PAlliative Care in chronic Kidney diSease: the PACKS study—quality of life, decision making, costs and impact on carers in people managed without dialysis

BACKGROUND: The number of patients with advanced chronic kidney disease opting for conservative management rather than dialysis is unknown but likely to be growing as increasingly frail patients with advanced renal disease present to renal services. Conservative kidney management includes ongoing medical input and support from a multidisciplinary team. There is limited evidence concerning patient and carer experience of this choice. This study will explore quality of life, symptoms, cognition, frailty, performance decision making, costs and impact on carers in people with advanced chronic kidney disease managed without dialysis and is funded by the National Institute of Health Research in the UK.

METHODS: In this prospective, multicentre, longitudinal study, patients will be recruited in the UK, by renal research nurses, once they have made the decision not to embark on dialysis. Carers will be asked to 'opt-in' with consent from patients. The approach includes longitudinal quantitative surveys of quality of life, symptoms, decision making and costs for patients and quality of life and costs for carers, with questionnaires administered quarterly over 12 months. Additionally, the decision making process will be explored via qualitative interviews with renal physicians/clinical nurse specialists.

DISCUSSION: The study is designed to capture patient and carer profiles when conservative kidney management is implemented, and understand trajectories of care-receiving and care-giving with the aim of optimising palliative care for this population. It will explore the interactions that lead to clinical care decisions and the impact of these decisions on informal carers with the intention of improving clinical outcomes for patients and the experiences of care givers.

Evaluation of the Retinal Vasculature in Hypertension and Chronic Kidney Disease in an elderly population of Irish nuns

Background: Chronic kidney disease (CKD) and hypertension are global public health problems associated with considerable morbidity, premature mortality and attendant healthcare costs. Previous studies have highlighted that non-invasive examination of the retinal microcirculation can detect microvascular pathology that is associated with systemic disorders of the circulatory system such as hypertension. We examined the associations between retinal vessel caliber (RVC) and fractal dimension (DF), with both hypertension and CKD in elderly Irish nuns.

Methods: Data from 1233 participants in the cross-sectional observational Irish Nun Eye Study (INES) were assessed from digital photographs with a standardized protocol using computer-assisted software. Multivariate regression analyses were used to assess associations with hypertension and CKD, with adjustment for age, body mass index (BMI), refraction, fellow eye RVC, smoking, alcohol consumption, ischemic heart disease (IHD), cerebrovascular accident (CVA), diabetes and medication use.

Results: In total, 1122 (91%) participants (mean age: 76.3 [range: 56-100] years) had gradable retinal images of sufficient quality for blood vessel assessment. Hypertension was significantly associated with a narrower central retinal arteriolar equivalent (CRAE) in a fully adjusted analysis (P = 0.002; effect size= -2.16 μm; 95% confidence intervals [CI]: -3.51, -0.81 μm). No significant associations between other retinal vascular parameters and hypertension or between any retinal vascular parameters and CKD were found.

Conclusions: Individuals with hypertension have significantly narrower retinal arterioles which may afford an earlier opportunity for tailored prevention and treatment options to optimize the structure and function of the microvasculature, providing additional clinical utility. No significant associations between retinal vascular parameters and CKD were detected.

A HuGE Review and Meta-Analyses of Genetic Associations in New Onset Diabetes after Kidney Transplantation

PURPOSE: New onset diabetes after transplantation (NODAT) is a serious complication following solid organ transplantation. There is a genetic contribution to NODAT and we have conducted comprehensive meta-analysis of available genetic data in kidney transplant populations.

METHODS: Relevant articles investigating the association between genetic markers and NODAT were identified by searching PubMed, Web of Science and Google Scholar. SNPs described in a minimum of three studies were included for analysis using a random effects model. The association between identified variants and NODAT was calculated at the per-study level to generate overall significance values and effect sizes.

RESULTS: Searching the literature returned 4,147 citations. Within the 36 eligible articles identified, 18 genetic variants from 12 genes were considered for analysis. Of these, three were significantly associated with NODAT by meta-analysis at the 5% level of significance; CDKAL1 rs10946398 p = 0.006 OR = 1.43, 95% CI = 1.11-1.85 (n = 696 individuals), KCNQ1 rs2237892 p = 0.007 OR = 1.43, 95% CI = 1.10-1.86 (n = 1,270 individuals), and TCF7L2 rs7903146 p = 0.01 OR = 1.41, 95% CI = 1.07-1.85 (n = 2,967 individuals).

CONCLUSION: Evaluating cumulative evidence for SNPs associated with NODAT in kidney transplant recipients has revealed three SNPs associated with NODAT. An adequately powered, dense genome-wide association study will provide more information using a carefully defined NODAT phenotype.

Validity of model devices used to assess canine temperament in behavioral tests

Temperament tests are widely accepted as instruments for profiling behavioral variability in dogs, and they are applied in numerous areas of investigation (e.g. suitability for adoption or for breeding). During testing, to elicit a dog's reaction toward novel stimuli and predict its behavior in everyday life, model devices such as a child-like doll, or a fake dog, are often employed. However, the reliability of these devices to accurately stimulate dogs' reactions to children or dogs, is unknown and perhaps overestimated. This may be a particular concern in the case of aggressive behavior toward humans, a significant public health issue. The aim of this study was to: (1) evaluate the correlation between dogs' reactions to these devices, and owners' reports of their dog's aggression history (using the C-BARQ ??); (2) compare reactions toward the devices of dogs with and without histories of aggression. Subjects were selected among those visiting for behavioral consultation at the Veterinary Hospital of the University of Pennsylvania, and previously categorized as aggressive toward unfamiliar children, conspecifics, or as non-aggressive dogs (control). The test consisted of different components: an unfamiliar female tester approaching the dog; the presentation of a child-like doll, an ambiguous object, and a fake plastic dog. All tests were videotaped and durations of behaviors were later analyzed on the basis of a specified ethogram. Dogs' reactions were compared to C-BARQ scores, and interesting correlations emerged for 'dog-directed aggression/fear' (R = 0.48, P = 0.004), and 'stranger-directed aggression' (R = 0.58, P <0.001) factors. Dogs differed in their reactions toward the devices: the child-like doll and the fake dog elicited more social behaviors than the ambiguous object used as a control stimulus. Issues concerning the reliability of these tools to assess canine temperament are discussed. ?? 2012 Elsevier B.V. All rights reserved.

Compositonal Analysis of Potentially harmful Elements in Soils: Implications for Epidemiology and Kidney Disease

A substantial proportion of aetiological risks for many cancers and chronic diseases remain unexplained. Using geochemical soil and stream water samples collected as part of the Tellus Project studies, current research is investigating naturally occurring background levels of potentially toxic elements (PTEs) in soils and stream sediments and their possible relationship with progressive chronic kidney disease (CKD). The Tellus geological mapping project, Geological Survey Northern Ireland, collected soil sediment and stream water samples on a grid of one sample site every 2 km2 across the rural areas of Northern Ireland resulting in an excess of 6800 soil sampling locations and more than 5800 locations for stream water sampling. Accumulation of several PTEs including arsenic, cadmium, chromium, lead and mercury have been linked with human health and implicated in renal function decline. The hypothesis is that long-term exposure will result in cumulative exposure to PTEs and act as risk factor(s) for cancer and diabetes related CKD and its progression. The ‘bioavailable’ fraction of total PTE soil concentration depends on the ‘bioaccessible’ proportion through an exposure pathway. Recent work has explored this bioaccessible fraction for a range of PTEs across Northern Ireland. In this study the compositional nature of the multivariate geochemical PTE variables and bioaccessible data is explored to augment the investigation into the potential relationship between PTEs, bioaccessibility and disease data.

Optimising the management of polycystic kidney disease

Polycystic kidney disease (PKD) is the most common inherited renal disorder that results in chronic kidney disease. Clinical features include visible haematuria, loin pain, UTI and hypertension. The typical clinical course is a progressive increase in the number and size of renal cysts associated with gradual loss of kidney function (falling eGFR).