This study examines the prevalence and distribution of genetic kidney diseases in a cohort of chronic kidney disease (CKD) patients. The literature and national registries hold a paucity of information on genetic kidney disease prevalence in adult patients with CKD. Through a questionnaire study of all patients of the Wessex Renal and Transplant Service in CKD stages 3-5 on family history, a systematic database search and patient interviews, this study established a prevalence of genetic kidney diseases other than polycystic kidney disease(PKD) of 7.6% amongst end-stage renal disease patients and 3.8% amongst CKD patients, which is higher than previously reported. The study reveals uromodulin associated kidney disease (UAKD) to be the most prevalent genetic kidney disease after PKD, which has not been reported previously. The prevalence for UAKD in Wessex was established at 8.5 per million by UMOD gene sequencing. This is much higher than the only published prevalence of 1.7 per million in Austria. Established diagnostic biochemical tests for UAKD were evaluated and found to have relatively poor sensitivity and specificity –70 and 45% respectively in the case of the fractional excretion of urate, and 70 and 63% for urinary uromodulin, measured by enzyme linked immunosorbent assay (ELISA). On review of clinical phenotypes, hyperuricaemia and gout as the typical clinical features were not statistically associated with UAKD, highlighting the need for gene testing to establish the diagnosis. 81 patients with the clinico-pathological diagnosis focal segmental glomerulosclerosis (FSGS) were recruited to examine underlying gene mutations by a custom-designed targeted next generation sequencing (NGS) panel. Underlying gene mutations were established in 13-20% of patients, which is higher than in previous adult series. Of relevance, the most frequent mutations occurred in the collagen 4 gene, which was unexpected and changed the clinical diagnosis of these patients to Alport disease. Half of the collagen 4 mutations occurred in COL4A5, which was a previously unpublished finding. Whole exome sequencing (WES) was employed in the search for a genetic diagnosis in a previously undiagnosed family. A systematic analysis of both renal and pan-genomic variants failed to identify a disease-causing variant and illustrated the challenges of WES, leading to a discussion of future genetic investigations by NGS.

Patients with End Stage Renal Disease (ESRD) face major challenges in their lives regarding dialysis therapy for survival, challenges which include making informed treatment choices. No research has been found which investigates what information, or education, patients in the Kingdom of Saudi Arabia (KSA) receive, nor what factors influence the choices made and treatments gained. This issue has been the impetus for this survey research that was designed to determine what information patients in KSA have been given and to identify patients’ perceptions of the factors that influence the treatment they receive. The data will be used to develop recommendations informing pre-dialysis education for ESRD in KSA. The questionnaire from the USA study by Mehrotra et al. (2005) was utilised, with additional questions related to patients' views and recommendations for pre-dialysis education. ESRD patients who were ? 18 years and who had been receiving dialysis, for at least 3 months to 1 year, were recruited from four hospitals in the western region of the KSA. Ninety-two patients out of 100 patients recruited completed the questionnaire (a response rate of 92%). The majority (61.9%) of participants were receiving haemodialysis (HD); 38% received peritoneal dialysis (PD). Nearly 20% of patients were not given any option about which treatment they received, although for many this was for clinical reasons. Almost 60% of patients were given a delayed treatment option; i.e. they received an option either after their treatment commenced or less than 1 month before they started dialysis. There was a significant association between participants rating the dialysis education/information as ‘poor’ or ‘totally inadequate’ and receiving HD (p=0.000) and between patients’ needs for additional information and treatment type (HD) (p=0.000). Binary logistic regression indicated that having someone at home to help with treatment was a predictor for patients who opted for PD. The study provided evidence that just under 20% had no, or delayed, presentation of treatment options. Just over 60% of patients were placed on HD and generally were not satisfied. Recommendations to improve pre-dialysis education include the patient’s right to be informed about available treatment options, the provision of more educational materials, and increased time to be spent on education for patients. The provision should be adjusted according to patients’ needs, level of education, and consideration made of family involvement in decisions.

The main aim of the study was to develop real-time detection method for the notification of acute kidney injury in patients where creatinine was requested. A software application was developed that evaluated creatinine results for acute kidney injury against a variety of algorithms. In the initial stage the only algorithm reported was that developed by the Acute Kidney Injury Network but, in 2013 following an NHS England Patient Safety Notice, this was changed to the mandated algorithm and all historical results were also re-evaluated. Between 2010 and 2014 a total of 346,780 patients aged 18 and over covering 1,800,545 individual requests were recorded in the database. Using the NHS England algorithm 25,551 (7.4%) of patients had AKI at some stage in the study period. Analysis suggested that the introduction of AKI alerts coincided with a significant reduction in the relative risk for thirty-day mortality following an AKI episode; stage 1 mortality falling from 19.5% to 14.6%, stage 2 mortality falling from 30.1% to 22.1% and stage 3 mortality falling from 35.3% to 25.9%. However, there was also a fall in mortality for stage 2 and 3 AKI at an associated Medical Unit that did not receive alerts suggesting a significant role for the educational elements and sharing of Consultant care across sites. The data also suggest that, following an episode of acute kidney injury full recovery of renal function may take in excess of 180 days. The data support the hypothesis that the introduction electronic alerts along with education can have significant impacts on subsequent mortality. However, other improvements in healthcare such as an increased focus on sepsis, an important factor in the development of acute kidney injury, may also have contributed to the reduction in mortality.

There has been an increasing recognition over the last ten years of the importance of integrating palliative care alongside other aspects of care for people with life-limiting illness including kidney disease. Over the same time period, policy initiatives have aimed to address and improve the end of life care for all adults with kidney disease. However, little is known about the transitions experienced by people with end-stage kidney disease (ESKD) as they approach the end of life. This qualitative study explored the transitions experienced by people with ESKD as they approached the end of their lives. A constructivist grounded theory methodology was used, and unstructured interviews were conducted with twelve people living with ESKD who were deemed to be approaching the end of their lives. The interview data were analysed and interpreted using the constant comparative method. The core category of ‘restructuring reality’ emerged from the data analysis alongside three dynamic, interrelated conceptual categories and the subcategories within these. These conceptual categories were: ‘striving to maintain autonomy and control in decision making’, ‘managing uncertainty: knowing without clarity or confirmation’, and ‘the importance of personal virtues in transitioning through the illness’. The substantive theory which emerged from the data analysis and which conceptualised the process and experience of transition for people with ESKD in this study was defined as 'the restructuring of reality during transition for people with ESKD approaching the end of life’. The study findings provided valuable insight into the experience of people with ESKD as they approach the end of their lives. The tentative theory presented in this study added to the knowledge of the transitions experienced by people with ESKD as they approached the end of their life. The theory captured how participants made sense of and adjusted to the changes they experienced as their health deteriorated; it emphasised that being able to continue to contribute and be involved in decision-making about care was an important aspect of the transition process as people approached the end of their lives. The study findings also highlighted the importance of healthcare professionals undertaking end of life discussions with patients throughout their illness trajectory to ensure people with ESKD are afforded the opportunity to be involved in timely decision making and provided with good quality end of life care.

No description available.

End stage renal failure is associated with major morbidity and mortality, and renal transplantation is the optimal form of renal replacement therapy. However, since the number of organs available for transplantation is limited, an additional (e.g. bioengineered) source of organs for transplantation is both attractive and necessary. Tissue engineering is an interdisciplinary field that applies the principles of engineering and life sciences towards the development of functional replacement tissues for clinical use. Within this field, the technique of whole organ decellularisation allows the preservation of the native vasculature and the complete 3-dimensional macro- and micro-architecture of the organ extracellular matrix (ECM) to create a whole organ ECM bioscaffold. This approach has been employed in the animal model to create viable and partially functional solid organ constructs, some of which have been implanted in vivo, including in the kidney. However, a number of major technical factors and challenges exist before clinical application can be considered, such as the pre-optimisation and standardisation of both decellularisation and recellularisation protocols. The current applications and methods in using xenogeneic whole organ ECM scaffolds to create potentially functional bio-artificial organ constructs for surgical implantation have been reviewed here; comparison of specific trends reveals the need for systematic rationalisation throughout the field. On this basis and using the rat model, the first aim of this project was to optimise the decellularisation process for whole kidney ECM bioscaffolds with regards to two fundamental parameters: concentration of decellularising agent and duration of perfusion, using the most common single decellularising agent drawn from the literature i.e. sodium dodecyl sulphate. Optimisation was determined with regards to structural and functional characteristics of the ECM bio-scaffold as assessed by histology, immunohistochemistry, quantitative assays of DNA and sulfated glycosaminoglycan content, and growth factor quantification. Secondly, recellularisation of the whole kidney bioscaffolds produced using this more optimised protocol was carried out to yield a viable and implantable organ graft/construct, with both primary renal cells and also adult-derived mesenchymal stem cells. Thirdly, both the decellularised and recellularised kidney constructs were implanted in vivo using the renal transplant model in order to investigate the long-term viability and function of the graft construct. This showed long-term viability and biocompatibility of the acellular (decellularised) kidney scaffold when implanted in vivo, but poor viability of all scaffolds (acellular or recellularised) when implanted in combination with vascular perfusion due to a postulated pro-thrombotic mechanism.

Background: It is possible to replicate the natural process of twinning by means of artificially spitting early-stage embryos in the laboratory. This method has resulted in applications relevant to agricultural and sporting animals. Embryo splitting, or in vitro twinning, has been successfully conducted in various livestock species. Human embryo splitting has been previously reported. The results were, however, inconsistent. Hypothesis: The quality of the human embryos generated by twinning in vitro is comparable to the quality of the embryos created by fertilisation. Experimental Approach: A total of 176 twin embryos created by splitting of 88 human embryos from either early (2 – 5 blastomeres, n = 43) or late (6 – 10 blastomeres, n = 45) cleavage stages were analysed in terms of morphokinetics and developmental competence. Data was compared to the morphometrics of embryos created by fertilisation and leading to pregnancy and live birth following single blastocyst transfer (n = 42). Furthermore, comparative analyses of the expression patterns of early lineage-specific markers (n=21 pairs) of twin blastocysts and non-manipulated Day 5 - 6 blastocysts using immunocytochemistry and human embryonic stem cells (hESCs) derivation was attempted (n = 5 pairs). Finally, comparative analyses of micor RNA (miRNA) profiles in spent blastocyst medium (SBM) of human twin embryos created by blastomere biopsy (n = 7 pairs) and SBM of blastocysts that led to a healthy pregnancy and live birth following embryo transfer (n = 7) were also conducted. Results: Morphokinetic data indicated that human preimplantation development is subject to strict temporal control according to a set ‘developmental clock’. The size of twin embryos generated in the study was directly proportional to the starting cell number of the embryos used in their genesis. Furthermore, the first commitment decision in terms of cell fate was delayed, with the inner cell mass (ICM) becoming distinguishable later in the study group than in the normal control blastocysts. The ICM, if present at all, was small in size and of low quality. Furthermore, most cells in the twin embryos concurrently expressed both ICM and trophectoderm (TE) markers. Finally, the nature of miRNA secretion in SBM consistently varied between the twin and control embryos. Conclusion: Taken together the data suggested that human twin embryos created in vitro by embryo splitting are unsuitable not only for clinical use but also for research purposes.

IgA nephropathy (IgAN) is the commonest primary glomerulonephritis worldwide, with 20-40% of patients developing progressive kidney disease. The most accurate predictors of prognosis are the presence of proteinuria and tubulointerstitial fibrosis, while the degree of mesangial IgA deposition is not a prognostic factor. These findings imply that tubular-specific factors play a key role in progressive IgAN. The aim of this thesis was to explore whether filtered IgA has a direct effect on proximal tubular epithelial cell (PTEC) activation and generation of pro-inflammatory and pro-fibrotic cytokines. The interaction between IgA and PTEC was initially investigated in vivo in Munich Wistar Frömter rats by multiphoton microscopy. These studies demonstrated that IgA, that crossed the glomerular filtration barrier, interacted with PTEC and underwent endocytosis via their apical surface. This process was greatly upregulated in a model of podocyte injury, resulting in increased amounts of filtered IgA. In vitro, human IgA1, and especially galactose-deficient polymeric IgA1, stimulated release of pro-inflammatory and pro-fibrotic cytokines from cultured human HK-2 PTEC. A mouse model of IgAN was optimised that developed both glomerular and tubulointerstitial inflammatory cell infiltration. Although glomerular deposition of complement component C3 was increased in the model, mice genetically deficient in key initiators of the lectin pathway, Collectin-11 (CL-11) or Mannose-binding lectin-associated serine protease-2 (MASP-2), were not protected from interstitial macrophage infiltration, while reductions in glomerular cell number and T cell infiltration were observed. These studies provide evidence for the first time that filtered IgA is able to interact with the proximal tubule and undergo endocytosis. IgA1, and especially galactosedeficient polymeric IgA1, stimulated a pro-inflammatory and pro-fibrotic response from PTEC that may contribute towards progressive IgAN. Understanding this interaction further may reveal novel targets for therapy in this condition. Deficiencies in CL-11 and MASP-2 did not protect against tubulointerstitial inflammation in a mouse model of IgAN, and further studies should concentrate on whether the alternative pathway is activated in this model.

The complement system mediates inflammatory diseases, including kidney disease, through one or more of three pathways named the classical, the alternative and the lectin pathway. The existing experimental data do not allow comprehensive understanding of the individual complement pathway or pathways that mediate the renal injury. This study therefore aimed to determine the complement pathway(s) that are involved in mediating the injury in three models of kidney disease: protein overload proteinuria, unilateral ureteric obstruction nephropathy and adriamycin nephropathy. In protein overload proteinuria, a highly significant increase in the expression levels of TGF-β, TNF-α and IL-6 was observed in WT mice compared to the lectin pathway deficient mice. Macrophage infiltration, apoptosis and the expression of the gene for Col4α1 were also significantly increased. These data suggested a significant role for the lectin pathway in mediating the injury. Most interestingly, the results indicated that antibody mediated inhibition of the lectin pathway led to less injury in some of the examined parameters. These data might suggest a novel therapeutic approach to relief the renal injury in proteinuric nephropathies by targeting the activation of the lectin pathway. In unilateral ureteric obstruction nephropathy, results indicated that deficiency in either the lectin or the classical pathways led to reduced macrophage infiltration and renal fibrosis. The expression levels of Il6, Ifn-γ, TGFβ-1 and Col4α1were reduced in the lectin pathway deficient mice but not in C1qKO mice when compared to WT. However, lower expression levels of these genes were not up to statistical significance. These data suggested that both the lectin and the classical pathways mediate the injury. Similarly, adriamycin nephropathy mice deficient in the lectin pathway showed significant reduction in renal inflammation and fibrosis when compared to WT mice. Additionally, two gene targeting approaches were utilized in order to establish a novel mouse line with specific deficiencies of both the lectin and the classical pathways of the complement. This mouse model should provide a powerful tool to investigate the possible synergetic cooperation between these two pathways in mediating inflammatory renal pathology.

No description available.