2016 BAPN Award Recipients. IPNA Brazil Sep 2016
Dr. Drew Maxted
The first encouragement I originally had for attending IPNA came from my parents whom had just arrived back from Iguazu Falls last year – when I told them the conference was in Brazil I was promptly told to “buckle down and get the work done to go!” Needless to say, I didn’t phrase it quite like that in my PDP!
The conference itself was held in Foz de Iguazu, a small town near the falls, which largely exists to supply a town for the workers at the nearby dam and tourists for the falls – there was not a lot else left to do – however, the academic work both on display and presented was excellent, and for a junior GRID trainee I learnt a tremendous amount.
I was fortunate enough to present two posters. The first was a case report on a complex patient who had a PD catheter migration soon post renal transplant presenting with minimal signs. Literature is slightly divided on when PD catheters should be removed, with some adult series suggesting at the time of transplantation to others up to 16 weeks later. Our learning point was that in an immunocompromised child signs can be subtle and that complications can occur outside of the immediate post-transplant period.
The other poster presented our center’s data on Rituximab use in frequently relapsing steroid sensitive nephrotics and steroid dependent patients. In our center we use a single dose of 375mg/m2 and then watch and wait to see the response. All of our patients had good B-cell depletion with the single dose and the response following this was both varied and interesting. 4 out of 20 patients remain in remission (median follow up period 734 days) and off steroids. What we found interesting were the other patients who had variable responses to B-cell repopulation. We had 3 patients in whom relapses followed B-cell repopulation – but with a median time lag of 203 days. A number of other patients either were given 2nd doses prophylactically or relapsed as soon as their B-cell numbers repopulated. Of the fifteen patients who didn’t get a prophylactic second dose the six-month chance of remaining in remission was 86.7% which is comparable to studies that use a higher dose. The differences in the patient groups can’t be easily explained by biopsy results, or other factors. This links in neatly to the presentation given by Professor Saleem during IPNA about the molecular reclassification of the nephrotic syndrome – splitting those into single gene, those with circulating factors and those with other mechanisms. Looking at our patient group it is clear to see there must be factors involved that, as yet, aren’t easily explained in order to rationalise the difference in B-cell repopulation that is seen.
I had some interesting conversations during conference – ranging from a physician in Boston asking for the blood of the 4 patients from our data set who have remained in remission after 1 dose, to starting to organise the joint French-British trainee night out in Paris with one of the French trainees! It was also interesting to talk to medics from non-NHS countries and hear about the genuine decision making that occurs secondary to cost – although we aim to cost save in England – we are lucky that our primary decision making is not always money driven – the NHS does have its good qualities!
Some key educational notes I made during the conference included the ASSESS-AKI study that, alongside other similar studies, shows the importance of long term nephrology follow up in patients who have had AKI – 16% of patients in this study having albuminuria at 3-5yr follow up. Balancing this “ideal” against healthcare planning is an interesting dilemma and was debated following the presentation – with some suggesting that if 1yr post AKI there is a normal eGFR, no proteinuria and a normal BP could the longer term follow up be with primary care?
Another trial that interested me was the ESCORT trial, which presented its preliminary data showing that targeting <50th centile rather than <95th centile post transplantation had no significant change in graft function, proteinuria or left ventricular mass index. The caveat to this is the low patient numbers (21) and still early data – however it is interesting that being overly aggressive in targeting BP may not be as worthwhile beyond the 95th centile as had been previously postulated. Full data is awaited.
Sessions on phosphate metabolism in CKD and tubular disorders were interesting and followed a similar pattern for me – seem logical and sensible when reading/hearing about it – but over the following weeks become more blurred and harder to recall without revision!
The nephrotic syndrome session was well attended which suggested long taper of initial steroid use doesn’t provide superior outcomes compared with 2-3 months (PREDNOS outcome interestingly awaited!) One speaker, suggested, based upon data from his group that we may reach a point where Rituximab is used as second or third line ahead of other drugs such as tacrolimus although the data to back this up is still awaited. New therapies such as Ofatumimab in SRNS showed some early promising results.
There was an interesting debate between differing opinions in the UTI session. The RIVUR study showed prophylaxis reduced UTI, but didn’t dramatically reduce scarring to a significant level. This was debated following the CUTIE study talk in which one side suggested prophylaxis does reduce UTIs and the morbidity associated with this, whereas others argued that it would require a significant number of patients needed to treat with antibiotics in order to prevent scarring – is this not the more important endpoint?
I attended the session on new therapies in SLE nephritis with hope considering some difficult patients we have been looking after recently – but, despite a number of new “imambs” – there doesn’t seem to be a significant step forward, with some studies showing harm with newer therapies.
The gala dinner was well attended on the Thursday and good fun – but the definite highlight outside of the conference were the falls – simply a breathtaking display of natural beauty and power – made the 27 hour journey home just about worth it!
Drew Maxted, Sep 2016
Dr. Cal Robinson
Through the generous support of the BAPN trainee travel grant scheme, I had the distinct opportunity to travel to Iguassu Falls, Brazil this year to present original research focused on the aetiology and outcomes of paediatric urolithiasis in the North West. Our research characterised the demographics, presenting features, identified aetiological factors, and DMSA results of 177 consecutive children presenting to two tertiary centres in Greater Manchester. This was a particularly exciting experience for me, having completed the research as a penultimate and final year medical student.
The trip to the International Paediatric Nephrology Association (IPNA) conference was an incredible adventure. I had the chance to meet and share ideas with a number of trainees from around the UK, Europe, Canada, and South America. I enjoyed attending a number of high-quality lectures, seminars, and research presentations on core topics and contemporary problems in paediatric nephrology. The insight and passion drawn from these speakers further inspired me towards pursuing paediatric specialty training, with an interest in nephrology. To complement the academic program, I was also fortunate enough to attend an excellent gala dinner (and a little post-meal samba), as well as explore the beautiful Iguassu Falls before travelling to Rio de Janeiro to enjoy some Brazilian culture in the “Cidade Maravilhosa”. This was a fantastic, inspiring trip and I am incredibly grateful to BAPN for helping to provide the opportunity for me to attend. I would strongly encourage anyone interested in applying for future BAPN trainee travel grants.
Dr Drew Maxted on ESPN 2017:
ESPN 2017 was always billed as an “extra special” ESPN, being the 50th anniversary of the first meeting and being held in Glasgow, the same location as the first meeting in 1967. I was fortunate enough to be released by my unit for the whole conference, and enjoyed the scientific and social content that was so well organised.
There was a difficult choice to make for the pre-congress symposium – dialysis, enuresis, Alport’s or history and evolution of paediatric nephrology. I opted for dialysis in the morning and enuresis in the afternoon – they were excellent informative updates on the latest innovations. We have been discussing incremental dialysis and HDF since coming back and the need to choose the right modality for the right patient at the right time. Enuresis guidelines were described, it is always helpful to challenge our own practice and think why we do things. Sessions on first and second line therapy for monosymptomatic nocturnal enuresis aided this and sparked good discussion.
The first day concluded with the welcome ceremony. We heard from some of the founders of paediatric nephrology in the UK, Europe and further afield and I was in awe at how pioneering these doctors had been. It was great to have played a small part in the “history videos” that had been put together – and to see we have a named YouTube channel cataloguing them all. The traditional Scottish bagpipes leading us to the welcome reception were amazing, and so loud!
The conference itself was a good mix of clinical updates on new advances as well as some inspiring plenary sessions. These really were an excellent example of how to blend public speaking with scientific knowledge – from the basement membrane, to growing a kidney and how to tackle inequalities in health provision across the world. It was also a good opportunity to engage with industry sponsors and have discussions with nephrologists from the UK and across the world – from Sydney to Minneapolis!
Scientific updates I took away from the first day included the outcome of PREDNOS – showing no clinical difference in time to relapse between standard therapy and extended course for nephrotic syndrome. Full data is still to be published, but secondary outcomes such as number of relapses seemed not statistically significant, apart from the extended course having better health economy outcomes. Other studies presented during the day suggested some patients may be able to be treated with lower doses of steroids during relapse (although numbers were small) and confirmed current NICE practice to give antibiotics prophylactically during MCUGs.
I was fortunate to present work I had been involved with over the last few years. On the first day I presented our unit’s experience of using double filtration plasmapheresis, we use this as an alternative to plasma exchange and have found similar clinical outcomes, without the need for replacement blood products and good clinical stability during sessions.
The next day I presented further work on Rituximab in nephrotic syndrome. Having presented our Rituximab data at the Franco-British meeting in Paris, we combined data with Glasgow and Newcastle. I presented that the lower dose is non-inferior to the higher dose and intermediate dose at preventing relapses at 12 months, as well as no statistical difference in B-cell re-constitution and relapses at 6 and 24 months.
I had a static poster displaying #kidneyschool – this is a trainee-led, interactive, video conferencing teaching programme. We set this up in response to trainees wanting more paediatric nephrology specific training and have had excellent feedback so far – trainees can not only learn from each other, but gain some experience of other centres.
The learning points I took away from the rest of the conference included the NEPHROVIR study that found a link between EBV and idiopathic nephrotic syndrome, the 3H study that showed no worsening of cIMT on HDF compared with standard HD, alongside improved convection rates. Another trainee gave an insightful talk on home HD and described over 11,000 sessions of HD had been done at home by parents – quite humbling to see how much parents will take on at home! There was an excellent talk on C3 glomerulopathies – both classification and treatment options. The talks on renal tubular acidosis and non-cystinotic Fanconi syndrome managed to make potentially complex pathology sound very logical – I just need to try and remember it all! There was an interesting update on using Chitotriosidase to monitor cystinotic patients – but the original study was low in numbers – be interesting to see where this leads.
Friday night was another highlight in the social programme with the gala dinner at the Kelvingrove Museum – great to chat with lots of colleagues and then try and avoid standing on too many feet during the Ceilidh dancing!
Thank you again to BAPN for supporting trainees with the travel bursary and to ESPN for an excellent conference – see you in Turkey!
Dr Matko Marlais (ST6 Paediatric Nephrology on ESPN 2017:
Thanks to the support of the BAPN I was fortunate enough to travel to Glasgow to attend the 50th Anniversary meeting of the European Society of Paediatric Nephrology. The significance of this meeting was clear throughout the conference, as the original meeting in 1967 was also held in Glasgow.
Throughout the three days I was able to attend many interesting sessions which provided me with some really interesting insights into the diverse field of paediatric nephrology. Having just started my paediatric nephrology grid training, this also provided me with an opportunity to consider all the areas of our specialty that I will be learning about through my training. A particular highlight for me was the excellent talk by Professor Melissa Little on the exciting prospects provided by stem cell research and the potential applications to paediatric nephrology in the future.
As well as being able to hear many fascinating lectures and presentations, I was also fortunate enough to be able to present two of my own studies at this conference. The first study I presented used data from NHS Blood and Transplant to establish whether being on dialysis at the time of kidney transplantation affected renal allograft survival in children. We found that children who were pre-emptively transplanted had a better 5-year renal allograft survival than those children who were on dialysis at the time of renal transplantation.
The second study I presented was a study that was kindly funded by the PKD Charity, looking at cardiovascular health in children with ADPKD. In this study we found that children with ADPKD had a higher peripheral and central blood pressure as well as an increased left ventricular mass index, compared to healthy children. The preliminary data from this study is now being used to apply for a larger research grant to perform a bigger study in children and young adults with ADPKD.
As well as learning a huge amount I had some very interesting conversations with colleagues at this conference and this has given me enthusiasm and ideas for future research. I am very grateful to the BAPN for providing me with the support of a travel grant to attend the 2017 ESPN meeting.
Dr B Ramnath on ESPN 2017:
I had the opportunity to attend the 50th annual meeting of the ESPN in Glasgow from September 5th to 9th 2017. This was my first time I attended the ESPN meeting and am grateful for the BAPN for their support through the travel award scheme. I attended all the days of the conference including the junior masterclass.
I attended the junior masterclass on 6th and 7th September. The first day gave me more insight into the understanding of UTI right from change in the definition to the change in approach to investigations. There was also an awesome lecture by a urologist from Turkey on the more practical aspects of UTI and voiding dysfunction. The afternoon of the first day had a couple of fantastic lectures, Prof Saleem on podocytopathies and Prof Oliver Gross on Alports. On the 2nd day of the masterclass I particularly enjoyed the session on renal involvement in metabolic disorders by Dr Pierre Cochat.
The conference was held in the SEC centre on the banks of the river Clyde. The opening ceremony was a gala event inaugurated by the mayor of Glasgow with traditional Scottish pipers making it a very festive atmosphere. It was a historic moment for ESPN being its 50th year and the entire history of paediatric nephrology was fascinating. In fact all the sessions had a theme on history 50 years before and 50 years ahead. It was a lifetime opportunity to listen to the stalwarts of the specialty like Dr Arneil. The finale that day was the video on 50 years of paediatric nephrology with interviews from eminent nephrologists across Europe.
In fact the next couple of days went in a whirl. I listened to talks on PREDNOS results, ethical dilemmas, psychosocial aspects of transition, path breaking research work on building a kidney from stem cells. The scientific content and the learning opportunity was so immense that we had to keep moving from one hall to the other to gain as much as possible. On Friday I had the opportunity to display and present my poster which was case report on a boy who was ultimately diagnosed to have paroxysmal nocturnal haemoglobinuria. It drew interest and questions from many trainees who were particularly fascinated by the pictures of hemosiderin staining on the kidney biopsy. The conference also was a fantastic opportunity to meet trainees and consultants from across Europe and exchange ideas. I met a lot of my friends and made may new friends by the end of the conference. On the whole, this was one of my best educational experience ever and I am immensely grateful for the BAPN who made it possible.
Dr Sara Roy, Paediatric Renal GRID trainee on ESPN 2017
As a paediatric registrar due to embark on GRID Paediatric Nephrology training I found the ESPN 2017 conference both inspiring and educational. It gave myself and other trainees’ opportunities to learn from experts across the field both nationally and internationally. Highlights for me included the update on clinical trials in paediatric nephrology, advances in Alport syndrome and the personal practice session on neonatal hypertension. I look forward to applying my learning into practice and attending ESPN conferences in the future.