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INTRODUCTION The Kidney Failure Risk Equation (KFRE) was developed to predict the risk of progression to end-stage kidney disease (ESKD). Although the KFRE has been validated in multinational cohorts, the Southeast Asian population was under-represented. This study aimed to validate the KFRE in a multi-ethnic Singapore chronic kidney disease (CKD) cohort. METHODS Stage 3–5 CKD patients referred to the renal medicine department at Singapore General Hospital in 2009 were included. The primary outcome (time to ESKD) was traced until 30 June 2017. The eight- and four-variable KFRE (non-North America) models using age, gender, estimated glomerular filtration rate, urine albumin-creatinine ratio, serum albumin, phosphate, bicarbonate and calcium were validated in our cohort. Cox regression, likelihood ratio (Χ2), adequacy index, Harrell’s C-index and calibration curves were calculated to assess the predictive performance, discrimination and calibration of these models on the cohort. RESULTS A total of 1,128 patients were included. During the study period, 252 (22.3%) patients reached ESKD at a median time to ESKD of 84.8 (range 0.1–104.7) months. Both the eight- and four-variable KFRE models showed excellent predictive performance and discrimination (eight-variable: C-index 0.872, 95% confidence interval [CI] 0.850–0.894, adequacy index 97.3%; four-variable: C-index 0.874, 95% CI 0.852–0.896, adequacy index 97.9%). There was no incremental improvement in the prediction ability of the eight-variable model over the four-variable model in this cohort. CONCLUSION The KFRE was validated in a multi-ethnic Singapore CKD cohort. This risk score may help to identify patients requiring early renal care.

Objective In this study, we trace the changes in the clinical and histological pattern of IgA nephritis (IgAN) in Singapore as it has evolved over 4 decades and compare the clinical, demographic, histological, and renal outcome of patients with IgAN from the 1st decade and the 4th decade. Materials and methods This is a retrospective study of all histologically proven IgAN diagnosed between 1976 and 2018. Clinical, laboratory, and histological characteristics between the 1st and the 4th decade, including treatment which could influence the disease progression and renal outcome of these two groups, were compared. We used the Oxford classification to compare the renal biopsy changes for these 2 decades as we were able to retrieve 125 renal biopsy tissues for the 1st cohort of IgAN studied in the 1970s for the comparative study. Results The commonest clinical presentation throughout the first 3 decades was asymptomatic hematuria and proteinuria (63, 52, and 49%, respectively). In the 4th decade, nephrotic syndrome (31%) was the commonest followed by asymptomatic hematuria and proteinuria (30%), hypertension (21%), and chronic renal failure (11%). The data showed that treatment can modify the Oxford MEST - Crescent scores. Renin-angiotensin system (RAS) blockers modified the S scores, immunosuppressants modified the T and C scores, and combination therapy with RAS blockers and immunosuppressants modified the E, S, and T scores. Conclusion The Oxford MEST classification offers a robust and expressive classification for early and late disease progression with respect to the development of end-stage renal disease (ESRD). E and S seem to be indices of continuing disease activity with progressive glomerulosclerosis, probably still amenable to therapy, but T was a predictive indicator for those destined for ESRD and no longer amenable to therapy.

Anemia is an important complication in patients with chronic kidney disease. Peritoneal dialysis (PD) is one of the most common modalities of kidney replacement therapy for patients with end-stage kidney disease. PD is particularly prevalent in the Asian Pacific region. Among the different countries and regions, including mainland China, Hong Kong, Japan, Malaysia, Singapore, South Korea, and Thailand, PD accounts for 2.8% to 74.6% of the dialysis population. In addition, 82% to 96% of the PD populations from these countries and regions are receiving erythropoiesis-stimulating agents (ESAs). Asian Pacific countries and regions follow the latest KDIGO (Kidney Disease: Improving Global Outcomes) guidelines for the initiation of treatment of anemia in PD patients. The types of ESAs commonly used include shorter-acting (epoetin alfa and beta) and longer-acting agents, including darbepoetin alfa or methoxy polyethylene glycol-epoetin beta. The most commonly used ESAs in Mainland China, Malaysia, Singapore, and Thailand are the shorter-acting agents, whereas in Hong Kong, Japan, and South Korea, longer-acting ESAs are most common. Oral iron therapy is still the most commonly used iron supplement. The route and dosage of iron administration in PD patients requires more research studies. With the introduction of oral hypoxia-inducible factor prolyl hydroxylase inhibitors into clinical use, the landscape of treatment of anemia in the PD population in the Asia Pacific region may change in the coming years.

Background Anxiety is associated with poor health outcomes among chronic kidney disease (CKD) patients. This review summarizes the prevalence and risk factors associated with elevated anxiety symptoms and disorders among CKD patients. Methods Articles evaluating the prevalence and risk factors associated with elevated anxiety symptoms and disorders among CKD patients, as diagnosed via DSM 4th or 5th edition criteria, clinical interviews or validated questionnaires, were searched in Medline®, Embase®, PsychINFO® and CINAHL®. Using random-effects meta-analyses, the prevalence of elevated anxiety symptoms and disorders were estimated. A narrative review on the risk factors associated with elevated anxiety symptoms and disorders was presented. Results From 4941 articles, 61 studies were included. The pooled prevalence of anxiety disorders (9 studies, n = 1071) among CKD patients across studies was 19% while that of elevated anxiety symptoms (52 studies, n = 10,739) was 43%. Across continents, prevalence of elevated anxiety symptoms was highest in Europe and Asia. Between pre-dialysis and dialysis patients, the prevalence of elevated anxiety symptoms was not statistically different at 31% and 42% respectively. Common risk factors associated with elevated anxiety symptoms included concomitant depression, lower parathyroid hormone levels, increased comorbidities, increased duration of hospitalization, reduced perceived quality of life, and decreased vitality levels. Conclusion Given the high prevalence of anxiety disorders and elevated anxiety symptoms, more studies are required to assess the role and outcomes of anxiety screening among CKD patients. This could facilitate early identification of at-risk patients and potentially improve their clinical outcomes.

Nodular glomerulosclerosis, typically diagnosed in patients with diabetes mellitus, has been reported in native kidneys of pre-diabetic patients but similar cases in kidney transplant recipients are lacking. We describe a case of nodular glomerulosclerosis in a kidney transplant recipient who had not been found to be diabetic despite regular screening and discuss the implications for the pathogenesis and diagnosis of nodular glomerulosclerosis and screening of post-transplant diabetes mellitus. ELECTRONIC SUPPLEMENTARY MATERIAL: The online version of this article (10.1007/s13730-020-00546-x) contains supplementary material, which is available to authorized users.

AIM This study aims to investigate the effect of low molecular weight heparin (LMWH) in maintaining the patency of arteriovenous (AV) access with recurrent thrombosis. METHODS Following successful thrombectomy, 66 patients with recurrent thrombosis were included in the study. The primary, assisted primary and secondary patency rates of patients who received LMWH (n = 24) were compared with those who did not receive anticoagulant (n = 42) using Kaplan-Meier analysis. Cox-regression analysis was performed to investigate potential predictors of patency rates. RESULTS The mean dose of enoxaparin used was 40 ± 13.1 mg or 0.74 ± 0.2 mg/kg daily for a median duration of 14 (IQR 7,28) days. The mean trough anti-Xa concentrations measured after two doses of LMWH was 0.17 ± 0.13 IU/mL. Kaplan-Meier analyses for mean primary, assisted primary and secondary patency rates of LMWH vs no anticoagulation groups were 149 (95% CI: 91 - 207) vs 87 (95% CI: 42-132) days (P

Introduction: Coronavirus Disease 2019 (COVID-19) has significantly affected the way healthcare is delivered in Singapore. Healthcare services such as renal transplantation had to rapidly adjust and meet the needs to (1) protect patients and staff, (2) ramp up, conserve or redeploy resources while (3) ensuring that critical services remained operational. This paper aims to describe the experience of the renal transplant programme at the Singapore General Hospital (SGH) in responding to the risks and constraints posed by the pandemic. Methods and Materials: This is a review and summary of the SGH renal transplant programme’s policy and protocols that were either modified or developed in response to the COVID-19 Pandemic. Results: A multi-pronged approach was adopted to respond to the challenges of COVID-19. These included ensuring business continuity by splitting the transplant team into different locations, adopting video and tele-consults to minimise potential patient exposure to COVID-19, streamlining work processes using electronic forms, ensuring safe paths for patients who needed to come to hospital, ring-fencing and testing new inpatients at risk for COVID-19, enhancing precautionary measures for transplant surgery, ensuring a stable supply chain of immunosuppression, and sustaining patient and staff education programmes via video conferencing. Conclusions: Though the COVID-19 pandemic has reduced access to kidney transplantation, opportunities arose to adopt telemedicine into mainstream transplant practice as well as use electronic platforms to streamline work processes. Screening protocols were established to ensure that transplantation could be performed safely, while webinars reached out to empower patients to take precautions against COVID-19. Keywords: COVID-19, Nephrology, Public Health, Renal Transplant, Transplantation, Urology

There has been a growing interest in urgent-start peritoneal dialysis (PD) in patients with end-stage kidney disease to avoid central venous catheter use and its complications. This study aimed to compare clinical outcomes between urgent-start PD (defined as PD commencement within 2 weeks of PD catheter insertion) and conventional-start PD. This was a single-centre retrospective cohort study of all incident PD patients at Singapore General Hospital between January 2017 and February 2018. The primary outcome was dialysate leak. Secondary outcomes included catheter malfunction, catheter readjustment, exit-site infection, peritonitis, technique and patient survival. A total of 187 incident PD patients were included. Of these, 66 (35%) initiated urgent-start PD. Dialysate leak was significantly higher in urgent-start PD compared with conventional-start PD groups (7.6% versus 0.8%; p = 0.02) whilst catheter malfunction (4.5% vs. 3.3%; p = 0.70) and catheter readjustment (1.5% vs. 2.5%; p = 1.00) were comparable between the two groups. Exit-site infection was comparable (IRR: 0.66 95% CI 0.25–1.74) whilst peritonitis was significantly higher in urgent-start PD compared with conventional-start PD (incidence risk ratio (IRR) 3.10, 95% confidence interval (CI) 1.29–7.44). Time to first episode of peritonitis, particularly Gram-positive peritonitis was significantly shorter with urgent-start PD. Technique survival (hazards ratio (HR) 1.95, 95% CI 0.89–4.31) and patient survival (HR 1.46, 95% CI 0.44–4.87) were comparable between the two groups. Urgent-start PD was associated with higher risks of dialysate leak and peritonitis but comparable technique and patient survival compared to conventional-start PD.

Early diagnosis remains key for effective prevention and treatment. Unfortunately, current screening with anti-hepatitis C virus antibody (anti-HCV Ab) test may have limited utility in the diagnosis of HCV infection and reinfection. This is of special concern to at-risk population, such as immunocompromised hosts and end-stage renal failure patients on hemodialysis. HCV antigen (Ag) could be useful in identifying the ongoing infection in such clinical scenarios. Hence, we aimed to study the utility of HCV Ag testing for the diagnosis of acute and chronic hepatitis C. Of 89 samples studied, 19 were from acute hepatitis C patients who were immunocompromised or were on hemodialysis, 43 were from active chronic hepatitis C patients and 27 were from patients treated for chronic hepatitis C. All samples were tested for HCV Ag using the Abbott ARCHITECT HCV Ag assay. HCV Ag was reactive in 19/19 samples from acute hepatitis C patients and 42/43 samples from active chronic hepatitis C patients. It was nonreactive in all samples from treated patients. The test showed a sensitivity and specificity of 98.4% and 100.0%, respectively. The positive and negative predictive values were 100.0% and 96.4%, respectively. The HCV antigen test has high clinical sensitivity and specificity and is useful for the diagnosis of acute and chronic hepatitis C infection in at-risk and immunocompromised patients. Its short turnaround time and relatively low cost are advantageous for use in patients on hemodialysis and other at-risk patients who require monitoring of HCV infection and reinfection.

To explore and understand the experiences of healthcare professionals (HCPs) delivering care in a multidisciplinary care (MDC) clinic for advanced chronic kidney disease (CKD) patients. This is a qualitative study based on semi-quantitative questionnaire and semi-structured interviews with thematic analysis and deductive mapping onto the Theoretical Framework of Acceptability. Sixteen HCPs caring for advanced CKD patients in a MDC clinic in a tertiary teaching hospital in Singapore were recruited based on maximum variation sampling procedures. The majority of the HCPs were supportive of a MDC clinic. There was a positive overall opinion of the programme [median 7.0 of 10.0 (IQR 7.0–8.0)], high satisfaction ratings for interaction with other members of team [6.9 (5.3–8.0)] and time spent with patients [7.0 (5.3–7.0)]. Thematic analysis of the interviews identified the value of MDC clinic in the provision of one-stop care, the improvement in communication and collaboration between HCPs, the facilitation of patient activation to make planned kidney care decisions, and the optimisation of medications. The main challenges were lack of continuity of care, manpower constraints, poor patient navigation between HCPs, poor patient attendance with allied HCPs, and the perception of increased cost and time spent by patients in each MDC clinic visit. The proposed interventions were notification of patients beforehand of the MDC clinic schedule and provision of navigation to patients within the MDC clinic. A multidisciplinary care clinic for advanced chronic kidney disease patients was viewed positively by the majority of the healthcare professionals, with areas for improvement.

Background In arteriovenous graft (AVG) for haemodialysis, the primary cause of failure is venous stenosis of the graft-vein junction from neointimal hyperplasia (NIH), resulting in thrombosis. While interventions to salvage clotted AVG are known to have high clinical success rates, long-term patency rates have been suboptimal. Drug-coated balloon (DCB) has been used to treat stenosed arteriovenous access in recent years with encouraging results but data on its effect in clotted AVG is unavailable. Methods This is an investigator-initiated, single-center, single-arm prospective pilot study to determine the safety and outcome of the sirolimus-coated balloon (SCB) in the salvage of thrombosed AVG. Twenty patients who undergo successful percutaneous thrombectomy will receive treatment with SCB at the graft vein junction. The patients will be followed-up for 6-months. The primary endpoint is the patency rates at 3-month while the secondary endpoints are the patency rates and the number of interventions needed to maintain patency at 6-month. Discussion Unremitting efforts have been made to prolong the patency of AV accesses over the years. DCB angioplasty combines mechanical and biological treatment for vascular stenosis. Sirolimus, being a cystostatic anti-proliferative agent, has been successfully used in coronary artery interventions. As the primary pathology of vascular stenosis in the dialysis circuit is neointimal hyperplasia, the use of sirolimus in balloon angioplasty may be effective. With this prospective study, we evaluate the efficacy and safety of SCB in patients with clotted AVG. Trial registration ClinicalTrials.gov Identifier: NCT03666208 on 11 September 2018.

AIM Clinical presentation and course of Immunoglobulin A nephropathy vary by ethnicity and geography and significance of extracapillary proliferation or crescents (IgAN-C) in Southeast Asia is not well described. We aimed to describe the clinical course of IgAN-C in Singapore. METHODS Retrospective cohort study of adult biopsy-proven IgAN diagnosed between February 2011 and October 2016 in 2 hospital-based nephrology units. Outcome was chronic kidney disease (CKD) progression, defined as reduction in eGFR ≥50% or end stage renal failure (ESRF). RESULTS One hundred and forty-five patients were studied. Among individuals with IgAN-C (n = 44, 30%), 38 patients had cellular or fibrocellular crescents in 1 to 25% of the glomeruli and 6 had crescents in >25%. Median eGFR was 54 (33, 83) mL/min/1.73 m2 . Compared to IgAN without crescents, IgAN-C had greater proteinuria (median 2.9 [1.4, 5.4] g/g vs 1.9 [1.1, 3.6] g/g, P = .03) and more had endocapillary hypercellularity (96% vs 39%, P

Peritoneal dialysis (PD) requires patients to develop a variety of self-management skills in order to effectively deliver and manage their dialysis at home. eHealth interventions may provide patients with accessible information to develop the skills and knowledge they require to manage their treatment. This review aims to identify and evaluate ‘active’ eHealth interventions in supporting patients on PD. Six databases were included within the review using the terms Peritoneal Dialysis, eHealth, telemedicine and remote consultation. Studies which explored patients who were delivering PD, an intervention where the main component involved a digital device and required active engagement from patients were included. The primary outcomes examined were identified using the core outcomes recommended by the Standardised Outcomes in Nephrology in Peritoneal Dialysis initiative (PD infection, cardiovascular disease, mortality, PD failure and life participation). Hospitalisation rates were also considered as a primary outcome. Secondary outcomes included quality of life, patient skills, patient knowledge and satisfaction. Using the inclusion criteria, 15 studies (1334 participants) were included in the study. The effectiveness of eHealth interventions was mixed. Due to high heterogeneity, a meta-analysis was not possible, and quality of evidence was low. Risk of bias across the randomised studies was unclear but bias across non-randomised studies was identified as critical. There were no reported adverse effects of eHealth interventions within the included studies. Despite the high interest of eHealth interventions in PD, good quality evidence is needed to explore their effectiveness before a wider application of eHealth interventions.

Medication adherence plays an essential role in slowing the progression of chronic kidney disease (CKD). This review aims to summarise factors affecting medication adherence among these pre-dialysis CKD patients. A systematic review of the literature was performed in Medline®, Embase®, SCOPUS® and CINAHL®. Peer-reviewed, English language articles which evaluated factors associated with medication adherence among pre-dialysis CKD patients were included. Meta-analysis was performed to assess the pooled medication adherence rates across studies. Factors identified were categorised using the World Health Organization’s five dimensions of medication adherence (condition, patient, therapy, health-system, and socio-economic domains). Of the 3727 articles reviewed, 18 articles were included. The pooled adherence rate across studies was 67.4% (95% CI 61.4–73.3%). The most studied medication class was anti-hypertensives (55.6%). A total of 19 factors and 95 sub-factors related to medication adherence were identified. Among condition-related factors, advanced CKD was associated with poorer medication adherence. Patient-related factors that were associated with lower medication adherence included misconceptions about medication and lack of perceived self-efficacy in medication use. Therapy-related factors which were associated with poorer medication adherence included polypharmacy while health system-based factors included loss of confidence in the physician. Socioeconomic factors such as poor social support and lower education levels were associated with poorer medication adherence. Factors associated with poor medication adherence among pre-dialysis CKD patients were highlighted in this review. This will aid clinicians in designing interventions to optimise medication adherence among pre-dialysis CKD patients.

Acute kidney injury (AKI) is a frequent complication of severe burn injury and is associated with a high mortality rate of up to 80%. We aimed to establish the incidence, mortality rate, and factors related to mortality in adult patients with severe burn injury and AKI with renal replacement therapy (RRT) in Singapore.We performed a retrospective cohort study of severely burned patients who were admitted to the Burns Intensive Care Unit (BICU) at the Singapore General Hospital (SGH) from January 2008 to December 2016. We compared patients with AKI with RRT who survived with those who did not survive. As there were changes in the protocol for burns management after 2013, we also compared patients with AKI with RRT who survived with non-survivors in each of the 2008-2012 and 2013-2016 cohorts.Data of 201 patients were studied. The incidence of AKI with RRT use in severe burn injury was 21.9% and their mortality rate was 50.0%. The non-survivors had significantly higher median burned total body surface area (p = 0.043), earlier AKI (p = 0.046), earlier use of RRT (p = 0.035), lower rate of renal recovery (p = 0.0001), higher rates of adult respiratory distress syndrome (ARDS) (p = 0.005) and shock with vasopressors (p = 0.009) compared to the survivors. The survival rate was 36.8% in the 2008-2012 cohort, but improved to 60.0% in the 2013-2016 cohort. In the 2008-2012 cohort, the non-survivors developed AKI earlier (day 0 admission vs. day 3 admission, p = 0.039), and were initiated on RRT at lower serum creatinine level (173.5 μmol/L vs. 254.0 μmol/L, p = 0.042), when compared to the survivors in this same cohort. On the other hand, there were no significant differences in the renal status and fluid balance parameters between the non-survivors and survivors in the 2013-2016 cohort.The incidence of AKI with RRT in the Singapore study cohort was high, but their mortality rate was relatively lower compared to other study cohorts. Severity of AKI and use of RRT were associated with poor prognosis. Large scale study is required to further study the risk factors for mortality in this group of patients and establish cause-and-effect relationship.

Introduction: Percutaneous renal biopsy remains critical for the workup of renal allograft dysfunction but is associated with the risk of bleeding. Prophylactic intravenous desmopressin has been proposed to reduce bleeding risk in native renal biopsies, but its efficacy in the renal transplant population is unclear and adverse events such as severe hyponatraemia have been reported. Materials and Methods: We conducted a single-centre retrospective cohort study involving adult (≥21 years old) renal transplant recipients with impaired renal function (serum creatinine ≥150 μmol/L) who underwent ultrasound-guided renal allograft biopsies from 2011‒2015 to investigate the effect of prebiopsy desmopressin on the risk of bleeding and adverse events. Results: Desmopressin was administered to 98 of 195 cases who had lower renal function, lower haemoglobin and more diuretic use.Postbiopsy bleeding was not significantly different between the 2 groups (adjusted odds ratio [OR] 0.79, 95% confidence interval [CI] 0.26‒2.43, P = 0.68) but desmopressin increased the risk of postbiopsy hyponatraemia (sodium [Na]

Background. In advanced chronic kidney disease (CKD), patients face complex decisions related to renal replacement modality that can cause decisional conflict and delay. This study aimed to evaluate the prevalence of severe decisional conflict across decision types and to identify the psychosocial and clinical factors associated with decisional conflict in this population. Design. Observational cross-sectional study. Methods. Patients with CKD in renal care were recruited. The Decisional Conflict Scale (DCS), Functional, Communicative, and Critical Health Literacy (FCCHL), Health Literacy Questionnaire (HLQ), Hospital Anxiety and Depression Scale (HADS), Brief Illness Perception Questionnaire (BIPQ), and the Kidney-disease Quality of Life (KDQOL)questionnaires were used. Clinical data were obtained from medical records. Bivariate and multivariable logistic regression models were used to identify predictors of severe decisional conflict (DCS score ≥ 37.5). Results. Participants (N = 190; response rate = 56.7%; mean age = 62.8 ± 10.8) reported moderate levels of decisional conflict (29.7 ± 14.5). The overall prevalence of severe decisional conflict was 27.5% (n = 46) with no significant differences across decision types (dialysis, modality, access). Ethnicity (Chinese), marital status (married), BIPQ treatment control, coherence, KDQOL staff encouragement, and all health literacy domains, except functional health literacy, were significant predictors of decisional conflict in the unadjusted models. In the multivariable model, only the health literacy domains of FCCHL Communicative, and HLQ Active Engagement remained significant. Conclusion. Even after pre-dialysis education, many CKD patients in this study still report severe decisional conflict, with rates remaining substantial across decision junctures. The associations of decisional conflict and health literacy skills related to communication and engagement with healthcare providers indicate that more collaborative and patient-centric pre-dialysis programs may support patient activation and resolve decisional conflict. National Medical Research Council (NMRC) This study was supported by the National Medical Research Council grant (NMRC/HSRG/0058/2016).

This article described the current state of vascular access management for patients with end-stage renal disease in Singapore. Over the past 10 years, there has been a change in the demographics of end-stage renal disease patients. Aging population and the increase in prevalence of diabetes mellitus has led to the acceleration of chronic kidney disease and increase in incidence and prevalence of end-stage renal disease. Vascular access care has, therefore, been more complicated, with the physical, psychological, and social challenges that occur with increased frequency in elderly patients and patients with multiple co-morbidities. Arteriovenous fistula and arteriovenous graft are created by vascular surgeons, while maintenance of patency of vascular access through endovascular intervention has been a shared responsibility between surgeons, interventional radiologists, and interventional nephrologists. Pre-emptive access creation among end-stage renal disease patients has been low, with up to 80% of new end-stage renal disease patients being commenced on hemodialysis via a dialysis catheter. Access creation is exclusively performed by a dedicated vascular surgeon with arteriovenous fistula success rate up to 78%. The primary and cumulative patency rates of arteriovenous fistula and arteriovenous graft were consistent with the results from many international centers. Vascular access surveillance is not universally practiced in all dialysis centers due to its controversies, in addition to the cost and the limited availability of equipment for surveillance. Timely permanent access placement, with reduced dependence on dialysis catheters, and improved vascular access surveillance are the main areas for potential intervention to improve vascular access management.

Introduction: A successful arteriovenous fistula is essential for effective haemodialysis. We aim to validate the existing failure to maturation equation and to propose a new clinical scoring system by evaluating arteriovenous fistula success predictors. Methods: Data of end-stage renal disease patients initiated on haemodialysis from January 2010 to December 2012 were retrospectively obtained from medical records with follow-up until 1 January 2014. Application of the failure to maturation equation was evaluated. A nomogram was developed using arteriovenous fistula success predictors and was calibrated with a bootstrapping technique. Results: A total of 694 patients were included with mean duration of follow-up of 2.3 years. Arteriovenous fistula maturation was achieved by 542 patients (78%). Comparing our cohort with the failure to maturation cohort, there were statistically significant differences in mean age, ethnicity and presence of diabetes mellitus. The failure to maturation equation failed to predict arteriovenous fistula outcomes with area under the curve performance of 0.519 on a receiver operating characteristic curve. Multivariate logistic regression showed that Malay patients (odds ratio = 0.628; 95% confidence interval = 0.403–0.978; p < 0.05) and patients requiring preoperative vein mapping (odds ratio = 0.601; 95% confidence interval = 0.410–0.883; p < 0.01) had a lower chance of arteriovenous fistula success, whereas male gender (odds ratio = 1.526; 95% confidence interval = 1.040–2.241; p < 0.05) and presence of postoperative good thrill (odds ratio = 3.137; 95% confidence interval = 2.127–4.625; p < 0.0001) had a higher chance of arteriovenous fistula success. The derived nomogram predicted arteriovenous fistula success (odds ratio = 1.030; 95% confidence interval = 1.022–1.038; p < 0.0001) with the area under the curve of 0.695 on a receiver operating characteristic curve and an adequacy index of 99.86% ( p < 0.0001). Conclusion: The failure to maturation equation was not validated in our cohort. The clinical utility of our proposed arteriovenous fistula scoring system requires external validation in larger studies.

Background Acute kidney injury (AKI) is a major global health problem. We aim to evaluate the epidemiology, risk factors and outcomes of AKI episodes in our single centre. Methodology We prospectively identified 422 AKI and acute on chronic kidney disease episodes in 404 patients meeting KDIGO definitions using electronic medical records and clinical data from 15th July to 22nd October 2016, excluding patients with baseline estimated GFR (eGFR) of

Introduction:Long-term use of peritoneal dialysis catheter is associated with complications such as infection and malfunction, necessitating removal of catheter with subsequent reinsertion or permanent transfer to haemodialysis. This study aims to investigate the outcome in patients who underwent reinsertion.Methods and materials:A single-centre retrospective study was performed in Singapore General Hospital for all adult incident peritoneal dialysis patients between January 2011 and January 2016. Study data were retrieved from patient electronic medical records up till 1 January 2017.Results:A total of 470 patients had peritoneal dialysis catheter insertion with median follow-up period of 29.2 (interquartile range = 16.7–49.7) months. A total of 92 patients required catheter removal. Thirty-six (39%) patients underwent catheter reinsertion. The overall technique survival at 3 and 12 months were 83% and 67%. Median time to technique failure of the second catheter was 6.74 (interquartile range = 0–50.2) months. The mean survival for patients who converted to haemodialysis and re-attempted peritoneal dialysis was comparable (54.9 ± 5.5 vs 57.3 ± 3.6 months; p = 0.75). Twelve (13%) patients had contraindication for peritoneal dialysis and were excluded from analysis. Of 11 patients who required catheter removal due to malfunction, 7 (64%) underwent catheter reinsertion and 6 (86%) patients ultimately converted to haemodialysis during study period. Of the 69 patients who had catheter removal due to infection, 29 (42%) underwent catheter reinsertion and 8 (28%) patients eventually converted to haemodialysis during the study period.Conclusion:Patient survival was comparable between patients who re-attempted peritoneal dialysis and patients who transferred to haemodialysis. Patients who had previous catheter removal due to infections had favourable technique survival than those due to catheter malfunction.

Background The incidence of elderly patients receiving peritoneal dialysis (PD) has increased. This study aimed to examine the clinical presentation and outcomes of peritonitis in elderly PD patients compared with younger PD patients. Methods This single-center, retrospective, observational cohort study included all adult PD patients who developed peritonitis between January 2011 and December 2014. Elderly was defined as ≥ 65 years old at PD initiation. The primary outcome was medical cure, defined as a peritonitis episode cured by antibiotics without being complicated by catheter removal, transfer to hemodialysis (HD), relapsing peritonitis, or death. The secondary outcomes were clinical manifestations (fever, cloudy dialysate) and complications (catheter removal, transfer to HD, relapse, hospitalization, and mortality). Peritonitis outcomes were compared using multivariable logistic regression. Results Overall, 377 peritonitis episodes occurred in 247 patients. Of these, 126 episodes occurred in 79 elderly patients and 251 episodes occurred in 168 younger patients. Baseline demographic data were comparable between the 2 groups, except that elderly patients were significantly more likely to have diabetes mellitus (66% vs 46%), diabetic nephropathy (55% vs 39%), and a lower serum albumin than younger patients. Medical cure was comparable between the 2 groups (71% vs 72%, respectively, p = 0.67, adjusted odds ratio [AOR] 0.89, 95% confidence interval [CI]: 0.52 – 1.53). Compared with younger patients, elderly patients experiencing peritonitis had lower odds of fever (OR 0.53, 95% CI: 0.30 – 0.94), cloudy dialysate (OR 0.45, 95% CI: 0.23 – 0.88), and catheter removal (AOR 0.50, 95% CI: 0.26 – 0.98), but similar odds of transfer to HD (AOR 0.70, 95% CI: 0.32 – 1.51), relapse (AOR 1.57, 95% CI: 0.46 – 5.40), hospitalization (AOR 1.55, 95% CI: 0.52 – 4.56), and all-cause mortality (AOR 1.88, 95% CI: 0.83 – 4.26). Conclusions Compared with younger patients, elderly PD patients with peritonitis achieved similar medical cure rates, a lower catheter removal rate, and comparable rates of HD transfer, relapse, hospitalization, and death. Elderly PD patients experiencing peritonitis were less likely to present with fever or cloudy dialysate.

Objective: The pattern of glomerulonephritis (GN) in Singapore is compared with that of 19 other countries to review changing trends in the evolution of GN in Asian, Eastern, and Western countries. Method: Three thousand two hundred and eighty-nine renal biopsies in Singapore were reviewed and compared with that of 19 other countries. Results: IgA nephritis is on the decline in many countries, including Singapore, though it still remains the commonest GN in Singapore. Membranous GN that if used to be more frequently present in Western countries has also declined though it continues a rising trend in countries such as Singapore and China. Worldwide, the frequency of focal sclerosing glomerulosclerosis (FSGS) continues to increase in many countries, but in some countries, the frequency is still low with mesangiocapillary GN remaining indigenous. Conclusion: Urbanization and socioeconomic changes and less exposure to parasitic and other infestations have transformed Singapore’s pattern, which is tending toward that of more developed countries. Antigenic exposure due to lifestyle changes, environmental, and industrial pollution are significant contributory factors that affect the evolutionary trend of GN in many countries. The rising trend in the frequency of FSGS may reflect aging and obesity.

and purpose: Among chronic kidney disease (CKD) patients, manipulative and body-based methods (MBM) have demonstrated efficacy in improving symptoms such as fatigue. This review aims to summarize the efficacy and safety of MBM among CKD patients.A systematic review was performed in PubMed, Embase, Scopus, CINAHL, CENTRAL and PsycInfo. Randomised controlled trials (RCTs) which evaluated the use of MBM among adult CKD patients were included. The grading of recommendations, assessment, development, and evaluation (GRADE) approach was used to determine the risk of bias and certainty of evidence. The efficacy of each MBM was determined by reduction in symptom severity scores. All adverse reactions were documented.Of 8529 articles screened, 55 RCTs were included. Acupressure (n = 23), massage therapy (n = 17), reflexology (n = 6) and acupuncture (n = 5) were the most studied MBMs. Acupressure and reflexology were shown to reduce sleep disturbance and fatigue by 6.2-50.0% and 9.1-37.7% respectively. For uremic pruritus, acupressure and acupuncture reduced symptoms by 34.5-77.7% and 56.5-60.2% respectively. Common adverse reactions associated with acupressure included intradialytic hypotension (20.4%) and dizziness (11.1%) while that of acupuncture included elbow soreness (7.5%) and bleeding (7.5%). No adverse effects were reported for massage therapy, moxibustion, reflexology and yoga therapy.Acupressure, reflexology and massage therapies were the most well-studied MBMs which have demonstrated efficacy in alleviating sleep disturbance, fatigue and uremic pruritus symptoms in CKD patients.

This study aimed at determining the feasibility of conducting a large-scale pragmatic effectiveness study on the implementation of multidisciplinary care (MDC) program for patients with advanced chronic kidney disease (CKD). This is a single-arm pre-post intervention design pilot study over 12 months. Participants with an estimated glomerular filtration rate (eGFR) between 11 and 20 ml/min/1.73m2 were screened and recruited at the initial MDC clinic visit and followed for 12 months. Clinical parameters, KDQOL™-36, questionnaires, and interviews were collected, administered, and analysed for enrolment and completion rates, baseline characteristics, implementation fidelity, adherence to CKD interventions, eGFR decline, CKD complications, health-related quality of life, and participants’ acceptability of the program. The study enrolment and completion rates were 43.1% (50/116 screened) and 66.0% (33/50 recruited) respectively. The participants had a mean age of 68.5 years (SD9.0) and a mean eGFR of 15.4 ml/min/1.73m2(3.2). After 12 months of MDC program, there was increased adherence to CKD interventions (difference − 0.6(1.0), 95%CI − 1.1, − 0.1, p = 0.02). There was good participants’ acceptability of the program with participants being more satisfied with the waiting time and having a better understanding of kidney failure after attending the program. No difference in the eGFR decline noted (difference 0.0 ml/min/1.73m2(5.3), 95%CI − 1.9, 1.9, p = 1.00). Our pilot data suggest increased adherence to CKD interventions and good acceptability to MDC program, albeit no difference in eGFR decline probably because of the small sample size. However, reasons for overall low enrolment and completion rates need to be explored and addressed while designing a future large-scale randomised controlled trial.

Peritoneal dialysis (PD) is the only well-established home-based dialysis therapy in Singapore. As it is a home-based modality, PD should be considered as a preferred mode of kidney replacement therapy (KRT) for patients with kidney failure during this COVID-19 pandemic as it avoids frequent visits to hospitals and/or satellite dialysis centres. The highly infectious nature of this virus has led to the implementation of the Disease Outbreak Response System Condition orange status in Singapore since early February 2020. This paper summarises the strategies for management of several aspects of PD in Singapore during this COVID-19 pandemic, including PD catheter insertion, PD training, home visit and assisted PD, outpatient PD clinic, inpatient management of PD patients with or without COVID-19 infection, PD as KRT for COVID-19 patients with acute kidney injury, management of common complications in PD (peritonitis and fluid overload), and management of PD inventory. Keywords: Home-based dialysis, kidney failure, practice, SARS-CoV-2

Influenza and pneumococcal vaccination rates among peritoneal dialysis (PD) patients remain suboptimal, despite availability of vaccinations and health recommendations. The primary aim was to improve influenza and pneumococcal vaccination rates among incident PD patients at our center to 80%. A secondary aim was to develop a sustainable workflow for vaccination in PD patients. A quality improvement (QI) initiative to increase vaccination rate among incident PD patients was conducted in a tertiary care hospital in Singapore from Jul 2017 to Dec 2018. Key drivers and barriers to success were identified through root cause analysis. Change ideas focusing on improving opportunities, access and enhancement of reminder systems were implemented using Plan-Do-Study-Act methodology. Vaccination rates were monitored at 3-month intervals. Total of 249 patients were eligible for vaccination. The baseline vaccination rate for influenza, pneumococcal conjugate vaccine (PCV13) and pneumococcal polysaccharide vaccine (PPSV23) were 63%, 54% and 14%, respectively. Root-cause analyses revealed several practice-related barriers, including lack of physician recommendation, time constraints and ineffective reminder systems. Multifaceted interventions, such as the provision of vaccination at non-traditional clinical settings, physician audit and feedback, utilisation of reminder tools, successfully increased influenza, PCV13 and PPSV23 vaccination rates to 86%, 85% and 63%, respectively. A robust influenza and pneumococcal vaccination program implemented using a standardized QI methodology and multidisciplinary approach is effective in improving and sustaining influenza and pneumococcal vaccination uptake among PD patients.

The study aimed to examine effect of chlorhexidine dressing in the prevention of peritoneal dialysis (PD)-related infection in PD patients. This single-center pilot study recruited 50 incident PD patients to use weekly chlorhexidine dressing. The primary outcome was exit-site/tunnel infection rate. Secondary outcomes were peritonitis rate, time to first PD-related infection, infection-related hospitalization, technique and patient survival, adverse events, and chlorhexidine dressing acceptability. These clinical outcomes were compared with those of a historical cohort (2016–2017) using daily gentamicin cream. A total of 50 patients were recruited to use chlorhexidine and followed up for one year. The exit-site/tunnel infection rate was 0.09 (95% confidence interval [CI] 0.02–0.22) and peritonitis rate was 0.07 (95% CI 0.01–0.19) episodes per patient-year with chlorhexidine dressing. The 1-year infection-free survival rates for exit-site/tunnel infection and peritonitis were 92% and 94%, respectively. The 1-year technique and patient survival rates were 86% and 96%, respectively. Overall, 12% of participants developed localized contact dermatitis with chlorhexidine. Most participants (73%) reported that chlorhexidine dressings were very acceptable. Compared to a historical cohort using gentamicin cream (n = 238), the chlorhexidine group had similar exit-site/tunnel infection rates (incidence rate ratio [IRR] 0.65, 95% CI 0.22–1.92) but had lower peritonitis rates (IRR 0.24, 95% CI 0.07–0.77), and lower PD infection-related hospitalization rates (IRR 0.21, 95% CI 0.06–0.69) after adjusting for age, sex, race, primary kidney disease, and diabetes mellitus. Weekly chlorhexidine dressing was associated with acceptable PD-related infection outcomes and was well-accepted by patients, although had a 12% rate of delayed localized contact dermatitis. The study was registered under www.clinicaltrials.gov with the reference number of NCT03406520 on 23 January 2018.

BackgroundAnxiety is associated with poor health outcomes among chronic kidney disease (CKD) patients. This review summarizes the prevalence and risk factors associated with anxiety symptoms and disorders among CKD patients.MethodsArticles evaluating the prevalence and risk factors associated with anxiety symptoms and disorders among CKD patients, as diagnosed via DSM 4th or 5th edition criteria, clinical interviews or validated questionnaires, were searched in Medline®, Embase®, PsychINFO® and CINAHL®. Using random-effects meta-analyses, prevalence of anxiety was estimated. A narrative review on the risk factors associated with anxiety was presented.ResultsFrom 4941 articles, 61 studies were included. Pooled prevalence of anxiety disorders (9 studies, n=1071) among CKD patients across studies was 18.9% while that of anxiety symptoms (52 studies, n=10,739) was 42.8%. Across continents, prevalence of anxiety symptoms was highest in Europe and Asia. Between pre-dialysis and dialysis patients, prevalence of anxiety symptoms was statistically comparable at 30.5% and 42.1% respectively. Most commonly studied risk factors associated with anxiety were female gender, increased age, concomitant depression, and increased comorbidities.ConclusionGiven the high prevalence of anxiety disorders and symptoms, there is a need for developing clinical guidelines on anxiety screening among CKD patients, facilitating early identification of at-risk patients.

Background and Aims Peritonitis in peritoneal dialysis (PD) patients can be directly related to PD or secondary to intrabdominal infection (secondary peritonitis). The indication and role of imaging of abdomen during peritonitis in PD patients is unclear. Method This was a single center, retrospective study, including all the first episode of peritonitis in incident PD patients from the period of January 2013 to October 2017. Primary aim of the study was to identify the incidence of secondary peritonitis diagnosed by imaging of abdomen (defined as positive scan finding of intraabdominal lesions) in PD patients with peritonitis. Secondary outcomes were predictors for secondary peritonitis analyzed by multivariable logistic regression. Results There were total 527 incident PD patients during the study period. Of these, 153 patients (29%) developed at least one episode of peritonitis. The mean age of patients with peritonitis was 57.7 ± 3.4 years, 49 % were male, and 52% had diabetes mellitus. Out of 153, 78 patients (51%) underwent diagnostic imaging of abdomen to look for secondary peritonitis. Majority of them had contrast enhanced computed tomography (CT) scan (95%) and the remaining had non-contrast CT scan or ultrasound of abdomen. Of 78 patients who underwent scan, 12 patients (16%) were reported to have intra-abdominal lesions (secondary peritonitis) including colitis (n=2), pancreatitis (n=1), cholecystitis (n=4), appendicitis (n=1), intestinal obstruction (n=2), liver abscess (n=1), gastric cancer (n=1). According to the causative micro-organisms, the positive scan finding of intra-abdominal lesions was more commonly observed in Gram-negative peritonitis (n=7, 58%), followed by fungal/mycobacterial peritonitis (n=2, 17%), Gram-positive peritonitis (n=2, 17%), polymicrobial peritonitis (n=1, 8%), but none (0%) in culture negative peritonitis. Among patients with Gram-negative peritonitis who underwent the imaging of abdomen, only 12% (7/58) were reported to have intra-abdominal lesions. In multivariable logistic regression, the presenting symptoms including fever (odds ratio (OR) 1.51, 95% confidence interval (CI) 0.40 – 5.68), abdominal pain (OR 1.08, 95% CI 0.24 -1.78), presence of cloudy of effluent (OR 0.66, 95% CI 0.19 -2.29), hypotension on presentation (OR 3.61, 95% CI 0.75 -17.46) or effluent white cell counts on presentation (OR 0.99, 95% CI 0.93 -1.05) were not significantly associated with secondary peritonitis. Conclusion A considerable number of patients underwent imaging of abdomen during peritonitis regardless of causative organisms, only a few of them had intra-abdominal lesions. Future prospective study is needed to guide the role of imaging in PD patients during peritonitis.

Background and Aims Anxiety is a common psychopathology that affects patients with chronic kidney disease (CKD) and has been associated with poor quality of life and clinical outcomes. This review aimed to summarize the prevalence of anxiety symptoms and disorders among CKD patients. Method A literature search for observational studies, which reported the prevalence of anxiety in CKD patients, was performed in Medline®, Embase®, PsychINFO® and CINAHL® (through January 2019), in accordance with the PRISMA checklist. Peer reviewed, full text articles in English language were included. Studies involving kidney transplant patients were excluded. Anxiety disorders and symptoms were diagnosed and assessed using the Diagnostic and Statistical Manual of Mental Disorders, 4th edition (DSM-IV) or DSM-V criteria in clinical interviews, or self-administered anxiety rating scale questionnaires. To estimate the prevalence of anxiety, random effects meta-analyses were used due to the expected heterogeneity across studies. Results Of the 4130 reports screened, 53 studies were included. Majority of studies were conducted in Asia (n=26, 49.1%) followed by Europe (n=14, 26.4%) and North America (n=7, 13.2%). The Hospital Anxiety and Depression Scale (HADS) was the most used instrument (n=28, 52.8%) followed by the Beck’s Anxiety Inventory (BAI) (n=11, 20.7%). The pooled point prevalence of anxiety across the studies involving 9,355 patients was 40.0% (95% confidence interval (CI): 33.3 – 46.7). Across continents, the prevalence of anxiety was highest in Asia (42.9%) (95% CI: 32.3 – 53.5) followed by North America (42.3%) (95% CI: 28.6 – 56.0). The prevalence of anxiety in studies that included only dialysis (n=45) or non-dialysis (n=4) patients were similar at 38.9% (95% CI: 31.8 – 46.1) and 30.5% (95% CI: 14.6 – 46.3) respectively. The prevalence of anxiety in studies that had both dialysis and non-dialysis patients (n=4) was 62.6% (95% CI: 47.1 – 78.2). Conclusion Given that anxiety is prevalent in 40% of CKD patients, future studies should explore developing effective anxiety screening tools and interventions as part of CKD patient management to improve clinical outcomes.

Background and Aims Population aging is an increasing phenomenon worldwide and consequently more are developing kidney diseases which may necessitate diagnostic kidney biopsy. However, older patients may be at increased risk for complications such as bleeding. We aimed to examine the utility and safety of native kidney biopsies among our older adults. Method This was a single-centre retrospective study of older adults (≥60 years) who had native kidney biopsies at the Singapore General Hospital between June 2011 and March 2015. Demographic data, co-morbid illnesses, clinical presentation at kidney biopsy, as well as laboratory results before and after kidney biopsy, were retrieved from electronic medical records. Patient outcomes were recorded until their last visit or death before 30th March 2017. End stage renal disease (ESRD) was defined as estimated glomerular filtration rate (eGFR) 3 months. All post biopsy bleeding events were documented, with major bleeding defined as the need for transfusion and/or intervention; or if bleeding was either a direct or contributory cause of death. Results Older adults accounted for 153 of 545 (28.1%) native renal biopsies performed. The indications for biopsy in older adults included microscopic hematuria with proteinuria (51.0%), nephrotic syndrome (32.0%) and isolated proteinuria (17.0%). One hundred and ten patients (71.9%) had eGFR Post biopsy, major bleeding was more frequent among older adults compared with younger adults (13.3% vs 5.7% respectively; p=0.04), although overall bleeding episodes between older and younger adults were not significantly different (15.9% vs 22.9% respectively; p=0.18). Among older adults, minimal change disease (MCD) or focal segmental glomerulosclerosis (FSGS) was the most frequent diagnosis (23.5%), followed by membranous nephropathy (20.9%) and IgA nephropathy (9.8%), whereas MCD/FSGS (26.5%), lupus nephritis (24.5%) and IgA nephropathy (19.6%) were the top three diagnoses amongst younger adults. Co-existing glomerulonephritis (GN) with diabetic nephropathy and isolated diabetic nephropathy were seen in 12 (7.8%) and 20 (13.1%) elderly patients respectively. The majority (124 patients, 81.0%) of biopsies in older adults had histological diagnoses of glomerulonephritis that were potentially amendable to treatment although only 90 (58.8%) patients subsequently received immunosuppressants. Among older adults with biopsy-proven glomerulonephritis, median follow up was similar between those treated and not treated with immunosuppressants (30.4 [27.3, 53.7] months versus 38.8 [30.7, 51.9] months, p=0.12). Among older adults with GN, ESRD was less frequent among those treated with immunosuppressants, compared to those who did not receive immunosuppressants, although the difference did not reach statistical significance (10.3% versus 18.9%, p=0.24). However, the combined endpoint of ESRD or mortality were similar (24.1% vs 21.6%, p=0.76). Conclusion Our findings support the utility of renal biopsy for diagnosis and to guide clinical care. Older adults undergoing kidney biopsy should be counselled and monitored for bleeding complications.

Background and Aims Nephrotic syndrome is associated with hypercholesterolemia, while its treatment, often involving high-dose glucocorticosteroids, may cause hyperglycemia. Proprotein convertase subtilisin /kexin type 9 (PCSK9) regulates plasma cholesterol and is associated with post-transplant diabetes. Although a potential therapeutic target in nephrotic syndrome, the relationships between PCSK9 and lipid parameters are not well established. We aimed to characterize serum PCSK9 and metabolic parameters among individuals with nephrotic syndrome. Method Single-center prospective cohort study of non-diabetic adults newly-diagnosed with nephrotic syndrome and subsequently treated with immunosuppressant. Fasting serum PCSK9 was measured using ELISA at diagnosis. Clinical history, blood pressure, body mass index (BMI), waist-to-hip ratio (WHR) and biochemistry (fasting glucose and lipid, HbA1c and fasting serum PCSK9) were obtained at diagnosis and at 3 months during immunosuppression therapy. Spearman’s correlation was used to evaluate for associations between PCSK9 and glycemic and lipid parameters. Results Among 15 adults with nephrotic syndrome, the majority was female (60%) and Chinese (80%). Median age was 40 (IQR 26, 51) years. The most frequent diagnoses were minimal change disease or focal segmental nephrosclerosis (n=7) and lupus nephritis (n=5); the minority had IgA nephropathy, membranous nephropathy or vasculitis. At diagnosis, median eGFR was 97.9 (59.5, 120.9) ml/min/1.73 m2, UPCR 7.6 (6.1, 10.4) g/g, LDL-cholesterol 4.6 (3.1, 6.7) mmol/L and fasting serum PCSK9 317.6 (276.8, 470.1) ng/ml. PCSK9 correlated positively with hypertriglyceridemia (r=0.55, p=0.03) at baseline. Most patients (n=14, 93%) were treated with prednisolone (monotherapy or in combination with other immunosuppressant) and 1 received tacrolimus monotherapy. At 3 months, the majority (n= 11, 73%) had achieved clinical remission. Fasting serum PCSK9 was higher at 3 months [median 430.6 (283.1, 496.0) ng/ml] compared to baseline, although the difference was not statistically significant. At 3 months, PCSK9 correlated positively with age (r=0.58, p=0.03), LDL-cholesterol (r=0.90, p=0.04) and change in BMI (r=0.72, p=0.01). Conclusion PCSK9 is associated with metabolic parameters at diagnosis and during the treatment course in patients with nephrotic syndrome treated with immunosuppressant.

Objective: This study on the prevalence of diabetic nephropathy (DN) and coexistence of non-diabetic renal disease (NDRD) in a cohort of 255 non-insulin-dependent diabetes mellitus (NIDDM) patients aims to determine the value of performing renal biopsies in these patients and elucidate the factors which could affect their progression to end-stage renal disease (ESRD). Methods: Among 255 NIDDM patients, 93 had DN alone, 69 had NDRD alone, and the remaining 93 had DN plus NDRD (mixed group). The indications for renal biopsy were based on clinical suspicion of superimposed NDRD, including heavy or rapidly increasing proteinuria, renal impairment even though diabetes is of relatively short duration, rapidly declining renal function, and presence of hematuria with dysmorphic red blood cells suggesting presence of glomerulonephritis. Results: The following were predictors of ESRD: high systolic BP at biopsy, longer duration of diabetes, heavy proteinuria, and presence of diabetic retinopathy. Comparing patients in the NDRD group with the DN group and the mixed group, the NDRD group had lower serum creatinine and higher eGFR with lower urinary proteinuria and higher serum albumin at presentation and on follow-up. Kimmelstiel-Wilson nodules were associated with a poorer prognosis leading to a higher occurrence of ESRD among patients with DN. Conclusion: Renal biopsy is of value in indicating the prognosis of NIDDM patients with DN based on the diabetic lesions. For NIDDM patients with atypical course and suspicion of associated NDRD, a renal biopsy would enable us to diagnose the underlying NDRD and offer appropriate therapy. Most nephrologists would consider renal biopsy for an NIDDM patient based on clinical indications like atypical clinical course and suspicion of an associated NDRD, but they would not perform a routine renal biopsy like for a CKD patient, unless it is for a research indication.

Early technique failure is a serious complication for peritoneal dialysis (PD) patients. The study aimed to examine the incidence, causes, and risk factors associated with early technique failure. METHODS: This retrospective study included all incident PD patients in a hospital in Singapore from 2013 to 2017. The primary outcome was early technique failure, which was defined as transfer to hemodialysis for ≥ 30 days or death, within the first year of PD initiation. Secondary outcomes were death, technique failure due to PD infection, and death-censored technique failure.Overall, 517 patients were included in the study. Of these, 98 patients (19.0%) developed early technique failure. The common causes of early technique failure were death (41.8%) and infection (40.8%). Peripheral vascular disease was significantly associated with a higher hazard of early technique failure [hazard ratio (HR) 1.95, 95% confidence interval (CI) 1.04-3.63] and death (HR 3.75, 95% CI 1.71-8.21), whilst glomerulonephritis as a cause of end-stage kidney disease (compared with hypertension) was associated with a lower hazard of early technique failure (HR 0.38, 95% CI 0.18-0.77) and death (HR 0.08, 95% CI 0.02-0.37). Male gender was associated with early technique failure due to PD infection (HR 2.55, 95% CI 1.32-4.95). No specific factor was associated with death-censored early technique failure.Technique failure in the first year of PD initiation occurs in one-fifth of PD patients and is associated with peripheral vascular disease and cause of end-stage kidney disease.

Lay summary The International Society for Peritoneal Dialysis last published a guideline on prescribing peritoneal dialysis (PD) in 2006. This focused on clearance of toxins and used a measure of waste product removal by dialysis using urea as an example. This guideline suggested that a specific quantity of small solute removal was needed to achieve dialysis `adequacy'. It is now generally accepted, however, that the well-being of the person on dialysis is related to many different factors and not just removal of specific toxins. This guideline has been written with the focus on the person doing PD. It is proposed that dialysis delivery should be `goal-directed'. This involves discussions between the person doing PD and the care team (shared decision-making) to establish care goals for dialysis delivery. The aims of these care goals are (1) to allow the person doing PD to achieve his/her own life goals and (2) to promote the provision of high-quality dialysis care by the dialysis team.Key recommendations 1. PD should be prescribed using shared decision-making between the person doing PD and the care team. The aim is to establish realistic care goals that (1) maintain quality of life for the person doing PD as much as possible by enabling them to meet their life goals, (2) minimize symptoms and treatment burden while (3) ensuring high-quality care is provided. 2. The PD prescription should take into account the local country resources, the wishes and lifestyle considerations of people needing treatment, including those of their families/caregivers', especially if providing assistance in their care. 3. A number of assessments should be used to help ensure the delivery of high-quality PD care. a. Patient reported outcome measures - this is a measure of how a person doing PD is experiencing life and his/her feeling of well-being. It should take into account the person's symptoms, impact of the dialysis regimen on the person's life, mental health and social circumstances. b. Fluid status is an important part of dialysis delivery. Urine output and fluid removed by dialysis both contribute to maintaining good fluid status. Regular assessment of fluid status, including blood pressure and clinical examination, should be part of routine care. c. Nutrition status should be assessed regularly through evaluation of the patient's appetite, clinical examination, body weight measurements and blood tests (potassium, bicarbonate, phosphate, albumin). Dietary intake of potassium, phosphate, sodium, protein, carbohydrate and fat may need to be assessed and adjusted as well. d. Removal of toxins. This can be estimated using a calculation called Kt/Vurea and/or creatinine clearance. Both are measures of the amount of dialysis delivered. There is no high-quality evidence regarding the need or benefit associated with the achievement of a specific target value for these measures. 4. The amount of kidney function that continues to remove waste products and the remaining urine volume should be known for all individuals doing PD. Management should focus on preserving this as long as possible. 5. For some people who require dialysis and who are old, frail or have a poor prognosis, there may be a quality of life benefit from a reduced dialysis prescription to minimize the burden of treatment. 6. In low and lower middle-income countries, every effort should be made to conform to the framework of these statements, taking into account resource limitations. 7. The principles of prescribing and assessing delivery of high-quality PD to children are the same as for adults. In all cases, the PD prescription should be designed to meet the medical, mental health social and financial needs of the individual child and family

Aim Traditional apprenticeship model (AM) of teaching in invasive procedures such as temporary haemodialysis catheter (THDC) insertion can result in propagation of errors and complications. Simulation-based learning (SBL) offers standardization of skills and allows trainees to repeatedly practice invasive procedures prior to performing them on actual patient. Methods Retrospective cohort study of first-, second- and third-year Nephrology Fellows from a tertiary teaching hospital from September 2008 to September 2015. The intervention group (n = 9) received simulation training in ultrasound-guided THDC placement. The historical control group (n = 12) received training through traditional AM. The primary and secondary outcomes were the immediate complications and success rates of THDC insertion. Results A total of 2481 THDCs were placed in 1787 patients. Success rate of internal jugular THDC placement for AM vs. SBL Fellow was 99.8% versus 100% (P = 0.90), while the success rate for femoral THDC placement was 99.6% versus 99.2% (P = 0.53). SBL Fellows reported fewer overall peri-procedure complications (8.3% vs. 11.2%, P = 0.02) and mechanical complications (1% vs. 2.4%, P = 0.02) compared to AM Fellows. The rate of reported technical difficulty was similar (7.5% vs. 9.2%, P = 0.17). After adjusting for side and site of THDC placement, body mass index and laboratory indices, THDC inserted by AM Fellows were independently associated with increased overall peri-procedure complications (OR = 1.396, 95% CI: 1.052-1.854, P = 0.02) and mechanical complications (OR = 2.481, 95% CI: 1.178-4.810, P = 0.02). Conclusions Simulation-based learning was associated with lower procedure related complications and should be an integral component in the teaching of procedural skills in Nephrology.

Background Mindfulness-based intervention (MBI) has not been evaluated for its feasibility and effectiveness in reducing stress and anxiety among family caregivers of patients on peritoneal dialysis (PD). Objectives (1) To evaluate the feasibility to include MBI during PD training for family caregivers. (2) To determine the effect of MBI on the caregivers’ levels of stress (perceived stress scale, PSS), anxiety state-trait anxiety inventory, STAI), QOL (short-form 36) and reactions to caregiving (caregiver reaction assessment, CRA). (3) To determine differences in the health-related QOL (Kidney Disease Quality of Life Instrument-Short Form, KDQOL PCS and SF-36 MCS) of care recipients with caregivers receiving MBI at 1 month, 3 months and 6 months when compared to those with caregivers receiving routine training. (4) To gather the caregiver’s feedback on the MBI. Methods This feasibility study recruited family caregivers to receive either mindfulness training (MT) or treatment-as-usual (TAU) group. Both groups received 4.5-days of structured PD training, but only caregivers in the MT group received 4 days of MT sessions, audio-guided mindfulness practice at home and weekly telephone follow-up. Results Forty-four family caregivers participated in this study. Including MBI as part of the PD training was feasible. There was a trend towards lower scores for PSS and T-STAI in the MT group compared to the TAU group. The baseline score of both PSS and T-STAI were positively correlated with post-intervention outcome scores. Conclusions Mindfulness-based intervention has the potential to improve psychological symptoms among caregivers of patients with PD.

ObjectivePrevention of exit-site infection (ESI) is of paramount importance to peritoneal dialysis (PD) patients. The aim of this study was to evaluate the effectiveness of chlorhexidine in the prevention of ESI in incident PD patients compared with mupirocin.MethodsThis retrospective, pre-test/post-test observational study included all incident PD patients at Singapore General Hospital from 2012 to 2015. Patients received daily topical exit-site application of either mupirocin (2012 – 2013) or chlorhexidine (2014 – 2015) in addition to routine exit-site cleaning with 10% povidone-iodine. The primary outcome was ESI rate during the 2 time periods. Secondary outcomes were peritonitis rate, times to first ESI and peritonitis, hospitalization rate, and infection-related catheter removal. Event rates were analyzed using Poisson regression, and infection-free survival was estimated using Kaplan-Meier and Cox regression survival analyses.ResultsThe study included 162 patients in the mupirocin period (follow-up 141.5 patient-years) and 175 patients in the chlorhexidine period (follow-up 136.9 patient-years). Compared with mupirocin-treated patients, chlorhexidine-treated patients experienced more frequent ESIs (0.22 vs 0.12 episodes/patient-year, p = 0.048), although this was no longer statistically significant following multivariable analysis (incidence rate ratio [IRR] 1.78, 95% confidence interval [CI] 0.98 – 3.26, p = 0.06). No significant differences were observed between the 2 groups with respect to time to first ESI ( p = 0.10), peritonitis rate ( p = 0.95), time to first peritonitis ( p = 0.60), hospitalization rate ( p = 0.21) or catheter removal rate (0.03 vs 0.04/patient-year, p = 0.56).ConclusionsTopical exit-site application of chlorhexidine cream was associated with a borderline significant, higher rate of ESI in incident PD patients compared with mupirocin cream.