ABSTRACT
Introduction: Early detection and management of community acquired Acute Kidney Injury (AKI) can reduce associated morbidity and mortality particularly in low and low middle-income countries where infrastructure for laboratory tests is limited and renal replacement therapy is largely unavailable. We have established a collaborative project between the Renal Unit of the University of Port Harcourt Teaching Hospital and the Renal Department of Salford Royal NHS Foundation Trust, supported by the International Society of Nephrology aiming at investigating the use of point of care (POC) Creatinine (Cr) for early identification and management of community acquired AKI. The first part of the study evaluated the accuracy of POC Cr technology by comparison with the central laboratory standard Cr assay used at the University of Port Harcourt Teaching Hospital and showed good overall correlation with mean bias of 27.2 umol/L concluding that POC Cr > 150 umol/L reflects AKI in the absence of known chronic kidney disease (CKD). Here we present the second part of the study investigating the use of POC Cr in the Emergency Department (ED) and the third part, that was formulated with the emergence of the COVID-19 pandemic, assessing the POC Cr technology in the COVID-19 isolation centres. Methods: The second part of this study was conducted at the ED of University of Port Harcourt Teaching Hospital (UPTH) between January and December 2020. Adult patients were screened by Nephrology residents with POC Cr using a capillary sample (fingerstick) with the NOVA Stasensor Xpress Cr analyser if there was clinical suspicion of community acquired AKI. The third part of this study was that of the use of POC Cr as screening tool to evaluate AKI in COVID-19 patients at 2 COVID-19 isolation centres in Rivers state. Data were extracted from the case notes of the patients and a proforma designed for the study. Results: In the second stage, between January and December 2020, 53 patients aged 48±19 with clinical suspicion of community acquired AKI were screened with POC Cr in the ED;45.3% were females, 5.7% had known chronic kidney disease and 75.5% had suspected infection and/or hypovolaemia. 21 out of 53 patients (39.6%) had POC Cr > 150 umol/L and 18 out 50 (36%) were attributed to AKI. In the third stage, 69 patients aged 38±14 diagnosed with COVID-19 were screened irrespective of symptoms. 21.7% were females and 1.4% had known CKD. 8 out of 61 (11.6%) had POC Cr > 150 umol/L attributed to AKI. COVID-19 associated AKI was associated with older age, higher respiratory rate, lower oxygen saturations and higher systolic blood pressure (55±11 vs 35±12 p <.001, 26±7 vs 21±2 p <.001, 88%±7 vs 97±3 p <.001 and 141±12 vs 124±15 p 0.002 respectively). Conclusions: POC Cr technology detected AKI in one third of patients with high-risk clinical presentation and can be a valuable and possibly cost-effective tool to assist clinical decision making regarding early interventions and triage decisions in the ED and in the community setting. In patients diagnosed with COVID-19, AKI was present in 1 out of 10 of patients irrespective of symptoms and was associated with clinical observations indicating disease severity. Conflict of interest Potential conflict of interest: I declare that the point of care creatinine device was provided by Nova in support of early detection and management of AKI.
ABSTRACT
Introduction: The ISN Sisters Renal Centre collaboration between University of Port Harcourt Teaching Hospital, Nigeria and Salford Royal NHS FT aims to establish PD in Port Harcourt CKD is a significant health issue in Nigeria. Treatment of ESRD is beyond the financial means of most people, exacerbating health inequalities. Intermittent HD with temporary central vascular access is the norm. Problems are exacerbated by technical issues with dialysis machines and water treatment PD offers more affordable life sustaining treatment, less dependence on technical infrastructure and multiple venous punctures for access Methods: Previous collaboration has included videoconferencing, visits to the UK by a Nigerian physician and clinical and academic links Visiting clinicians from the UK 2019 participated in a project of point of care testing of creatinine in acute kidney injury with a multidisciplinary workshop, designing the algorithm for the subsequent testing. Didactic and practical skills training for HD and PD access. Long term tunnelled HD access was established for the first time locally The major objective of establishing PD was not possible–no fluid available in the country and international commercial suppliers without reliable supply chain Coinciding with the Covid pandemic a commercial suppler began producing PD fluid in Nigeria Despite enthusiasm for hands on collaboration further visits to establish physician inserted PD catheter access were cancelled An alternative programme of collaboration at distance was established Results: Regular monthly planning Zoom meetings maintained contact between clinicians Recognising that PD is nurse delivered and will not be successful without MDT working, alliances were formed by the respective nursing teams Zoom teaching helped established working relationships with the anticipation of offering real time support and troubleshooting once PD is established The nursing team in Salford produced video teaching of PD exchanges to produce a teaching aid available on the group YouTube channel Relatively low-tech use of available equipment, including a head mount for mobile phones to allow operator eye view of procedures via the phone camera have helped with real time teaching of dialysis access and point of care ultrasound for junior and senior clinicians The proposed commencement of PD recognises local issues: housing, water supply and sanitation pose major difficulties in the standard model of patient delivered home PD The new commercially available PD fluid is potentially more affordable than intermittent HD, but not if utilised in traditional standard pattern of 4 CAPD exchanges daily. Local practice in the UK unit has changed in keeping with recent ISPD guidelines towards incremental, patient specific dialysis prescription. The new PD project in Port Harcourt is being designed around patient reported outcomes and technique tolerability in keeping with modern best practice Conclusions: The huge challenge of the covid pandemic for practising clinicians maintaining collaboration needs to be recognised. Continued enthusiasm across the MDT and innovative ways of delivering training means this ISN project is well placed to deliver major improvements in care in Nigeria with a high quality patient centred PD programme The hope is to narrow the huge health inequalities which have been exacerbated by the Covid pandemic No conflict of interest
ABSTRACT
Introduction: Under the auspices of the International Society of Nephrology Sisters Renal Centres programme, Renal centres from Port Harcourt, Nigeria and Salford UK have maintained collaboration in various aspects of kidney care. A key issue in sustaining dialysis care in a lower middle income economy is access for haemodialysis (HD). Before this project all HD access was via temporary femoral vein lines inserted for a single dialysis session. Methods: Pre-visit video conferencing provided educational and planning opportunities in the delivery of peritoneal dialysis for acute kidney injury (AKI). A Nigerian kidney doctor in training visited the UK centre to gain first-hand experience of line insertion techniques. An initial visit to the sister hospital was undertaken by UK nephrologists with special interests in dialysis and interventional nephrology. A pop-up dialysis access workshop was undertaken in the dialysis unit over 3 days for junior and senior doctors and members of the multi-disciplinary team: Didactic teaching on dialysis access methods Small group teaching on the basics of HD, PD and prescriptions Simple and sustainable training tools for basic surgical procedures, HD and PD catheter insertion and Seldinger technique Dialysis access ultrasound training with volunteers examining abdominal anatomy and vascular access imaging Hands on training with simple access phantoms, made from accessible materials for ongoing practice. Results: Tunnelled haemodialysis line insertion was achieved by local and visiting nephrologists, unique to the dialysis centre which normally relies on temporary femoral venous access. All three patients achieved successful permanent venous line access without complication. The local nephrologist was able to place catheters with the visiting interventional nephrologist closely supervising. The procedures were recorded to allow analysis and reflection on the procedures. Since the 4 lines have been successfully inserted by the local nephrologist. This has been supported with ongoing video and telephone links. This has allowed continued updates on technique, difficulties and complications. One episode of local exit site bleeding was encountered and managed with follow up calls and advice. Covid 19 has precluded the planned follow up visits. This has highlighted the issues of keeping colleagues up to date and maintaining skills when practice is significantly altered. The collaboration is investing in more robust internet communication to facilitate teaching and mentorship while planning the next part of the project to establish a peritoneal dialysis programme. Conclusions: Significant gains have been made on our journey to establishing long term HD vascular access for the dialysis patients in Port Harcourt Teaching Hospital, despite the major obstacles faced. The global pandemic has disrupted services and more direct collaboration but illustrated how long-distance support can be developed and improved to maintain progress in the ISN Sister Renal Centre Programme. No conflict of interest