Moderating discussion on topical themes in nephrology

Ahead of the Irish Nephrology Society’s Annual Scientific Meeting, President Prof Liam Plant spoke to Catherine Reilly about some of the meeting’s key themes

The Irish Nephrology Society (INS) Annual Scientific Meeting on 12-13 May will feature a distinguished array of national and international experts offering insights into the latest research developments in nephrology and updates on clinical practice.

INS President Prof Liam Plant, Consultant Renal Physician at Cork University Hospital and Clinical Professor in Renal Medicine at University College Cork, told the Medical Independent there are several themes the Society wanted to address at this meeting, including kidney disease in children.

In this regard, two Consultant Paediatric Nephrologists at Children’s Health Ireland at Temple Street will be presenting on aspects of paediatric care. Prof Atif Awan will present on the topic of paediatric transplantation in Ireland while Dr Susan McAnallen’s presentation is titled, ‘Mind the gap: Interface between paediatric and adult nephrology services.’

“At any one time there are about 70 young people in Ireland under the age of 18 who have permanent kidney failure,” commented Prof Plant.

The causes of kidney failure in children and adults are generally different in nature.

“Children are more likely to have been born with some kind of developmental abnormality in their kidneys…. There is more what I would call structural abnormalities of the kidney and the bladder as a cause… than there is in adults.”

The majority of under-18s who have permanent kidney failure are transplanted and many have received transplants before having to go on dialysis. “That is the best outcome, because they don’t spend any time on dialysis, and that is not always achievable, but it is pretty commonly achieved.”

In regard to the subject of Dr McAnallen’s presentation, Prof Plant said it is vitally important to facilitate a secure transition for the patient from the paediatric to adult hospital environment. He said this transition needs to be well planned in advance for the patient’s medical and psychological wellbeing.

Dialysis or no dialysis?

The second major theme relates to a presentation titled ‘Very low, but stable GFR, dialysis or no dialysis’, which will be discussed by Prof Robert Foley, Nephrology Specialist, University of Minnesota, US, who has a special interest in renal outcomes research.

Prof Plant noted that one-in-10 adults in Ireland (and one-in-three over the
age of 70) have kidney disease of different degrees.

“As people’s kidney function starts to get lower and lower, the probability that they get more and more complications increases. If you are a fit young teenager in that circumstance, then obviously trying to get a transplant at the appropriate time is the most important thing for you…and maybe you need to go on dialysis as a bridge for that.

“If you are at the other end of the age spectrum – you might be in your 80s, you might have a number of other comorbidities – one of the questions there is, does somebody in that circumstance need to have dialysis; will dialysis enhance their survival and will it enhance their quality-of-life, or will it have a minimal effect on their survival, and give them a difficult quality-of-life?

“For some people when their kidney function gets lower and lower, should we be ramping up what we would call the maximum conservative medical management?”

This means continuing to provide the best standard of care to the individual excluding dialysis, where the burdens of dialysis treatment override the benefits.

Studies have indicated that some older people will live almost as long and have much less disruption and hospitalisations with a maximum conservative treatment regimen as opposed to being put on dialysis.

“The whole issue is not to treat blood tests, but to treat individuals, to treat patients, and a solution for one patient may not be the solution for another patient,” said Prof Plant. “In the past people might have thought no dialysis meant no treatment. In actual fact, no dialysis should still mean excellent patient-focused treatment, which tries to maximise people being well, being in their homes, as opposed to ‘we have to treat them [with dialysis] because their kidney function is at a certain level’.”

Heart failure is another topic of significant import that will be covered at the meeting. ‘Renal outcomes in contemporary trials of heart failure’ will be discussed by Prof Finnian McCausland, Consultant Nephrologist, Brigham and Women’s Hospital, Boston, US.

“There is enormous overlap between kidney disease and heart failure. Heart failure is the commonest reason for admission to hospital in adults over 75 years of age in Ireland” and large numbers of people with heart failure have kidney disease, and vice versa.

If cancer can broadly be considered as one domain of health problem, another large group is what Prof Plant termed the ‘cardio-renal-metabolic’ collective.

Prof Plant added that Prof David Wheeler’s talk on high-impact clinical trials in nephrology will prominently feature trials which have an impact on cardio-renal outcomes. Prof Wheeler is Consultant Nephrologist at the Royal Free London NHS Foundation Trust, UK.

dd-cfDNA

Another major topic at the meeting relates to the potential to monitor donor-derived cell-free DNA (dd-cfDNA) after kidney transplant to identify signs of rejection at a very early stage. This will be the subject of a presentation by Prof Sam Kant, Assistant Professor of Medicine in the Division of Nephrology and Comprehensive Transplant Centre, Johns Hopkins Hospital, Baltimore, US.

“Much of the mental picture people have of rejection of a transplant is that it is working one day and the next day it is suddenly being attacked by the immune system,” said Prof Plant. “But actually it can be much more subtle than that and can gradually damage the kidney, and you can miss the opportunity to intervene depending on how well you can monitor damage to the kidney.”

In Ireland, 54 per cent of people with permanent kidney failure have a renal transplant, “and we want them to keep it as long as possible.”

“Donor-derived cell-free DNA is, effectively speaking, a marker of damage to the kidney. It is a blood test which can be analysed, and it can be a very early sign that the kidney is being damaged by a rejection process and it changes before the measurements of kidney function change.”

This relatively novel approach is not yet a part of standard practice, stated Prof Plant.

“People have been doing it as a research phenomenon for some time and it can be used not just in kidney transplantation, but in other kinds of transplants as well.… That is something that might become a standard of care in the future.”

Other anticipated presentations include a talk on fibromuscular dysplasia by Dr Áine de Bhailís, Consultant Nephrologist, Salford Royal NHS Foundation Trust, UK; and AI-empowered dry weight management by Dr Vicki Sandys, Research Fellow, Beaumont Hospital, Dublin. An update from the HSE National Renal Office will be provided by National Clinical Lead Prof George Mellotte, while a point of care ultrasound course for NCHDs will be led by Dr Saeed Ahmed, a Consultant Interventional Nephrologist from the UK.

Some 80 abstracts were submitted for the scientific programme, of which 50 were accepted for presentation.

Meanwhile, Prof Plant said consultant posts in nephrology continue to attract high-calibre applicants.

“We have been fortunate up to now that we continue to attract the highest quality of applicants for the consultant posts as they come up, many of whom, but not all, are our own graduates and most of whom have worked in very distinguished centres abroad.”