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McGovern DP, Lees JS, Traynor JP, Mackinnon B, Bell S, Hunter RW, Dhaun N, Metcalfe W, Kidder D, Lim M, Joss N, Kelly M, Taylor A, Cousland Z, Dey V, Buck K, Brix S, Geddes CC, McQuarrie EP, Stevens KI. Outcomes in ANCA-Associated Vasculitis in Scotland: Validation of the Renal Risk Score in a Complete National Cohort. Kidney Int Rep 2023; 8:1648-1656. [PMID: 37547534 PMCID: PMC10403670 DOI: 10.1016/j.ekir.2023.05.029] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2022] [Revised: 05/24/2023] [Accepted: 05/26/2023] [Indexed: 08/08/2023] Open
Abstract
Introduction Antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV) causes autoimmune-mediated inflammation of small blood vessels in multiple organs, including the kidneys. The ability to accurately predict kidney outcomes would enable a more personalized therapeutic approach. Methods We used our national renal biopsy registry to validate the ability of ANCA Renal Risk Score (ARRS) to predict end-stage kidney disease (ESKD) for individual patients. This score uses histopathological and biochemical data to stratify patients as high, medium, or low risk for developing ESKD. Results A total of 288 patients were eligible for inclusion in the study (low risk n = 144, medium risk n = 122, high risk n = 12). Using adjusted Cox proportional hazard models with the low-risk group as reference, we show that outcome differs between the categories: high-risk hazard ratio (HR) 16.69 (2.91-95.81, P = 0.002); medium risk HR 4.14 (1.07-16.01, P = 0.039). Incremental multivariable-adjusted Cox proportional hazards models demonstrated that adding ARRS to a model adjusted for multiple clinical parameters enhanced predictive discrimination (basic model C-statistic 0.864 [95% CI 0.813-0.914], basic model plus ARRS C-statistic 0.877 [95% CI 0.823-0.931]; P <0.01). Conclusion The ARRS better discriminates risk of ESKD in AAV and offers clinicians more prognostic information than the use of standard biochemical and clinical measures alone. This is the first time the ARRS has been validated in a national cohort. The proportion of patients with high-risk scores is lower in our cohort compared to others and should be noted as a limitation of this study.
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Affiliation(s)
- Dominic P. McGovern
- Glasgow Renal and Transplant Unit, Queen Elizabeth University Hospital, Glasgow, UK
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
| | - Jennifer S. Lees
- Glasgow Renal and Transplant Unit, Queen Elizabeth University Hospital, Glasgow, UK
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
| | - Jamie P. Traynor
- Glasgow Renal and Transplant Unit, Queen Elizabeth University Hospital, Glasgow, UK
| | - Bruce Mackinnon
- Department of Nephrology and Transplantation, John Hunter Hospital, New South Wales, Australia
| | - Samira Bell
- Division of Population Health and Genomics, University of Dundee, Dundee, UK
| | - Robert W. Hunter
- Centre for Cardiovascular Science, The Queen's Medical Research Institute, The University of Edinburgh, Edinburgh, UK
| | - Neeraj Dhaun
- Centre for Cardiovascular Science, The Queen's Medical Research Institute, The University of Edinburgh, Edinburgh, UK
| | | | - Dana Kidder
- Renal Unit, Aberdeen Royal Infirmary, Aberdeen, UK
| | - Michelle Lim
- Renal Unit, Ninewells Hospital and Medical School, Dundee, UK
| | - Nicola Joss
- Renal Unit, Raigmore Hospital, Inverness, UK
| | - Michael Kelly
- Renal Unit, Dumfries and Galloway Royal Infirmary, Dumfries, UK
| | | | | | - Vishal Dey
- Renal Unit, University Hospital Crosshouse, Kilmarnock, UK
| | - Kate Buck
- Renal Unit, Queen Margaret Hospital, Fife Acute Hospitals Trust, Kirkcaldy, Fife, UK
| | - Silke Brix
- Renal, Urology and Transplantation Unit, Manchester University Hospitals, Manchester, UK
- Cardiovascular Science, University of Manchester, Manchester, UK
| | - Colin C. Geddes
- Glasgow Renal and Transplant Unit, Queen Elizabeth University Hospital, Glasgow, UK
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
| | - Emily P. McQuarrie
- Glasgow Renal and Transplant Unit, Queen Elizabeth University Hospital, Glasgow, UK
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
| | - Kathryn I. Stevens
- Glasgow Renal and Transplant Unit, Queen Elizabeth University Hospital, Glasgow, UK
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
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2
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Aiyegbusi O, Frleta-Gilchrist M, Traynor JP, Mackinnon B, Bell S, Hunter RW, Dhaun N, Kidder D, Stewart G, Joss N, Kelly M, Shah S, Dey V, Buck K, Stevens KI, Geddes CC, McQuarrie EP. ANCA-associated renal vasculitis is associated with rurality but not seasonality or deprivation in a complete national cohort study. RMD Open 2021; 7:rmdopen-2020-001555. [PMID: 33875562 PMCID: PMC8057563 DOI: 10.1136/rmdopen-2020-001555] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2020] [Revised: 04/04/2021] [Accepted: 04/07/2021] [Indexed: 11/30/2022] Open
Abstract
Background Small 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. Methods Using 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. Results 339 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). Conclusions Seasonality 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.
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Affiliation(s)
- Oshorenua Aiyegbusi
- Glasgow Renal and Transplant Unit, Queen Elizabeth University Hospital, Glasgow, UK
| | | | - Jamie P Traynor
- Glasgow Renal and Transplant Unit, Queen Elizabeth University Hospital, Glasgow, UK
| | - Bruce Mackinnon
- Department of Nephrology & Hypertension, John Hunter Hospital, New Lambton Heights, New South Wales, Australia
| | - Samira Bell
- Division of population Health and Genomics, University of Dundee, Dundee, UK
| | - Robert W Hunter
- Centre for Cardiovascular Science, The Queen's Medical Research Institute, The University of Edinburgh, Edinburgh, UK
| | - Neeraj Dhaun
- Centre for Cardiovascular Science, The Queen's Medical Research Institute, The University of Edinburgh, Edinburgh, UK
| | - Dana Kidder
- Renal Unit, Aberdeen Royal Infirmary, Aberdeen, UK
| | - Graham Stewart
- Renal Unit, Ninewells Hospital and Medical School, Dundee, UK
| | - Nicola Joss
- Renal Unit, Raigmore Hospital, Inverness, UK
| | - Michael Kelly
- Renal Unit, Dumfries and Galloway Royal Infirmary, Dumfries, UK
| | | | - Vishal Dey
- Renal Unit, University Hospital Crosshouse, Kilmarnock, UK
| | - Kate Buck
- Renal Unit, Queen Margaret Hospital, Fife Acute Hospitals Trust, Kirkcaldy, Fife, UK
| | - Kathryn I Stevens
- Glasgow Renal and Transplant Unit, Queen Elizabeth University Hospital, Glasgow, UK
| | - Colin C Geddes
- Glasgow Renal and Transplant Unit, Queen Elizabeth University Hospital, Glasgow, UK
| | - Emily P McQuarrie
- Glasgow Renal and Transplant Unit, Queen Elizabeth University Hospital, Glasgow, UK
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3
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Stevens K, Kidder D, Lim M, Hunter R, Kelly M, Joss N, Cousland Z, Traynor J, Geddes CC, McQuarrie E, Mackinnon B. P0209PRESENTATION AND OUTCOMES OF ANCA ASSOCIATED VASCULITIS: THE SCOTTISH EXPERIENCE. Nephrol Dial Transplant 2020. [DOI: 10.1093/ndt/gfaa142.p0209] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Abstract
Background and Aims
This is a national project undertaken on behalf of the Scottish Renal Biopsy Registry describing the presentation, biopsy appearances, management and outcomes of patients presenting with a new diagnosis of renal biopsy proven ANCA associated vasculitis (AAV) to all units in Scotland.
Method
The Scottish Renal Biopsy Registry collects data annually on all renal biopsies performed across Scotland. From the Registry, all patients with a possible diagnosis of AAV found on renal biopsy performed between1/1/2014 and 31/12/2017 were identified. Individual units searched the electronic patient records of each patient and identified all those with a new diagnosis of AAV. Those undergoing repeat biopsy or who were not felt to have AAV on biopsy were excluded. Demographic data including immunological and outcome data were recorded and statistical analysis was undertaken in SPSS (v22).
Results
267 patients were identified as having AAV across 8 centres and followed up for an average of 989 (IQR 610-1247) days. In 52% (n= 140) the biopsy indication was acute kidney injury.
38% (n=101) had a diagnosis of granulomatosis with polyangiitis (GPA). 52% (n=140) were female and the mean age at biopsy was 66.6±12.1 years. 38% (n=100) were PR3 positive. The average number of glomeruli on biopsy was 14 (IQR 11-21) with 3 (IQR 2-7 crescents. 28% (IQR 7-51) of viable glomeruli contained crescents. 41% (n=110) had at more than 10% interstitial fibrosis on biopsy. Creatinine at biopsy was 208µmol/L (IQR 141-380 µmol/L) and at 90 days 141 µmol/L (IQR 101-222 µmol/L).
Most patients received standard induction therapy of cyclophosphamide and steroid. 24% (n=65) had plasma exchange at presentation and 11% (n=30) renal replacement therapy (RRT).
15% (n=39) patients relapsed with an average time to relapse of 511 (IQR 223-11127) days. 62% (n=24) of relapses were treated with rituximab. Those with GPA relapsed earlier.
12% (n= 31) developed end stage renal disease (ESRD). 18% (n=49) died with 14 patients (5%) dying within 90 days of biopsy. Average time to death was 246 (IQR 89-321) days. There was a trend towards an increased risk of death with those who developed ESRD. Patients who received PEX or RRT during initial admission were no more likely to relapse or die than those who did not.
Conclusion
This study accurately describes the presentation, management and outcomes of patients with AAV and renal involvement in Scotland. This allows comparison between centres within Scotland and other countries. The cohort will added to and followed to look at longer term outcomes.
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Affiliation(s)
- Kate Stevens
- Glasgow Renal and Transplant Unit, Glasgow, United Kingdom
| | - Dana Kidder
- Renal Unit, Aberdeen Royal Infirmary, Aberdeen, United Kingdom
| | - Michelle Lim
- Renal Unit, Ninewells Hospital, Dundee, United Kingdom
| | - Rob Hunter
- Renal and Transplant Unit, Edinburgh Royal Infirmary, Edinburgh, United Kingdom
| | - Mike Kelly
- Renal Unit, Dumfries and Galloway Royal Infirmary, Dumfries, United Kingdom
| | - Nicola Joss
- Renal Unit, Raigmore Hospital, Inverness, United Kingdom
| | - Zoe Cousland
- Renal Unit, University Hospital Monklands, Airdrie, United Kingdom
| | - Jamie Traynor
- Glasgow Renal and Transplant Unit, Glasgow, United Kingdom
| | - Colin C Geddes
- Glasgow Renal and Transplant Unit, Glasgow, United Kingdom
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Weiner M, Bjørneklett R, Hrušková Z, Mackinnon B, Poulton CJ, Sindelar L, Mohammad AJ, Eriksson P, Gesualdo L, Geetha D, Crnogorac M, Jayne D, Hogan SL, Geddes C, Tesar V, Aasarød K, Segelmark M. Proteinase-3 and myeloperoxidase serotype in relation to demographic factors and geographic distribution in anti-neutrophil cytoplasmic antibody-associated glomerulonephritis. Nephrol Dial Transplant 2020; 34:301-308. [PMID: 29718465 DOI: 10.1093/ndt/gfy106] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2017] [Accepted: 03/21/2018] [Indexed: 01/29/2023] Open
Abstract
Background In anti-neutrophil cytoplasmic antibody (ANCA)-associated glomerulonephritis, antigen specificity varies between myeloperoxidase (MPO) and proteinase 3 (PR3). This has been reported to vary in relation to age, gender, geography and extrarenal manifestations. However, studies are difficult to compare as criteria for inclusion vary. The aim of this study was to investigate the relationship between ANCA serotype, latitude, ultraviolet (UV) radiation levels, age, gender and renal function at diagnosis in a large study with uniform inclusion criteria. Methods Patients with biopsy-proven ANCA-associated glomerulonephritis were identified from regional or nationwide registries in 14 centres in Norway, Sweden, the UK, the Czech Republic, Croatia, Italy and the USA during the period 2000-13. UV radiation levels for 2000-13 in Europe were obtained from the Swedish Meteorological and Hydrological Institute. Results A total of 1408 patients (45.2% PR3-ANCA) were included in the study. In univariable analysis, PR3-ANCA was significantly associated with male gender {odds ratio [OR] 2.12 [95% confidence interval (CI) 1.71-2.62]}, younger age [OR per year 0.97 (95% CI 0.96-0.98)] and higher glomerular filtration rate [OR per mL/min 1.01 (95% CI 1.01-1.02); P < 0.001] at diagnosis but not with latitude or UV radiation. In multivariable logistic regression analysis, latitude and UV radiation also became significant, with higher odds for PR3-ANCA positivity at northern latitudes/lower UV radiation levels. However, the latitudinal difference in MPO:PR3 ratio is smaller than differences previously reported concerning microscopic polyangiitis and granulomatosis with polyangiitis. Conclusions The ratio between PR3-ANCA and MPO-ANCA varies in glomerulonephritis with respect to age, gender, renal function and geographic latitude/UV radiation levels.
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Affiliation(s)
- Maria Weiner
- Department of Nephrology and Medical and Health Sciences, Linköping University, Linköping, Sweden
| | - Rune Bjørneklett
- Renal Research Group, Department of Clinical Medicine, University of Bergen, Bergen, Norway.,Emergency Care Clinic, Haukeland University Hospital, Bergen, Norway
| | - Zdenka Hrušková
- Department of Nephrology, First Faculty of Medicine, Charles University and General University Hospital, Prague, Czech Republic
| | - Bruce Mackinnon
- Glasgow Renal and Transplant Unit, Queen Elizabeth University Hospital, Glasgow, UK
| | - Caroline J Poulton
- University of North Carolina School of Medicine, Chapel Hill, NC, USA.,Division of Nephrology and Hypertension, Department of Medicine UNC Kidney Center, Chapel Hill, NC, USA
| | - Leo Sindelar
- Department of Nephrology and Medical and Health Sciences, Linköping University, Linköping, Sweden.,Glasgow Renal and Transplant Unit, Queen Elizabeth University Hospital, Glasgow, UK
| | - Aladdin J Mohammad
- Department of Clinical Sciences, Section of Rheumatology, Lund University, Lund, Sweden.,Department of Medicine, University of Cambridge, Cambridge, UK
| | - Per Eriksson
- Department of Rheumatology and Clinical and Experimental Medicine, Linköping University, Linköping, Sweden
| | - Loreto Gesualdo
- Nephrology, Dialysis and Transplantation Unit, University of Bari, Bari, Italy
| | - Duvuru Geetha
- Division of Nephrology, Department of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Matija Crnogorac
- Department of Nephrology and Dialysis, Dubrava University Hospital, Zagreb, Croatia
| | - David Jayne
- Department of Medicine, University of Cambridge, Cambridge, UK
| | - Susan L Hogan
- University of North Carolina School of Medicine, Chapel Hill, NC, USA.,Division of Nephrology and Hypertension, Department of Medicine UNC Kidney Center, Chapel Hill, NC, USA
| | - Colin Geddes
- Glasgow Renal and Transplant Unit, Queen Elizabeth University Hospital, Glasgow, UK
| | - Vladimir Tesar
- Department of Nephrology, First Faculty of Medicine, Charles University and General University Hospital, Prague, Czech Republic
| | - Knut Aasarød
- Department of Nephrology, Saint Olavs University Hospital, Trondheim, Norway.,Faculty of Medicine, Norwegian University of Science and Technology, Trondheim, Norway
| | - Mårten Segelmark
- Department of Nephrology and Medical and Health Sciences, Linköping University, Linköping, Sweden
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5
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Rankin AJ, Cannon E, Gillis K, Crosby J, Mark PB, Geddes CC, Fox JG, Mackinnon B, McQuarrie EP, Kipgen D. Predicting outcome in acute interstitial nephritis: a case-series examining the importance of histological parameters. Histopathology 2019; 76:698-706. [PMID: 31691330 DOI: 10.1111/his.14031] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2019] [Accepted: 12/05/2019] [Indexed: 12/14/2022]
Abstract
AIMS The clinical significance of common histological parameters in acute interstitial nephritis (AIN) is uncertain. We aimed to evaluate the utility of histology in predicting clinical outcomes in patients with AIN. METHODS AND RESULTS Adult renal biopsies yielding a diagnosis of AIN between 2000 and 2015 were re-examined. Patients were divided into groups based on: (i) the percentage of non-fibrotic cortex containing inflammation (NFI score) (NFI-1 = 0-24%; NFI-2 = 25-74%; NFI-3 = 75-100%) and (ii) the percentage of cortex containing tubular atrophy (TA score) (TA1 = 0-9%; TA2 = 10-24%; TA3 = 25-100%). The primary outcome was a composite of ≥50% reduction in serum creatinine (sCr) or an estimated glomerular filtration rate (eGFR) > 60 ml/min/1.73 m2 1 year post-biopsy. From a total of 2817 native renal biopsies, there were 120 patients with AIN and adequate data for analysis. Of these, 66 (56%) achieved the primary outcome. On univariable logistic regression, NFI-3 was associated with a 16 times increased likelihood of achieving the primary outcome compared to NFI-1 [odds ratio (OR) = 16, 95% confidence interval (CI) = 5.2-50)]. In contrast, TA3 was associated with a 90% reduced likelihood of achieving the primary outcome compared to TA1 (OR = 0.10, 95% CI = 0.0-0.3). Maximal clinical utility was achieved by combining TA and NFI into a single prognostic 'TANFI' score, which had an independent predictive effect on the primary outcome in a multivariable regression model consisting of age, sex, baseline sCr and identified drug cause. CONCLUSIONS In patients with biopsy-proven AIN, a lower percentage of cortical tubular atrophy and, paradoxically, a higher percentage of inflammation in non-fibrosed cortex were associated with an increased likelihood of a positive clinical outcome.
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Affiliation(s)
- Alastair J Rankin
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK.,Glasgow Renal and Transplant Unit, Queen Elizabeth University Hospital, Glasgow, UK
| | - Emma Cannon
- Glasgow Renal and Transplant Unit, Queen Elizabeth University Hospital, Glasgow, UK
| | - Keith Gillis
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK.,Glasgow Renal and Transplant Unit, Queen Elizabeth University Hospital, Glasgow, UK
| | - Jana Crosby
- Department of Pathology, Queen Elizabeth University Hospital, Glasgow, UK
| | - Patrick B Mark
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
| | - Colin C Geddes
- Glasgow Renal and Transplant Unit, Queen Elizabeth University Hospital, Glasgow, UK
| | - Jonathan G Fox
- Glasgow Renal and Transplant Unit, Queen Elizabeth University Hospital, Glasgow, UK
| | - Bruce Mackinnon
- Glasgow Renal and Transplant Unit, Queen Elizabeth University Hospital, Glasgow, UK
| | - Emily P McQuarrie
- Glasgow Renal and Transplant Unit, Queen Elizabeth University Hospital, Glasgow, UK
| | - David Kipgen
- Department of Pathology, Queen Elizabeth University Hospital, Glasgow, UK
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6
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Elyan BMP, Lees JS, Gillis KA, Mackinnon B, Fox JG, Geddes CC, McQuarrie EP. Obesity is not associated with progression to end stage renal disease in patients with biopsy-proven glomerular diseases. BMC Nephrol 2019; 20:237. [PMID: 31266462 PMCID: PMC6604373 DOI: 10.1186/s12882-019-1434-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2018] [Accepted: 06/23/2019] [Indexed: 11/23/2022] Open
Abstract
Background Body mass index (BMI) is associated with renal disease progression in unspecified CKD. The relationship between BMI and primary glomerular disease (GN) may be more complex. We aimed to evaluate the association between BMI and renal disease progression in patients with primary glomerular disease (GN). Methods This was a single-centre retrospective cohort study performed in adult patients with biopsy-proven primary GN (excluding minimal change disease) from January 2000 to December 2015, with follow-up data until June 2017. BMI at time of biopsy was categorised as ≤25 kg/m2, > 25 to ≤30 kg/m2 and > 30 kg/m2. We used univariate and multivariate survival analyses to evaluate factors associated with progression to a composite endpoint of stage 5 CKD or renal replacement therapy (Major Adverse Renal Event - MARE) censoring for competing risk of death using Fine and Gray subdistribution hazards model. Results We included 560 patients with biopsy-proven primary GN and available BMI data: 66.1% were male with median age 54.8 (IQR 41.1–66.2) years and BMI 28.2 (IQR 24.9–32.1) kg/m2. Those with BMI 25-30 kg/m2 (n = 210) and with BMI > 30 kg/m2 (n = 207) were older (p = 0.007) with higher systolic and diastolic blood pressures (p = 0.02 and 0.004 respectively) than those with BMI < 25 kg/m2 (n = 132). There was a greater proportion of focal segmental glomerulosclerosis in those with higher BMI (3.9% in BMI < 25 kg/m2, 7.9% in BMI 25–30 kg/m2 and 10.7% in BMI > 30 kg/m2 of biopsies (p = 0.01)), but similar proportions of other GN diagnoses across BMI groups. Baseline eGFR (p = 0.40) and uPCR (p = 0.17) were similar across BMI groups. There was no interaction between BMI and time to MARE (log-rank p = 0.98) or death (log-rank p = 0.42). Censoring for competing risk of death, factors associated with progression to MARE were: younger age, lower baseline eGFR and higher uPCR, but not BMI (SHR 0.99, 95%CI 0.97–1.01, p = 0.31) nor blood pressure or GN diagnosis. Conclusion BMI was not associated with progression to MARE in this patient cohort with primary GN. Efforts should be directed to managing other known risk factors for CKD progression.
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Affiliation(s)
- Benjamin M P Elyan
- Glasgow Renal and Transplant Unit, Queen Elizabeth University Hospital, Glasgow, UK
| | - Jennifer S Lees
- Glasgow Renal and Transplant Unit, Queen Elizabeth University Hospital, Glasgow, UK. .,Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK.
| | - Keith A Gillis
- Glasgow Renal and Transplant Unit, Queen Elizabeth University Hospital, Glasgow, UK.,Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
| | - Bruce Mackinnon
- Glasgow Renal and Transplant Unit, Queen Elizabeth University Hospital, Glasgow, UK
| | - Jonathan G Fox
- Glasgow Renal and Transplant Unit, Queen Elizabeth University Hospital, Glasgow, UK
| | - Colin C Geddes
- Glasgow Renal and Transplant Unit, Queen Elizabeth University Hospital, Glasgow, UK
| | - Emily P McQuarrie
- Glasgow Renal and Transplant Unit, Queen Elizabeth University Hospital, Glasgow, UK
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7
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Smith J, Stevens K, Mackinnon B, Methven S, Kidder D. FP203THE PROGNOSTIC UTILITY OF RENAL BIOPSY CHRONICITY SCORING IN ANCA ASSOCIATED GLOMERULONEPHRITIS. Nephrol Dial Transplant 2019. [DOI: 10.1093/ndt/gfz106.fp203] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- James Smith
- Aberdeen Royal Infirmary, Aberdeen, United Kingdom
| | - Kathryn Stevens
- Queen Elizabeth University Hospital, Glasgow, United Kingdom
| | - Bruce Mackinnon
- Queen Elizabeth University Hospital, Glasgow, United Kingdom
| | | | - Dana Kidder
- Aberdeen Royal Infirmary, Aberdeen, United Kingdom
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8
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Cannon E, Rankin A, Gillis K, Crosby J, Mark P, Geddes C, Fox J, Mackinnon B, Mcquarrie E, Kipgen D. FP105HISTOLOGICAL FINDINGS IN ACUTE INTERSTITIAL NEPHRITIS – A ROLE FOR SCORING NON-FIBROTIC INFLAMMATION. Nephrol Dial Transplant 2019. [DOI: 10.1093/ndt/gfz106.fp105] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Emma Cannon
- Queen Elizabeth University Hospital, Glasgow, United Kingdom
| | - Alastair Rankin
- Queen Elizabeth University Hospital, Glasgow, United Kingdom
| | - Keith Gillis
- Queen Elizabeth University Hospital, Glasgow, United Kingdom
| | - Jana Crosby
- Queen Elizabeth University Hospital, Glasgow, United Kingdom
| | - Patrick Mark
- Queen Elizabeth University Hospital, Glasgow, United Kingdom
| | - Colin Geddes
- Queen Elizabeth University Hospital, Glasgow, United Kingdom
| | - Jonathan Fox
- Queen Elizabeth University Hospital, Glasgow, United Kingdom
| | - Bruce Mackinnon
- Queen Elizabeth University Hospital, Glasgow, United Kingdom
| | - Emily Mcquarrie
- Queen Elizabeth University Hospital, Glasgow, United Kingdom
| | - David Kipgen
- Queen Elizabeth University Hospital, Glasgow, United Kingdom
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9
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Kramer A, Pippias M, Noordzij M, Stel VS, Andrusev AM, Aparicio-Madre MI, Arribas Monzón FE, Åsberg A, Barbullushi M, Beltrán P, Bonthuis M, Caskey FJ, Castro de la Nuez P, Cernevskis H, De Meester J, Finne P, Golan E, Heaf JG, Hemmelder MH, Ioannou K, Kantaria N, Komissarov K, Korejwo G, Kramar R, Lassalle M, Lopot F, Macário F, Mackinnon B, Pálsson R, Pechter Ü, Piñera VC, Santiuste de Pablos C, Segarra-Medrano A, Seyahi N, Slon Roblero MF, Stojceva-Taneva O, Vazelov E, Winzeler R, Ziginskiene E, Massy Z, Jager KJ. The European Renal Association - European Dialysis and Transplant Association (ERA-EDTA) Registry Annual Report 2016: a summary. Clin Kidney J 2019; 12:702-720. [PMID: 31583095 PMCID: PMC6768305 DOI: 10.1093/ckj/sfz011] [Citation(s) in RCA: 104] [Impact Index Per Article: 20.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2018] [Indexed: 11/30/2022] Open
Abstract
Background This article summarizes the ERA-EDTA Registry’s 2016 Annual Report, by describing the epidemiology of renal replacement therapy (RRT) for end-stage renal disease (ESRD) in 2016 within 36 countries. Methods In 2017 and 2018, the ERA-EDTA Registry received data on patients undergoing RRT for ESRD in 2016 from 52 national or regional renal registries. In all, 32 registries provided individual patient data and 20 provided aggregated data. The incidence and prevalence of RRT and the survival probabilities of these patients were determined. Results In 2016, the incidence of RRT for ESRD was 121 per million population (pmp), ranging from 29 pmp in Ukraine to 251 pmp in Greece. Almost two-thirds of patients were men, over half were aged ≥65 years and almost a quarter had diabetes mellitus as their primary renal diagnosis. Treatment modality at the start of RRT was haemodialysis for 84% of patients. On 31 December 2016, the prevalence of RRT was 823 pmp, ranging from 188 pmp in Ukraine to 1906 pmp in Portugal. In 2016, the transplant rate was 32 pmp, varying from 3 pmp in Ukraine to 94 pmp in the Spanish region of Catalonia. For patients commencing RRT during 2007–11, the 5-year unadjusted patient survival probability on all RRT modalities combined was 50.5%. For 2016, the incidence and prevalence of RRT were higher among men (187 and 1381 pmp) than women (101 and 827 pmp), and men had a higher rate of kidney transplantation (59 pmp) compared with women (33 pmp). For patients starting dialysis and for patients receiving a kidney transplant during 2007–11, the adjusted patient survival probabilities appeared to be higher for women than for men.
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Affiliation(s)
- Anneke Kramer
- ERA-EDTA Registry, Department of Medical Informatics, Amsterdam UMC, University of Amsterdam, Amsterdam Public Health Research Institute, Amsterdam, The Netherlands
| | - Maria Pippias
- ERA-EDTA Registry, Department of Medical Informatics, Amsterdam UMC, University of Amsterdam, Amsterdam Public Health Research Institute, Amsterdam, The Netherlands
| | - Marlies Noordzij
- ERA-EDTA Registry, Department of Medical Informatics, Amsterdam UMC, University of Amsterdam, Amsterdam Public Health Research Institute, Amsterdam, The Netherlands
| | - Vianda S Stel
- ERA-EDTA Registry, Department of Medical Informatics, Amsterdam UMC, University of Amsterdam, Amsterdam Public Health Research Institute, Amsterdam, The Netherlands
| | - Anton M Andrusev
- State-financed health institution, City Clinical Hospital #52 of Moscow City Health Department, Moscow, Russia
| | | | | | - Anders Åsberg
- Department of Transplantation Medicine, Oslo University Hospital-Rikshospitalet, Oslo, Norway
| | | | | | - Marjolein Bonthuis
- ERA-EDTA Registry, Department of Medical Informatics, Amsterdam UMC, University of Amsterdam, Amsterdam Public Health Research Institute, Amsterdam, The Netherlands.,ESPN/ERA-EDTA Registry, Department of Medical Informatics, Amsterdam UMC, University of Amsterdam, Amsterdam Public Health Research Institute, Amsterdam, The Netherlands
| | - Fergus J Caskey
- UK Renal Registry, Southmead Hospital, Bristol, UK.,Population Health Sciences, University of Bristol, Bristol, UK
| | - Pablo Castro de la Nuez
- Information System of the Autonomic Transplant Coordination of Andalucia (SICATA), Seville, Andalucia, Spain
| | - Harijs Cernevskis
- Department of Internal Medicine, Riga Stradins University, Riga, Latvia
| | - Johan De Meester
- Department of Nephrology, Dialysis and Hypertension, Dutch-speaking Belgian Renal Registry (NBVN), Sint-Niklaas, Belgium
| | - Patrik Finne
- Finnish Registry for Kidney Diseases, Helsinki, Finland.,Nephrology, Abdominal Center, University of Helsinki, Helsinki University Hospital, Helsinki, Finland
| | - Eliezer Golan
- Israel Renal Registry-ISNH, Hemodialysis Unit, Meir Medical Center, Kfar-Saba, Israel
| | - James G Heaf
- Department of Medicine, Zealand University Hospital, Roskilde, Denmark
| | - Marc H Hemmelder
- Dutch Renal Registry Renine, Nefrovisie Foundation, Utrecht, The Netherlands
| | - Kyriakos Ioannou
- Nephrology Department, Apollonion Private Hospital, Nicosia, Cyprus.,Nephrology Department, American Medical Center, Nicosia, Cyprus
| | - Nino Kantaria
- Georgian Renal Registry, Dialysis, Nephrology, and Transplantation Union of Georgia, Tbilisi State Medical University, Tbilisi, Georgia
| | - Kirill Komissarov
- Belarusian Medical Academy of Postgraduate Education, Minsk, Belarus
| | - Grzegorz Korejwo
- Department of Nephrology, Gdańsk Medical University, Gdansk, Poland
| | | | - Mathilde Lassalle
- REIN Registry, Agence de la biomédecine, Saint-Denis La Plaine, France
| | - František Lopot
- Department of Medicine Prague, General University Hospital, Prague-Strahov, Czech Republic
| | - Fernando Macário
- Nephrology Department, Centro Hospitalar e Universitario de Coimbra, Coimbra, Portugal
| | - Bruce Mackinnon
- Scottish Renal Registry, Glasgow Renal & Transplant Unit, Queen Elizabeth University Hospital, Glasgow, UK
| | - Runólfur Pálsson
- Division of Nephrology, Landspitali - The National University Hospital of Iceland, Reykjavik, Iceland.,Faculty of Medicine, School of Health Sciences, University of Iceland, Reykjavik, Iceland
| | - Ülle Pechter
- Department of Internal Medicine, Tartu University, Tartu, Estonia
| | - Vicente C Piñera
- Servicio de Nefrología, Hospital Universitario Valdecilla, Santander, Spain
| | - Carmen Santiuste de Pablos
- Registro de Enfermos Renales de la Región de Murcia, Servicio de Epidemiología, Consejería de Sanidad, IMIB-Arrixaca, Murcia, Spain
| | | | - Nurhan Seyahi
- Department of Nephrology, Cerrahpasa Medical Faculty, Istanbul University, Cerrahpaşa, Istanbul, Turkey
| | | | | | - Evgueniy Vazelov
- Dialysis Clinic, "Alexandrovska" University Hospital, Sofia Medical University, Sofia, Bulgaria
| | - Rebecca Winzeler
- Institute of Nephrology, Stadtspital Waid Zurich, Zurich, Switzerland
| | - Edita Ziginskiene
- Lithuanian Nephrology, Dialysis and Transplantation Association, Kaunas, Lithuania.,Nephrology Department, Medical Academy, Lithuanian University of Health Sciences, Kaunas, Lithuania
| | - Ziad Massy
- Division of Nephrology, Ambroise Paré University Hospital, Boulogne-Billancourt, France.,Institut National de la Santé et de la Recherche Médicale (INSERM) Unit 1018 team5, Research Centre in Epidemiology and Population Health (CESP), University of Paris Ouest-Versailles-St Quentin-en-Yveline, Villejuif, France
| | - Kitty J Jager
- ERA-EDTA Registry, Department of Medical Informatics, Amsterdam UMC, University of Amsterdam, Amsterdam Public Health Research Institute, Amsterdam, The Netherlands
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10
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Rankin AJ, Kipgen D, Geddes CC, Fox JG, Milne G, Mackinnon B, McQuarrie EP. Assessment of active tubulointerstitial nephritis in non-scarred renal cortex improves prediction of renal outcomes in patients with IgA nephropathy. Clin Kidney J 2018; 12:348-354. [PMID: 31198533 PMCID: PMC6543968 DOI: 10.1093/ckj/sfy093] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2018] [Indexed: 12/13/2022] Open
Abstract
Background The addition of tubulointerstitial inflammation to the existing pathological classification of IgA nephropathy (IgAN) is appealing but was previously precluded due to reportedly wide inter-observer variability. We report a novel method to score percentage of non-atrophic renal cortex containing active tubulointerstitial inflammation (ATIN) in patients with IgAN and assess its utility to predict clinical outcomes. Methods All adult patients with a native renal biopsy diagnosis of IgAN between 2010 and 2015 in a unit serving 1.5 million people were identified. Baseline characteristics, biopsy reports and outcome data were collected. ATIN was calculated by subtracting the percentage of atrophic cortex from the percentage of total cortex with tubulointerstitial inflammation, with ≥10% representing significant ATIN. The primary outcome was a composite of requiring renal replacement therapy or doubling of serum creatinine. Results In total 153 new cases of IgAN were identified, of which 111 were eligible for inclusion. Of these, 76 (68%) were male and 54 (49%) had ATIN on biopsy. During a median follow-up of 2.3 years, 34 (31%) reached the primary outcome. On univariable Cox regression analysis, ATIN was associated with a five-fold increase in the primary outcome [hazard ratio (HR) (95% confidence interval) 4.9 (95% confidence interval (CI) 2.1–11.3)]. On multivariable analysis, mesangial hypercellularity, tubular atrophy and interstitial fibrosis and ATIN independently associated with renal outcome (P = 0.02 for ATIN). Inter-observer reproducibility revealed fair agreement in the diagnosis of ATIN (κ=0.43, P = 0.05). Conclusions Within our centre, ATIN was significantly associated with renal outcome in patients with IgAN, independently of established histological features and baseline clinical characteristics.
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Affiliation(s)
- Alastair J Rankin
- Institute of Cardiovascular & Medical Sciences, University of Glasgow, Glasgow, UK.,Glasgow Renal & Transplant Unit, Queen Elizabeth University Hospital, Glasgow, UK
| | - David Kipgen
- Department of Pathology, Queen Elizabeth University Hospital, Glasgow, UK
| | - Colin C Geddes
- Glasgow Renal & Transplant Unit, Queen Elizabeth University Hospital, Glasgow, UK
| | - Jonathan G Fox
- Glasgow Renal & Transplant Unit, Queen Elizabeth University Hospital, Glasgow, UK
| | - Gordon Milne
- Department of Pathology, University Hospital Monklands, Airdrie, UK
| | - Bruce Mackinnon
- Glasgow Renal & Transplant Unit, Queen Elizabeth University Hospital, Glasgow, UK
| | - Emily P McQuarrie
- Glasgow Renal & Transplant Unit, Queen Elizabeth University Hospital, Glasgow, UK
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11
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Abstract
To obtain truly informed consent, we must be able to advise our patients accurately about the relative risk and benefit of any treatment plan. Percutaneous renal biopsy remains the gold standard investigation in the evaluation of intrinsic renal disease. There have been significant improvements in practice over the past decades with regards to percutaneous renal biopsy. Across centres, we appear now to have reached agreement on many aspects of this procedure, such as the need for blood pressure control, avoidance of coagulopathy, use of spring-loaded needles under direct imaging guidance and a need to monitor for complications. The authors from Rush University Medical Centre provide reassurance that renal biopsy in the modern era remains a safe procedure with a low rate of significant bleeding. There remain areas of divergence in practice that may have unintended and deleterious consequences: administration of desmopressin and discontinuation of aspirin, for example, both carry a risk of thrombosis. It is our opinion that it is time to reach consensus on our interpretation of the available data and to draw up guidelines to standardize our biopsy practice internationally.
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Affiliation(s)
- Jennifer S Lees
- Glasgow Renal and Transplant Unit, NHS Greater Glasgow and Clyde, Glasgow, UK
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
| | - Emily P McQuarrie
- Glasgow Renal and Transplant Unit, NHS Greater Glasgow and Clyde, Glasgow, UK
| | - Bruce Mackinnon
- Glasgow Renal and Transplant Unit, NHS Greater Glasgow and Clyde, Glasgow, UK
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12
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McVay G, Stevens K, Kidder D, Cousland Z, Joss N, Kelly M, Spalding E, Stewart G, Hunter R, Traynor J, Geddes C, Mackinnon B. FP101PRESENTATION AND OUTCOMES OF ANCA ASSOCIATED VASCULITIS: THE SCOTTISH EXPERIENCE. Nephrol Dial Transplant 2018. [DOI: 10.1093/ndt/gfy104.fp101] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
- Gillian McVay
- Respiratory Unit, Glasgow Royal Infirmary, Glasgow, United Kingdom
| | - Kathryn Stevens
- Renal Unit, Queen Elizabeth University Hospital, Glasgow, United Kingdom
| | - Dana Kidder
- Renal Unit, Aberdeen Royal Infirmary, Aberdeen, United Kingdom
| | - Zoe Cousland
- Renal Unit, Monklands Hospital, Glasgow, United Kingdom
| | - Nicola Joss
- Renal Unit, Raigmore Hospital, Inverness, United Kingdom
| | - Mike Kelly
- Renal Unit, Dumfries and Galloway Royal Infirmary, Dumfries, United Kingdom
| | | | | | - Rob Hunter
- Renal Unit, Edinburgh Royal Infirmary, Edinburgh, United Kingdom
| | - Jamie Traynor
- Renal Unit, Queen Elizabeth University Hospital, Glasgow, United Kingdom
| | - Colin Geddes
- Renal Unit, Queen Elizabeth University Hospital, Glasgow, United Kingdom
| | - Bruce Mackinnon
- Renal Unit, Queen Elizabeth University Hospital, Glasgow, United Kingdom
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13
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Stevens K, Mackinnon B, Kipgen D, Coley S, Clancy M, Geddes C. FP717HISTOLOGICAL DIAGNOSIS AND PREDICTORS OF TRANSPLANT FAILURE IN PATIENTS UNDERGOING INDICATION RENAL BIOPSY. Nephrol Dial Transplant 2018. [DOI: 10.1093/ndt/gfy104.fp717] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
- Kathryn Stevens
- Renal Unit, Queen Elizabeth University Hospital, Glasgow, United Kingdom
| | - Bruce Mackinnon
- Renal Unit, Queen Elizabeth University Hospital, Glasgow, United Kingdom
| | - David Kipgen
- Pathology Department, Queen Elizabeth University Hospital, Glasgow, United Kingdom
| | - Shana Coley
- Pathology Department, Queen Elizabeth University Hospital, Glasgow, United Kingdom
| | - Marc Clancy
- Renal Unit, Queen Elizabeth University Hospital, Glasgow, United Kingdom
| | - Colin Geddes
- Renal Unit, Queen Elizabeth University Hospital, Glasgow, United Kingdom
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14
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Stevens K, Mackinnon B, Kipgen D, Coley S, Clancy M, Geddes C. MP788PREDICTORS OF TRANSPLANT FAILURE IN PATIENTS UNDERGOING INDICATION RENAL BIOPSY. Nephrol Dial Transplant 2017. [DOI: 10.1093/ndt/gfx182.mp788] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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15
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Rankin A, Mackinnon B, Kipgen D, Fox J, Geddes C, McQuarrie E. MP084APPLICATION OF THE OXFORD CLASSIFICATION OF IGA NEPHROPATHY IN THE REAL WORLD. Nephrol Dial Transplant 2017. [DOI: 10.1093/ndt/gfx162.mp084] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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16
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Lees JS, McQuarrie EP, Mordi N, Geddes CC, Fox JG, Mackinnon B. Risk factors for bleeding complications after nephrologist-performed native renal biopsy. Clin Kidney J 2017; 10:573-577. [PMID: 28852497 PMCID: PMC5570080 DOI: 10.1093/ckj/sfx012] [Citation(s) in RCA: 57] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2016] [Indexed: 01/27/2023] Open
Abstract
Background Bleeding is a recognized complication of native percutaneous renal biopsy. This study aimed to describe the incidence of major bleeding after biopsy in a single centre over a 15-year period and examine factors associated with major bleeding. Methods We identified consecutive adult patients undergoing ultrasound-guided native renal biopsy in the Glasgow Renal and Transplant Unit from 2000 to 2014. From the electronic patient record, we collected data pertaining to biopsy indication, pre- and post-biopsy laboratory measurements, prescribed medication and diagnosis. Aspirin was routinely continued. We defined major bleeding post-biopsy as the need for blood transfusion, surgical or radiological intervention or death. Binary logistic regression analysis was used to assess factors associated with increased risk of major bleeding. Results There were 2563 patients who underwent native renal biopsy (1499 elective, 1064 emergency). The average age of patients was 57 (SD 17) years and 57.4% were male. Overall, the rate of major bleeding was 2.2%. In all, 46 patients required transfusion (1.8%), 9 patients underwent embolization (0.4%), no patient required nephrectomy and 1 patient died as a result of a significant late retroperitoneal bleed. Major bleeding was more common in those undergoing emergency compared with elective renal biopsy (3.4 versus 1.1%; P < 0.001). Aspirin was being taken at the time of biopsy in 327 of 1509 patients, with no significant increase in the risk of major bleeding (P = 0.93). Body mass index (BMI) data were available for 546 patients, with no increased risk of major bleeding in 207 patients classified as obese (BMI >30). Conclusions The risk of major bleeding following native renal biopsy in the modern era is low. Complications are more common when biopsy is conducted as an emergency, which has implications for obtaining informed consent. Our data support the strategy of not stopping aspirin before renal biopsy.
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Affiliation(s)
- Jennifer S Lees
- Glasgow Renal and Transplant Unit, Queen Elizabeth University Hospital, Glasgow, UK
| | - Emily P McQuarrie
- Glasgow Renal and Transplant Unit, Queen Elizabeth University Hospital, Glasgow, UK
| | - Natalie Mordi
- Renal Unit, Ninewells Hospital, James Arnott Drive, Dundee, UK
| | - Colin C Geddes
- Glasgow Renal and Transplant Unit, Queen Elizabeth University Hospital, Glasgow, UK
| | - Jonathan G Fox
- Glasgow Renal and Transplant Unit, Queen Elizabeth University Hospital, Glasgow, UK
| | - Bruce Mackinnon
- Glasgow Renal and Transplant Unit, Queen Elizabeth University Hospital, Glasgow, UK
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17
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McQuarrie EP, Mackinnon B, Bell S, Fleming S, McNeice V, Stewart G, Fox JG, Geddes CC. Multiple socioeconomic deprivation and impact on survival in patients with primary glomerulonephritis. Clin Kidney J 2017. [PMID: 28639628 PMCID: PMC5469556 DOI: 10.1093/ckj/sfw127] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
Background: The impact of multiple socio-economic deprivation on patient outcomes in primary renal diseases is unknown. We aimed to assess whether risk of death or requiring renal replacement therapy (RRT) in patients with primary glomerulonephritis (GN) was higher in patients living in an area of multiple socio-economic deprivation. Methods: Patients undergoing native renal biopsy between 2000 and 2014 were identified. Baseline demographics, postcode at time of biopsy, follow-up blood pressure, proteinuria and time to death or RRT were recorded. The Scottish Index of Multiple Deprivation (SIMD) is a multidimensional model used to measure deprivation based on postcode. Using SIMD, patients were separated into tertiles of deprivation. Results: A total of 797 patients were included, 64.2% were male with mean age of 54.1 (standard deviation 17.0) years. Median follow-up was 6.3 (interquartile range 3.7–9.4) years during which 174 patients required RRT and 185 patients died. Patients in the most deprived tertile of deprivation were significantly more likely to die than those in the least deprived tertile [hazard ratio (HR) 2.2, P < 0.001], independent of age, baseline serum creatinine and blood pressure. They were not more likely to require RRT (P = 0.22). The increased mortality risk in the most deprived tertile was not uniform across primary renal diseases, with the association being most marked in focal segmental glomerulosclerosis (HR 7.4) and IgA nephropathy (HR 2.7) and absent in membranous nephropathy. Conclusion: We have demonstrated a significant independent 2-fold increased risk of death in patients with primary GN who live in an area of multiple socio-economic deprivation at the time of diagnosis as compared with those living in less deprived areas.
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Affiliation(s)
- Emily P McQuarrie
- Glasgow Renal and Transplant Unit, Queen Elizabeth University Hospital, Glasgow, UK
| | - Bruce Mackinnon
- Glasgow Renal and Transplant Unit, Queen Elizabeth University Hospital, Glasgow, UK
| | | | | | | | | | - Jonathan G Fox
- Glasgow Renal and Transplant Unit, Queen Elizabeth University Hospital, Glasgow, UK
| | - Colin C Geddes
- Glasgow Renal and Transplant Unit, Queen Elizabeth University Hospital, Glasgow, UK
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18
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Lees J, Mackinnon B, Fox JG, Geddes CC, McQuarrie EP. SP138GLOMERULAR DISEASE IN OBESE PATIENTS: NOT ALWAYS FSGS. Nephrol Dial Transplant 2016. [DOI: 10.1093/ndt/gfw160.19] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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19
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Findlay MD, Donaldson K, Doyle A, Fox JG, Khan I, McDonald J, Metcalfe W, Peel RK, Shilliday I, Spalding E, Stewart GA, Traynor JP, Mackinnon B. Factors influencing withdrawal from dialysis: a national registry study. Nephrol Dial Transplant 2016; 31:2041-2048. [PMID: 27190373 DOI: 10.1093/ndt/gfw074] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2016] [Accepted: 03/16/2016] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Dialysis withdrawal is the third most common cause of death in patients receiving dialysis for established renal failure (ERF) in Scotland. We describe incidence, risk factors and themes influencing decision-making in a national renal registry. METHODS Details of deaths in those receiving renal replacement therapy (RRT) for ERF in Scotland are reported to the Scottish Renal Registry via a unique mortality report. We extracted patient demographics and comorbidity, cause and location of death, duration of RRT and pertinent free text comments from 1 January 2008 to 31 December 2014. Withdrawal incidence was calculated and logistic regression used to identify significantly influential variables. Themes emerging from clinician comments were tabulated for descriptive purposes. RESULTS There were 2596 deaths; median age at death was 68 [interquartile range (IQR) 58, 76] years, 41.5% were female. Median duration on RRT was 1110 (IQR 417, 2151) days. Dialysis withdrawal was the primary cause of death in 497 (19.1%) patients and withdrawal contributed to death in a further 442 cases (17.0%). The incidence was 41 episodes per 1000 patient-years. Regression analysis revealed increasing age, female sex and prior cerebrovascular disease were associated with dialysis withdrawal as a primary cause of death. Conversely, interstitial renal disease, angiographically proven ischaemic heart disease, valvular heart disease and malignancy were negatively associated. Analysis of free text comments revealed common themes, portraying an image of physical and psychological decline accelerated by acute illnesses. CONCLUSIONS Death following dialysis withdrawal is common. Factors important to physical independence-prior cerebrovascular disease and increasing age-are associated with withdrawal. When combined with clinician comments this study provides an insight into the clinical decline affecting patients and the complexity of this decision. Early recognition of those likely to withdraw may improve end of life care.
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Affiliation(s)
- Mark D Findlay
- The Glasgow Renal & Transplant Unit, South Glasgow University Hospital, Glasgow, UK
| | | | | | - Jonathan G Fox
- The Glasgow Renal & Transplant Unit, South Glasgow University Hospital, Glasgow, UK
| | | | - Jackie McDonald
- ISD Healthcare Information Group, NHS Scotland National Services Division, Edinburgh, UK
| | - Wendy Metcalfe
- Department of Renal Medicine, Edinburgh Royal Infirmary, Edinburgh, UK
| | | | | | - Elaine Spalding
- The John Stevenson Lynch Renal Unit, Crosshouse Hospital, Kilmarnock, UK
| | | | - Jamie P Traynor
- The Glasgow Renal & Transplant Unit, South Glasgow University Hospital, Glasgow, UK
| | - Bruce Mackinnon
- The Glasgow Renal & Transplant Unit, South Glasgow University Hospital, Glasgow, UK
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20
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Barbour SJ, Espino-Hernandez G, Reich HN, Coppo R, Roberts IS, Feehally J, Herzenberg AM, Cattran DC, Bavbek N, Cook T, Troyanov S, Alpers C, Amore A, Barratt J, Berthoux F, Bonsib S, Bruijn J, D’Agati V, D’Amico G, Emancipator S, Emmal F, Ferrario F, Fervenza F, Florquin S, Fogo A, Geddes C, Groene H, Haas M, Hill P, Hogg R, Hsu S, Hunley T, Hladunewich M, Jennette C, Joh K, Julian B, Kawamura T, Lai F, Leung C, Li L, Li P, Liu Z, Massat A, Mackinnon B, Mezzano S, Schena F, Tomino Y, Walker P, Wang H, Weening J, Yoshikawa N, Zhang H, Coppo R, Troyanov S, Cattran D, Cook H, Feehally J, Roberts I, Tesar V, Maixnerova D, Lundberg S, Gesualdo L, Emma F, Fuiano L, Beltrame G, Rollino C, RC, Amore A, Camilla R, Peruzzi L, Praga M, Feriozzi S, Polci R, Segoloni G, Colla L, Pani A, Angioi A, Piras L, JF, Cancarini G, Ravera S, Durlik M, Moggia E, Ballarin J, Di Giulio S, Pugliese F, Serriello I, Caliskan Y, Sever M, Kilicaslan I, Locatelli F, Del Vecchio L, Wetzels J, Peters H, Berg U, Carvalho F, da Costa Ferreira A, Maggio M, Wiecek A, Ots-Rosenberg M, Magistroni R, Topaloglu R, Bilginer Y, D’Amico M, Stangou M, Giacchino F, Goumenos D, Kalliakmani P, Gerolymos M, Galesic K, Geddes C, Siamopoulos K, Balafa O, Galliani M, Stratta P, Quaglia M, Bergia R, Cravero R, Salvadori M, Cirami L, Fellstrom B, Kloster Smerud H, Ferrario F, Stellato T, Egido J, Martin C, Floege J, Eitner F, Lupo A, Bernich P, Menè P, Morosetti M, van Kooten C, Rabelink T, Reinders M, Boria Grinyo J, Cusinato S, Benozzi L, Savoldi S, Licata C, Mizerska-Wasiak M, Martina G, Messuerotti A, Dal Canton A, Esposito C, Migotto C, Triolo G, Mariano F, Pozzi C, Boero R, Bellur S, Mazzucco G, Giannakakis C, Honsova E, Sundelin B, Di Palma A, Ferrario F, Gutiérrez E, Asunis A, Barratt J, Tardanico R, Perkowska-Ptasinska A, Arce Terroba J, Fortunato M, Pantzaki A, Ozluk Y, Steenbergen E, Soderberg M, Riispere Z, Furci L, Orhan D, Kipgen D, Casartelli D, Galesic Ljubanovic D, Gakiopoulou H, Bertoni E, Cannata Ortiz P, Karkoszka H, Groene H, Stoppacciaro A, Bajema I, Bruijn J, Fulladosa Oliveras X, Maldyk J, Ioachim E. The MEST score provides earlier risk prediction in lgA nephropathy. Kidney Int 2016; 89:167-75. [DOI: 10.1038/ki.2015.322] [Citation(s) in RCA: 150] [Impact Index Per Article: 18.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2015] [Revised: 08/17/2015] [Accepted: 09/03/2015] [Indexed: 01/12/2023]
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21
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Valluri A, Hetherington L, Mcquarrie E, Fleming S, Kipgen D, Geddes CC, Mackinnon B, Bell S. Acute tubulointerstitial nephritis in Scotland. QJM 2015; 108:527-32. [PMID: 25434050 DOI: 10.1093/qjmed/hcu236] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2014] [Indexed: 01/22/2023] Open
Abstract
BACKGROUND AND AIMS Acute tubulointerstitial nephritis (ATIN) is a potentially reversible cause of acute kidney injury with the majority of cases drug related. Our aims were to examine the incidence profile of patients with ATIN in Scotland and to assess the impact of corticosteroid treatment. DESIGN AND METHODS All adult patients with biopsy-proven ATIN, diagnosed between 2000 and 2012, presenting to renal units serving 1.9 of Scotland's 5 million population were included. Patient demographics, presenting, aetiologic and pathologic features, treatment given and outcome were extracted from patient records. RESULTS In total, 171 cases representing 4.7% of native renal biopsies were identified. Median serum creatinine (sCr) was 327 μmol/l at biopsy (106 μmol/l at baseline). Eosinophilia, fever or rash was present in 57% with all 3 in only 1.1%. Active urinary sediment was found in 68%. Aetiology appeared drug induced in 73%. Proton pump inhibitors (PPIs) were likely causative in almost as many cases as antibiotics (35% each) and were more frequently implicated than non-steroidal anti-inflammatory drugs (20%). Number of PPI-related cases paralleled the rising prescription of these drugs. Corticosteroids were prescribed in 59% of drug-induced ATIN (median sCr at biopsy: 356 μmol/l vs. 280 μmol/l in those managed conservatively). There was no difference in sCr at 1, 6 and 12 months, with similar proportions of both groups experiencing complete renal recovery (48% vs. 41%) and becoming dialysis dependent (10% in both). CONCLUSIONS Incidence of biopsy-proven ATIN in Scotland has been rising over the past decade with the majority of cases drug induced. Evidence supporting corticosteroid treatment is lacking.
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Affiliation(s)
- A Valluri
- From the Department of Renal Medicine, Ninewells Hospital & Medical School, Dundee, DD1 9SY, Glasgow Renal & Transplant Unit, Western Infirmary, Dumbarton Road, Glasgow, G11 6NT, Department of Pathology, Ninewells Hospital & Medical School, Dundee, DD1 9SY and Department of Pathology, Western Infirmary, Glasgow, G11 6NT, UK
| | - L Hetherington
- From the Department of Renal Medicine, Ninewells Hospital & Medical School, Dundee, DD1 9SY, Glasgow Renal & Transplant Unit, Western Infirmary, Dumbarton Road, Glasgow, G11 6NT, Department of Pathology, Ninewells Hospital & Medical School, Dundee, DD1 9SY and Department of Pathology, Western Infirmary, Glasgow, G11 6NT, UK
| | - E Mcquarrie
- From the Department of Renal Medicine, Ninewells Hospital & Medical School, Dundee, DD1 9SY, Glasgow Renal & Transplant Unit, Western Infirmary, Dumbarton Road, Glasgow, G11 6NT, Department of Pathology, Ninewells Hospital & Medical School, Dundee, DD1 9SY and Department of Pathology, Western Infirmary, Glasgow, G11 6NT, UK
| | - S Fleming
- From the Department of Renal Medicine, Ninewells Hospital & Medical School, Dundee, DD1 9SY, Glasgow Renal & Transplant Unit, Western Infirmary, Dumbarton Road, Glasgow, G11 6NT, Department of Pathology, Ninewells Hospital & Medical School, Dundee, DD1 9SY and Department of Pathology, Western Infirmary, Glasgow, G11 6NT, UK
| | - D Kipgen
- From the Department of Renal Medicine, Ninewells Hospital & Medical School, Dundee, DD1 9SY, Glasgow Renal & Transplant Unit, Western Infirmary, Dumbarton Road, Glasgow, G11 6NT, Department of Pathology, Ninewells Hospital & Medical School, Dundee, DD1 9SY and Department of Pathology, Western Infirmary, Glasgow, G11 6NT, UK
| | - C C Geddes
- From the Department of Renal Medicine, Ninewells Hospital & Medical School, Dundee, DD1 9SY, Glasgow Renal & Transplant Unit, Western Infirmary, Dumbarton Road, Glasgow, G11 6NT, Department of Pathology, Ninewells Hospital & Medical School, Dundee, DD1 9SY and Department of Pathology, Western Infirmary, Glasgow, G11 6NT, UK
| | - B Mackinnon
- From the Department of Renal Medicine, Ninewells Hospital & Medical School, Dundee, DD1 9SY, Glasgow Renal & Transplant Unit, Western Infirmary, Dumbarton Road, Glasgow, G11 6NT, Department of Pathology, Ninewells Hospital & Medical School, Dundee, DD1 9SY and Department of Pathology, Western Infirmary, Glasgow, G11 6NT, UK
| | - S Bell
- From the Department of Renal Medicine, Ninewells Hospital & Medical School, Dundee, DD1 9SY, Glasgow Renal & Transplant Unit, Western Infirmary, Dumbarton Road, Glasgow, G11 6NT, Department of Pathology, Ninewells Hospital & Medical School, Dundee, DD1 9SY and Department of Pathology, Western Infirmary, Glasgow, G11 6NT, UK
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McQuarrie E, Mackinnon B, McNeice V, Fox J, Geddes C. FP134THE INFLUENCE OF SOCIOECONOMIC DEPRIVATION ON OUTCOMES IN PATIENTS WITH PRIMARY GLOMERULOPATHIES. Nephrol Dial Transplant 2015. [DOI: 10.1093/ndt/gfv171.23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Rankin A, McQuarrie E, Fox JG, Geddes C, Mackinnon B. FP126IS THE RISK OF VENOUS THROMBOEMBOLISM OVERSTATED IN PRIMARY NEPHROTIC SYNDROME? Nephrol Dial Transplant 2015. [DOI: 10.1093/ndt/gfv171.15] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Findlay MD, Traynor J, Metcalfe W, Mackinnon B. FP750AREAS OF CLINICAL CONCERN CONTRIBUTING TO OR CAUSING DEATH IN PATIENTS ON RENAL REPLACEMENT THERAPY. Nephrol Dial Transplant 2015. [DOI: 10.1093/ndt/gfv183.68] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Bray BD, Boyd J, Daly C, Doyle A, Donaldson K, Fox JG, Innes A, Khan I, Mackinnon B, Peel RK, Shilliday I, Simpson K, Stewart GA, Traynor JP, Metcalfe W. How safe is renal replacement therapy? A national study of mortality and adverse events contributing to the death of renal replacement therapy recipients. Nephrol Dial Transplant 2013; 29:681-7. [PMID: 24068777 DOI: 10.1093/ndt/gft197] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Patients receiving treatment with renal replacement therapy (RRT) have high mortality, and ensuring patient safety in this population is difficult. We aimed to estimate the incidence and nature of medical adverse events contributing to the death of patients being treated with RRT. METHODS This population registry-based retrospective case review study included all patients being treated with RRT for established renal failure in Scotland and who died between 1 January 2008 and 30 June 2011. Deaths were reviewed by consultant nephrologists using a structured questionnaire to identify factors contributing to death occurring in both the inpatient and outpatient setting. Reviewers were able to use any information source deemed relevant, including paper and electronic clinical records, mortality and morbidity meetings and procurator fiscal (Scottish coroner) investigations. Deaths occurring in 2008 and 2009 where avoidable factors were identified that may have or did lead to death of a patient were subject to further review and root cause analysis, in order to identify recurrent themes. RESULTS Of 1551 deaths in the study period, 1357 were reviewed (87.5%). Cumulative RRT exposure in the cohort was 2.78 million person-days. RRT complications were the primary cause of death in 28 (2.1%). Health-care-associated infection had contributed to 9.6% of all deaths. In 3.5% of deaths, factors were identified which may have or did contribute to death. These were both organizational and human error related and were largely due to five main causes: management of hyperkalaemia, prescribing, out of hours care, infection and haemodialysis vascular access. CONCLUSIONS Adverse events contributing to death in RRT recipients mainly relate to the everyday management of common medical problems and not the technical aspects of RRT. Efforts to avoid harm in this population should address these ubiquitous causes of harm.
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McQuarrie EP, Mackinnon B, McNeice V, Fox JG, Geddes CC. The incidence of biopsy-proven IgA nephropathy is associated with multiple socioeconomic deprivation. Kidney Int 2013; 85:198-203. [PMID: 24025641 DOI: 10.1038/ki.2013.329] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2012] [Revised: 05/22/2013] [Accepted: 05/29/2013] [Indexed: 11/09/2022]
Abstract
Chronic kidney disease is more common in areas of socioeconomic deprivation, but the relationship with the incidence and diagnosis of biopsy-proven renal disease is unknown. In order to study this, all consecutive adult patients undergoing renal biopsy in West and Central Scotland over an 11-year period were prospectively analyzed for demographics, indication, and histologic diagnosis. Using the Scottish Index of Multiple Deprivation, 1555 eligible patients were separated into quintiles of socioeconomic deprivation according to postcode. Patients in the most deprived quintile were significantly more likely to undergo biopsy compared with patients from less deprived areas (109.5 compared to 95.9 per million population/year). Biopsy indications were significantly more likely to be nephrotic syndrome, or significant proteinuria without renal impairment. Patients in the most deprived quintile were significantly more likely to have glomerulonephritis. There was a significant twofold increase in the diagnosis of IgA nephropathy in the patients residing in the most compared with the least deprived postcodes not explained by the demographics of the underlying population. Thus, patients from areas of socioeconomic deprivation in West and Central Scotland are significantly more likely to undergo native renal biopsy and have a higher prevalence of IgA nephropathy.
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Affiliation(s)
- Emily P McQuarrie
- Glasgow Renal and Transplant Unit, Western Infirmaryon behalf of the Scottish Renal Biopsy Registry, Glasgow, UK
| | - Bruce Mackinnon
- Glasgow Renal and Transplant Unit, Western Infirmaryon behalf of the Scottish Renal Biopsy Registry, Glasgow, UK
| | | | - Jonathan G Fox
- Glasgow Renal and Transplant Unit, Western Infirmaryon behalf of the Scottish Renal Biopsy Registry, Glasgow, UK
| | - Colin C Geddes
- Glasgow Renal and Transplant Unit, Western Infirmaryon behalf of the Scottish Renal Biopsy Registry, Glasgow, UK
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McQuarrie EP, Shakerdi L, Jardine AG, Fox JG, Mackinnon B. Fractional excretions of albumin and IgG are the best predictors of progression in primary glomerulonephritis. Nephrol Dial Transplant 2010; 26:1563-9. [PMID: 20921302 DOI: 10.1093/ndt/gfq605] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Proteinuria is the most sensitive predictor of development of progressive renal insufficiency, with increasing focus on the composition of proteinuria, particularly high molecular weight proteins such as immunoglobulin G (IgG) (molecular weight 150 kDa). Differing methods of assessing excretion of proteinuria molecules have limited interpretation of results. We aimed to assess the utility of available indices of IgG, total proteinuria and albumin excretions as predictors of chronic kidney disease (CKD) progression in patients with primary glomerulonephritis. METHODS We recruited 97 patients with primary glomerulonephritis and measured 24-h urinary protein excretion, 24-h urinary albumin excretion, selectivity index, albumin:creatinine ratio, urinary IgG:creatinine ratio, fractional excretion of albumin (FE Alb) and fractional excretion of IgG (FE IgG) at baseline. The composite endpoint was developing stage 5 CKD, requiring RRT or death. Receiver operating characteristics curve analysis was used to assess the value of each measure in predicting outcome. From this analysis, high- and low-risk patient groups according to each measure were established. These were then tested using Kaplan-Meier and Cox survival analysis. RESULTS During a median follow-up of 7.07 years, 23 patients developed the primary endpoint. FE IgG and FE Alb were the most sensitive predictive tests. The hazard ratios (HR) of developing the primary endpoint using FE IgG [HR 37.1 (95% CI 8.6-158.8)] and FE Alb [HR 35.2 (95% CI 8.2-150.8)] cut-offs were double those using the other measures. CONCLUSIONS FE IgG and FE Alb are superior to conventional measures of proteinuria in predicting outcome in patients with primary glomerulonephritis, possibly because they are more accurate indicators of impairment of glomerular permselectivity. FE Alb should be used, in conjunction with other measures of proteinuria, in future studies of prediction of CKD progression.
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Affiliation(s)
- Emily P McQuarrie
- Renal Research Group, British Heart Foundation Cardiovascular Research Centre, University of Glasgow, Glasgow, UK.
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McQuarrie EP, Mackinnon B, Stewart GA, Geddes CC. Membranous nephropathy remains the commonest primary cause of nephrotic syndrome in a northern European Caucasian population. Nephrol Dial Transplant 2009; 25:1009-10; author reply 1010-1. [PMID: 20037184 DOI: 10.1093/ndt/gfp665] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Mackinnon B, McKinlay J, McQuarrie E, Geddes C. Early ultrasound to detect complications after renal biopsy. Nephrol Dial Transplant 2009; 25:316-7; author reply 317-8. [PMID: 19854850 DOI: 10.1093/ndt/gfp540] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
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Cattran DC, Coppo R, Cook HT, Feehally J, Roberts ISD, Troyanov S, Alpers CE, Amore A, Barratt J, Berthoux F, Bonsib S, Bruijn JA, D'Agati V, D'Amico G, Emancipator S, Emma F, Ferrario F, Fervenza FC, Florquin S, Fogo A, Geddes CC, Groene HJ, Haas M, Herzenberg AM, Hill PA, Hogg RJ, Hsu SI, Jennette JC, Joh K, Julian BA, Kawamura T, Lai FM, Leung CB, Li LS, Li PKT, Liu ZH, Mackinnon B, Mezzano S, Schena FP, Tomino Y, Walker PD, Wang H, Weening JJ, Yoshikawa N, Zhang H. The Oxford classification of IgA nephropathy: rationale, clinicopathological correlations, and classification. Kidney Int 2009; 76:534-45. [PMID: 19571791 DOI: 10.1038/ki.2009.243] [Citation(s) in RCA: 839] [Impact Index Per Article: 55.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
IgA nephropathy is the most common glomerular disease worldwide, yet there is no international consensus for its pathological or clinical classification. Here a new classification for IgA nephropathy is presented by an international consensus working group. The goal of this new system was to identify specific pathological features that more accurately predict risk of progression of renal disease in IgA nephropathy, thus enabling both clinicians and pathologists to improve individual patient prognostication. In a retrospective analysis, sequential clinical data were obtained on 265 adults and children with IgA nephropathy who were followed for a median of 5 years. Renal biopsies from all patients were scored by pathologists blinded to the clinical data for pathological variables identified as reproducible by an iterative process. Four of these variables: (1) the mesangial hypercellularity score, (2) segmental glomerulosclerosis, (3) endocapillary hypercellularity, and (4) tubular atrophy/interstitial fibrosis were subsequently shown to have independent value in predicting renal outcome. These specific pathological features withstood rigorous statistical analysis even after taking into account all clinical indicators available at the time of biopsy as well as during follow-up. The features have prognostic significance and we recommended they be taken into account for predicting outcome independent of the clinical features both at the time of presentation and during follow-up. The value of crescents was not addressed due to their low prevalence in the enrolled cohort.
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Affiliation(s)
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- University Health Network, Toronto General Research Institute, Toronto, Ontario, Canada
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McQuarrie EP, Mackinnon B, Young B, Yeoman L, Stewart G, Fleming S, Robertson S, Simpson K, Fox J, Geddes CC. Centre variation in incidence, indication and diagnosis of adult native renal biopsy in Scotland. Nephrol Dial Transplant 2008; 24:1524-8. [DOI: 10.1093/ndt/gfn677] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Mackinnon B, Fraser EP, Cattran DC, Fox JG, Geddes CC. Validation of the Toronto formula to predict progression in IgA nephropathy. Nephron Clin Pract 2008; 109:c148-53. [PMID: 18663327 DOI: 10.1159/000145458] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2008] [Accepted: 04/21/2008] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND/AIM Predicting outcome in IgA nephropathy (IgAN) is difficult. The Toronto formula uses average mean arterial blood pressure and proteinuria during the first 2 years of follow-up (MAP(0-2), UP(0-2)) to predict the subsequent slope of estimated creatinine clearance (eCrCl). We aimed to validate the Toronto formula in a Scottish cohort and test the hypothesis that adding the slope eCrCl over the first 2 years of follow-up (eCrCl(0-2)) would improve the predictive utility of a similar multivariate model. METHODS Adultsfrom our centre with biopsy-proven IgAN (n = 169) and at least 2 years of follow-up (median 129.4 months) were included. Clinical data were used to calculate MAP(0-2),UP(0-2),slope eCrCl(0-2 )and predicted slope eCrCl (using the Toronto formula). RESULTS There was a significant correlation between predicted slope eCrCl using the Toronto formula and actual slope eCrCl (R(2 =) 0.21; p < 0.001). The formula predicted the actual rate of progression to within 4 ml/min/year in 75% of subjects, predicting patients with the most rapid deterioration with the greatest accuracy. The multivariate linear regression model created in our cohort using the same independent variables as the Toronto formula to predict the overall slope eCrCl had an R(2) of 0.22 (p < 0.001) and adding the slope CrCl(0-2) only increased this to 0.25. CONCLUSIONS The Toronto formula is valid in a European population and useful for identifying patients at high risk of future deterioration in renal function. Adding slope eCrCl(0-2) to a predictive model containing MAP(0-2), andUP(0-2 )does not appear to improve prediction of the overall slope of eCrCl.
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Mackinnon B, Fraser E, Simpson K, Fox JG, Geddes C. Is it necessary to stop antiplatelet agents before a native renal biopsy? Nephrol Dial Transplant 2008; 23:3566-70. [PMID: 18503099 DOI: 10.1093/ndt/gfn282] [Citation(s) in RCA: 51] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND The practice of advising patients to stop antiplatelet agents before an elective renal biopsy is widespread. The aim of this study was to compare the rate of bleeding complications in two centres that have different policies regarding the ongoing use of antiplatelet agents in patients undergoing an elective renal biopsy. Neither centre routinely checks bleeding time before renal biopsy. A secondary aim, therefore, was to compare complication rates from this cohort with those reported in the literature where screening for prolonged bleeding time is standard practice. METHODS A retrospective study of 1120 biopsies performed by nephrologists under direct ultrasound guidance in the two renal units in Glasgow, Scotland (Jan 2000 to May 2007) was undertaken. Antiplatelet agents were stopped 5 days before biopsy in one centre but continued in the other. Bleeding time was not measured before biopsy and pro-coagulants were not routinely administered. Major bleeding was defined as the need for blood transfusion, surgical or radiological intervention. Minor bleeding was defined as an >or=1.0 g/dL fall in haemoglobin following biopsy without the need for transfusion or intervention. RESULTS Haemoglobin fell by >or=1.0 g/dL in 221 (19.7%) patients. There were 21 (1.9%) major bleeding complications. No patient died or required nephrectomy. Gender, advancing age or worse renal impairment was not associated with an increased likelihood of bleeding. Bleeding complications in 75 patients continuing antiplatelet agents were compared with those occurring in 60 patients whose antiplatelet agents were discontinued. Minor complications were commoner in the first group (31.0 versus 11.7%; P = 0.008), though there was no difference in the rate of major complications. CONCLUSIONS The risk of major bleeding following a native renal biopsy under ultrasound guidance is low. Stopping antiplatelet agents before biopsy was associated with a lower rate of minor complications but there was no difference in the rate of major complications. Complication rates compare favourably with other published series in which bleeding time was checked and corrected.
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Affiliation(s)
- Bruce Mackinnon
- Renal Unit, Glasgow Royal Infirmary, Glasgow, United Kingdom.
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Mackinnon B, Deighan CJ, Ferrell WR, Sattar N, Fox JG. Endothelial Function in Patients with Proteinuric Primary Glomerulonephritis. ACTA ACUST UNITED AC 2008; 109:c40-7. [DOI: 10.1159/000135632] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2007] [Accepted: 02/18/2008] [Indexed: 11/19/2022]
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Nelson AW, Mackinnon B, Traynor J, Geddes CC. The relationship between serum creatinine and estimated glomerular filtration rate: implications for clinical practice. Scott Med J 2007; 51:5-9. [PMID: 17137139 DOI: 10.1258/rsmsmj.51.4.5] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
INTRODUCTION A new classification of chronic kidney disease (CKD) has been widely adopted that stratifies patients into 5 'stages' according to estimated glomerular filtration rate (eGFR). In adults the most commonly used formulae to calculate eGFR are the Cockcroft and Gault (C and G) and Modification of Diet in Renal Disease (MDRD) formulae. The UK Renal Association has recommended calculation of MDRD eGFR to screen for reduced kidney function in primary and secondary care. AIM The aim of this study was to explore the implication of using these predictive formulae. METHODS We searched for patients currently attending a renal clinic who have ever had a serum creatinine (SCr) of exactly 100 micromol/L, 150 micromol/L or 200 micromol/L. The C and G and MDRD eGFRs corresponding to that SCr were calculated. The proportion of patients in each stage of the CKD classification was determined. RESULTS For a SCr of 100 micromol/L mean eGFR was 86.5 ml/min (range 31.0 - 192.8) by C and G and 63.8 ml/min (range 39.7 - 99.9) by MDRD (p < 0.0001; t-test of mean). For SCr 150 micromol/L mean eGFR was 51.7 ml/min (18.0 - 110.4) by C and G and 38.0 ml/min (20.7 - 54.8) by MDRD (p < 0.0001). For SCr of 200 micromol/L mean eGFR was 34.4 ml/min (12.6 - 89.5) by C and G and 27.3 ml/min (16.7 - 41.3) by MDRD (p < 0.0001). Using MDRD eGFR 46.5% patients with a SCr of 100 micromol/L have stage 3 CKD (GFR 30-60 ml/min) and all patients with a SCr of 150 micromol/L or 200 micromol/L have CKD 3 or worse. 8.6% of males with SCr 100 micromol/L had stage 3 CKD or worse compared with 86.8% females. 70.2% patients > 65 years old with SCr 100 micromol/L had stage 3 CKD. CONCLUSIONS Targeted screening of patients at-risk for CKD will identify a large number of patients who require management of CKD and potential referral to nephrology services even at levels of SCr regarded as 'normal' or mildly.
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Affiliation(s)
- A W Nelson
- Faculty of Medicine, University of Glasgow, United Kingdom
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Kahn SR, Kearon C, Julian JA, Mackinnon B, Kovacs MJ, Wells P, Crowther MA, Anderson DR, Van Nguyen P, Demers C, Solymoss S, Kassis J, Geerts W, Rodger M, Hambleton J, Ginsberg JS. Predictors of the post-thrombotic syndrome during long-term treatment of proximal deep vein thrombosis. J Thromb Haemost 2005; 3:718-23. [PMID: 15733061 DOI: 10.1111/j.1538-7836.2005.01216.x] [Citation(s) in RCA: 137] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND The post-thrombotic syndrome is a chronic, poorly understood complication of deep venous thrombosis (DVT). OBJECTIVES To evaluate predictors of the post-thrombotic syndrome, including intensity of long-term anticoagulation, and to assess the impact of the post-thrombotic syndrome on quality of life. PATIENTS AND METHODS The setting was 13 Canadian hospitals and one US hospital. One hundred and forty-five patients with an unprovoked episode of proximal DVT who were initially treated with 3 months of conventional-intensity warfarin [target International Normalized Ratio (INR) of 2.5] then participated in a trial comparing two intensities of long-term warfarin therapy (target INR 2.5 vs. INR 1.7). Post-thrombotic syndrome was assessed at the end of the trial using a validated clinical scale. Generic and venous disease-specific quality of life was compared in patients with and without the post-thrombotic syndrome. Multivariable regression analyses were performed to identify predictors of the post-thrombotic syndrome and of its severity. RESULTS After an average follow-up of 2.2 years, the prevalence of post-thrombotic syndrome was 37% and of severe post-thrombotic syndrome was 4%. Quality of life was worse in patients with the post-thrombotic syndrome compared with patients who did not have it. The presence of factor (F)V Leiden or the prothrombin gene mutation was an independent predictor of both a lower risk (P = 0.006) and reduced severity (P = 0.045) of the post-thrombotic syndrome. Intensity of anticoagulation did not influence the risk of developing the post-thrombotic syndrome. CONCLUSIONS The post-thrombotic syndrome is a frequent and burdensome complication of proximal DVT, even among patients maintained on long-term oral anticoagulation. While the presence of FV Leiden or prothrombin gene mutation appears to be associated with a reduced risk of post-thrombotic syndrome, this finding requires further evaluation in prospective studies.
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Affiliation(s)
- S R Kahn
- McGill University, Montreal, Quebec, Canada.
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Mackinnon B, Deighan CJ, Norrie J, Boulton-Jones JM, Sattar N, Fox JG. The link between circulating markers of endothelial function and proteinuria in patients with primary glomerulonephritis. Clin Nephrol 2005; 63:173-80. [PMID: 15786817 DOI: 10.5414/cnp63173] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
INTRODUCTION It is well established that there is an increase in the incidence of cardiovascular mortality in patients with proteinuric renal disease. The magnitude of the increase in risk is unlikely to be explained by traditional risk factors for cardiovascular disease alone. Proteinuria itself may constitute an additional risk factor, and proteinuric patients are known to have a degree of endothelial dysfunction. The nature of this relationship between proteinuria and endothelial function is the subject of intense investigation. AIM The aim of this study was to examine the relationship between proteinuria and endothelial dysfunction, as reflected by serum von Willebrand factor (vWF), and the soluble cell adhesion molecules VCAM and ICAM, in patients with primary glomerulonephritis (GN). A secondary aim was to discern whether any relationship could be explained by renal function, lipid profile, inflammation or blood pressure. METHODS A cross-sectional study was undertaken in consecutive patients attending a general nephrology clinic with biopsy-proven primary GN. Patients with end-stage renal disease (ESRD), those on immunosuppressive drugs, or with intercurrent infective illnesses were excluded. Blood pressure and body mass index were recorded. Routine lab assays were undertaken for serum creatinine, lipid profile, and 24-hour urinary protein (U(Prot)). Additional serum samples were stored at -80 degrees C for subsequent measurement of vWF, VCAM, ICAM and sensitive C reactive protein (sCRP). RESULTS Data were collected from 129 (86 male) patients. Mean (standard deviation) estimated creatinine clearance was 64 (32) ml/min, and median (interquartile range) 24-hour proteinuria was 1.1 (0.22-2.9) g. Mean vWF was 173 (68) IU/dl, median VCAM, ICAM and sCRP were 594 (410-708) ng/ml, 235 (208-286) ng/ml, and 2.33 (0.83-5.68) mg/l, respectively. There was a significant positive correlation between vWF and U(Prot) (Spearman rank correlation, r = 0.41, p < 0.001). When split into tertiles, according to U(Prot) (0-500 mg, 500-2000 mg, and > 2000 mg), there was a significant, stepwise increase in mean vWF (p < 0.001), log VCAM (p < 0.001), and log ICAM (p = 0.002). On multivariate analysis with vWF as the continuous dependent variable, U(Prot), age, total cholesterol and sCRP were the only significantly independent correlates (model-adjusted R2 = 33%). CONCLUSION In patients with primary GN, there is a significant association between endothelial activation as reflected by vWF, VCAM, or ICAM and increasing proteinuria. Elevations in vWF, as well as being related to classical risk factors, are associated with increases in total proteinuria and low-grade inflammation. Thus, future prospective studies should examine the extent to which vWF and other circulating markers of endothelial activation predict coronary heart disease risk in patients with proteinuric renal disease.
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Affiliation(s)
- B Mackinnon
- Renal Unit, Glasgow Royal Infirmary, Glasgow, Scotland, UK.
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Kearon C, Ginsberg JS, Anderson DR, Kovacs MJ, Wells P, Julian JA, Mackinnon B, Demers C, Douketis J, Turpie AG, Van Nguyen P, Green D, Kassis J, Kahn SR, Solymoss S, Desjardins L, Geerts W, Johnston M, Weitz JI, Hirsh J, Gent M. Comparison of 1 month with 3 months of anticoagulation for a first episode of venous thromboembolism associated with a transient risk factor. J Thromb Haemost 2004; 2:743-9. [PMID: 15099280 DOI: 10.1046/j.1538-7836.2004.00698.x] [Citation(s) in RCA: 103] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
BACKGROUND The risk of recurrence is lower after treatment of an episode of venous thromboembolism associated with a transient risk factor, such as recent surgery, than after an episode associated with a permanent, or no, risk factor. Retrospective analyses suggest that 1 month of anticoagulation is adequate for patients whose venous thromboembolic event was provoked by a transient risk factor. METHODS In this double-blind study, patients who had completed 1 month of anticoagulant therapy for a first episode of venous thromboembolism provoked by a transient risk factor were randomly assigned to continue warfarin or to placebo for an additional 2 months. Our goal was to determine if the duration of treatment could be reduced without increasing the rate of recurrent venous thromboembolism during 11 months of follow-up. RESULTS Of 84 patients assigned to placebo, five (6.0%) had recurrent venous thromboembolism, compared with three of 81 (3.7%) assigned to warfarin, resulting in an absolute risk difference of 2.3%[95% confidence interval (CI) - 5.2, 10.0]. The incidence of recurrent venous thromboembolism after discontinuation of warfarin was 6.8% per patient-year in those who received warfarin for 1 month and 3.2% per patient-year in those who received warfarin for 3 months (rate difference of 3.6% per patient-year; 95% CI - 3.8, 11.0). There were no major bleeds in either group. CONCLUSION Duration of anticoagulant therapy for venous thromboembolism provoked by a transient risk factor should not be reduced from 3 months to 1 month as this is likely to increase recurrent venous thromboembolism without achieving a clinically important decrease in bleeding.
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Affiliation(s)
- C Kearon
- McMaster University, Hamilton, Ontario, Canada.
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Mackinnon B, Boulton-Jones M, McLaughlin K. Analgesic-associated nephropathy in the West of Scotland: a 12-year observational study. Nephrol Dial Transplant 2003; 18:1800-5. [PMID: 12937227 DOI: 10.1093/ndt/gfg230] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND Analgesic-associated nephropathy (AAN) is an important and preventable cause of chronic renal failure (CRF). Although its incidence is falling in some countries, others are witnessing an increase in the number of new cases. METHODS The aim of this study was to evaluate the natural history of AAN, determine the correlates of the rate of decline in renal function and examine factors conferring an increased risk of death or dialysis in such patients. A prospective observational cohort study of all patients with AAN attending a single-centre was conducted. RESULTS Seventy-eight patients (25 male), with at least 24 months of follow-up for analysis, were diagnosed as having AAN over the 10-year period 1989-1999. During follow up, the mean (+/-SD) rate of change in estimated creatinine clearance (ECC) was -1.2 ml/min/year (+/-5.28). By multiple linear regression three variables were found to independently predict the rate of deterioration in ECC; continuing analgesic use (P < 0.001), degree of proteinuria at presentation (P = 0.002) and male sex (P = 0.03). A Cox's model revealed a 6-fold increase in the hazard of reaching the combined end-point of death or dialysis in those patients with AAN who continue to use analgesics. This was independent of the other two significant risk factors of pre-existing vascular disease (HR 3.93, 1.36-11.29) and ECC at presentation (HR 0.95, 0.91-0.98 per ml/min). CONCLUSIONS In patients with CRF due to AAN ongoing analgesic use, male gender and increasing proteinuria predict a more rapid decline in renal function. Patients who continue analgesics, those with pre-existing vascular disease and those with more advanced renal impairment at presentation, are at a significantly increased risk of reaching the combined end-point of death or end-stage renal failure requiring dialysis. The design of this study, however, leaves it open to the criticism that selection bias may account for some of its effects, and as with all work on AAN the possible confounding issue of reverse causality is difficult to dismiss.
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Affiliation(s)
- Bruce Mackinnon
- Renal Unit, Glasgow Royal Infirmary, Glasgow, UK and Foothills Hospital, Calgary, Alberta, Canada.
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Kovacs M, Kearon C, Julian J, Mackinnon B, Douketis J, Demers C, Wells P, Turpie AGG, Anderson DR, Kahn S, Van Nguyen P, Green D, Kassis J, Geerts W, Ginsberg JS. Influence of warfarin use on symptoms of fatigue: a randomized cross-over trial. J Thromb Haemost 2003. [DOI: 10.1111/j.1538-7836.2003.tb05629.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Mackinnon B, Shakerdi L, Deighan CJ, Fox JG, O'Reilly DSJ, Boulton-Jones M. Urinary transferrin, high molecular weight proteinuria and the progression of renal disease. Clin Nephrol 2003; 59:252-8. [PMID: 12708564 DOI: 10.5414/cnp59252] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
AIMS Proteinuria predicts rate of progression in a variety of nephropathies. There is considerable evidence that iron-transferrin is toxic to proximal tubular cells in vitro, and recent clinical work suggests that selectivity of proteinuria influences the outcome of renal disease. The aim of this study was to examine the relationship between the nature of proteinuria and progression of renal disease. METHODS This was a prospective, cross-sectional study in 66 patients with primary glomerulonephritis, diabetic nephropathy and a variety of other renal diseases. Urinary transferrin was measured by sandwich ELISA and correlated with rate of change in estimated creatinine clearance (ECC). Urinary SDS-PAGE was undertaken to divide proteinuria into tertiles according to molecular weight and to quantify the protein in each tertile. The magnitude of each tertile was then correlated with rate of change in ECC over a median period of 20 months. RESULTS Rate of change of renal function correlated with total proteinuria (r2 = 18%, p < 0.001) and albuminuria (r2 = 17%, p < 0.001), but not urinary transferrin (r2 = 0%, p = 0.235). On univariate analysis high molecular weight proteinuria (r2 = 21%, p < 0.001), intermediate molecular weight proteinuria (r2 = 15%, p = 0.001) and low molecular weight proteinuria (r2 = 10%, p = 0.005) correlated with rate of change in ECC as did total fasting cholesterol (r2 = 7%, p = 0.003). On multivariate analysis, however, the only independent predictors of rate of change in ECC were high molecular weight proteinuria (r2 = 19%, p < 0.001), and total fasting cholesterol (r2 = 5%, p = 0.035). CONCLUSIONS We found no evidence to support the hypothesis that iron-transferrin is important in the development of human renal injury. High molecular weight proteinuria correlates more strongly with rate of progression of renal disease than intermediate molecular weight, low molecular weight or even total proteinuria. This suggests either, that one or more high molecular weightproteins are implicated in causing progressive renal impairment, or that loss of size selectivity at the glomerular basement membrane is associated with accelerated tubulointerstitial damage.
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Affiliation(s)
- B Mackinnon
- Renal Unit, Glasgow Royal Infirmary, Glasgow, Scotland.
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Peake PW, Pussell BA, Mackinnon B, Charlesworth JA. The effect of pH and nucleophiles on complement activation by human proximal tubular epithelial cells. Nephrol Dial Transplant 2002; 17:745-52. [PMID: 11981058 DOI: 10.1093/ndt/17.5.745] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Activation of urinary complement proteins in situ by proximal tubular epithelial cells (PTEC) may contribute to the mediation of tubulointerstitial injury in patients with significant proteinuria. However, the mechanism involved is unclear, and the role of changes in urinary pH and in the concentrations of urea or ammonia requires further clarification. METHODS The protein fraction of urine samples from nine patients with proteinuria >1.5 g/day was purified. A cell ELISA involving cultured HK-2 PTEC was used to investigate the capacity of urinary protein to promote the deposition of both C3 and C9 on the cell surface. The effect of variations in pH (5.5-8.0) and in the concentration of urea and ammonia was also examined. C3 was purified and used to further investigate the mechanism of complement deposition. RESULTS Urine samples from the majority of patients induced deposition of C3 and C9 on the surface of HK-2 cells via the alternative pathway. This process was maximal at acidic pH values. Preincubation of urinary complement or serum with urea or ammonia inhibited C3 deposition. Purified C3 incubated with HK-2 cells showed no evidence of activation in the absence of other complement components. CONCLUSIONS These data suggest that bicarbonate protects against complement-mediated damage in the lumen by increasing the local pH, rather than by inhibiting the generation of ammonia. PTEC appear to activate complement through provision of a 'protected site' on their surface, rather than by the activation of C3 by convertase-like protease(s).
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Affiliation(s)
- Philip W Peake
- Department of Nephrology, Prince of Wales Hospital, Randwick, NSW, Australia.
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Cole CH, Frantz ID, Mackinnon B, Shah B, Abbasi S, Colton T, Demissie S. Reply. J Pediatr 2000; 136:852. [PMID: 10839893 DOI: 10.1067/mpd.2000.104063] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Affiliation(s)
- CH Cole
- Division of Newborn Medicine, New England Medical Center, Boston, MA 02111, USA
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Ginsberg JS, Magier D, Mackinnon B, Gent M, Hirsh J. Intermittent compression units for severe post-phlebitic syndrome: a randomized crossover study. CMAJ 1999; 160:1303-6. [PMID: 10333832 PMCID: PMC1230312] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/12/2023] Open
Abstract
BACKGROUND Although uncommon, severe post-phlebitic syndrome may be associated with persistent, intractable pain and swelling that interfere with work and leisure activities. This study was performed to determine whether intermittent compression therapy with an extremity pump benefits patients with this condition and, if so, whether the benefit is sustained. METHODS The study was a randomized crossover trial. Over the period 1990 to 1996, all patients in the clinical thromboembolism program of an Ontario teaching hospital who had a history of deep vein thrombosis and intractable symptoms of post-phlebitic syndrome were recruited into the study. The study involved using an extremity pump twice daily for a total of 2 months (20 minutes per session). The patients were randomly assigned to use either a therapeutic pressure (50 mm Hg) or a placebo pressure (15 mm Hg) for the first month. For the second month, the patients used the other pressure. A questionnaire assessing symptoms and functional status served as the primary outcome measure and was administered at the end of each 1-month period. A symptom score was derived by summing the scores for individual questions. At the end of the 2-month study, patients were asked to indicate their treatment preference and to rate the importance of the difference between the 12 pressures. Treatment was considered successful if the patient preferred the therapeutic pressure and stated that he or she would continue using the extremity pump and that the difference between the therapeutic and placebo pressures was of at least slight importance. All other combinations of responses were considered to represent treatment failure. Patients whose treatment was classified as successful were offered the opportunity to keep the pump and to alter pressure, frequency and duration of pump use to optimize symptom management. In July 1996 the authors contacted all study participants whose treatment had been classified as successful to determine whether they were still using the pump and, if so, whether they were still deriving benefit. RESULTS In total 15 consecutive patients (12 women and 3 men) were enrolled in the study. The symptom scores were significantly better with the therapeutic pressure (mean 16.5) than with the placebo pressure (mean 14.4) (paired t-test, p = 0.007). The treatment for 12 of the patients (80%, 95% confidence interval 52% to 96%) was considered successful. Of these, 9 patients continued to use the pump beyond the crossover study and to derive benefit. INTERPRETATION The authors conclude that a trial of pump therapy is worthwhile for patients with severe post-phlebitic syndrome and that a sustained beneficial response can be expected in most such patients.
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Affiliation(s)
- J S Ginsberg
- Department of Medicine, McMaster University, Hamilton, Ont.
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