Claire Gardiner

BACKGROUND: Dietitian-led coeliac clinics have the potential to be a cost-effective way of monitoring patients living with coeliac disease (CD). The aim of this service evaluation was to explore the impact of a dietitian-led coeliac clinic on gluten-free diet (GFD) adherence and the frequency of endoscopies with repeat duodenal biopsies. METHODS: Adults with biopsy-proven CD were transferred to a new dietitian-led coeliac clinic where data were collected from medical records and analysed using SPSS. GFD adherence was assessed by a specialist dietitian, specialist nurse, consultant gastroenterologists and a validated GFD adherence questionnaire. Repeat duodenal biopsy findings were compared with the most recent dietitian GFD adherence assessment. Project and ethics approval was granted by the hospital trust and affiliated university. RESULTS: Data from 170 patients (White: 51%, South Asian: 45%) are presented, with most being 35-64 years old (61%). Specialist dietitian assessments identified 67 (39%) of patients were adhering to the GFD, whereas prior gastroenterologist or coeliac nurse assessments identified 122 (72%) (p < 0.001) and the validated GFD adherence questionnaire identified 97 (57%) (p < 0.001). Dietitian assessments identified involuntary gluten consumption in 39/104 (38%) of those who self-reported GFD adherence, consequently avoiding the need for nine endoscopies with repeat duodenal biopsies once patients had received dietary education from the dietitian. On follow-up, within the dietitian-led coeliac clinic, significantly fewer patients consumed gluten involuntarily (14%, p < 0.001). In addition, a reduction in voluntary gluten consumption was observed from three to five to one to two times per month (p < 0.001) in 66 patients. CONCLUSIONS: The dietitian-led coeliac clinic helped to identify involuntary gluten ingestion, avoid repeat endoscopies with duodenal biopsies and was associated with significantly improved GFD adherence.

Malnutrition is common in haemodialysis (HD) and is linked to poor outcomes. This study aimed to describe changes in body composition after the initiation of HD and investigate whether any routinely collected parameters were associated with these changes. The study cohort came from the HD population of a single centre between 2009 and 2014. Body composition measurements were obtained from a database of bioimpedance results using the Body Composition Monitor (BCM), while demographics and laboratory values came from the renal unit database. Primary outcomes were changes in normohydration weight, lean tissue mass and adipose tissue mass over the two years after HD initiation. A total of 299 patients were included in the primary analyses, showing an increase in adipose tissue, loss of lean tissue and no significant change in normohydration weight. None of the routinely collected parameters were associated with the lean tissue changes. Loss of lean tissue over the first year of dialysis was associated with increased mortality. The results showing loss of lean tissue that is not limited to those traditionally assumed to be at high risk supports interventions to maintain or improve lean tissue as soon as possible after the initiation of HD. It highlights the importance of monitoring nutrition and the potential for routine use of bioimpedance.

This guideline is written primarily for doctors and nurses working in dialysis units and related areas of medicine in the UK, and is an update of a previous version written in 2009. It aims to provide guidance on how to look after patients and how to run dialysis units, and provides standards which units should in general aim to achieve. We would not advise patients to interpret the guideline as a rulebook, but perhaps to answer the question: “what does good quality haemodialysis look like?” The guideline is split into sections: each begins with a few statements which are graded by strength (1 is a firm recommendation, 2 is more like a sensible suggestion), and the type of research available to back up the statement, ranging from A (good quality trials so we are pretty sure this is right) to D (more like the opinion of experts than known for sure). After the statements there is a short summary explaining why we think this, often including a discussion of some of the most helpful research. There is then a list of the most important medical articles so that you can read further if you want to – most of this is freely available online, at least in summary form. A few notes on the individual sections: 1. This section is about how much dialysis a patient should have. The effectiveness of dialysis varies between patients because of differences in body size and age etc., so different people need different amounts, and this section gives guidance on what defines “enough” dialysis and how to make sure each person is getting that. Quite a bit of this section is very technical, for example, the term “eKt/V” is often used: this is a calculation based on blood tests before and after dialysis, which measures the effectiveness of a single dialysis session in a particular patient. 2. This section deals with “non-standard” dialysis, which basically means anything other than 3 times per week. For example, a few people need 4 or more sessions per week to keep healthy, and some people are fine with only 2 sessions per week – this is usually people who are older, or those who have only just started dialysis. Special considerations for children and pregnant patients are also covered here. 3. This section deals with membranes (the type of “filter” used in the dialysis machine) and “HDF” (haemodiafiltration) which is a more complex kind of dialysis which some doctors think is better. Studies are still being done, but at the moment we think it’s as good as but not better than regular dialysis. 4. This section deals with fluid removal during dialysis sessions: how to remove enough fluid without causing cramps and low blood pressure. Amongst other recommendations we advise close collaboration with patients over this. 5. This section deals with dialysate, which is the fluid used to “pull” toxins out of the blood (it is sometimes called the “bath”). The level of things like potassium in the dialysate is important, otherwise too much or too little may be removed. There is a section on dialysate buffer (bicarbonate) and also a section on phosphate, which occasionally needs to be added into the dialysate. 6. This section is about anticoagulation (blood thinning) which is needed to stop the circuit from clotting, but sometimes causes side effects. 7. This section is about certain safety aspects of dialysis, not seeking to replace well-established local protocols, but focussing on just a few where we thought some national-level guidance would be useful. 8. This section draws together a few aspects of dialysis which don’t easily fit elsewhere, and which impact on how dialysis feels to patients, rather than the medical outcome, though of course these are linked. This is where home haemodialysis and exercise are covered. There is an appendix at the end which covers a few aspects in more detail, especially the mathematical ideas. Several aspects of dialysis are not included in this guideline since they are covered elsewhere, often because they are aspects which affect non-dialysis patients too. This includes: anaemia, calcium and bone health, high blood pressure, nutrition, infection control, vascular access, transplant planning, and when dialysis should be started.

BACKGROUND: Decisions around planned ultrafiltration volumes are the only part of the haemodialysis prescription decided upon at every session. Removing too much fluid or too little is associated with both acute symptoms and long-term outcomes. The degree to which patients engage with or influence decision-making is not clear. We explored patient perspectives of prescribing ultrafiltration volumes, their understanding of the process and engagement with it. METHODS: A questionnaire developed for this study was administered to 1077 patients across 10 UK Renal Units. Factor analysis reduced the dataset into factors representing common themes. Relationships between survey results and factors were investigated using regression models. ANCOVA was used to explore differences between Renal Units. RESULTS: Patients generally felt in control of their fluid management and that they were given the final say on planned ultrafiltration volumes. Around half of the respondents reported they take an active role in their treatment. However, respondents were largely unable to relate signs and symptoms to fluid management practice and a third said they would not report common signs and symptoms to clinicians. A fifth of patients reported not to know how ultrafiltration volumes were calculated. Patients responded positively to questions relating to healthcare staff, though with significant variation between units, highlighting differences in perception of care. CONCLUSIONS: Despite a lack of formal acknowledgement in fluid management protocols, patients have significant involvement in decisions regarding fluid removal during dialysis. Furthermore, substantial gaps remain in patient knowledge and engagement. Formalizing the role of patients in these decisions, including patient education, may improve prescription and achievement of target weights.

Providing cost- and clinically-effective services is essential in today's NHS, but it can be difficult to capture this data in day to day practice. The identification and development of outcome measures for dietetics is an ongoing challenge. This article describes how the Renal Nutrition Group of the British Dietetic Association developed three renal-specific Dietetic Outcome Models and a Renal Dietetic Outcome Tool (RDOT) to measure dietetic outcomes in potassium and phosphate management and oral nutrition support in patients with chronic kidney disease for use in daily clinical practice

eduational article discussing the management of phopshate in chronic kidney disease

Our haemodialysis service comprises two teaching hospital-based centres and six satellite units, which merged some years ago. The teaching hospitals were traditionally managed by separate groups of dietitians and dialysis staff. Consequently, there were differences in practice within the service, including the methods used to determine an acceptable interdialytic weight gain (IDWG). High IDWG is regarded as a negative factor due to associated intradialytic hypotension, interdialytic hypertension and cardiovascular disease.1 As such, patients with excessive IDWG are frequently advised to limit their daily fluid intake and may be encouraged to reduce their salt intake because of the association between salt intake and thirst.2 Different members of the multidisciplinary team (MDT) act as advisors in this area. This may lead to confusion and non-compliance if the information is conflicting or provided in a negative manner.3 We undertook an audit throughout the haemodialysis service to standardise the advice given to patients. This article reports the results of a questionnaire used to determine how staff respond to excessive IDWG. It also examined their knowledge of the salt and fluid content of common foods.

The kidneys play a vital role in maintaining normal tissue hydration and serum sodium level. In haemodialysis patients, with impaired or absent kidney function, fluid status is managed by removing excess fluid using ultrafiltration and by restricting dietary sodium intake. Ideally, haemodialysis patients should remain close to normal hydration throughout the interdialytic period, with minimal periods of excessive dehydration or fluid overload and with no fluid–related co-morbidity. Optimal fluid management is achieved by adjusting the post-dialysis ‘target’ weight and, where necessary, limiting the fluid gained between dialysis sessions. While clinical history and examination remain the basis for prescribing the target weight, technology can provide useful objective information especially where the clinical indications are ambiguous. A simple non-invasive test can now be carried out when a patient attends for dialysis enabling staff to pick up changes in body composition so that their target weight can be adjusted to maintain optimal fluid status. In most patients, interdialytic fluid gain (IDFG) is directly related to sodium intake. Acceptable fluid gains can usually be achieved by limiting salt intake to the recommended daily allowance for the general population and avoiding unnecessary sodium loading during dialysis. Low pre-dialysis serum sodium levels can help identify patients with other causes of high IDFG, such as high blood sugar or social drinking, who need additional counselling. For the patients, lowering sodium intake may also improve blood pressure control and reduce requirements for antihypertensive medication. Staff education, and preferably participation, is vital when implementing salt restriction in a haemodialysis unit.

Educational article discussing the dietary management of hyperphosphotaemia in chronic kidney disease patients

ABSTRACT

Background Posttransplant diabetes mellitus (PTDM) is associated with reduced patient survival and death-censored graft survival and has been linked to steroid use and obesity. Steroid avoidance regimens have been associated with a reduction in PTDM without impacting patient or graft survival followed up for 5 years following kidney transplantation; however, acute rejection remains a concern. The primary objective of this study was to assess death-censored graft and patient survival outcomes and report on PTDM onset in patients receiving steroid-avoidance immunosuppressant regimens over 11 years. Methods This was a retrospective cohort study from a single center in the UK that included first kidney transplants between 2010 and 2021. Logistic regression models and Cox proportional hazards models were used to investigate associations between survival and PTDM. A P value < 0.05 was considered to indicate statistical significance. Results There was no difference in patient or graft survival among those with PTDM, preexisting diabetes or no diabetes. 16% (n = 55) developed PTDM over a median follow-up of 7.1 years (range: 0.9–13.8 years). After adjusting for confounding factors, the odds of PTDM diagnosis were associated with increasing BMI (odds ratio (OR): 1.01; 95% CI: 1.03–1.18), and white ethnicity was associated with reduced odds of PTDM (OR: 0.45; 95% CI: 0.23–0.90). Conclusions Our findings support lower PTDM rates and safe longer-term outcomes following a steroid-free regimen. Timely weight management interventions before transplantation, particularly in high-risk groups, may reduce PTDM in this population. Clinical trial number Not applicable.