The gap between guidelines and practice regarding care for myocardial infarction is greater amongst individuals with chronic kidney disease than those without. Identifying why variation exists enables determination of its clinical significance and facilitates the development of effective interventions to reduce disparities in care, where appropriate. The aim of this study was to understand the process of treatment decision-making for myocardial infarction amongst patients with kidney disease and their clinicians. Semi-structured qualitative interviews were conducted with patients and clinicians from four National Health Service hospital centers in the United Kingdom from February 2022 to July 2024. All centers offered cardiology and acute medical services; some offered nephrology in addition. Participants were purposively sampled, aiming for diversity in gender, ethnicity, specialty (clinicians only) and/or use of kidney replacement therapy (patient participants). Clinicians were senior doctors-in-training or consultants in cardiology, nephrology, acute or emergency care or cardiac surgery. Patient participants had chronic kidney disease, defined as an estimated glomerular filtration rate of less than 60 ml/min/1.73 m2, or receipt of kidney replacement therapy, in addition to a recent hospital admission for myocardial infarction. Braun and Clarke's reflexive thematic analysis was used to analyze interview data and generate themes associated with myocardial infarction treatment decision-making for, and by, patients with chronic kidney disease. Participants included 32 clinicians (12 cardiologists, 9 nephrologists, 8 acute and emergency clinicians and 3 cardiac surgeons) and 14 patients with chronic kidney disease. Seven main themes were identified:(1) Limited patient involvement in treatment decisions, (2) Inter-clinician communication supports high-risk decision-making, (3) Variation in use of written guides to decision-making, (4) The safety net of associated health services support intervention, (5) The value assigned to experience over evidence, (6) Individual perception of risk and benefit, (7) Harm from action perceived as worse than inaction. Despite holding strong health preferences, patients had minimal involvement in inpatient treatment decisions regarding myocardial infarction. Clinicians’ decision-making was driven by the fear of causing harm by active intervention. Fear and self-blame for negative outcomes were some of the most influential factors biasing clinicians towards making conservative treatment decisions for patients with chronic kidney disease (Figs 1 and 2a). This was despite evidence and guidelines recommending more aggressive treatment. Collaborative decision-making between trusted colleagues and the existence of a clinical safety-net for managing treatment complications were however reported by clinicians to counter this bias and enable them to make what they perceived to be appropriately aggressive treatment decisions (Fig. 2b). Interventions to foster teamworking between specialists and ensure adequately resourced clinical service safety-nets may improve access to perceived “higher-risk” treatments for myocardial infarction amongst people with chronic kidney disease. Intervention development and evaluation should follow to determine if quality of care and outcomes for people with chronic kidney disease and myocardial infarction can be improved by these means.

Objectives To understand why patients with chronic kidney disease (CKD) may not be treated according to international guidelines for myocardial infarction (MI).Design Multicentre qualitative interview study. Interviews were analysed using reflexive thematic analysis approach as outlined by Braun and Clarke to generate themes associated with MI treatment decision-making for, and by, patients with CKD.Setting Four National Health Service hospital centres in the UK (February 2022 to July 2024).Participants A purposive sample of 46 participants (patients and clinicians). Clinicians (n=32) were senior doctors-in-training or consultants in cardiology, nephrology, acute or emergency care or cardiac surgery. Patient participants (n=14) had CKD, defined as an estimated glomerular filtration rate <60 mL/min/1.73 m2, or receipt of kidney replacement therapy (KRT).Results Despite expressing strong views regarding their health priorities, patients reported minimal involvement in treatment decision-making. Decision-making by clinicians was driven by the desire to avoid causing harm to patients by ‘active’ treatment initiation. In general, despite the concept of evidence-based medicine being widely accepted, there remained scepticism of guidelines or epidemiological data, especially in the light of personal adverse experiences or anecdotes. Clinicians described how, in the absence of collaborative decision-making and a clinical safety-net for managing treatment complications, they tended to make conservative treatment decisions for patients with CKD.Conclusion Interventions to foster teamworking between specialists and ensure adequately resourced specialist clinical service safety-nets may improve access to treatments for MI for people with CKD. Intervention development and evaluation should follow to determine if outcomes for people with CKD and MI can be improved.

Background: People with chronic kidney disease (CKD) have significantly higher morbidity and mortality following myocardial infarction (MI) than the general population. Despite this, they are less likely to receive invasive management and guideline-directed medications than those without kidney disease. It is unclear why this treatment variation exists and whether or not it reflects equal and appropriate access to care for the high-risk CKD population. Aims: The aims are to (1) understand how management decisions following an MI are made for, and with, people with CKD, and (2) describe the experiences of people with CKD who have recently received MI care in England. Method: We will recruit 15–20 patients with CKD and previous MI, and 15–20 clinical staff who are involved in treatment decision-making, from 3–5 NHS hospital trusts in the UK. Purposive sampling will be used to ensure diversity in participants with respect to age, gender, ethnicity and, where relevant, profession or degree of kidney impairment. We will undertake semi-structured interviews following flexible topic guides developed for patients and clinical staff. Interviews will be audio-recorded and transcribed. Transcripts will be analysed using the six steps outlined in Braun and Clarke’s thematic analysis, within an interpretivist, constructionist approach. Analysis will be primarily inductive. We will label sections of text with codes to reflect semantic or latent meaning and cluster similar codes together to derive themes which we will define and name. We will produce a report comprising themes central to MI treatment decision-making in people with CKD, illustrated with examples of data and analytic commentary, and demonstrate where our research stands within the context of the literature and wider context.

Abstract Background Acute myocardial infarction (AMI) causes significant mortality and morbidity in people with impaired kidney function. Previous observational research has demonstrated reduced use of invasive management strategies and inferior outcomes in this population. Studies from the USA have suggested that disparities in care have reduced over time. It is unclear whether these findings extend to Europe and the UK. Methods Linked data from four national healthcare datasets were used to investigate management and outcomes of AMI by estimated glomerular filtration rate (eGFR) category in England. Multivariable logistic and Cox regression models compared management strategies and outcomes by eGFR category among people with kidney impairment hospitalised for AMI between 2015–2017. Results In a cohort of 5 835 people, we found reduced odds of invasive management in people with eGFR < 60mls/min/1.73m2 compared with people with eGFR ≥ 60 when hospitalised for non-ST segment elevation MI (NSTEMI). The association between eGFR and odds of invasive management for ST-elevation MI (STEMI) varied depending on the availability of percutaneous coronary intervention. A graded association between mortality and eGFR category was demonstrated both in-hospital and after discharge for all people. Conclusions In England, patients with reduced eGFR are less likely to receive invasive management compared to those with preserved eGFR. Disparities in care may however be decreasing over time, with the least difference seen in patients with STEMI managed via the primary percutaneous coronary intervention pathway. Reduced eGFR continues to be associated with worse outcomes after AMI.

MB, TM, AN and JS all contributed to organisation and delivery of events organised under the Renal Starter Club. All authors contributed to manuscript preparation.

ObjectivesAcute myocardial infarction (AMI) case ascertainment improves for the UK general population using linked health data sets. Because care pathways for people with chronic kidney disease (CKD) change based on disease severity, AMI case ascertainment for these people may differ compared with the general population. We aimed to determine the association between CKD severity and AMI case ascertainment in two secondary care data sets, and the agreement in estimated glomerular filtration rate (eGFR) between the same data sets.MethodsWe used a cohort study design. Primary care records for people with CKD or risk factors for CKD, identified using the National CKD Audit (2015–2017), were linked to the Myocardial Ischaemia National Audit Project (MINAP, 2007–2017) and Hospital Episode Statistics (HES, 2007–2017) secondary care registries. People with an AMI recorded in either MINAP, HES or both were included in the study cohort. CKD status was defined using eGFR, derived from the most recent serum creatinine value recorded in primary care. Moderate–severe CKD was defined as eGFR <60 mL/min/1.73 m2, and mild CKD or at risk of CKD was defined as eGFR ≥60 mL/min/1.73 m2or eGFR missing. CKD stages were grouped as (1) At risk of CKD and Stages 1–2 (eGFR missing or ≥60 mL/min/1.73 m2), (2) Stage 3a (eGFR 45–59 mL/min/1.73 m2), (3) Stage 3b (eGFR 30–44 mL/min/1.73 m2) and (4) Stages 4–5 (eGFR <30 mL/min/1.73 m2).ResultsWe identified 6748 AMIs: 23% were recorded in both MINAP and HES, 66% in HES only and 11% in MINAP only. Compared with people at risk of CKD or with mild CKD, AMIs in people with moderate–severe CKD were more likely to be recorded in both MINAP and HES (42% vs 11%, respectively), or MINAP only (22% vs 5%), and less likely to be recorded in HES only (36% vs 84%). People with AMIs recorded in HES only or MINAP only had increased odds of death during hospitalisation compared with those recorded in both (adjusted OR 1.61, 95% CI 1.32 to 1.96 and OR 1.60, 95% CI 1.26 to 2.04, respectively). Agreement between eGFR at AMI admission (MINAP) and in primary care was poor (kappa (K) 0.42, SE 0.012).ConclusionsAMI case ascertainment is incomplete in both MINAP and HES, and is associated with CKD severity.

Objectives To determine the response process validity, feasibility of completion, acceptability and preferences for three patient-reported outcome measures that could be used in economic evaluation—the EQ-5D-5L, ICECAP-A and ICECAP-O—in people requiring kidney care.Design Participants were asked to ‘think-aloud’ while completing the EQ-5D-5L, ICECAP-A and ICECAP-O, followed by a semistructured interview. Five raters identified errors or struggles in completing the measures from the think-aloud component of the transcripts. Patient preferences for measures were extracted from the semistructured interview.Setting Eligible patients were identified through a large UK secondary care renal centre.Participants In total, 30 participants were included in the study, consisting of patients attending renal outpatients for chronic kidney disease (n=18), with a functioning kidney transplant (n=6) and receiving haemodialysis (n=6).Results Participants had few errors and struggles in completing the EQ-5D-5L (11% error rate, 3% struggle rate), ICECAP-A (2% error rate, 2% struggle rate) and ICECAP-O (4% error rate, 3% struggle rate). The main errors with the EQ-5D-5L were judgements that did not comply with the ‘your health today’ instruction. Comprehension errors were most prominent on ICECAP-O. Judgement errors were the only errors reported on ICECAP-A. Although the EQ-5D-5L had slightly more errors and struggles, it was the measure most preferred, with participants able to make a clearer link with EQ-5D-5L and their health condition.Conclusions The EQ-5D-5L, ICECAP-A and ICECAP-O are feasible for people requiring kidney care to complete and can be included in studies conducting economic evaluations of kidney care interventions. Further research is required to assess how health (eg, EQ-5D) and capability (eg, ICECAP) measures can be included in an economic evaluation simultaneously, as well as what ICECAP measure(s) to include when patient groups straddle the age ranges for ICECAP-A (18 years and older) and ICECAP-O (65 years and older).

Background The risk of acute kidney injury (AKI) attributable to renin angiotensin aldosterone (RAAS) inhibitors and diuretics remains unclear. Methods We conducted a prospective cohort study using the Clinical Practice Research Datalink (2008–2015) linked to Hospital Episode Statistics – Admitted Patient Care and Office for National Statistics mortality data. Patients were included if they had one or more chronic diagnoses requiring medication. Exposed patients had a first ever prescription for RAAS inhibitors/diuretics during the study period. AKI risk associated with exposure was determined by multivariable Cox regression, propensity score-adjusted Cox regression and a prior event rate ratio (PERR) analysis. Results One hundred forty thousand nine hundred fifty-two individuals were included. Increased AKI risk in the exposed group was demonstrated in both the multivariable and propensity score-adjusted cox regressions (HR 1.23 (95% CI 1.04–1.45) and HR 1.24 (1.05–1.47) respectively). The PERR analysis provided a similar overall hazard ratio with a wider confidence interval (HR 1.29 (0.94–1.63)). The increased AKI risk in the exposed group was present only in those receiving two or more antihypertensives. Absolute AKI risk was small. Conclusions RAAS inhibitors/diuretics result in an increased risk of AKI. The absolute increase in AKI risk is small, however, and needs to be considered in the context of any potential benefits.

intermediate-risk group and in 14 out of 15 high -risk group.In the low-intermediate risk group (0-5), we observed 2 short-term (i.e.: within 1 week after the disease onset) deaths, both in patients with severe sepsis and aHUS (one was also treated with Eculizumab V R ).All 27 patients started PEX and steroids.Nine patients [4 with a refractory TTP and 5 with relapsed TTP (2 of 3 patients having previous episodes of TTP)] were also treated by rituximab.We identified a TTP relapse in 3 (1 with score of 5) severely-deficient patients: in 2 of them (score¼ 6), who were diagnosed with cancer (pancreatic cancer and myeloproliferative neoplasm), a long-term death occurred.CONCLUSIONS: In our patients PLASMIC score has a good predictive value of the pretest likelihood of a severe ADAMTS13 deficiency.Further research is needed to confirm present data.

INTRODUCTION AND AIMS:We developed a renal taster day to attract junior doctors to a career in Nephrology and counteract current low applicant numbers in the UK.Junior doctors commonly believe that Renal Medicine is an impossibly academic specialty with a poor work-life balance, and we hoped to demonstrate that this is not always the case!We advertised via email to all administrators of UK junior doctor training programmes.The course was also promoted by the Renal Association and Royal College of Physicians.METHODS: The one day programme involved talks in lecture format as well as small group workshops, all with ample time for questions.Clinical topics covered included dialysis, conservative care, renal transplantation and vasculitidis.Nineteen junior doctors attended from across the UK.RESULTS: The feedback received was excellent.Participants appeared to enjoy the day as well as finding it valuable in terms of settling on a specialist career pathway.Participants were on average 20% more likely to apply for renal training having attended the course.The team was commended for their approachability as well as the informal and inclusive atmosphere generated.CONCLUSIONS: We plan to run this course on a regular basis.Greater use of social media and publicity by "word of mouth" should enable us to to attract more applicants with each successive year.We would like to keep the cost low for participants and may look into alternative sources of funding in order to be able to offer further experiences such as simulated renal biopsy and central line insertion.

Objective To explore dialysis decision-making for adults who lack capacity due to cognitive impairment, a common and under-recognised condition in those with advanced chronic kidney disease (CKD). Design Secondary analysis of qualitative data collected during the Conservative Kidney Management Assessment of Practice Patterns Study programme of research was performed. Sixty semistructured interviews were conducted with multiprofessional team members from UK renal centres. Staff were asked about local facilities, the value of conservative kidney management (CKM), when and with whom CKM was discussed and how CKM could be improved. Thematic analysis was employed to identify, characterise and report on themes that emerged from the data, focused on the specific issues experienced by people with dementia. Setting A purposive sample of nine UK renal centres differing in the scale of their CKM programmes. Participants Clinical directors of renal centres identified staff involved in CKM. Staff were asked to participate if they had experience of low clearance clinics or of caring for patients with advanced CKD (estimated glomerular filtration rate <20mL/min/1.73(2) or >65 years with end-stage kidney disease). Results Two overarching themes were identified: factors taken into consideration during decision-making, and the process of decision-making itself. Comorbidity, social support, quality of life and the feasibility of dialysis were reported as factors pertinent to clinicians' decisions regarding suitability. The majority of renal centres practised multidisciplinary best interests' decision-making for those without capacity. Attitudes to advance care planning were divided. Conclusions In view of the prevalence of cognitive impairment among those with advanced CKD, we suggest consideration of routine assessment of cognition and capacity. In the UK, dialysis is initiated and continued for individuals with dementia and services should be adapted to meet the needs of this population.

Fat embolism is a recognised complication of bony injury and orthopaedic surgery, commonly involving the long bones and pelvis. We report on the case of a 68-year-old renal transplant recipient who developed acute kidney injury following surgical stabilisation of metastatic carcinoma of the acetabulum and replacement of the proximal femur. A CT renal angiogram demonstrated a large fat embolus in the inferior vena cava (IVC) and left iliac veins below the level of IVC filter, with impaired renal perfusion. The risks of open or endovascular lipothrombectomy were felt to outweigh the potential benefits. The patient was managed with systemic anticoagulation and prepared for transplant failure. Subsequently, there was spontaneous improvement in urine output and 4 months postoperatively her transplant function had returned to her baseline level and this has remained stable at 1 year postsurgery.

Background: Intravenous drug use is associated with progressive kidney disease of several aetiologies. It is associated with behavioural and lifestyle characteristics that make the provision of renal replacement therapies (RRTs) challenging. We observed that patients who use intravenous drugs [people who inject drugs (PWID)] present late to renal services and struggle to engage with treatment. We describe the experience of a UK centre providing renal services to a mixed city and rural population. Methods: A review of electronic patient records (2003-16) was performed to identify patients actively using intravenous drugs at the time of dialysis initiation. Descriptive statistics were used to describe aetiology, treatment, complications and prognosis. Results: Twenty-three patients were identified; 15 had a biopsy-proven diagnosis of AA amyloidosis. The median time from presentation to dialysis initiation was 47 days [interquartile range (IQR) 8-147.5]. Hepatitis C infection, venous thromboembolism and mental health disorders were common comorbidities. Eight patients attempted peritoneal dialysis; all failed after a median of 30 days (IQR 21.75-83). One-year survival was 65% (95% confidence interval 42-80), significantly lower than 2013 UK renal registry statistics for incident haemodialysis patients <65 years of age (94.2%). Conclusions: PWID who develop end-stage kidney disease in our region predominantly have AA amyloidosis. Most present late to renal services and have poor outcomes on all forms of RRT. Rates of transplantation are low. Management challenges include coexisting alcohol and mental health problems, low socio-economic status, contamination of intravenous dialysis access and chaotic lifestyles. Multidisciplinary management with enhanced social support may be beneficial in improving outcomes for this patient group.