Publications by authors named "Hugh S Cairns"

8 Publications

  • Page 1 of 1

Effect of exercise training on estimated GFR, vascular health, and cardiorespiratory fitness in patients with CKD: a pilot randomized controlled trial.

Am J Kidney Dis 2015 Mar 16;65(3):425-34. Epub 2014 Sep 16.

Department of Renal Medicine, King's College Hospital, London, United Kingdom.

Background: Exercise capacity, which is predictive of all-cause mortality and cardiovascular disease risk, is reduced significantly in patients with non-dialysis-dependent chronic kidney disease. This pilot study examined the effect of moderate-intensity exercise training on kidney function and indexes of cardiovascular risk in patients with progressive chronic kidney disease stages 3 to 4.

Study Design: Single-blind, randomized, controlled, parallel trial.

Setting & Participants: 20 patients (aged 18-80 years; 17 men) randomly assigned to rehabilitation (n=10) or usual care (n=10). Participants were included if they were 18 years or older and had evidence of rate of decline in creatinine-based estimated glomerular filtration rate (eGFRcr)≥2.9mL/min/1.73m(2) per year for 12 months preintervention. Patients were excluded if they had unstable medical conditions or had recently started regular exercise.

Intervention: The rehabilitation group received resistance and aerobic training (3 days per week) for a 12-month period. The usual care group received standard care.

Outcomes: Kidney function assessed by comparing mean rate of change in eGFRcr (mL/min/1.73m(2) per year) from a 12-month preintervention period against the 12-month intervention period. Pulse wave velocity (PWV), peak oxygen uptake (Vo2peak), and waist circumference assessed at 0, 6, and 12 months.

Measurements: eGFR assessed using creatinine, cystatin C (eGFRcys), and a combination of both values (eGFRcr-cys).

Results: 18 participants (rehabilitation, 8; usual care, 10) completed the study. A significant mean difference in rate of change in eGFRcr (+7.8±3.0 [95% CI, 1.1-13.5] mL/min/1.73m(2) per year; P=0.02) was observed between the rehabilitation and usual care groups, with the rehabilitation group demonstrating a slower decline. No significant between-group mean differences existed in absolute eGFRcr, eGFRcr-cys, or eGFRcys at 12 months of study intervention. Significant between-group mean differences existed in PWV (-2.30 [95% CI, -3.02 to -1.59] m/s), waist circumference (-7.1±12.8 [95% CI, -12.4 to -3.2] cm), and Vo2peak (5.7 [95% CI, 1.34-10.10] mL/kg/min). Change in eGFRcr was correlated inversely with PWV (r=-0.5; P=0.04) at 12 months.

Limitations: Small sample size, inconsistency between primary and secondary measures of kidney function.

Conclusions: The effect of a 1-year exercise intervention on progression of kidney disease is inconclusive. A larger study with longer follow-up may be necessary.
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March 2015

Psychological intervention in fluid management.

Palliat Support Care 2006 Dec;4(4):419-24

Academic Department of Psychological Medicine, Section of General Hospital Psychiatry, GKT School of Medicine & Institute of Psychiatry, Weston Education Centre, London, UK.

Background: Hemodialysis is a palliative treatment for patients with established renal failure (ERF), and volume overload is a common problem for hemodialysis patients with low urinary output. Volume overload is thought to be mostly attributable to interdialytic fluid intake by the patient and is associated with an increased symptom burden and the development of serious medical complications. Repeated episodes of volume overload may adversely affect staff-patient relationships and the perception of care in this patient population. The aim of this case series study was to evaluate the effect and experience of a psychological intervention on interdialytic weight gain in a small group of patients.

Methods: Five patients were treated. The intervention involved using techniques derived from both cognitive behavior therapy and motivational interviewing. The main outcome measures were interdialytic weight gain and patient perception of the intervention.

Results: Three of the five patients reduced both mean interdialytic weight gain and the frequency with which they gained in excess of 3% of their dry weight during the intervention phase. The intervention was found to be acceptable to patients.

Significance Of Results: The intervention was effective in helping three of the five patients to reduce both the frequency and the severity of volume overload, and two of these patients maintained this for at least 6 months post intervention. The intervention used actively engaged the patients and appeared to be experienced positively. The methods used to mobilize patient resources and optimize staff-patient relationships as vehicles of change are discussed. Both may have implications for treatment concordance and the perception of care delivered.
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December 2006

The second United Kingdom Heart and Renal Protection (UK-HARP-II) Study: a randomized controlled study of the biochemical safety and efficacy of adding ezetimibe to simvastatin as initial therapy among patients with CKD.

Am J Kidney Dis 2006 Mar;47(3):385-95

Clinical Trial Service Unit, University of Oxford, Churchill Hospital, Oxford, UK.

Background: Evaluating the effects of decreasing low-density lipoprotein (LDL) cholesterol levels requires large randomized trials. In preparation for such a trial, we assessed the biochemical efficacy, safety, and tolerability of adding ezetimibe, 10 mg/d, to simvastatin, 20 mg/d, as initial therapy for such patients.

Methods: Two hundred three patients (152 predialysis patients with creatinine levels > or = 1.7 mg/dL [> or = 150 micromol/L], 18 patients on peritoneal dialysis therapy, and 33 patients on hemodialysis therapy) were randomly assigned to the administration of simvastatin, 20 mg/d, plus ezetimibe, 10 mg/d; or simvastatin, 20 mg, plus placebo ezetimibe daily.

Results: After 6 months, allocation to simvastatin monotherapy was associated with a 31-mg/dL (0.8-mmol/L) decrease in nonfasting LDL cholesterol levels compared with baseline. Allocation to simvastatin plus ezetimibe produced an additional 18-mg/dL (0.47-mmol/L) decrease in LDL cholesterol level, representing an incremental 21% reduction over that achieved with simvastatin monotherapy (P < 0.0001). There were no statistically significant effects of the addition of ezetimibe to simvastatin on triglyceride or high-density lipoprotein cholesterol levels. Ezetimibe was not associated with an excess risk of abnormal liver function test results or of elevated creatine kinase levels and did not impair absorption of fat-soluble vitamins. There were no serious adverse events caused by study treatment.

Conclusion: This 6-month study shows that the addition of ezetimibe to simvastatin, 20 mg/d, as initial therapy for patients with chronic kidney disease was well tolerated and produced an additional 21% decrease in LDL cholesterol levels. The clinical efficacy and safety of combination therapy in this population are now being assessed in a large randomized trial.
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March 2006

First United Kingdom Heart and Renal Protection (UK-HARP-I) study: biochemical efficacy and safety of simvastatin and safety of low-dose aspirin in chronic kidney disease.

Am J Kidney Dis 2005 Mar;45(3):473-84

Clinical Trial Service Unit, Oxford University, Oxford, UK.

Background: Patients with chronic kidney disease are at increased risk for cardiovascular disease, but the efficacy and safety of simvastatin and aspirin are unknown in this patient group.

Methods: Patients were randomly assigned in a 2 x 2 factorial design to the administration of: (1) 20 mg of simvastatin daily versus matching placebo, and (2) 100 mg of modified-release aspirin daily versus matching placebo.

Results: Overall, 448 patients with chronic kidney disease were randomly assigned (242 predialysis patients with a creatinine level > or = 1.7 mg/dL [> or =150 micromol/L], 73 patients on dialysis therapy, and 133 patients with a functioning transplant). Compliance with study treatments was 80% at 12 months. Allocation to treatment with 100 mg of aspirin daily was not associated with an excess of major bleeds (aspirin, 4 of 225 patients [2%] versus placebo, 6 of 223 patients [3%]; P = not significant [NS]), although there was a 3-fold excess of minor bleeds (34 of 225 [15%] versus 12 of 223 patients [5%]; P = 0.001). Among those with predialysis renal failure or a functioning transplant at baseline, aspirin did not increase the number of patients who progressed to dialysis therapy (7 of 187 [4%] versus 6 of 188 patients [3%]; P = NS) or experienced a greater than 20% increase in creatinine level (63 of 187 patients [34%] versus 56 of 188 patients [30%]; P = NS). After 12 months of follow-up, allocation to 20 mg of simvastatin daily reduced nonfasting total cholesterol levels by 18% (simvastatin, 163 mg/dL [4.22 mmol/L] versus placebo, 196 mg/dL [5.08 mmol/L]; P < 0.0001), directly measured low-density lipoprotein cholesterol levels by 24% (89 mg/dL [2.31 mmol/L] versus 114 mg/dL [2.96 mmol/L]; P < 0.0001), and triglyceride levels by 13% (166 mg/dL [1.87 mmol/L] versus 186 mg/dL [2.10 mmol/L]; P < 0.01), but there was no significant effect on high-density lipoprotein cholesterol levels (2% increase; P = NS). Allocation to simvastatin therapy was not associated with excess risk for abnormal liver function test results or elevated creatine kinase levels.

Conclusion: During a 1-year treatment period, simvastatin, 20 mg/d, produced a sustained reduction of approximately one quarter in low-density lipoprotein cholesterol levels, with no evidence of toxicity, and aspirin, 100 mg/d, did not substantially increase the risk for a major bleeding episode. Much larger trials are now needed to assess whether these treatments can prevent vascular events.
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March 2005

The Renal National Service Framework: a step in the right direction.

Clin Med (Lond) 2004 Sep-Oct;4(5):458-61

Guy's King's and St Thomas' School of Medicine, London.

Part one of the National Service Framework (NSF) for Renal Services was published early in 2004. The document covers the treatment of patients with end stage renal failure with dialysis and transplantation. Five standards to be achieved by 2014 are proposed. These cover access to information, timely preparation for dialysis, quality planned access surgery, patient choice for dialysis modality, and improvements in the quantity and success of renal transplants. These standards are underpinned by five early actions to be achieved by 2006. These include improved information flow about current practice and outcomes, increases in haemodialysis capacity and adherence to National Institute for Clinical Excellence guidelines on immunosuppression. The Renal NSF is welcome as a significant boost to the profile of renal services in England. Implementation will be difficult and will require the sustained pressure of the 'Kidney Alliance' representing patients, clinicians and supporting organisations.
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December 2004

Management of mild to moderate chronic renal failure.

Hugh S Cairns

Clin Med (Lond) 2003 Nov-Dec;3(6):499-503

King's College Hospital, London.

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April 2004

Infective endocarditis in dialysis patients: new challenges and old.

Kidney Int 2003 Aug;64(2):720-7

Renal Unit, Guy's and St. Thomas' Hospital, London, United Kingdom.

Background: Since the 1960s chronic hemodialysis (HD) has been recognized as a risk factor for the development of infective endocarditis (IE). Historically, it has been particularly associated with vascular access via dual lumen catheters. We wished to examine the risk factors for, and consequences of, IE in the modern dialysis era.

Methods: Cases of IE (using the Duke criteria) at St. Thomas' Hospital (1980 to 1995), Guy's (1995 to 2002), and King's College Hospitals (1996 to 2002) were reviewed.

Results: Twenty-eight patients were identified as having developed IE (30 episodes of IE). Twenty-seven patients were on long-term HD and one patient was on peritoneal dialysis (PD). Mean age was 54.1 years, and mean duration of HD prior to IE was 46.3 months. Eight patients were diabetic. Primary HD hemoaccess was an arteriovenous fistula (AVF) in 41.3%, a dual-lumen tunneled catheter (DLTC) in 37.9%, a polytetrafluoroethylene (PTFE) graft in 10.3%, and a dual- lumen non-tunneled catheter (DLNTC) in 4%. The presumed source of sepsis was directly related to hemoaccess in 25 HD patients: DLTC in 48%; AVF in 32%; PTFE in 12%; and DLNTC in 4%. Staphylococcus aureus[including methicillin resistant Staphylococcus aureus (MRSA)] was present in 63.3%. The mitral valve was affected in 41.4% of patients, aortic valve in 37.9% of patients, and both valves were affected in 17.2% of patients. Of note, 51.7% of patients had an abnormal valve before the episode of IE. In 15 cases surgery was undertaken. Fourteen patients survived to discharge, and 12 survived for 30 days. In 15 cases antibiotic treatment alone was employed; in this case, eight patients died and seven survived to discharge.

Conclusion: This is the largest reported confirmed IE series in dialysis patients. Infective endocarditis in HD patients remains a challenging problem-although hemoaccess via dual-lumen catheters remains a significant risk, many cases developed in patients with AVFs and this group suffered the greatest mortality. An abnormal valve (frequently calcified) was another risk factor; because valve calcification is now common after 5 years on dialysis, more effort in preventing this avoidable form of ectopic calcification may reduce the risk of developing IE.
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August 2003

Seven cases of granulomatous interstitial nephritis in the absence of extrarenal sarcoid.

Nephrol Dial Transplant 2003 Feb;18(2):280-4

Renal Unit, Kings College Hospital, Denmark Hill, London SE5 9RS, UK.

Background: Renal disease in sarcoidosis may occur due to granulomatous interstitial nephritis. However, granulomatous interstitial nephritis in the absence of features of extrarenal sarcoid, or other causes, has been reported very rarely. In this report we describe seven such patients.

Methods: Since 1995, we have identified a number of patients with biopsy-proven granulomatous interstitial nephritis. Patients were excluded if they had (i) evidence of extrarenal sarcoid, (ii) infections that may have contributed to pathogenesis or (iii) an obvious drug-related aetiology.

Results: Seven patients were identified, of whom five were male and two female, with a median age of 69. Median calculated creatinine clearance at presentation was 14 ml/min. Two had raised serum calcium at presentation and three had a raised serum angiotensin-converting enzyme. All patients were treated with steroids and five out of seven had an improvement in their renal function. Two patients progressed to end-stage renal failure despite treatment with steroids.

Conclusions: Idiopathic granulomatous interstitial nephritis may represent a renal-limited form of sarcoid. It may be associated with hypercalcaemia and a raised serum angiotensin-converting enzyme and usually responds to treatment with corticosteroids.
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February 2003