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Background Patients receiving in-center hemodialysis treatment face unique challenges during the COVID-19 pandemic, specifically the need to attend for treatment that prevents self-isolation. Dialysis unit attributes and isolation strategies that might reduce dialysis center COVID-19 infection rates have not been previously examined. Methods We explored the role of variables including community disease burden, dialysis unit attributes (size, layout) and infection control strategies, on rates of COVID-19 among patients receiving in center hemodialysis in London, UK, between March 2nd 2020 and May 31st 2020. The two outcomes were defined as (i) a positive test for infection or admission with suspected COVID19 and (ii) admission to the hospital with suspected infection. Associations were examined using a discrete-time multi-level time-to-event analysis. Results Data on 5,755 patients, dialysing in 51 units were analysed. 990 (17%) tested positive and 465 (8%) were admitted with suspected COVID-19 between 2nd March and 31st May 2020. Outcomes were associated with age, diabetes, local community COVID-19 rates and dialysis unit size. Greater number of available side rooms and introduction of mask policies for asymptomatic patients were inversely associated with outcomes. No association was seen with sex, ethnicity, or deprivation indices nor with any of the different isolation strategies. Conclusions Rates of COVID-19 in the in center-hemodialysis population relate to individual factors, underlying community transmission, unit size and layout.

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Background Hemodialysis patients are at high risk from Covid-19, though vaccination has significant efficacy in preventing and reducing the severity of infection. Little information is available on disease severity and vaccine efficacy since dissemination of the Omicron variant. Methods In a multi-center study, during a period of the epidemic driven by the Omicron variant, all hemodialysis patients positive for SARS-CoV-2 were identified. Outcomes were analysed according to predictor variables including vaccination status. Risk of infection was analysed using a Cox proportional hazards model. Results SARS-CoV-2 infection was identified in 1126 patients including 200 (18%) unvaccinated, 56 (5%) post first dose, 433 (38%) post second dose, and 437 (39%) at least 7 days beyond their third dose. The majority of patients had a mild course but 160 (14%) were hospitalised and 28 (2%) died. In regression models adjusted for age and comorbidity, two-dose vaccination was associated with a 39% (95%CI: 2-62%) reduction in admissions, but third doses provided additional protection, with a 51% (95%CI: 25-69%) further reduction in admissions. Amongst 1265 patients at risk at the start of the observation period, SARS-CoV-2 infection was observed in 211 (17%). Two-dose vaccination was associated with a 41% (95%CI: 3-64%) reduction in the incidence of infection, with no clear additional effect provided by third doses. Conclusions These data demonstrate lower incidence of SARS-CoV-2 infection after vaccination in dialysis patients during an Omicron dominant period of the epidemic. Amongst those developing infection, severe illness was less common with prior vaccination, particularly after third vaccine doses.

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Acute kidney injury (AKI) is a common presentation which can result from a number of different underlying pathological processes. Haematological malignancies, particularly multiple myeloma (MM), are known to frequently present with AKI. Anti-neutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV) is a rare condition which can cause crescentic glomerulonephritis (GN), resulting in AKI. We present the case of a 60-year-old man who presented with clinical features suggestive of AAV in the context of blood tests which demonstrated AKI and positive perinuclear ANCA (p-ANCA) and anti-myeloperoxidase (anti-MPO) titres. Further in

IntroductionPractical Assessment of Clinical Examination Skills (PACES) constitutes the final part of the mandatory Royal College of Physicians exam series for progression to higher specialty training. Pass rates were lower for core medical trainees (CMTs) in Coventry and Warwickshire in comparison to other regions within the West Midlands and nationally.ObjectivesOur aim was to improve pass rates in the region through the introduction of a stimulating and supportive teaching framework, designed to enhance the quality and frequency of PACES teaching.MethodsTo identify key areas for change a baseline questionnaire, including Likert Scale and free text questions related to PACES teaching, was distributed to all CMTs in the region. Many trainees highlighted concern over lack of PACES-orientated teaching and support, with particular emphasis on: lack of bedside-teaching with feedback; infrequent opportunities for practising communication skills; and difficulty identifying suitable patients in an efficient manner. To address these concerns the following interventions were implemented over two Plan, Do, Study, Act (PDSA) cycles which were analysed at 6 months and 12months: a digital forum to highlight relevant inpatients for examination practice; a peer-to-peer mentoring scheme; a consultant-led bedside-teaching rota; and classroom-based communication skills sessions.ResultsPass rates at Annual Review of Competence Progression improved from baseline to the end of the first year of implementation, 56.3% to 77.3%, respectively. Furthermore, following analysis of questionnaires at each PDSA cycle, we demonstrated a progressive improvement in trainee satisfaction in exposure, quality and relevance of teaching.ConclusionOur innovative, cost-effective teaching framework for PACES preparation has improved exam outcomes and facilitated swift junior doctor career progression, while raising the profile of the trust. Furthermore, this innovation provides a template for potential adoption in other National Health Service institutions.

Background: Up to one third of patients on renal replacement programmes have an unknown cause of kidney disease, and the diagnosis may only be established following renal transplantation when the disease recurs or if new extra-renal symptoms develop. Case presentation: We present two patients who presented with progressive chronic kidney disease of unknown cause. Both patients underwent successful renal transplantation but subsequently developed multisystem abnormalities, and were ultimately diagnosed with mitochondrial cytopathy 10-15 years following transplantation. Conclusions: Mitochondrial cytopathies are rare inborn errors of metabolism that should be considered in adults with renal impairment, especially in those with a family history of kidney or other multisystem disease. The widespread availability of genetic testing provides the potential for earlier diagnoses, thereby enhancing management decisions, anticipation of complications, avoidance of mitotoxic drugs, and informed prognosis prediction.