Primary Sjögren’s syndrome (pSS) is a chronic autoimmune disorder characterised by lymphocytic infiltration of the exocrine glands, predominantly the salivary and lacrimal glands, leading to sicca symptoms. Patients may have extraglandular disease involving multiple organs, including the kidneys. 5% of patients with pSS can have renal involvement. Kidney disease in pSS presents a diagnostic challenge, as clinical symptoms are often insidious and can precede sicca symptoms. pSS affects the kidney through lymphocytic infiltration of renal tubules or immune complex deposition, leading to an array of clinical features. Tubulointerstitial nephritis is the most common histological pattern of kidney disease. Other tubular injuries include renal tubular acidosis with hypokalaemia, Fanconi’s syndrome and diabetes insipidus. Glomerular disease is less common and typically involves an immune complex-mediated process. Optimal treatment for kidney diseases in pSS is not established, and treatment is guided by the pattern of disease. For tubulointerstitial nephritis, management involves electrolyte imbalance correction and the use of immunosuppression, including steroids. Treatment of glomerular disease is targeted to the histological pattern, and often requires a combination of immunosuppressive agents. The risk of end-stage kidney disease is low. Nevertheless, patients with pSS and kidney disease have significantly reduced quality of life.
Background Acute kidney injury (AKI) is associated with decreased survival, future risk of chronic kidney disease and longer hospital stays. Electronic alerts (e-alerts) for AKI have been introduced in the UK in order to facilitate earlier detection and improve management. The aim of this study was to establish if e-alerts in primary care were acted on by examining timing of repeat creatinine testing. Methods The National Health Service England Acute Kidney Injury electronic alert algorithm was introduced in April 2015 across both primary and secondary care in NHS Tayside accompanied by a programme of education. Data from a 12-month period (2012) predating introduction of the e-alerts were compared with a 12-month period following implementation of e-alerts for AKI. Biochemistry testing following the AKI episode, timing of repeat tests and numbers of patients hospitalized within 7 days of episode were compared between the two time periods. Results During the 12 months after e-alert introduction, 9781 AKI e-alerts were generated. Of these, 1460 (14.9%) alerts were generated in primary care. Median duration to repeat blood testing for these primary care alerts was 5 days for AKI Stage 1 [interquartile range (IQR) 2–10], 2 days for Stage 2 (IQR 1–5) and 1 day (IQR 0–2) for Stage 3. During 2012 (prior to e-alert implementation) 8812 AKI episodes were identified. Of these, 2650 tests (30.1%) were requested by primary care staff. Median duration to repeat creatinine testing was longer: 55 days (IQR 20–142) for Stage 1, 38 days (IQR 15–128) for Stage 2 was and 53 days (IQR 20–137) for Stage 3. More patients had biochemistry tests repeated within 7 days of AKI onset, pre-alert implementation; 252 (9.5%) versus 857 (58.7%) (P < 0.001). Rates of hospitalization within 7 days of AKI increased from 342 (12.9%) pre-implementation to 372 (25.5%) post-implementation (P < 0.001). Conclusions Within primary care, e-alert implementation was associated with higher rates of creatinine monitoring, but also higher rates of hospitalization.
BackgroundSmall studies suggest an association between ANCA-associated vasculitis (AAV) incidence and rurality, seasonality and socioeconomic deprivation. We examined the incidence of kidney biopsy-proven AAV and its relationship with these factors in the adult Scottish population.MethodsUsing the Scottish Renal Biopsy Registry, all adult native kidney biopsies performed between 2014 and 2018 with a diagnosis of granulomatosis with polyangiitis (GPA) or microscopic polyangiitis (MPA) were identified. The Scottish Government Urban Rural Classification was used for rurality analysis. Seasons were defined as autumn (September–November), winter (December–February), spring (March–May) and summer (June–August). Patients were separated into quintiles of socioeconomic deprivation using the validated Scottish Index of Multiple Deprivation and incidence standardised to age. Estimated glomerular filtration rate and urine protein:creatinine ratio at time of biopsy were used to assess disease severity.Results339 cases of renal AAV were identified, of which 62% had MPA and 38% had GPA diagnosis. AAV incidence was 15.1 per million population per year (pmp/year). Mean age was 66 years and 54% were female. Incidence of GPA (but not MPA) was positively associated with rurality (5.2, 8.4 and 9.1 pmp/year in ‘urban’, ‘accessible remote’ and ‘rural remote’ areas, respectively; p=0.04). The age-standardised incidence ratio was similar across all quintiles of deprivation (p=ns).ConclusionsSeasonality and disease severity did not vary across AAV study groups. In this complete national cohort study, we observed a positive association between kidney biopsy-proven GPA and rurality.
Background: Urinary Tract Infections (UTIs) are the most common bacterial infections in the elderly. First line antibiotic therapy includes Trimethoprim and Nitrofurantoin, both of which should be used with caution in renal impairment. The project aim was to improve antibiotic prescribing in UTIs for patients with renal impairment. Methods: Initially an online questionnaire was sent to prescribers working in Forth Valley Hospital to ascertain their knowledge of antibiotic prescribing in renal failure. Quantitative data was obtained reviewing Trimethoprim and Nitrofurantoin prescriptions over 1 month (19/02/19-19/03/19) using HEPMA electronic prescribing system. These results were cross matched with patients renal function collected from SciStore database. Results: Despite 95% of medical staff having experience of prescribing in renal failure, 35% of those still did not feel confident in prescribing the correct antibiotic dosage with 90% of the opinion that prescribing guidance was necessary. Quantitative data showed that 12.9% (28/217) of patients treated with either trimethoprim or nitrofurantoin had renal impairment. Of these 79% had an Acute Kidney Injury and 71% a degree of Chronic Kidney Injury. 78% of the patients on Trimthoprim had an AKI and 38% of these developed hyperkalaemia. Those prescribed Nitrofurantoin 100% of this group had a concurrent Acute on Chronic Kidney Disease. Conclusion: 79% of patients prescribed Trimthoprim or Nitrofurantoin had a degree of renal impairment leading to potential undertreatment or renal damage in the patient. As a result NHS Forth Valley has now updated prescribing guidelines regarding UTI treatment in patients with renal impairment advising alternative antibiotic therapy.
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