistics and Office of National Statistics. Socioeconomic status was evaluated with the Index of Multiple Deprivation (IMD). Results: Incidence of AKI was higher in men compared to women (11.3% vs 7.1%; P < 0.001). Model regression analysis revealed significant association of male sex with higher AKI risk (OR, 1.659; 95% CI, 1.311-2.099; P < 0.001); this association remained significant after adjustment for age, eGFR, IMD, smoking, alcohol consumption, ethnicity, existing comorbidities and treatment (OR, 1.599; 95% CI, 1.215-2.103; P = 0.001). All-cause mortality was higher in patients with compared to those without AKI. Males with AKI had higher mortality rates in the first 6-month and 1-year periods after the index AKI event. The association of male sex with mortality was independent of socioeconomic factors but was not statistically significant after adjustment for existing comorbidities. Conclusions: Men are at higher risk of AKI and this association is independent from existing risk factors for AKI. The association between male sex and AKI-related mortality was not independent from existing comorbidities. A better understanding of factors associated with AKI may help accurately identify high-risk patients.Publication Association between non-malignant monoclonal gammopathy and adverse outcomes in chronic kidney disease: a cohort study.(Public Library of Science, 2020-02-28) Fenton, Anthony; Chinnadurai, Rajkumar; Gullapudi, Latha; Kampanis, Petros; Dasgupta, Indranil; Ritchie, James; Harding, Stephen; Ferro, Charles J; Kalra, Philip A; Taal, Maarten W; Cockwell, Paul; Renal medicine; Medical and Dental; Dasgupta, Indranil; Ferro, Charles; Cockwell, PaulBackground: In studies including the general population, the presence of non-malignant monoclonal gammopathy (MG) can be causally associated with kidney damage and shorter survival. We assessed whether the presence of an MG is associated with a higher risk of kidney failure or death in individuals with chronic kidney disease (CKD). Methods and findings: Data were used from 3 prospective cohorts of individuals with CKD (not on dialysis or with a kidney transplant): (1) Renal Impairment in Secondary Care (RIISC, Queen Elizabeth Hospital and Heartlands Hospital, Birmingham, UK, N = 878), (2) Salford Kidney Study (SKS, Salford Royal Hospital, Salford, UK, N = 861), and (3) Renal Risk in Derby (RRID, Derby, UK, N = 1,739). Participants were excluded if they had multiple myeloma or any other B cell lymphoproliferative disorder with end-organ damage. Median age was 71.0 years, 50.6% were male, median estimated glomerular filtration rate was 42.3 ml/min/1.73 m2, and median urine albumin-to-creatinine ratio was 3.4 mg/mmol. All non-malignant MG was identified in the baseline serum of participants of RIISC. Further, light chain MG (LC-MG) was identified and studied in participants of RIISC, SKS, and RRID. Participants were followed up for kidney failure (defined as the initiation of dialysis or kidney transplantation) and death. Associations with the risk of kidney failure were estimated by competing-risks regression (handling death as a competing risk), and associations with death were estimated by Cox proportional hazards regression. In total, 102 (11.6%) of the 878 RIISC participants had an MG. During a median follow-up time of 74.0 months, there were 327 kidney failure events and 202 deaths. The presence of MG was not associated with risk of kidney failure (univariable subhazard ratio [SHR] 0.97 [95% CI 0.68 to 1.38], P = 0.85; multivariable SHR 1.16 [95% CI 0.80 to 1.69], P = 0.43), and although there was a higher risk of death in univariable analysis (hazard ratio [HR] 2.13 [95% CI 1.49 to 3.02], P < 0.001), this was not significant in multivariable analysis (HR 1.37 [95% CI 0.93 to 2.00], P = 0.11). Fifty-five (1.6%) of the 3,478 participants from all 3 studies had LC-MG. During a median follow-up time of 62.5 months, 564 of the 3,478 participants progressed to kidney failure, and 803 died. LC-MG was not associated with risk of kidney failure (univariable SHR 1.07 [95% CI 0.58 to 1.96], P = 0.82; multivariable SHR 1.42 [95% CI 0.78 to 2.57], P = 0.26). There was a higher risk of death in those with LC-MG in the univariable model (HR 2.51 [95% CI 1.59 to 3.96], P < 0.001), but not in the multivariable model (HR 1.49 [95% CI 0.93 to 2.39], P = 0.10). An important limitation of this work was that only LC-MG, rather than any MG, could be identified in participants from SKS and RRID. Conclusions: The prevalence of MG was higher in this CKD cohort than that reported in the general population. However, the presence of an MG was not independently associated with a significantly higher risk of kidney failure or, unlike in the general population, risk of death.Publication Evaluation of effect of cooled haemodialysis on cognition in patients with end-stage kidney disease (ECHECKED) feasibility randomised controlled trial results.(BioMed Central, 2024-12-19) Dasgupta, Indranil; Odudu, Aghogho; Baharani, Jyoti; Fergusson, Niall; Griffiths, Helen; Harrison, John; Hameed, Awais; Maruff, Paul; Ryan, Louise; Thomas, Neil; Woodhall, Gavin; Tadros, George; Renal Medicine; Medical and Dental; Dasgupta, Indranil; Baharani, Jyoti; Hameed, AwaisBackground: Cognitive impairment is common in haemodialysis patients with no known beneficial interventions. Cooler dialysate slows brain white-matter changes, but its effect on cognition is unknown. This feasibility trial was performed to inform a fully-powered, randomised trial to assess this. Methods: We aimed to randomise (1:1) 90 haemodialysis patients to this double-blinded, randomised controlled feasibility trial to standard care (dialysate-temperature 36.5 °C) or intervention (35 °C). Eligible patients were adult chronic haemodialysis recipients with no established diagnosis of dementia or psychiatric disease. The primary outcome was change in Montreal Cognitive Assessment (MoCA) score at 12-months. Secondary outcomes included recruitment and attrition rates, reasons for non-recruitment, intradialytic hypotension, depression, patient burden, computerised cognition test battery, and quality of life. Findings: Of 334 patients screened, 160 were eligible. 99 declined mainly for the extra non-dialysis day study visits. Sixty-one patients consented, 43 randomised - 20 in standard care, 23 in intervention arms; 13 withdrew for non-dialysis day visits and 5 without reason before randomisation. 27 patients (12 standard care, 15 intervention) completed the trial - 5 died, 1 transplanted, 4 withdrew consent, and 6 could not attend due to the pandemic. Low temperature dialysis was well tolerated. There was no difference in change in MoCA from baseline to 12 months between the standard and intervention arms; 1.0 (-2.8-3.0, p = 0.755) and - 2.0 (-1.0 - -4.0, p = 0.047) respectively. There were no differences between groups on any secondary measures. There were no significant adverse events reported. Discussion: The trial was significantly affected by the COVID-19 pandemic contributing to an attrition rate of 27%. The non-dialysis day research visits were mainly responsible for low recruitment and consent withdrawal. There are several learning points, described in the article, which will inform design of definitive trials in this area in the future. Trial registration: ClinicalTrials.gov Identifier NCT03645733. Registration date 24/08/2018.Publication Robotic Renal Surgery and adoption of technology in Integrated Care System era: Paradigm shift in UK practice.(W.B. Saunders Ltd, 2024-12-17) Aftab, Shah B; Shahzad, Syed; The Dudley Group NHS Foundation TrustIn the UK, kidney cancer is the sixth most common cancer, comprising 4% of new cases. Since the first robot-assisted partial nephrectomy in 2002, robotic surgery has shown benefits such as instrument stabilisation, improved ergonomics, and superior visualisation. The uptake of robotic surgery in the UK and Europe has been rapid, with a fivefold increase in England from 2013 to 2018 and continued growth since. This study compares functional and oncologic outcomes between robot-assisted and laparoscopic renal surgery using a single surgeon to reduce inter-operator bias.Publication Exploring the role of intracorporeal ultrasound in partial nephrectomies: a systematic review(Cureus, 2024-11-08) Mohsin, Mohamed S; Jess, Rebecca; Abdulrasheed, Habeeb; Almedej, Humood; Osman, Banan; Gaballa, Nader; Chandrasekharan, Shankar; University Hospitals Birmingham NHS Foundation Trust; Urology; Surgery; Medical and Dental; Mohsin, Mohamed S; Jess, Rebecca; Abdulrasheed, Habeeb; Almedej, Humood; Osman, Banan; Gaballa, Nader; Chandrasekharan, ShankarRenal cell carcinoma accounts for the sixth most common cancer in the United Kingdom. With the increasing application of cross-sectional imaging, the frequency of incidental renal masses has increased over time. Laparoscopic and robot-assisted partial nephrectomy has become the standard of care in the management of size and stage-appropriate renal masses. The objective of this systematic review was to analyse the surgical outcomes when intracorporeal ultrasound was utilised as an adjunct in partial nephrectomy. A comprehensive search in PubMed and Google Scholar was performed in July 2024 for publications in the English language. The primary endpoint was to evaluate the role of intracorporeal ultrasound as an adjunct in robotic partial nephrectomies and its impact on tumour clearance. After identifying 609 records, 52 records were screened and 44 records were sought for retrieval. Eight publications were included in this systematic review comprising 765 patients. Seven of the eight studies reported outcomes from single centres. The mean percentage of negative surgical margins was 97.6% (range = 92.1-100%). The use of intracorporeal ultrasound as an adjunct in partial nephrectomy for T1 renal cell cancer has proven to improve the rates of negative surgical margins thereby reducing the incidence of local recurrence and distant metastasis.Publication Biological variation of cardiac troponins in chronic kidney disease(Sage, 2020-02-27) Jones, R A; Barratt, J; Brettell, E A; Cockwell, P; Dalton, R N; Deeks, J J; Eaglestone, G; Pellatt-Higgins, T; Kalra, P A; Khunti, K; Morris, F S; Ottridge, R S; Sitch, A J; Stevens, P E; Sharpe, C C; Sutton, A J; Taal, M W; Lamb, E J; East Kent Hospitals University NHS Foundation Trust; University Hospitals of Leicester; University of Birmingham; University Hospitals Birmingham NHS Foundation Trust; Evelina London Children's Hospital; Test Evaluation Research Group; University of Kent; Salford Royal NHS Foundation Trust; University of Leicester; King's College London; King's College Hospital NHS Foundation Trust; Institute of Health Economics, Canada; University of Nottingham; Royal Derby Hospital; Renal Medicine; Medical and Dental; Cockwell, PaulBackground Patients with chronic kidney disease often have increased plasma cardiac troponin concentration in the absence of myocardial infarction. Incidence of myocardial infarction is high in this population, and diagnosis, particularly of non ST-segment elevation myocardial infarction (NSTEMI), is challenging. Knowledge of biological variation aids understanding of serial cardiac troponin measurements and could improve interpretation in clinical practice. The National Academy of Clinical Biochemistry (NACB) recommended the use of a 20% reference change value in patients with kidney failure. The aim of this study was to calculate the biological variation of cardiac troponin I and cardiac troponin T in patients with moderate chronic kidney disease (glomerular filtration rate [GFR] 30–59 mL/min/1.73 m2). Methods and results Plasma samples were obtained from 20 patients (median GFR 43.0 mL/min/1.73 m2) once a week for four consecutive weeks. Cardiac troponin I (Abbott ARCHITECT® i2000SR, median 4.3 ng/L, upper 99th percentile of reference population 26.2 ng/L) and cardiac troponin T (Roche Cobas® e601, median 11.8 ng/L, upper 99th percentile of reference population 14 ng/L) were measured in duplicate using high-sensitivity assays. After outlier removal and log transformation, 18 patients’ data were subject to ANOVA, and within-subject (CVI), between-subject (CVG) and analytical (CVA) variation calculated. Variation for cardiac troponin I was 15.0%, 105.6%, 8.3%, respectively, and for cardiac troponin T 7.4%, 78.4%, 3.1%, respectively. Reference change values for increasing and decreasing troponin concentrations were +60%/–38% for cardiac troponin I and +25%/–20% for cardiac troponin T. Conclusions The observed reference change value for cardiac troponin T is broadly compatible with the NACB recommendation, but for cardiac troponin I, larger changes are required to define significant change. The incorporation of separate RCVs for cardiac troponin I and cardiac troponin T, and separate RCVs for rising and falling concentrations of cardiac troponin, should be considered when developing guidance for interpretation of sequential cardiac troponin measurements.Publication Efficacy of continuous glucose monitoring in people living with diabetes and end stage kidney disease on dialysis: a systematic review(BioMed Central, 2024-10-25) Zhang, Yimeng; Singh, Pushpa; Ganapathy, Kavitha; Suresh, Vijayan; Karamat, Muhammad Ali; Baharani, Jyoti; Bellary, Srikanth; General Medicine; Renal Medicine; Endocrinology and Diabetes; Medical and Dental; Zhang, Yimeng; Singh, Pushpa; Suresh, Vijayan; Karamat, Muhammad Ali; Baharani, Jyoti; Bellary, SrikanthBackground: Patients with diabetes on dialysis experience wide variations in glucose levels and an increased risk of hypoglycaemia. Due to the inaccuracies of HbA1c in dialysis patients, JBDS-IP and KDIGO recommend the use of continuous glucose monitoring (CGM). We conducted a systematic review to examine the current evidence for CGM use and its impact on clinical outcomes in patients with diabetes on dialysis. Methods: A search of MEDLINE(R) ALL, Ovid Emcare, Journals@Ovid Full Text and Embase databases were conducted. Clinical or observational trials in adults with Type 1(T1D) or Type 2 (T2D) diabetes on dialysis and CGM intervention reporting on glycaemic outcomes were included. Results: Of the 936 citations identified, 49 duplicates were removed. 887 citations were screened by title and abstract. 9 full texts were reviewed and a further 7 excluded due to duplications or failure to meet to selection criteria. Data was extracted for 2 studies, both prospective before-and-after interventional studies with no control group. Joubert et al. (2015) showed results for 15 participants with T1D. Mean CGM glucose level decreased from 8.37mmol/L at baseline to 7.7mmol/L at the end of the CGM period (p < 0.05) while HbA1c decreased from 6.9 to 6.5% (p < 0.05) during the same period. Mean CGM was lower on dialysis days (7.68mmol/L vs. 7.8mmol/L, p < 0.05). Képénékian et al. (2014) reported on data from 29 T2D patients. Following a 3 month CGM-adapted insulin regimen, HbA1c decreased from 8.4% at baseline to 7.6% (p < 0.01) by the end of study. Mean CGM values decreased from 9.9mmol/L to 8.9mmol/L (p = 0.05) and the frequency of glucose values > 10mmol/L decreased from 41 to 30% (p < 0.05), without a significant increase in hypoglycaemia frequency. Both studies were deemed to be of 'good' quality. Conclusion: Evidence demonstrating the benefits of CGM in patients with diabetes receiving dialysis is lacking. There is a need for well-designed randomised controlled trials to ascertain the benefits of this technology in this patient group. Trail registration: PROSPERO registration number: CRD42023371635, https://www.crd.york.ac.uk/PROSPERO/display_record.php?RecordID=371635 .Publication Impairment of cardiovascular functional capacity in mild-to-moderate kidney dysfunction.(Wolters Kluwer Health, 2024-10-14) Lim, Kenneth; Nayor, Matthew; Arroyo, Eliott; Burney, Heather N; Li, Xiaochun; Li, Yang; Shah, Ravi; Campain, Joseph; Wan, Douglas; Ting, Stephen; Hiemstra, Thomas F; Thadhani, Ravi; Moe, Sharon; Zehnder, Daniel; Larson, Martin G; Vasan, Ramachandran S; Lewis, Gregory D; General Medicine; Medical and Dental; Ting, StephenKey Points: Mild-to-moderate CKD is associated with impairment in cardiovascular functional capacity as assessed by oxygen uptake at peak exercise (VO2Peak). Cardiac output is significantly reduced in patients with mild-to-moderate CKD and is associated with impaired VO2Peak. Assessment of VO2Peak by cardiopulmonary exercise testing can detect decrements in cardiovascular function during early stages of kidney function decline that may not be captured using resting left ventricular geometric indices alone. Background: Traditional diagnostic tools that assess resting cardiac function and structure fail to accurately reflect cardiovascular alterations in patients with CKD. This study sought to determine whether multidimensional exercise response patterns related to cardiovascular functional capacity can detect abnormalities in mild-to-moderate CKD. Methods: In a cross-sectional study, we examined 3075 participants from the Framingham Heart Study (FHS) and 451 participants from the Massachusetts General Hospital Exercise Study (MGH-ExS) who underwent cardiopulmonary exercise testing. Participants were stratified by eGFR: eGFR ≥90, eGFR 60–89, and eGFR 30–59. Our primary outcomes of interest were peak oxygen uptake (VO2Peak), VO2 at anaerobic threshold (VO2AT), and ratio of minute ventilation to carbon dioxide production (VE/VCO2). Multiple linear regression models were fitted to evaluate the associations between eGFR group and each outcome variable adjusted for covariates. Results: In the FHS cohort, 1712 participants (56%) had an eGFR ≥90 ml/min per 1.73 m2, 1271 (41%) had an eGFR of 60–89 ml/min per 1.73 m2, and 92 (3%) had an eGFR of 30–59 ml/min per 1.73 m2. In the MGH-ExS cohort, 247 participants (55%) had an eGFR ≥90 ml/min per 1.73 m2, 154 (34%) had an eGFR of 60–89 ml/min per 1.73 m2, and 50 (11%) had an eGFR of 30–59 ml/min per 1.73 m2. In FHS, VO2Peak and VO2AT were incrementally impaired with declining kidney function (P < 0.001); however, this pattern was attenuated after adjustment for age. Percent-predicted VO2Peak at AT was higher in the lower eGFR groups (P < 0.001). In MGH-ExS, VO2Peak and VO2AT were incrementally impaired with declining kidney function in unadjusted and adjusted models (P < 0.05). VO2Peak was associated with eGFR (P < 0.05) in all models even after adjusting for age. On further mechanistic analysis, we directly measured cardiac output (CO) at peak exercise by right heart catheterization and found impaired CO in the lower eGFR groups (P ≤ 0.007). Conclusions: Cardiopulmonary exercise testing–derived indices may detect impairment in cardiovascular functional capacity and track CO declines in mild-to-moderate CKD.Publication Routine serum biomarkers, but not dual-energy X-ray absorptiometry, correlate with cortical bone mineral density in children and young adults with chronic kidney disease(Oxford University Press, 2020-10-23) Lalayiannis, Alexander D; Crabtree, Nicola J; Ferro, Charles J; Askiti, Varvara; Mitsioni, Andromachi; Biassoni, Lorenzo; Kaur, Amrit; Sinha, Manish D; Wheeler, David C; Duncan, Neill D; Popoola, Joyce; Milford, David V; Long, Jin; Leonard, Mary Beth; Fewtrell, Mary; Shroff, Rukshana; Great Ormond St Hospital for Children NHS Foundation Trust; University College London; Birmingham Women's and Children's NHS Foundation Trust; University Hospitals Birmingham NHS Foundation Trust; "P. & A. Kyriakou" Children’s Hospital; Manchester University NHS Foundation Trust; Guy's & St Thomas' NHS Foundation Trust; Hammersmith Hospital; George's University Hospital NHS Foundation Trust; Stanford University; Renal Medicine; Medical and Dental; Ferro, CharlesBackground: Biomarkers and dual-energy X-ray absorptiometry (DXA) are thought to be poor predictors of bone mineral density (BMD). The Kidney Disease: Improving Global Outcomes guidelines suggest using DXA if the results will affect patient management, but this has not been studied in children or young adults in whom bone mineral accretion continues to 30 years of age. We studied the clinical utility of DXA and serum biomarkers against tibial cortical BMD (CortBMD) measured by peripheral quantitative computed tomography, expressed as Z-score CortBMD, which predicts fracture risk. Methods: This was a cross-sectional multicentre study in 26 patients with CKD4 and 5 and 77 on dialysis. Results: Significant bone pain that hindered activities of daily living was present in 58%, and 10% had at least one low-trauma fracture. CortBMD and cortical mineral content Z-scores were lower in dialysis compared with CKD patients (P = 0.004 and P = 0.02). DXA BMD hip and lumbar spine Z-scores did not correlate with CortBMD or biomarkers. CortBMD was negatively associated with parathyroid hormone (PTH; r = -0.44, P < 0.0001) and alkaline phosphatase (ALP; r = -0.22, P = 0.03) and positively with calcium (Ca; r = 0.33, P = 0.001). At PTH <3 times upper limit of normal, none of the patients had a CortBMD below -2 SD (odds ratio 95% confidence interval 7.331 to infinity). On multivariable linear regression PTH (β = -0.43 , P < 0.0001), ALP (β = -0.36, P < 0.0001) and Ca (β = 0.21, P = 0.005) together predicted 57% of variability in CortBMD. DXA measures did not improve this model. Conclusions: Taken together, routinely used biomarkers, PTH, ALP and Ca, but not DXA, are moderate predictors of cortical BMD. DXA is not clinically useful and should not be routinely performed in children and young adults with CKD 4-5D.Publication Reply(Wolters Kluwer Health, 2022-03-01) Sarafidis, Pantelis A; Ortiz, Alberto; Ferro, Charles J; Halimi, Jean-Michel; Kreutz, Reinhold; Mallamaci, Francesca; Mancia, Giuseppe; Wanner, Christoph; Aristotle University of Thessaloniki; University Autonoma of Madrid; University Hospitals Birmingham NHS Foundation Trust; CHRU de Tours-Hospital Bretonneau; Freie Universität Berlin; Humboldt-Universität zu Berlin; Berlin Institute of Health; CNR-Institute of Clinical Physiology, Clinical Epidemiology and Physiopathology of Renal Diseases and Hypertension; Università Milano-Bicocca; Wuerzburg University Clinic; Renal Medicine; Medical and Dental; Ferro, CharlesNo abstract availablePublication Renin-angiotensin system blockers during the COVID-19 pandemic: an update for patients with hypertension and chronic kidney disease(Oxford University Press, 2021-12-14) Theodorakopoulou, Marieta P; Alexandrou, Maria-Eleni; Boutou, Afroditi K; Ferro, Charles J; Ortiz, Alberto; Sarafidis, Pantelis; Aristotle University of Thessaloniki; G. Papanikolaou Hospital; University Hospitals Birmingham NHS Foundation Trust; IIS-Fundacion Jimenez Diaz UAM; Renal Medicine; Medical and Dental; Ferro, CharlesHypertension and chronic kidney disease (CKD) are among the most common comorbidities associated with coronavirus disease 2019 (COVID-19) severity and mortality risk. Renin-angiotensin system (RAS) blockers are cornerstones in the treatment of both hypertension and proteinuric CKD. In the early months of the COVID-19 pandemic, a hypothesis emerged suggesting that the use of RAS blockers may increase susceptibility for COVID-19 infection and disease severity in these populations. This hypothesis was based on the fact that angiotensin-converting enzyme 2 (ACE2), a counter regulatory component of the RAS, acts as the receptor for severe acute respiratory syndrome coronavirus 2 cell entry. Extrapolations from preliminary animal studies led to speculation that upregulation of ACE2 by RAS blockers may increase the risk of COVID-19-related adverse outcomes. However, these hypotheses were not supported by emerging evidence from observational and randomized clinical trials in humans, suggesting no such association. Herein we describe the physiological role of ACE2 as part of the RAS, discuss its central role in COVID-19 infection and present original and updated evidence from human studies on the association between RAS blockade and COVID-19 infection or related outcomes, with a particular focus on hypertension and CKD.