Q&A: Clinician Questions for Dr Hameed Anijeet
1. It’s too late for me, but for other patients who don’t respond to the normal pathway of treatment and medications, what is being done? Are you opening up to more ‘trial drugs’ or looking into non-traditional methods of treatment?
Thank you for your question. Like all the kidney units in the UK, we are also linking primary care to identify chronic kidney disease patients as early as possible. This will help us to identify patients with CKD early and slow down the progression. On the question of trial drugs, we take part in many national clinical trials and hope to undertake some pioneering research locally as well. We are duty-bound to make sure that we only undertake research that has passed through robust safety mechanisms that are laid out by national research committees. Unfortunately, we will not be able to offer nontraditional treatments if they have not been proven to be beneficial and have been accepted
nationally as a treatment choice. I hope you understand the balance all of us have to strike between the safety and efficacy of treatment.
2. I would like to ask why it takes months to get on the transplant list and get friends tested for matches. All the tests could be done in a couple of weeks. Total lack of urgency.
Thank you for your question regarding this. We do recognise the need for quick assessment and surgery when a suitable donor and recipients are identified. We are going to undertake a quality initiative (QI) project on “transplant first”, which will address all aspects of patients being referred to transplantation. May I also point out that sometimes many donors may have to be tested before we can identify the most suitable one to donate. We also may need to undertake sometimes detailed
examination and help from other specialities before a donor is deemed suitable. In view of patient confidentiality, we are not in a position to divulge details of donor work to the potential recipient. As you may know, to avoid any conflict of interest, donor workup is done by a team that has no input on the recipient’s clinical care. We will always strive to work with the patient and family to try and improve this, and we are quite hopeful with the transplant first quality initiative, we will achieve this.
3. I saw an interesting post elsewhere this week – that might be worth asking about – it was discussing when to start on treatment – & whether a phased start would be beneficial. i.e. if we currently start treatment on a 12-hour 3×4 treatment plan at an eGFR of, say, 10. Does Dr Anijeet think it would help preserve kidney function for longer if, instead, we started with 4 hour 2x 2-hour treatments at an eGFR of 20 to relieve some of the pressure on the failing
kidneys?
Thank you for your question regarding what is described in the medical literature as “incremental dialysis”. The jury is still out on this issue, and at the moment, there is no national guidance on this. It is suggested that the patients starting on incremental dialysis may lose their residual function (passing urine) slower, but there’s no evidence that starting early will relieve any pressure on the failing kidneys. There’s also evidence to suggest that the patients who started on incremental dialysis are very reluctant to increase dialysis hours and frequency at a later stage. This could be detrimental to their care.
When to start dialysis has always been very difficult to identify, and a randomised control controlled trial (the gold standard in answering a clinical question) did not show any improvement in patients starting early versus patients starting late. The start of dialysis is usually quite individualised depending on the eGFR, symptoms of fluid overload, acidosis, potassium levels, etc. It is possible that in some patients, incremental dialysis may be beneficial; this will have to be individualised depending on the clinical situation.
In view of these uncertainties, I cannot see incremental dialysis becoming a normal practice either in our unit or nationally at present.
4. I’d like to ask if there is a medical pathway for long-term Dx patients to manage the disease in conjunction with other co-morbidities and specialities. If not, this is something that is sadly lacking in terms of communication between specialities and the best interests of the patient.
Thank you for your question regarding the long-term management of comorbid conditions in patients who have chronic kidney disease. This has been a particularly important area for our kidney unit, and we have started to do some initial work to identify whether these patients can be seen in a clinic with maybe a GP or the practice nurse leading the care, with the secondary care input as and when needed. As you can see, this needs a lot of buy-in from all the stakeholders, and we will continue to try to get everybody on board regarding this. At the moment, we do copy our clinic letters to all the different specialities, and they also normally communicate with us; the copies of these are available in our electronic system to be seen by the clinical team. The new electronic patient record that is being implemented between Royal and Aintree is likely to improve communication.
I do hope that you understand that there’s a lot of work needed to achieve fully integrated clinical care between all the teams looking after a particular patient.
5. I’d like to know why other non renal consultants won’t do elective operations and use the line ‘well there’s no point your a renal patient, if it becomes serious we can think about it then’! It seems no communication between disciplines, why? We’re not dead we should have access to other treatments before they become life threatening.
I’m uncertain what the question is regarding, but I assume that this is about dialysis line being used by other specialities. Most of our patients undergo other operations like hernia operation or joint replacement, etc.
When a patient is dialysing through a line, am sure you agree that this is essential to provide dialysis treatment. When it gets used by clinical teams who do not know how to use them, we have noticed an increased risk of clotting and infection. Many clinical teams do not know that these lines are locked with medications to prevent clotting. When they use the line without aspiration first, they are likely to push the locking solution into the patient, which may lead to problems with anticoagulation and infections. In view of this, we do tend to suggest that the dialysis line only be used by the specialist team, i.e. the dialysis nurses who are able to undertake the right sterile precautions and are aware of the locking solution.
I hope I have answered your question. I’m happy to clarify if this is not what the question was about.
May I add that we do try and communicate with other specialities, and at the Royal, we do have an on-call team, which I can be contacted by any specialities and the teams around the region.
6. Also, when will Stem cell therapy and mitochondria transplants be looked at? I’m sure many of us would offer to take part, as we have nothing to lose, everything to gain.
7. Are there any promising lines of research that could lead to alternative treatments to
dialysis/transplant, e.g. stem cell treatments, artificial kidneys, etc.
Thank you for your question. The therapies that are mentioned are at a very early stage of development. It takes many years for something developed in a lab to become routine clinical practice. This is usually described as “Bench to bedside” or Translational research. There’s Wikipedia website on this https://en.wikipedia.org/wiki/Translational_research
As you can see, most of these projects have to go through many stages before they become part of routine clinical practice. We do need to make sure that the safety of patients is not compromised. We understand the frustration that is expressed, but we cannot offer experimental treatments to our patients unless it has gone through robust processes. Thank you.
8. What is the general recommendation regarding transplant and pregnancy? Is it best to be planned with the renal/transplant team and will it be fully supported throughout if deemed safe?
In general, we would recommend delaying trying to conceive for 1 year after transplant. Usually, by this time, you would have achieved stable kidney functions and stable immunosuppressive drug therapy. If you take Mycophenolate Mofetil, it is very important to use reliable contraception as this drug has been shown to be associated with a risk of developmental abnormalities in the baby if used in pregnancy.
Pregnancy in a transplant patient is generally higher risk than in the general population, and so it does have to be well planned. Some medications may have to be changed prior to you getting pregnant,
once pregnant you will require closer monitoring for you and the growth of the baby.
We have a special kidney-obstetrics clinic run by Dr Brown and Dr Clement-Jones at Liverpool Women’s Hospital. When you are thinking of getting pregnant, let us know, and we will refer you to the specialist clinic for pre-pregnancy counselling. Here, they can discuss the implications of pregnancy on an individual basis to allow you and your partner to make informed decisions about pregnancy, and they will then look after you during the pregnancy.
9. What are the reasons/causes for recurrent UTIs post-transplant?
Thank you for your question regarding UTIs. There are many reasons why post-transplant patients are at a higher risk of UTIs and also other infections.
The main reason is that your immune system is suppressed by the medications you have to take after a kidney transplant. When the immune system is suppressed, this will lead to an increased chance of infection. Females are more likely to get UTIs due to small urethra. There may be other reasons like vaginal prolapse, lax pelvic floor muscles, kidney and bladder stones, etcetera. If you are experiencing
repeated UTIs, please highlight this to one of the clinicians in the kidney transplant clinic, who will organise further investigations and referral to the Urology and/or Gynaecology teams.
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