Chronic Kidney Disease (CKD)
Renal Risk in Derby (RRID) Study
In 2008 we commenced a long-term study of 1741 people with CKD, most of who have not previously seen a kidney consultant. Our initial analysis showed that the majority of people were at relatively low risk for complications and only 6% required assessment by a kidney consultant. Although blood pressure control was good overall, up to a third of the people studied would benefit from better blood pressure control.The study also identified the potential value of some new markers of prognosis including arterial stiffness, skin autofluorescence, serum free light chains and fibroblast growth factor 23. Other analyses have focused on the role of salt intake in contributing to the risks associated with CKD as well as the importance of monitoring protein levels in the urine.We have now completed reassessment of all the participants five years after their first study visit. The information we obtain from these visits should provide valuable insights into the long term complications of CKD. Using this information, we aim to develop methods to predict risk in people with CKD so that those at high risk can be referred early for more intensive treatment, whereas those at low risk will be spared unnecessary referral.
Multiparametric MRI for patients with kidney disease
In collaboration with the Sir Peter Mansfield MRI centre in the School of Astronomy and Physics, we are using a novel MRI protocol to study acute and chronic kidney disease.
New techniques will allow us to visualise pathophysiological changes in man by measuring blood flow, perfusion and fibrosis. We will correlate these measures with biopsy scores of fibrosis, measured GFR values and long term change in renal function.
Results have the potential to improve assessment of kidney diseases, assess response to treatments and add prognostic information about long term kidney health.
Acute Kidney Injury (AKI)
The ARID study (AKI risk in Derby), funded by Kidney Research UK and the British Renal Society, aims to determine if acute kidney injury (AKI) contributes to the development of CKD.
The study involves the recruitment of over 1,000 former hospital in-patients; we are on target to achieve this by March 2016. We are focussing on two groups of people – those who have experienced sudden reductions in kidney function (AKI group) and those who have not (the control or comparator group). Both groups will be asked to give blood and urine samples over a three year period and we will keep track of their general health for a further two years.
AKI is very common in hospitalised patients, often occurring when they are unwell from another illness, especially in more vulnerable patients with long term medical conditions. AKI is not a physical injury to the kidney and usually occurs without symptoms. In many cases kidney function improves before patients leave hospital. However, there is relatively little research that follows the progress of these patients in the months and years following AKI to find out if it has any effect on patients and their kidney function in the longer term. By doing so, we aim to develop strategies to identify patients who are at higher risk at a much earlier stage, which in turn will enable future work to determine more effective treatments.
Tackling AKI: a multicenter quality improvement project
Tackling AKI is a quality improvement project that is funded by the Health Foundation. The aim is to test whether a package of interventions that have been developed and shown to be successful in Derby Teaching Hospitals can be adopted and be effective in other hospitals.
The interventions consist of electronic AKI detection and alerting (using the nationally approved algorithm), hospital wide education and an AKI care bundle. Their aim is to increase recognition of AKI, enhance awareness and understanding and drive improvements in basic elements of care. We will support their successful implementation with a dedicated change management strategy.
Our project is being run with a number of different partner organisations and in a number of different UK hospitals. Derby Teaching Hospitals is the lead centre; Leeds Teaching Hospitals, Bradford Teaching Hospitals, Frimley Park, Ashford and St Peters Hospital and Surrey Pathology Services are the sites where the AKI interventions are to be tested; the UK Renal Registry and University of Bradford are leading the project evaluation; and NHS England and the Think Kidneys AKI programme are also partners. As well as simply rolling out the intervention, it is very important that its effect is measured in a robust and independent way. This will allow us to determine whether the interventions really are effective in improving the care that patients receive and in improving their outcomes. The project will be evaluated in several ways: the impact on patient outcomes will be measured, as will process measures that track whether more patients with AKI receive appropriate treatment.
We are also conducting a qualitative evaluation, so we will learn how the interventions can be successfully introduced into different hospitals, and to record the lessons learnt from the process. One particular feature of our study is the use of a ‘stepped wedge design’. This means that instead of introducing the AKI interventions in all hospitals at the same time, there will be a staggered roll-out, the time and hence the sequence of hospitals that start the intervention at each period determined randomly. Randomisation has already occurred. All clusters will start the project in a control phase with no intervention being delivered at any site, then sequentially cross over from the control group to the intervention group, until all sites are receiving the intervention.
Outcomes are measured in the partner organisations at regular time periods, with measurement taking place at each step in the wedge; each partner organisation provides data points in the control and intervention periods allowing each site to act as its own control. To maintain independence of the evaluation, it is not being carried out by any of the teams involved in implementation but by the UK Renal Registry and University of Bradford. Follow our progress via our Twitter feed: @TacklingAki
CArdiac MR In Dialysis (CAMRID) Studies
Dialysis treatment is life-saving for people with kidney failure but may also be associated with severe complications affecting the heart, arteries, brain, bones and muscles as well as a risk of infection.
We have recently completed a groundbreaking study in which we performed functional cardiac MRI during dialysis for the first time. Results have given us unprecedented information about how dialysis acutely affects cardiac structure, function and perfusion.
We are now setting up a follow up study in which intra-dialytic MRI will be used to concurrently study the impact of dialysis on the heart, brain and kidneys and the mechanisms by which carefully regulated cooling of the dialysate lessens adverse effects.
New applications for dialysis treatments
CKRI is leading the PD-Heart Failure study, a multicentre randomised controlled trial of peritoneal dialysis to treat intractable heart failure, funded by the British Heart Foundation and supported by the UK CardioRenal Clinical Study Group. Primary outcome is an improvement in exercise tolerance and quality of life. The study is due to start recruiting in January 2016.
This is a collaborative project between The Centre for Kidney Research and Innovation and the Institute for Innovation in Sustainable Engineering from the University of Derby.
By working together, we aim to develop technologies to improve patient monitoring during dialysis that will inform and feed refinements in the delivery of dialysis treatments that will ultimately improve patient outcomes. This three year programme of work will develop models to process continuous physiological data in real time, to predict changes of haemodynamic stress prior to their occurrence and ultimately lead to feedback systems involving dialysis based interventions.