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To determine the incidence and characteristics of ICU admissions in the Scottish population of patients treated with chronic kidney replacement therapy (KRT) over an 11-year period and determine factors associated with post-ICU admission mortality.Retrospective observational cohort study.We analyzed admissions to Scottish intensive care environments between January 1, 2009, and December 31, 2019.All patients receiving chronic KRT-including maintenance dialysis and kidney transplant-in Scotland.None.Descriptive statistics and factors associated with mortality using logistic regression and Cox proportional hazard models. From 10,657 unique individuals registered in the Scottish Renal Registry over the 11-year study period and alive as of January 1, 2009, 1,402 adult patients were identified as being admitted to a Scottish critical care setting. Between 2009 and 2019, admissions to ICU increased in a nonlinear manner driven by increases in admissions for renal causes and elective cardiac surgery. The ICU admission rate was higher among patients on chronic dialysis than in kidney transplant recipients (59.1 vs 19.9 per 1,000 person-years), but post-ICU mortality was similar (about 24% at 30 d and 40% at 1 year). Admissions for renal reasons were most common (20.9%) in patients undergoing chronic dialysis, whereas kidney transplant recipients were most frequently admitted for pneumonia (19.3%) or sepsis (12.8%). Adjusted Cox PH models showed that receiving invasive ventilation and vasoactive drugs was associated with an increased risk of death at 30 days post-ICU admission (HR, 1.75; 95% CI, 1.28-2.39 and 1.72; 95% CI, 1.28-2.31, respectively).With a growing population of kidney transplant recipients and the improved survival of patients on chronic dialysis, the number of ICU admissions is rising in the chronic KRT population. Mortality post-ICU admission is high for these patients.

BackgroundPatients with kidney failure requiring kidney replacement therapy (KRT) are at high risk of complications and death following SARS-CoV-2 infection with variable antibody responses to vaccination reported. We investigated the effects of COVID-19 vaccination on incidence of infection, hospitalization and death of COVID-19 infection.MethodsStudy design was an observational data linkage cohort study. Multiple healthcare datasets were linked to ascertain all SARS-CoV-2 testing, vaccination, hospitalization, and mortality data for all patients treated with KRT in Scotland, from the start of the pandemic over a period of 20 months. Descriptive statistics, survival analyses and vaccine effectiveness were calculated.ResultsAs of 19th September 2021, 93% (n=5281) of the established KRT population in Scotland had received two doses of an approved SARS-CoV-2 vaccine. Over the study period, there were 814 cases of SARS-CoV-2 infection (15.1% of the KRT population). Vaccine effectiveness against infection and hospitalization was 33% (95% CI 0-52) and 38% (95% CI 0-57) respectively. 9.2% of fully vaccinated individuals died within 28 days of a SARS-CoV-2 positive PCR test (7% dialysis patients and 10% kidney transplant recipients). This compares to ConclusionsThese data demonstrate a primary vaccine course of two doses has limited impact on COVID-19 infection and its complications in patients treated with KRT. Adjunctive strategies to reduce risk of both COVID-19 infection and its complications in this population are urgently required.

Background and Aims Outcomes in ANCA vasculitis remain difficult to predict and therapeutic decision-making can be challenging. We aimed to establish if a renal risk score (RRS) could predict outcomes in this population. Method The Scottish Renal Biopsy Registry is a complete national dataset of all renal biopsies performed in Scotland. Those who had a first renal biopsy between 01/01/2014 and 31/12/2017 with evidence of ANCA vasculitis were included. Demographic data, treatment regimens, episodes of relapse and patient and kidney survival were recorded, retrospectively. The RRS was calculated using the system proposed by Brix et al (1). Each patient was categorised according to % of normal glomeruli (N0 >25%, N1 10 to 25%, N2 25%) and eGFR (CKD-EPI) at time of biopsy (eGFR: G0 >15 mL/min/1.73 m2, G1 ≤15 mL/min/1.73 m2). Individual scores were summated and patients defined as low, medium or high risk. Cox proportional hazard models were created for survival to ESKD, relapse and death, stratified by risk category. Analyses were conducted using R statistical software. Results Two-hundred and forty-six patients with biopsy proven ANCA vasculitis were identified. Fifty percent (n=123), 46% (n=112) and 5% (n=11) were stratified as low, medium and high risk respectively. Fifty-two percent (n=129) were male and mean age at biopsy was 66.7±12.2 years. This was similar across the risk categories. Mean eGFR was lower in the high-risk category (High risk 8.6±6.1 ‘v’ Low risk 45.7±26.0 ml/min/1.73m2, p Those categorised as medium or high risk were more likely to receive plasma exchange and/or haemodialysis at presentation (p Conclusion A simple RRS, using routinely reported data, in patients with renal biopsy proven ANCA vasculitis can help to predict development of ESKD. It may also be predictive of future relapse in those with a lower RRS, most likely explained by reduced irreversible damage in this group. The RRS could inform monitoring and treatment decisions. Whilst the numbers are small, a unique strength of this data is that it is based on a complete national dataset making it less susceptible to bias from regional variations in diagnostic and therapeutic practice.

ObjectivesPatients requiring haemodialysis are at increased risk of serious illness with SARS-CoV-2 infection. To improve the understanding of transmission risks in six Scottish renal dialysis units, we utilised the rapid whole-genome sequencing data generated by the COG-UK consortium.MethodsWe combined geographical, temporal and genomic sequence data from the community and hospital to estimate the probability of infection originating from within the dialysis unit, the hospital or the community using Bayesian statistical modelling and compared these results to the details of epidemiological investigations.ResultsOf 671 patients, 60 (8.9%) became infected with SARS-CoV-2, of whom 16 (27%) died. Within-unit and community transmission were both evident and an instance of transmission from the wider hospital setting was also demonstrated.ConclusionsNear-real-time SARS-CoV-2 sequencing data can facilitate tailored infection prevention and control measures, which can be targeted at reducing risk in these settings.

IntroductionInfection with the severe acute respiratory coronavirus 2 (SARS-CoV-2) has led to a worldwide pandemic with coronavirus disease 2019 (COVID-19), the disease caused by SARS-CoV-2, overwhelming healthcare systems globally. Preliminary reports suggest a high incidence of infection and mortality with SARS-CoV-2 in patients receiving renal replacement therapy (RRT). The aims of this study are to report characteristics, rates and outcomes of all patients affected by infection with SARS-CoV-2 undergoing RRT in Scotland.MethodsStudy design was an observational cohort study. Data were linked between the Scottish Renal Registry, Health Protection Scotland and the Scottish Intensive Care Society Audit Group national data sets using a unique patient identifier (Community Health Index (CHI)) for each individual by the Public Health and Intelligence unit of Public Health, Scotland. Descriptive statistics and survival analyses were performed.ResultsDuring the period 1stMarch 2020 to 31stMay 2020, 110 patients receiving RRT tested positive for SARS-CoV-2 amounting to 2% of the prevalent RRT population. Of those affected, 87 were receiving haemodialysis or peritoneal dialysis and 24 had a renal transplant. Patients who tested positive were older and more likely to reside in more deprived postcodes. Mortality was high at 26.7% in the dialysis patients and 29.2% in the transplant patients.ConclusionThe rate of detected SARS-CoV-2 in people receiving RRT in Scotland was relatively low but with a high mortality for those demonstrating infection. Although impossible to confirm, it appears that the measures taken within dialysis units coupled with the national shielding policy, have been effective in protecting this population from infection.

Background and Aims This is a national project undertaken on behalf of the Scottish Renal Biopsy Registry describing the presentation, biopsy appearances, management and outcomes of patients presenting with a new diagnosis of renal biopsy proven ANCA associated vasculitis (AAV) to all units in Scotland. Method The Scottish Renal Biopsy Registry collects data annually on all renal biopsies performed across Scotland. From the Registry, all patients with a possible diagnosis of AAV found on renal biopsy performed between1/1/2014 and 31/12/2017 were identified. Individual units searched the electronic patient records of each patient and identified all those with a new diagnosis of AAV. Those undergoing repeat biopsy or who were not felt to have AAV on biopsy were excluded. Demographic data including immunological and outcome data were recorded and statistical analysis was undertaken in SPSS (v22). Results 267 patients were identified as having AAV across 8 centres and followed up for an average of 989 (IQR 610-1247) days. In 52% (n= 140) the biopsy indication was acute kidney injury. 38% (n=101) had a diagnosis of granulomatosis with polyangiitis (GPA). 52% (n=140) were female and the mean age at biopsy was 66.6±12.1 years. 38% (n=100) were PR3 positive. The average number of glomeruli on biopsy was 14 (IQR 11-21) with 3 (IQR 2-7 crescents. 28% (IQR 7-51) of viable glomeruli contained crescents. 41% (n=110) had at more than 10% interstitial fibrosis on biopsy. Creatinine at biopsy was 208µmol/L (IQR 141-380 µmol/L) and at 90 days 141 µmol/L (IQR 101-222 µmol/L). Most patients received standard induction therapy of cyclophosphamide and steroid. 24% (n=65) had plasma exchange at presentation and 11% (n=30) renal replacement therapy (RRT). 15% (n=39) patients relapsed with an average time to relapse of 511 (IQR 223-11127) days. 62% (n=24) of relapses were treated with rituximab. Those with GPA relapsed earlier. 12% (n= 31) developed end stage renal disease (ESRD). 18% (n=49) died with 14 patients (5%) dying within 90 days of biopsy. Average time to death was 246 (IQR 89-321) days. There was a trend towards an increased risk of death with those who developed ESRD. Patients who received PEX or RRT during initial admission were no more likely to relapse or die than those who did not. Conclusion This study accurately describes the presentation, management and outcomes of patients with AAV and renal involvement in Scotland. This allows comparison between centres within Scotland and other countries. The cohort will added to and followed to look at longer term outcomes.

Background and Aims Frailty and comorbidity have been shown to predict mortality in end stage renal failure patients. This knowledge can help inform patients and clinicians when undertaking the joint decision-making process regarding the management of advanced renal disease. This project sets out to record the serial and net frailty scores of patients with stage 4 and 5 kidney disease and study the change of frailty score in association with mortality and patient’s preferred modality of renal replacement therapy (RRT). Method All patients followed up in Low Clearance Clinic with eGFR Results 125 patients with CKD stage 4 and 5 had a baseline CFS in April 2018. 54.4% were female and median age was 66 years old. 40.8% patients had a diagnosis of diabetes. Table 1 shows the demographics for patients with baseline CFS 1-3 (not frail), 4-5 (mild frailty) and 6-9 (moderate – severe frailty) respectively. RRT was planned for 82.8% of patients with CFS1-3 (63.3% HD, 36.7 PD), 52.1% of patients with CFS 4-5 (96.0% HD, 4.0% PD) and 36.8% patients with CFS 6-9 (100% HD, 0% PD). 29.2% of patients with CFS 4-5 and 47.4% of patients with CFS 6-9 were for conservative care. 1-year mortality for patients with CFS 1-3, 4-5 and 6-9 was 1.7%, 18.8% and 26.3% respectively. A total of 362 CFS were recorded over the 12-month period (125 at month 0, 88 at month 4, 80 at month 8 and 69 at month 12). 49 changes in CFS were noted in 37 patients. 34 patients had a net deterioration of CFS by the end of month 12. Figure 1 shows the changes in patients’ CFS at 4-monthly interval and the net changes by the end of 12-month follow up. Four patients changed their RRT planning from dialysis to conservative care and they all had a deterioration of CFS. Comparing the patients with deterioration of CFS against those without, they had similar number of hospital admissions and clinic appointments and appear to have no association with having the diagnosis of diabetes. However, patients with deterioration of CFS had higher rate of death (14.3% vs 4.7%) and higher likelihood to change their preferred modality of RRT (8.6% vs 4.7%). Conclusion Frailty is common among patients with advanced CKD and is associated with significant mortality rate. Serial assessment of frailty score is helpful in monitoring patients’ physical and functional status. Consistently high or deteriorating frailty score may correlate with higher mortality and this should trigger a review of their suitability for RRT, and consideration of anticipatory care planning.

Summary Background: The reduction in the length of hospital stay for surgical patients at a time of expanding medical student numbers has created challenges in the provision of adequate exposure to surgical patients. This has required the use of surgical learning opportunities in the ambulatory setting, including the preoperative assessment clinic. At Keele University, fourth-year medical students follow patient journeys through the preoperative assessment process, gaining experience of history taking, examination, prescribing and practical skills. This is followed by group discussion with a clinical teaching fellow, focusing on management and clinical reasoning. We audited the experience our students gained in the preoperative assessment clinic against the relevant Tomorrow’s Doctors outcomes. Methods: An audit tool was created by reviewing the patient journey to identify potential learning opportunities. These were then mapped to the relevant Tomorrow’s Doctors outcomes. Audit pro formas were completed for each student at the end of the clinic by the clinical educator, with a total of 42 sessions audited. Results: Our findings show that it is possible for students to gain experience in all nine of the identified Tomorrow’s Doctors outcomes in the preoperative assessment clinic. Practical procedure experience was gained by 92 per cent of students, and 70 per cent demonstrated clinical judgment and decision skills. Discussion: This study shows that students can gain experience in multiple Tomorrow’s Doctors outcomes in the preoperative assessment clinic. In particular, it is a useful environment to learn and teach practical procedures, clinical reasoning and decision-making skills.