The past, the present, and the future of nephrology

The Irish Nephrology Society’s (INS) Annual Scientific Meeting 2023, which took place in the Glenroyal Hotel, Maynooth, Co Kildare on 12-13 May, featured a notable line-up of national and international speakers, researchers, and experts. The two-day event examined the wide spectrum of renal disease that affects patients across the lifespan. INS President Prof Liam Plant welcomed attendees after what he termed the “prequel” of the meeting. This included several insightful presentations and an accredited pre-course in point-of-care ultrasound (POCUS) for NCHDs, delivered by the INS POCUS faculty and Dr Saeed Ahmed, Consultant Interventional Nephrologist and General Medicine Physician, UK. Primary themes throughout the meeting included education and scientific research; the value of patient registries; evidence-based medicine; and future developments in the field of nephrology, as well as a heavy emphasis on the patient journey.

Prof David Wheeler, Professor of Kidney Medicine, University College London, UK, gave a presentation that encompassed all of these major themes, which was titled: ‘High impact clinical trials in nephrology.’ Comparing the evidence-based approach to an eminence-based one, he recalled a time in his career when he was reprimanded for prescribing beta blockers to a heart failure patient, and reflected on how “clinical trials have changed practice in nephrology”. 

Emphasising the importance of asking questions, Prof Wheeler revisited several practice-changing studies, and commented that cultural changes are still required to fully integrate trials into practice. Also noting that clinical trials have become “complicated and expensive”, he advocated for “simplified, pragmatic designs” that allow more questions to be addressed in “real-life settings”. He also promoted the randomisation of groups of patients instead of individuals, and the use of patient registries in simplifying designs. Telling attendees how he would like to see a change in the current guideline process, and referencing the ‘pop-up’ guidelines that evolved and changed as data became available during the Covid-19 pandemic, Prof Wheeler explained how he hoped for a move towards a similar guideline process for nephrology in future.

A wide array of recent, ongoing, and planned trials and innovations were discussed throughout the meeting. The potential to monitor donor-derived cell-free DNA after kidney transplant to identify signs of rejection at a very early stage was presented on by Prof Sam Kant, Assistant Professor of Medicine in the Division of Nephrology and Comprehensive Transplant Centre, Johns Hopkins Hospital, Baltimore, US. 

Attendees also heard from Dr Susan McGrath, who discussed ‘Ultrafiltration management with sorbent-based automated wearable artificial kidney peritoneal dialysis prescriptions in a pig model’; Mr Kane Collins, who presented on ‘The utility of donor polygenic risks scores in predicting long term graft function; and Dr Elhussein Elhassan, who talked about the Irish kidney gene project, and ‘Novel dominant ALG5 variant in Irish families with late-onset autosomal dominant polycystic kidney disease and atypical tubulointerstitial changes’. 

Dr Vicki Sandys, post-CSCT Renal Fellow at Beaumont Hospital, Dublin, presented on ‘Artificial intelligence empowered dry weight management’, outlining the development of a machine-learning algorithm to make predictions that could potentially be used to guide ultrafiltration and interdialytic weight gain goals. The model is currently awaiting external validation, with plans for randomised controlled trials in future. 

Dr Sandys described the myriad ongoing challenges in assessing fluid status, in establishing an accurate dry weight, and maintaining balance between volume overload and depletion during her talk. Highlighting that currently, there is “no gold standard for dry weight assessment”, and that ultrafiltration goals are often determined by the nurse, she outlined the weak evidence supporting the routine practices of blood volume monitoring and body composition monitoring. She also presented evidence from clinical trials indicating that the majority of patients are volume-depleted and receiving excessive ultrafiltration, before explaining how the technology could help clinicians to overcome these challenges in future.

Prof George Mellotte, HSE National Clinical Lead for Renal Services, also looked into the past and future of renal services. He provided a National Renal Office update, beginning with an overview of the annual changes in end-stage kidney disease (ESKD) treatment modalities since 2009, followed by changes in patterns during the Covid-19 pandemic. He commended the high levels of patient protection seen within nephrology services during the pandemic, before discussing the decrease in kidney transplants during the same period. Increased prevalence of ESKD, higher demands for renal replacement therapy, the economic consequences of that increased demand, and an urgent need to upgrade parent renal units featured heavily throughout the update. Prof Mellotte noted a “good uptake in home therapies” in several regions, and told attendees how more patients want these therapies, before acknowledging a major deficit in outreach support services in many areas across the country. 

Commenting on the future, Prof Mellotte outlined the extra €25 million funding renal services received in the HSE National Service Plan 2022, and described how expanding dialysis capacity in parent hospital renal units through clinical governance and developing home dialysis services are priorities to support the 30 per cent growth in dialysis activity. Planned advances in renal palliative care services and an expansion of multidisciplinary team members to include more psychologists, dietitians, specialist nurses, and other clinicians were also discussed. 

“Two-hundred-and-twelve whole-time equivalent new posts have been approved, with 50 filled to date,” he explained, before finishing with an overview of plans to extend the HSE structured chronic disease management programme to include chronic kidney disease (CKD) as a specified disease, and to finalise a model of care for the management of early CKD.