Lateral percutaneous nephrolithotomy: A safe and effective surgical approach

Indian Journal of Urology (INDIAN J UROL), Jan-Mar 2018; 34(1): 45-50

Percutaneous nephrolithotomy (PCNL) is traditionally performed with the patient in the prone position for large renal calculi. However, anesthetic limitations exist with the prone position. Similarly, the supine position is associated with poorer ergonomics due to the awkward downward position of the renal tract, a smaller window for percutaneous puncture, and a higher risk of anterior calyx puncture. This study aimed to demonstrate the feasibility and safety of lateral-PCNL in managing large renal calculi without the disadvantages of prone and supine positions.
UHCW Research: Jonathan Jian Wei Gan

New deal will give people with kidney cancer another treatment option

People with advanced kidney cancer are set to benefit from a new treatment, after NICE has said lenvatinib should be available on the NHS.

NICE recommends lenvatinib, also known as kisplyx, be given in conjunction with another drug called everolimus.

This drug-duo is recommended as an option for people who have previously been treated for advanced renal cell carcinoma (RCC).

Kidney retransplantation from HLA incompatible living donors: a single centre study of 3rd /4th transplants

Clin Transplant. 2017 Sep 4. doi: 10.1111/ctr.13104. [Epub ahead of print]

The demand for kidney retransplantation following graft failure is rising. Repeat transplantation is often associated with poorer outcomes due to both immunological and surgical challenges. The aim of this study was to compare surgical and functional outcomes of kidney retransplantation in recipients that had previously had at least 2 kidney transplants with a focus on those with antibody incompatibility.

UHCW Research: Barnes, J. C. H., Lam, F. T., Kashi, S. H., Tan L. C., Higgins, R. amd Imray C. H. E.

A qualitative examination of patients experiences of dietitians ' consultation engagement styles within nephrology

J Hum Nutr Diet. 00, 00–00 https://doi.org/10.1111/jhn.12504

Dietitians provide individuals with tailored, practical nutritional advice. For this reason, skills in effective interpersonal communication are essential. In the case of chronic kidney disease, the specifics of dietary advice may change according to renal function. The conveyance of accurate dietary advice and compliance is critical and requires full engagement with the service. The effect of communication styles on patients ' engagement experiences with renal dietetics is unknown. Accordingly, the present study aimed to explore patients ' engagement experiences with renal dietitians.

UHCW Research: Andrew Morris

Cabozantinib for previously treated advanced renal cell carcinoma - guidance (TA463)

New technology appraisal guidance on cabozantinib (Cabometyx) for previously treated advance renal cell carcinoma (kidney cancer) in adults.

Cabozantinib is recommended, within its marketing authorisation, as an option for treating advanced renal cell carcinoma in adults after vascular endothelial growth factor (VEGF)-targeted therapy, only if the company provides cabozantinib with the discount agreed in the patient access scheme.

Chronic kidney disease in adults

New Quality Standard from NICE:

Healthcare professionals should offer statins to millions of people with chronic kidney disease (CKD). This will help to manage their increased risk of cardiovascular disease (CVD), says NICE.

The new NICE standard lists Atorvastatin as the preferred statin to offer patients because it is both clinically and cost effective.

The UK National Registry of ABO and HLA Antibody Incompatible Renal Transplantation: Pretransplant Factors Associated With Outcome in 879 Transplants

Transplant Direct. 2017 Jun 26;3(7):e181. doi: 10.1097/TXD.0000000000000695. eCollection 2017 Jul.

ABO and HLA antibody incompatible (HLAi) renal transplants (AIT) now comprise around 10% of living donor kidney transplants. However, the relationship between pretransplant factors and medium-term outcomes are not fully understood, especially in relation to factors that may vary between centers.

Results of AIT were acceptable, certainly in the context of a choice between living donor AIT and an antibody compatible deceased donor transplant. Several factors were associated with increased chance of transplant loss, and these can lead to testable hypotheses for further improving therapy.

UHCW Research: Fuggle SV and Higgins RM

A new treatment option for people with kidney cancer

People with advanced kidney cancer are set to benefit from a new treatment, after NICE has said cabozantinib should be available on the NHS.  It recommends cabozantinib as an option for people with advanced renal cell carcinoma (RCC).

Catheter-free nephrectomy: A safe change to routine practice

Journal of Clinical Urology.  First Published May 26, 2017 

The aim of this article is to assess any difference in length of stay (LOS), complications and readmission rates between patients who had catheter-free nephrectomy compared to those who had a catheter inserted as routine peri-operatively.

UHCW Research: E. F. Zimmermann.

Patients with rare conditions to benefit from new treatments

NHS England hasconfirmed that three new specialised treatments will be made available for patients in England.

• Second allogeneic haematopoietic stem cell transplants – estimated to cover around 15 patients a year who suffer a relapse following a first transplant.
• Eculizumab for the treatment of the kidney condition C3 glomerulopathy – which includes C3 glomerulonephritis and dense deposit disease – estimated to benefit up to 5 patients a year who suffer a relapse following a kidney transplant.
• Riociguat for pulmonary arterial hypertension – estimated to benefit around 90-125 patients a year for whom other treatments have failed, subject to confirmation of a commercially in confidence discounted price offered by the manufacturer.

Decision tree and random forest models for outcome prediction in antibody incompatible kidney transplantation

Biomedical Signal Processing and Control Available online 9 February 2017

Clinical datasets are commonly limited in size, thus restraining applications of Machine Learning (ML) techniques for predictive modelling in clinical research and organ transplantation. We explored the potential of Decision Tree (DT) and Random Forest (RF) classification models, in the context of small dataset of 80 samples, for outcome prediction in high-risk kidney transplantation. The DT and RF models identified the key risk factors associated with acute rejection: the levels of the donor specific IgG antibodies, the levels of IgG4 subclass and the number of human leucocyte antigen mismatches between the donor and recipient. Furthermore, the DT model determined dangerous levels of donor-specific IgG subclass antibodies, thus demonstrating the potential of discovering new properties in the data when traditional statistical tools are unable to capture them. The DT and RF classifiers developed in this work predicted early transplant rejection with accuracy of 85%, thus offering an accurate decision support tool for doctors tasked with predicting outcomes of kidney transplantation in advance of the clinical intervention.

UHCW Research: Robert Higgins and Sunil Daga

A new data-driven model for post-transplant antibody dynamics in high risk kidney transplantation

Mathematical biosciences, 284 pp. 3-11. http://dx.doi.org/10.1016/j.mbs.2016.04.008

The dynamics of donor specific human leukocyte antigen antibodies during early stage after kidney transplantation are of great clinical interest as these antibodies are considered to be associated with short and long term clinical outcomes. The limited number of antibody time series and their diverse patterns have made the task of modelling difficult. Focusing on one typical post-transplant dynamic pattern with rapid falls and stable settling levels, a novel data-driven model has been developed for the first time. A variational Bayesian inference method has been applied to select the best model and learn its parameters for 39 time series from two groups of graft recipients, i.e. patients with and without acute antibody-mediated rejection (AMR) episodes. Linear and nonlinear dynamic models of different order were attempted to fit the time series, and the third order linear model provided the best description of the common features in both groups. Both deterministic and stochastic parameters are found to be significantly different in the AMR and no-AMR groups showing that the time series in the AMR group have significantly higher frequency of oscillations and faster dissipation rates. This research may potentially lead to better understanding of the immunological mechanisms involved in kidney transplantation.

UHCW Research: Krishnan, Nithya and Higgins, Robert

National Chronic Kidney Disease Audit

This report details the findings of the audit programme, which compared GP practice performance against NICE quality standards

It asked: 

1. Are people with risk factors being tested for CKD? 
2. Are people with CKD being correctly identified and given an appropriate CKD Read code? 
3. For people with CKD: 

• Are blood pressure targets being met?
• Is appropriate CVD risk management being initiated?
• Are annual CKD reviews being performed?
• Are appropriate immunisations being given?

Summary
National Report (Part 1)
Infographics

NICE approves kidney cancer drug for NHS use

Patients with advanced kidney cancer will have routine NHS access to the drug everolimus following recommendations by NICE, rather than apply to the Cancer Drugs Fund (CDF).

NHS machines: the utilisation of high-value capital equipment at NHS trusts

The note from the Taxpayers' Alliance looks at the utilisation of five different types of machines in NHS trusts in England. It feels that when it comes to the utilisation of expensive machines, many NHS trusts are not sweating their assets. If NHS Trusts are to achieve genuine efficiency, the management of machines must be improved as part of a greater efficiency drive:

• Computerised Tomography (CT) scanners which provide a detailed view of different tissue types not available with traditional x-rays.
• Magnetic Resonance Imaging (MRI) which are is a safe means of producing detailed internal scans useful in diagnosis and treatment. 
• Linear accelerators (LINACs) which play a critical role in cancer care
• Lithotripters which use ultrasound shock waves to break up kidney stones. 
• Positron Emission Tomography (PET) scanners which are useful in effectively diagnosing and treating cancer.

Chronic kidney disease: network meta-analysis compares the effectiveness of calcium-based and non-calcium-based phosphate binders

New Medicines Evidence Commentary from NICE:

A network meta-analysis that included 28 studies (n=8,335) found that calcium-basedphosphate binders increased mortality compared with sevelamer, with an absolute mortality increase of 43 per 1,000 people treated. This network meta-analysis did not consider the cost effectiveness and relative safety of the different phosphate binders and there were some limitations. It is difficult to say whether the difference in mortality is related to harmful effects of calcium-based binders or beneficial effects of sevelamer. The NICE guideline on hyperphosphataemia in chronic kidney disease recommends calcium acetate as the first-line phosphate binder in adults with stage 4 or 5 CKD, with calcium carbonate an option for people who find calcium acetate unpalatable or intolerable. Non-calcium-based phosphate binders are recommended in certain circumstances, for example if hypercalcaemia develops.

Uncertainty over the use of stents after telescopic surgery for kidney stones

Inserting a stent, a narrow tube, after ureteroscopic surgery for removal of kidney stones reduces unplanned hospital readmissions but causes more pain upon urination.

This review compared outcomes for patients having ureteroscopic surgery for stones who had a stent placed in the ureter (the tube connecting the kidney with the bladder) with patients who had the stent left out. There was significant variability in the results of the individual studies, and it is possible that clinical judgment was influencing the decision of whether or not to place a stent.
From the NIHR Dissemination Centre

Minimal change disease and focal segmental glomerulosclerosis in adults: rituximab

New NICE Evidence Summary:

Minimal change disease (MCD) and focal segmental glomerulosclerosis (FSGS) are types of glomerulonephritis. MCD is an immune-mediated condition affecting the kidneys, FSGS is not a specific disease entity but a histological lesion, often of unknown aetiology, which is characterised by segmental areas of glomerular sclerosis. 

Most of the evidence for using rituximab in adults with MCD and FSGS comes from uncontrolled and non‑randomised observational studies performed outside the UK with small sample sizes. The populations in the included studies varied, as did the dose of rituximab used, adjuvant treatment, and follow-up time. The studies in people with MCD and FSGS in their native kidneys reported that treatment with rituximab reduced disease relapse rates, or achieved complete or partial remission. The study in renal transplant recipients with MCD and FSGS did not report any significant difference in treatment outcomes for those treated with rituximab compared to those receiving other immunosuppressants. However, the limitations outlined above make it difficult to draw firm conclusions on the efficacy and safety of rituximab for treating adults with MCD or FSGS.

Safety and Efficacy of Pazopanib Therapy Prior to Planned Nephrectomy in Metastatic Clear Cell Renal Cancer

JAMA Oncology 2(10) 2016, pp. 303-1309. http://dx.doi.org/10.1001/jamaoncol.2016.1197


The role of cytoreductive nephrectomy in patients with metastatic renal cancer in the era of targeted therapy is uncertain. To establish the safety and efficacy of upfront pazopanib therapy prior to cytoreductive nephrectomy in previously untreated patients with metastatic clear cell renal cancer. Single-arm phase 2 study of 104 previously untreated patients with metastatic clear cell renal cancer recruited between June 2008 and October 2012 at cancer treatment centers with access to nephrectomy services.


UHCW Research: A. Stockdale

New treatment recommended for kidney cancer

NICE recommends nivolumab for people with advanced renal cell cancer (RCC) – a type of kidney cancer.

Nivolumab is a form of immunotherapy, a treatment that has been hailed as a an innovative way to battle cancer – it works by harnessing the power of the patient’s own immune system to destroy their cancer cells