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Pregnancy-associated VTE (PA-VTE) is a leading cause of maternal morbidity and mortality in the developed world.1 However, in many cases, PA-VTE is preventable using pharmacological thromboprophylaxis. In 2014, a comprehensive VTE prevention protocol was introduced at the Rotunda Hospital to streamline the identification of women at risk of VTE and promote use of risk-appropriate thromboprophylaxis in line with local guidelines. The VTE prevention protocol centred on two components; a postnatal VTE electronic risk assessment tool called ‘Thrombocalc’, and a comprehensive clinical guideline on the prevention of PA-VTE.The aim of this thesis was to explore the need for, and potential impact of, a comprehensive, systematic postpartum VTE prevention protocol. Three distinct studies were carried out to achieve this.First, in a cross-sectional study of over 21,000 postpartum women from an Irish maternity hospital, a high prevalence of VTE risk factors was observed, which in some cases was higher than other European populations. VTE risk was noted to be highly individualised and dynamic, supporting the need for systematic VTE risk assessment and an individualised approach to VTE prevention.Then, Thrombocalc’s novel risk score was validated using a cohort of over 300,000 pregnancies recorded in the Danish Medical Birth Register. At the risk threshold used in the Rotunda Hospital, the VTE risk score had a sensitivity of 67% and a specificity of 62%. Thrombocalc’s risk score demonstrated higher sensitivity when compared with previous and current risk assessment tools from the Royal College of Obstetricians and Gynaecologists in the UK.Finally, using a before and after study design, implementation of the VTE prevention protocol was shown to increased compliance with documented VTE risk assessment (2% to 98%, p < 0.001), increase prescription (67% to 91%, OR 5.05, p In conclusion, this body of research demonstrates that a comprehensive VTE prevention protocol enables systematic and individualised assessment of VTE risk and promotes the implementation risk-appropriate thromboprophylaxis in line with local guidelines. It is hypothesised that such improvements may ultimately contribute to effective prevention of postpartum VTE.

Bloodstream infections carry a high economic and health burdenand can develop into invasive life-threatening conditions such as sepsis, meningitis and infective endocarditis, characterised byaberrant thrombus formation and endothelial dysregulation. The intestinal and vaginal microflora, Streptococcus agalactiae, commonly known as Group B Streptococcus (GBS), is the mostcommonneonatalinvasive bloodstream infection pathogenin the western world. The aim of this thesis was to investigate the molecularinteractions between GBS,platelets and endothelial cells and the potential value of these interactions inGBS bloodstream infectionmanagement.Here, we demonstrate a GBS strain dependent platelet and endothelialcell interaction. GBS signal driven platelet aggregation was dependent on the bacterial strain, trypsin sensitive bacterial surface proteins and immunoglobulin G.We have delineated the functional role of the platelet receptor FcγRIIain GBS driven thrombus formation using a microfluidic physiological shear flow system coupled with real time microscopy, revealingits non-involvement in the initial platelet rolling and adhesion interaction with GBSeven as GBS was shown to interact withplatelets optimally only at low shear rate (≤ 200 s-1). GBS strain dependent endothelial cell invasion was accompanied by endothelial cell damage and necrosis as seen in our flow cytometric analysis and electron micrograph of GBS infected endothelial cells. These endothelial abnormalities coincided with an increase in endothelial permeability as seenin our FITC-dextran monolayer flux analysis.While epidemiological studies suggest an association between GBS serotype and clonal complex groups with GBS pathogenicity,our observation of GBS strain dependent platelet and endothelial dysregulation reveals that predicting disease outcome, particularly thrombotic and endothelial dysfunction, based on serotype or clonal complex group could be misleading.Our studyhas revealedthe usefulness of the flow system in studying GBS platelet-bacterial interactions andadds to theevidence of FcγRIIaas a potential target in bacterial induced thrombosis.

Prolonged outpatient waiting times are a global healthcare concern affecting most hospital specialties, including in Ireland. Improvement of waiting times is a constant battle and priority for Ireland’s health service, the Health Service Executive. The result of lengthy waiting for outpatient Holter monitor appointments can mean a delay in diagnosis and the potential consequences of delay in treatment. Patient satisfaction and trust in healthcare providers is negatively impacted by long waits. This quality improvement project plan focuses on improving waiting times for outpatient Holter monitoring. With guidance from Lean Six Sigma and the Define, Measure, Analyse, Improve, Control framework, quality improvement tools such as process flow mapping and the fishbone diagram aided in establishing root causes of the problem. While several areas for improvement are identified, an achievable, low-cost intervention around the patient process was identified. The inclusion of text message reminders sent to patients five days prior to their appointments is proposed as a strategy to reduce the amount of Did Not Attend patients, which will allow patients on the waiting list to be allocated the appointment slot and thereby provide an improvement to outpatient Holter monitor waiting lists.

Long waiting lists are continuing to be a global healthcare issue and Ireland is no exception. The World Health Organisation declared a global pandemic in early 2020 and as a consequence, waiting lists are lengthened even further. Data collection from this study revealed that in November 2019, a total of 181 patients attended the private dermatology clinic yet only 8% were new patients. The average time new patients waited for this appointment was 121.77 days. In November 2019 the practice received 48 referrals from general practitioners and similarly, patients were required to wait for an average of 121.8 days before their first appointment. Moles or lesions requiring further investigation were the most common reason for referral (56%) followed by acne (15%). Further data collection and analysis was unattainable due to the cessation of clinical placement as a result of COVID-19 at the time. However, data did show a large volume of return patients attended the clinic. The focus of this quality improvement plan is to reduce waiting times for new patients referred to a private dermatology clinic. Patients referred due to suspicious moles or lesions will be streamlined to a nonphysician led clinic, specifically an Advanced Practice Provider, to see these cohort of patients. The Lean Six Sigma Model with the use of the DMAIC framework and quality improvement tools assisted with the development of this project. This proposed plan anticipates to reduce waiting times for new patients by 50% following two years of implementation.

Pulmonary embolism (PE) is a potentially fatal condition which affects millions of people globally. Traditionally, people diagnosed with a PE are treated in hospital. However, published guidelines from the European Society of Cardiology (ESC) and British Thoracic Society (BTS) suggest that the early discharge and outpatient management of low-risk PE patients is safe and non-inferior to inpatient management. Despite the evidence and the publication of these guidelines, approximately 80% of low-risk PE patients are managed in the hospital. The practice of hospitalising all patients confirmed with a PE leads to prolonged hospital length of stay and poorer patient outcomes. Using the DMAIC (Define, measure, analyse, improve and control) framework for quality improvement (QI), this project examined the contributing factors leading to the prolonged hospital length of stay of low-risk PE patients. Through the use of various QI tools such as process flow maps, stakeholder analysis and fishbone diagrams, the root cause of prolonged hospitalisation was identified. The data collected identified a low prevalence of low-risk PE patients at the project site; however, it did reveal that hospital days could potentially be saved if these patients were managed as per the ESC and BTS guidelines. Furthermore, physician awareness of these guidelines and the use of stratification tools designed to identify low-risk PE patients was not deemed to be sufficient. The lack of a PE management pathway at the QI site was also amongst the problems identified. This QI project plan discusses several feasible options which could be implemented to overcome the identified problems. These options include increasing physician awareness of PE guidelines and PE risk stratification tools via education modalities, in combination with implementing an early discharge pathway for low-risk PE patients.

Central diabetes insipidus is a common complication of transsphenoidal pituitary surgery. Damage to the pituitary stalk during surgery results in the disruption of water homeostasis, resulting in increased thirst and the production of large volumes of dilute urine. While symptomatic central diabetes insipidus can be managed with the administration of desmopressin, it has the potential to progress to severe dehydration, hypernatremia and become a life-threatening medical emergency. This project utilised the DMAIC framework and associated quality improvement tools to structure a quality improvement plan aimed to reduce the length of stay for patients diagnosed with central diabetes insipidus post-transsphenoidal pituitary surgery by investigating the current management pathway. The results of this project revealed that (1) the median length of stay for a patient diagnosed with post-operative central diabetes insipidus increased from 15 days to 17 days and (2) there is an increased incidence of both hypernatremia and hyponatremia amongst these patients. Specific laboratory results and clinical observations are used to determine a patients eligibility to receive treatment for diabetes insipidus. The lack of an available standardised reference guide in this institution may have resulted in the inconsistencies in available results found in this project. Based upon a review of literature pertinent to this topic and the analysis of results this quality improvement project plan proposes the implementation of standardised guidelines for the inpatient management of central diabetes insipidus post-transsphenoidal pituitary surgery to maintain and promote safe and effective patient care in the future.

The clinical presentation of neurosurgical patients tends to be sporadic in nature. These patients present to healthcare settings across the country before being referred to the National Referral Centre for Neurosurgery and Neurology in Ireland. The growing demands on the healthcare sector, such as an ageing population and finite resources, has limited the luxury of in-patient pre-operative assessment days prior to surgery. The organisation in question had established a nurse-led pre-operative assessment clinic for elective neurosurgical referrals. This pre-assessment clinic improved the day of surgery admission rate by almost 50%. An additional cohort of neurosurgical patient referrals were identified, which are neither surgically elective nor emergency, but deemed ‘urgent.’ These are predominantly patients with newly diagnosed brain tumours. In October 2019, the Neurosurgery Outreach Pre-Operative Assessment Service (NeurO-PAS) was established at this organisation to pre-assess urgent brain tumour referrals from the referring hospital – prior to inter-hospital transfer. This quality improvement (QI) project aims to improve compliance with the NeurO-PAS pathway, therefore, reducing the investigation duplication rate. The Lean Six Sigma QI model was utilised to develop this project, under guidance of the DMAIC framework. QI tools, such as, stakeholder analysis, process flow maps and a fishbone diagram, were compiled to identify the root cause of duplicated investigations. Analysis of collected data portrays that duplications are associated with a lack of pathway awareness and communication breakdown. Improved compliance with the pathway could potentially reduce the rate of investigations duplicated, thus, improving the patient flow to neurosurgery.

Numerous guidelines have been published outlining evidence-based bestpractice in secondary stroke prevention, including optimal target control of riskfactors. Despite these guidelines failure to achieve these recommendations inclinical practice is common. This study, ASPIRE-S2 is a 5-year follow-up studyof the ASPIRE-S Study (Action on Secondary Prevention Interventions andRehabilitation in Stroke). The primary aim of this study was to prospectivelyassess secondary prevention profiles of Irish ischaemic stroke patients at 5-years and compare them to that measured at 6-months. Secondary outcomesat 5-years (cognitive impairment, recurrent stroke events and mortality) andtheir association with secondary risk factors measured at 6-months post-strokeare also reported. The secondary aims of this thesis were to review bloodpressure profiles at 6-months post-stroke among the original ASPIRE-S cohort.This included examining the prevalence of inter-arm blood pressure differenceand to investigate its associated risk factors. Ambulatory blood pressure profilesand their association with cognitive impairment 6-months post-stroke was alsoreviewed.Numerous secondary risks were measured at 5-year review including bloodpressure (both clinic and ABPM), fasting risks (lipids and glucose and HBA1C indiabetics), anticoagulation control in patients on warfarin therapy, and physicalmeasurements (weight, waist circumference, height). Lifestyle risk factors(alcohol and smoking) were documented. These were compared to thosemeasured in the same patient group at 6-months. Secondary end-points at 5-years post-stroke that were reviewed included death, cognitive impairment,vulnerability and psychological wellbeing. Association of secondary risk factorsmeasured at 6-months with mortality at 5-years was analysed. Blood pressureanalysis including inter-arm blood pressure analysis in a post-stroke populationand ambulatory blood pressure patterns associated with cognitive impairmentpost-stroke included those patients from the original ASPIRE-S study withmeasurements taken at 6-months post-stroke.Results of this follow-up study revealed that secondary risk factor managementremains suboptimal among stroke survivors at 5-years post-ischaemic strokewith a substantial proportion of patients not reaching recommended targetcontrol for secondary risks, especially in relation to blood pressure control.Comparative analysis of risk factors between the two time-points (6-months and5-years post-stroke) showed an increase in the prevalence of cardiovascularrisk factors (ex: hypertension, hypercholesterolaemia, atrial fibrillation) at 5-yearreview. There was no statistically significant improvement in secondary riskfactor control (blood pressure, lipid, diabetic management) at 5-years poststrokewhen compared to that measured at 6-months. Analysis of secondaryrisk factors measured at 6-months showed that atrial fibrillation, high TC/HDLratio, cognitive impairment and vulnerability were associated with mortality at 5-years.Results from our blood pressure analysis at 6-months post-stroke showed thatthere was a high prevalence of inter-arm blood pressure difference among thispatient population. 40.3% had an intra-arm systolic blood pressure difference(IASBP) of >10mmHg and 20.6% had a difference of >15mmHg. A history ofalcohol excess was associated with an increased IASBP >15mmHg.Review of nocturnal blood pressure profiles at 6-months and their associationwith cognitive impairment was performed. A reduction in normal systolic dippingat night-time predicted the presence of cognitive decline (MOCA months post-stroke (OR 1.06 CI 1.01-1.11 p=0.02).The results from this study reveals that secondary risk factor control continuesto be suboptimal in long-term follow-up. This research aims to highlight theimportance for increased vigilance among healthcare professionals in managingsecondary cardiovascular risks in high-risk patient populations. The need forcontinued audit of clinical practise should be encouraged to ensure guidelinesare met. Public health bodies should promote healthy lifestyle advise andsecondary prevention strategies so to encourage patient involvement and tofurther the education on secondary stroke prevention.

Sildenafil, a phosphodiesterase type-5 inhibitor, is used for the treatment of infants with pulmonary hypertension (PH). Intravenous (IV) sildenafil (Revatio®) is approved for the treatment of PH in adults but is used off-label in paediatrics. The absence of compatibility data between sildenafil and other commonly used IV medications such as adrenaline, noradrenaline, vasopressin, milrinone and heparin necessitates the use of a dedicated IV line for sildenafil. In the critically unwell child, limited IV access can make the delivery of multiple IV infusions particularly problematic. The application of devices known as Y-site or multi-lumen connectors allows multiple drug infusions to converge and enter through a single venous port of entry. However these devices can only be utilised if compatibility studies are available demonstrating the drug mixture stability. Chemical incompatibilities can lead to drug-drug interactions, potentially resulting in sub-therapeutic outcomes. The overall aim of this thesis was to establish the physical and chemical compatibility of sildenafil with the commonly administered drugs in the management of PH in paediatrics. This study evaluated the Y-site and multi-lumen chemical and physical compatibility, of 42 different combinations of sildenafil with (adrenaline, noradrenaline, milrinone, vasopressin and heparin), and different diluents (NaCl 0.9%w/v, Glucose 5%w/v, and Glucose 10%w/v), in two environmental conditions frequently encountered in the Paediatric Intensive Care Unit (PICU) (room temperature 18-22°C and 37°C). Prior to drug combination analysis, HPLC methods were developed and optimised to allow for the quantification of drugs in accordance with current pharmaceutical guidance as outlined in Chapter 2. In first part of Chapter 3, binary drug mixtures of sildenafil were examined for physical and chemical compatibility to establish Y-site compatibility. All drugs proved to be compatible when combined with sildenafil, except the binary mixture of heparin that lead to a physical and chemical incompatibility. In the second part of Chapter 3, multiple drug combinations of four and five drugs were combined with sildenafil to establish multi-lumen compatibility. The limited and incomplete data presented in the literature for the compatibility of drugs administered via Y-site in combination with sildenafil, makes studies such as this one invaluable to clinicians. The overall aim of this work is to provide a complete compatibility chart of all five drugs identified as critical in combination with Sildenafil at RT and at 37°C. This preliminary data provides a starting point in the investigation of the compatibility of Sildenafil in combination with commonly used ICU drug infusions. This research will help inform clinical judgement to allow for the safe IV Y-site and multi-lumen drug administration in the PICU.

Background: Mobility is acknowledged in the literature as the highest predictorof pressure ulcer development, however most of clinical studies assess mobilitysubjectively. The few studies that have analysed mobility objectively usingtechnology have the limitation of not measuring small postural changes, whichare important for pressure relief. A more comprehensive analysis of mobility,including all types of movement is needed to better understand mobility andpressure ulcer development, and to further correlate it with other risk factors.Therefore, a quantitative, prospective, non-experimental study among the elderlypopulation was undertaken.Aim: The primary objective of the study was to explore how activity and mobility,along with other risk factors lead to pressure ulcer development in older personscared for in long-term facilities. The secondary objectives of the study were firstlyto report pressure ulcer incidence among the study participants using visual skinassessment and sub-epidermal moisture (SEM) measurement. Secondly, toexplore mobility in healthy volunteers using a mobility sensor in order to compareto mobility levels of older people cared for in long-term settings.Methods: Ethical approval was received. The chosen explanatory variables wereincluded as they are common to the three most widely used risk assessment tools(Waterlow, Norton and Braden), namely, mobility, activity, nutritional status andincontinence. Following statistical advice and after the results of the pilot study of48 participants, the sample size was recalculated based on the two causal factorsthat varied over the 20-day follow-up, namely mobility and activity. Therefore, atotal of 150 participants were included. The pilot study also identified the need toinclude healthy participants to better determine mobility among a healthypopulation, in order to enhance the understanding of the older participants’movements. Following ethical approval, a total of 22 healthy participants wereincluded and their mobility were assessed over a 2-night period, using the samemotion sensor employed within the main study.

Chronic kidney disease (CKD) is a growing global health concern with an age-standardized global prevalence of approximately 10%. Of those with CKD, approximately 2% will go on to require renal replacement therapy within any given 5-year period. Renal transplantation is accepted as the most clinically- and cost-effective treatment for end-stage kidney failure. In this thesis, we set out to examine the impact of common genetic variation on renal transplant function as well as a common post-transplant complication: non-melanoma skin cancer. We also aimed to examine a common form of CKD, IgA nephropathy, in a familial context using next generation sequencing techniques. We demonstrated that polygenic (but not single variant) effects of common genetic variation found in both the kidney donor and recipient impacts the function of the renal allograft in the early stages post-transplant. We also illustrated how measures of post-transplant renal outcomes do not correlate with the level of shared genetic ancestry between unrelated kidney donors and recipients in a cohort of European, deceased-donor transplants. We also showed that polygenic (but not single variant) effects of common genetic variation impacts both whether or not an individual develops post-transplant non-melanoma skin cancer but also, the speed at which they develop non-melanoma skin cancer. Finally, in our exome sequencing analysis of familial IgAN, we found that a number of Irish families carried rare, damaging and potentially disease-causing mutations in type IV collagen-related genes, known to cause kidney disease. In summary, this thesis demonstrates the impact of genetic variation on both kidney disease and transplant outcomes.

IntroductionLymphoedema is an incurable, progressive condition, which results in the swelling of a limb or limbs and impairs mobility (Lymphatic Framework, 2006). The psychosocial impact of lower limb lymphoedema is also devastating as body image and quality of life are greatly affected (Lasinski et al, 2012). Although lymphoedema is a chronic condition, it is manageable through treatment modalities which include manual lymphatic drainage, compression bandaging, compression hosiery, skin care and exercise, otherwise known as Complex Decongestive Therapy (CDT) (Todd, 2012). The area of lower limb, non-cancer related, lymphoedema is poorly resourced and poorly researched, therefore this thesis proposes to explore treatment outcomes for patients with non-cancer related lower limb lymphoedema during the intensive and maintenance phases of CDT,examine their experiences of living with lymphoedema and the challenges of lifelong self-care maintenance.Research QuestionsThe research questions for the study were as follows;1. What is the impact of Complex Decongestive Therapy (CDT) as a treatment for primary and secondary lower limb lymphoedema during the intensive and maintenance phases of CDT, in relation to;a. Quality of life?b. Limb circumferential and volumatic changes?c. Self-efficacy in managing lymphoedema self care?2. What are the patients’ experiences of living with lymphoedema?3. What are the patients’ experiences of the four elements of CDT used during the intensive and maintenance phases of treatment?Aims & ObjectivesThe aims of this study were twofold;1. To examine the impact of Complex Decongestive Therapy (CDT) as a treatment for primary and secondary, non-cancer related, lower limb lymphoedema during the intensive and maintenance phases of CDT;2. To explore the experiences of patients with primary and secondary, non-cancer related lower limb lymphoedema during the intensive and maintenance phases of CDT.The objectives of the study are as follows:1. To determine the impact of CDT on limb circumference and quality of life.2. To explore the patients’ experience of living with lymphoedema.3. To investigate the patients’ reported experience of the four elements of CDT.4. To examine the patients’ reported maintenance regimen of self-care and its resulting effect on limb volume and quality of life.MethodsA mixed methodology, using both quantitative and qualitative data in a sequential manner was used. This study was divided into 3 parts,Part 1 a quantitative approach was used to measure;a) Limb volume changes.b) Quality of Life changesc) Self-efficacyPart 2 –A qualitative approach was used to analyse data from face to face, semi-structured interviews with 18 participants exploring the experiences of patients living with lymphoedema and their experiences of Complex Decongestive Therapy.Part 3 – Descriptive analysis of 18 participant diaries was used during maintenance self-care, over a 4-month period, to examine the participants’ experiences of lymphoedema self care.ResultsA purposive sample of 20 participants were recruited to this study All participants were diagnosesd with lower limb lymphoedema, 10 participants had primary lymphoedema and 10 participants had secondary, non-cancer related lymphoedema. The study setting was a lymphoedema clinic in the Midlands of Ireland, run by the researcher who is also a Tissue Viability Nurse and Manual Lymphatic Drainage Therapist.The findings included a reduction in limb volume from baseline to week 8 during intensive therapy and then a fluctuation of oedema for 6 of the participants during the 4-month self-maintenance period. Quality of life improved for all participants from baseline to week 24. Thematic analysis of the interviews identified themes of lack of knowledge, delayed diagnosis, physical, psychosocial and financial burden of lymphoedema and positive therapeutic effect of treatment. The diary analysis identified self-care challenges that were influenced by elevated body mass index and carer support.ConclusionPrimary and secondary, non-cancer related lower limb lymphoedema is an area of lymphoedema that is poorly researched. It is also true to say that there is a sparsity of research in the area of lymphoedema self maintenance care. The aims of this research study were twofold, to explore patient outcomes with regard to limb volume, quality of life and self-efficacy during the intensive and maintenance phases of CDT and to examine the experiences of the patients living with lymphoedema, during their treatment and following on into self maintenance. The findings included reduction in limb volume during therapy, an improvement in quality of life and a fluctuation in self-efficacy that was influenced by elevated body mass index. Thematic analysis of interviews concluded that living with lymphoedema poses many challenges resulting from poor knowledge within the health professions and a lack of referral pathways and services. The success of lymphoedema self maintenance is greatly influenced by the patients physical ability and support structures, especially in the case of the patient with an elevated body mass index.

IntroductionIn Ireland, it is estimated that 10,000 people have a stroke annually. A high numberof stroke-survivors with residual deficits requiring care are discharged to their own.Informal carers are often central in homecare provision. The discharge planningprocess (DPP) is the process used to establish the requirements necessary for apatient to transition from one level of care to another, and may involve carers.Aims and ObjectivesThe aim of this study was to explore the experiences of carers of stroke-survivors inIreland, in relation to the DPP and transition of care to the home setting. Theobjectives were; to identify carers’ perceptions of being engaged in necessarydiscussions when discharge-planning. To identify experiences of the DPP thataffected planning for and impacted upon effective transition to the home setting,including perceived supports and barriers. To explore the impact of onward referral,and access to support services, on the DPP and transition of care to the home setting.MethodsThis study employed a qualitative descriptive design using semi-structuredinterviews, with carers of stroke-survivors in Ireland (n=6). The Caregiver BurdenScale (CBS) was used a thematic prompt by participants prior to conductinginterviews. Key themes emerged from data analysis, which were identified usingthematic analysis.ResultsResults of the CBS (Macera et al., 1993) identified areas where participants providedcare and areas that increased their stress. Theme one involved preparation fordischarge while in the hospital. Supports at this time, included access to aninformation-pack on aspects related to their relative’s care. Theme two related toaccess to community-services and life at home post-discharge, with access to earlysupported discharge described as beneficial.ConclusionsEffective communication of information, provision of necessary training and accessto community services upon discharge, were considered key components of effectivedischarge planning.Implications of FindingsHealth professionals must ensure that adequate information exchange and trainingoccurs with carers of stroke-survivors, to support their involvement in the DPP andensure continuity of care on discharge.

Patients with advanced chronic kidney disease (CKD) or end-stage renaldisease (ESRD) have a large burden of symptoms, with sleepdisturbance, restless legs syndrome and fatigue among the mostprevalent (1). These sleep-related symptoms are considered an absolutepriority for both treatment and research by patients and their caregivers(2). Despite this, clinicians consistently underestimate and overlook thesesymptoms in clinical encounters (3). The impact of RRT modality choiceon such symptoms is not well defined and is poorly communicated topatients choosing between modalities. In fact, communication regardingthe impact of modality choice is so poor that patients consistently reportfeeling excluded entirely from ‘shared decision-making’ (4). It is criticalthat physicans consider the impact of RRT modality on all aspects ofpatient care, including sleep, engage patients in this major decision, andcommunicate in outcomes that patients understand and value (such assymptoms and quality of life).Disturbed sleep has a major negative impact on health-related quality oflife, mood, and neurocognitive function. There is a growing body ofevidence suggesting that sleep disturbance in general, and some of thespecific sleep disorders in particular, are independent cardiovascular riskfactors (5). The American Heart Association called for promotion ofhealthy sleep along with other risk factor modifications in their 2019scientific statement (6). Patients with advanced CKD or ESRD are alreadyat high cardiovascular risk, and any modifiable element to this risk shouldbe aggressively managed.The impact of initiating a particular RRT modality or changing RRTmodality on sleep-related symptoms is not well understood, particularly inthe case of the nocturnal therapies, where alarms and anxiety maycounteract any positve effects of improved uraemia and extracellular fluidvolume control. My published, peer-reviewed, systematic review aimed toassess the impact of a change in RRT modality on sleep quality inpatients with ESRD (7). Sixteen heterogeneous studies, with a combinedtotal of 670 patients and 191 controls, were included. Meta-analysis of thesixteen studies favoured increased intensity RRT (either intensivehemodialysis (HD), automated peritoneal dialysis (APD) or transplant)over conventional RRT (conventional HD or continuous ambulatoryperitoneal dialysis (CAPD)) in terms of overall sleep quality, with statisticalsignificance. Restless legs syndrome (RLS) and sleep apnoea alsoimproved in the majority of patients following a switch to increasedintensity RRT.This cohort study assessed sleep quality in sixty patients (unselected forsleep disturbance) with advanced CKD or ESRD. There was a highprevalence of self-reported poor sleep quality (54%), RLS, (44%) andexcessive daytime sleepiness (22%). Polysomnography (PSG) andactigraphy studies identified marked sleep fragmentation and distortedsleep architecture, with longer time than usual spent in the lighter stagesof sleep, and shorter time than usual spent in the deeper, restorativestages of sleep. Sleep apnoea and abnormal periodic limb movements(PLMs) were also highly prevalent (44% and 47% respectively). Markedbenefits in terms of sleep quality, health related quality of life (HRQoL)and sleep apnoea were demonstrated post-transplant in the subgroup thatwere transplanted. Many parameters of subjective and objective sleepquality improved after either initiating dialysis from chronic kidney disease(CKD) or optimisation dialysis in those already on some form of dialysis.There was a high prevalence (44%, n=14) of sleep apnoea in the 32patients that underwent baseline PSG, with older age as an independentrisk factor. Screening tools (such as the Epworth Sleepiness Scale) andactigraphy did not accurately predict the diagnosis or obviate the need forPSG for the diagnosis. 70% of patients with an abnormal apnoeahypopnoeaindex (AHI) had subjective and / or objective improvementwith initiation of continuous positive airways pressure (CPAP) oroptimisation of RRT. As there is emerging evidence that sleep apnoea isan independent cardiovascular risk factor in ESRD, the concept of treatingsleep apnoea and potentially improving the cardiovascular risk profile isan appealing one (8).RLS and abnormal PLMs were also prevalent (45% and 47%respectively). Increased age was, again, an independent risk factor.Actigraphy did not predict an abnormal PLM index but was useful inselected cases. 73% of patients with an abnormal PLM index hadsubjective and / or objective improvement with pharmacologic therapy oroptimisation of RRT. As there is emerging evidence that PLMs areassociated with nocturnal hypertension and increased cardiovascular riskin ESRD, the concept of treating them and modifying this risk is, again,appealing (9).With regard to screening for sleep disturbance, the individualquestionnaires performed poorly in terms of predicting their specificoutcome of interest in this study cohort. However, the Pittsburgh SleepQuality Index (PSQI) proved useful in identifying those patients who hadsleep disturbance in general (rather than a specific problem). Pairedactigraphy and PSG analyses showed good agreement for sleepefficiency and time spent awake after sleep onset. The PSQI and wristactigraphy may, therefore, help to triage patients for PSG assessment injurisdictions with limited PSG access. There were no safety issues withthe 55 unattended home PSG studies and seventy actigraphy studies,including those performed during nocturnal dialysis (PD or HD).To conclude, sleep disorders are highly prevalent, easily and safelystudied with unattended home PSG and eminently modifiable in stableoutpatients with advanced CKD or ESRD. Given that the sleep disordershave such a negative impact on clinical outcomes in these patients,identification and management of sleep disorders should be a priority inNephrology clinics. With ongoing dissemination of these researchfindings, we hope to highlight the prevalence of sleep disorders in thispopulation, guide appropriate investigations, facilitate discussionsregarding modality choice, encourage patients and doctors to intensifydialysis, and ultimately contribute to improved management of sleepdisorders and patient outcomes in patients with advanced CKD or ESRD.