In this meta-analysis of 16 studies, investigators evaluated the use of cystatin C, alone or with creatinine, to calculate the estimated glomerular filtration rate (eGFR). Measurement of cystatin C ...improved the prediction of outcomes in chronic kidney disease.
The estimated glomerular filtration rate (eGFR) is the clinical standard for the assessment of kidney function.
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The eGFR thresholds for the definition and staging of chronic kidney disease are based on risk,
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but measurement of creatinine to determine the eGFR has limitations in risk prediction, particularly in patients with reduced muscle mass.
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Cystatin C has received much attention as an alternative filtration marker with stronger and more linear risk relationships than creatinine.
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Several studies have suggested that the addition of cystatin C measurements to creatinine measurements in calculating the eGFR significantly improves the risk classification for death, cardiovascular . . .
Reliable estimates of the long-term outcomes of acute kidney injury (AKI) are needed to inform clinical practice and guide allocation of health care resources. This systematic review and ...meta-analysis aimed to quantify the association between AKI and chronic kidney disease (CKD), end-stage kidney disease (ESKD), and death. Systematic searches were performed through EMBASE, MEDLINE, and grey literature sources to identify cohort studies in hospitalized adults that used standardized definitions for AKI, included a non-exposed comparator, and followed patients for at least 1 year. Risk of bias was assessed by the Newcastle-Ottawa Scale. Random effects meta-analyses were performed to pool risk estimates; subgroup, sensitivity, and meta-regression analyses were used to investigate heterogeneity. Of 4973 citations, 82 studies (comprising 2,017,437 participants) were eligible for inclusion. Common sources of bias included incomplete reporting of outcome data, missing biochemical values, and inadequate adjustment for confounders. Individuals with AKI were at increased risk of new or progressive CKD (HR 2.67, 95% CI 1.99-3.58; 17.76 versus 7.59 cases per 100 person-years), ESKD (HR 4.81, 95% CI 3.04-7.62; 0.47 versus 0.08 cases per 100 person-years), and death (HR 1.80, 95% CI 1.61-2.02; 13.19 versus 7.26 deaths per 100 person-years). A gradient of risk across increasing AKI stages was demonstrated for all outcomes. For mortality, the magnitude of risk was also modified by clinical setting, baseline kidney function, diabetes, and coronary heart disease. These findings establish the poor long-term outcomes of AKI while highlighting the importance of injury severity and clinical setting in the estimation of risk.
Background In the context of clinical research, investigators have historically selected the outcomes that they consider to be important, but these are often discordant with patients’ priorities. ...Efforts to define and report patient-centered outcomes are gaining momentum, though little work has been done in nephrology. We aimed to identify patient and caregiver priorities for outcomes in hemodialysis. Study Design Nominal group technique. Setting & Participants Patients on hemodialysis therapy and their caregivers were purposively sampled from 4 dialysis units in Australia (Sydney and Melbourne) and 7 dialysis units in Canada (Calgary). Methodology Identification and ranking of outcomes. Analytical Approach Mean rank score (of 10) for top 10 outcomes and thematic analysis. Results 82 participants (58 patients, 24 caregivers) aged 24 to 87 (mean, 58.4) years in 12 nominal groups identified 68 outcomes. The 10 top-ranked outcomes were fatigue/energy (mean rank score, 4.5), survival (defined by patients as resilience and coping; 3.7), ability to travel (3.6), dialysis-free time (3.3), impact on family (3.2), ability to work (2.5), sleep (2.3), anxiety/stress (2.1), decrease in blood pressure (2.0), and lack of appetite/taste (1.9). Mortality ranked only 14th and was not regarded as the complement of survival. Caregivers ranked mortality, anxiety, and depression higher than patients, whereas patients ranked ability to work higher. Four themes underpinned their rankings: living well, ability to control outcomes, tangible and experiential relevance, and severity and intrusiveness. Limitations Only English-speaking participants were eligible. Conclusions Although trials in hemodialysis have typically focused on outcomes such as death, adverse events, and biological markers, patients tend to prioritize outcomes that are more relevant to their daily living and well-being. Researchers need to consider interventions that are likely to improve these outcomes and measure and report patient-relevant outcomes in trials, and clinicians may become more patient-orientated by using these outcomes in their clinical encounters.
The Fragility Index is a tool for testing robustness of randomized controlled trial results for dichotomous outcomes. It describes the minimum number of individuals in whom changing an event status ...would render a statistically significant result nonsignificant. Here we identified all randomized controlled trials in five nephrology and five general journals from 2005-2014. A total of 127 randomized controlled trials reporting at least one dichotomous statistically significant outcome (p less than 0.05) were included and the Fragility Index was calculated. Twenty randomized controlled trials had a Fragility Index of zero and were excluded from further analysis. Linear regression was performed to assess factors associated with Fragility Indexes stratified by primary or secondary outcomes. The median sample size was 134 (range 2211506) with 36 (range 5–2743) total number of events. The median Fragility Index was three (range 1–166), indicating that in half the trials the addition of three events to the treatment with the lowest number of events rendered the result nonsignificant. For primary outcome studies a doubling in total event number and sample size significantly increased the geometric mean Fragility Index by 52% and 42%, respectively. Compared to a reported p value of 0.05 to 0.01, those reporting 0.01 to 0.001 or less than 0.001 had a significant 57% and 472% increase in the median Fragility Index, respectively. Forty-one percent had a Fragility Index less than the total loss to follow-up, indicating a potential to change a trial result had all individuals been accounted for. Thus, our study highlights the need for larger randomized controlled trials with accurate accounting for loss to follow-up to adequately guide evidence-based practice.
CONTEXT The Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) equation more accurately estimates glomerular filtration rate (GFR) than the Modification of Diet in Renal Disease (MDRD) Study ...equation using the same variables, especially at higher GFR, but definitive evidence of its risk implications in diverse settings is lacking. OBJECTIVE To evaluate risk implications of estimated GFR using the CKD-EPI equation compared with the MDRD Study equation in populations with a broad range of demographic and clinical characteristics. DESIGN, SETTING, AND PARTICIPANTS A meta-analysis of data from 1.1 million adults (aged ≥ 18 years) from 25 general population cohorts, 7 high-risk cohorts (of vascular disease), and 13 CKD cohorts. Data transfer and analyses were conducted between March 2011 and March 2012. MAIN OUTCOME MEASURES All-cause mortality (84 482 deaths from 40 cohorts), cardiovascular mortality (22 176 events from 28 cohorts), and end-stage renal disease (ESRD) (7644 events from 21 cohorts) during 9.4 million person-years of follow-up; the median of mean follow-up time across cohorts was 7.4 years (interquartile range, 4.2-10.5 years). RESULTS Estimated GFR was classified into 6 categories (≥90, 60-89, 45-59, 30-44, 15-29, and <15 mL/min/1.73 m2) by both equations. Compared with the MDRD Study equation, 24.4% and 0.6% of participants from general population cohorts were reclassified to a higher and lower estimated GFR category, respectively, by the CKD-EPI equation, and the prevalence of CKD stages 3 to 5 (estimated GFR <60 mL/min/1.73 m2) was reduced from 8.7% to 6.3%. In estimated GFR of 45 to 59 mL/min/1.73 m2 by the MDRD Study equation, 34.7% of participants were reclassified to estimated GFR of 60 to 89 mL/min/1.73 m2 by the CKD-EPI equation and had lower incidence rates (per 1000 person-years) for the outcomes of interest (9.9 vs 34.5 for all-cause mortality, 2.7 vs 13.0 for cardiovascular mortality, and 0.5 vs 0.8 for ESRD) compared with those not reclassified. The corresponding adjusted hazard ratios were 0.80 (95% CI, 0.74-0.86) for all-cause mortality, 0.73 (95% CI, 0.65-0.82) for cardiovascular mortality, and 0.49 (95% CI, 0.27-0.88) for ESRD. Similar findings were observed in other estimated GFR categories by the MDRD Study equation. Net reclassification improvement based on estimated GFR categories was significantly positive for all outcomes (range, 0.06-0.13; all P < .001). Net reclassification improvement was similarly positive in most subgroups defined by age (<65 years and ≥65 years), sex, race/ethnicity (white, Asian, and black), and presence or absence of diabetes and hypertension. The results in the high-risk and CKD cohorts were largely consistent with the general population cohorts. CONCLUSION The CKD-EPI equation classified fewer individuals as having CKD and more accurately categorized the risk for mortality and ESRD than did the MDRD Study equation across a broad range of populations.
Relationship between Dialysis Modality and Mortality MCDONALD, Stephen P; MARSHALL, Mark R; JOHNSON, David W ...
Journal of the American Society of Nephrology,
2009, 2009-Jan, 2009-01-00, 20090101, Letnik:
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Mortality differences between peritoneal dialysis (PD) and hemodialysis (HD) are widely debated. In this study, mortality was compared between patients treated with PD and HD (including home HD) ...using data from 27,015 patients in the Australia and New Zealand Dialysis and Transplant Registry, 25,287 of whom were still receiving PD or HD 90 d after entry into the registry. Overall mortality rates were significantly lower during the 90- to 365-d period among those being treated with PD at day 90 (adjusted hazard ratio HR 0.89; 95% confidence interval CI 0.81 to 0.99; P < 0.001). This effect, however, varied in direction and size with the presence of comorbidities: Younger patients without comorbidities had a mortality advantage with PD treatment, but other groups did not. After 12 mo, the use of PD at day 90 was associated with significantly increased mortality (adjusted HR 1.33; 95% CI 1.24 to 1.42; P < 0.001). In a supplementary as-treated analysis, PD treatment was associated with lower mortality during the first 90 d (adjusted HR 0.67; 95% CI 0.56 to 0.81; P < 0.001). These data suggest that the effect of dialysis modality on survival for an individual depends on time, age, and presence of comorbidities. Treatment with PD may be advantageous initially but may be associated with higher mortality after 12 mo.
Although measuring albuminuria is the preferred method for defining and staging chronic kidney disease (CKD), total urine protein or dipstick protein is often measured instead.
To develop equations ...for converting urine protein-creatinine ratio (PCR) and dipstick protein to urine albumin-creatinine ratio (ACR) and to test their diagnostic accuracy in CKD screening and staging.
Individual participant-based meta-analysis.
12 research and 21 clinical cohorts.
919 383 adults with same-day measures of ACR and PCR or dipstick protein.
Equations to convert urine PCR and dipstick protein to ACR were developed and tested for purposes of CKD screening (ACR ≥30 mg/g) and staging (stage A2: ACR of 30 to 299 mg/g; stage A3: ACR ≥300 mg/g).
Median ACR was 14 mg/g (25th to 75th percentile of cohorts, 5 to 25 mg/g). The association between PCR and ACR was inconsistent for PCR values less than 50 mg/g. For higher PCR values, the PCR conversion equations demonstrated moderate sensitivity (91%, 75%, and 87%) and specificity (87%, 89%, and 98%) for screening (ACR >30 mg/g) and classification into stages A2 and A3, respectively. Urine dipstick categories of trace or greater, trace to +, and ++ for screening for ACR values greater than 30 mg/g and classification into stages A2 and A3, respectively, had moderate sensitivity (62%, 36%, and 78%) and high specificity (88%, 88%, and 98%). For individual risk prediction, the estimated 2-year 4-variable kidney failure risk equation using predicted ACR from PCR had discrimination similar to that of using observed ACR.
Diverse methods of ACR and PCR quantification were used; measurements were not always performed in the same urine sample.
Urine ACR is the preferred measure of albuminuria; however, if ACR is not available, predicted ACR from PCR or urine dipstick protein may help in CKD screening, staging, and prognosis.
National Institute of Diabetes and Digestive and Kidney Diseases and National Kidney Foundation.
Central venous catheters (CVCs) are widely used for hemodialysis but are prone to burdensome and costly bloodstream infections. We determined whether multifaceted quality improvement interventions in ...hemodialysis units can prevent hemodialysis catheter-related bloodstream infections (HDCRBSI).
Systematic review.
PubMed, EMBASE, and CENTRAL were searched from inception to April 23, 2022, to identify randomized trials, time-series analyses, and before-after studies that examined the effect of multifaceted quality improvement interventions on the incidence of HDCRBSI or access-related bloodstream infections (ARBSI) among people receiving hemodialysis outside of the intensive care unit (ICU).
Two people independently extracted data and assessed the risk of bias and quality of evidence using validated tools.
Intervention effects, validity, and characteristics of studies with the same design were compared. Differences between study designs were described.
We included 21 studies from 8,824 identified by our search. Among 15 studies that measured HDCRBSI, 2 methodologically heterogenous cluster randomized trials reported discordant intervention effects, 2 interrupted time-series analyses reported favorable interventions with discordant patterns of effect, and 11 before-after studies reported favorable interventions with a very high risk of bias. Among 6 studies that only measured ARBSI, 1 time-series analysis and 1 before-after study did not find a favorable intervention effect, and 4 before-after studies reported a favorable effect with a very high risk of bias. The overall quality of evidence was low for HDCRBSI and very low for ARBSI.
Nine definitions of HDCRBSI were used. Ten studies included hospital-based and satellite facilities but did not report separate intervention effects for each type of facility.
Multifaceted quality improvement interventions may prevent HDCRBSI outside the ICU. However, evidence supporting them is of low quality, and further carefully conducted studies are warranted.
Registered at PROSPERO with registration number CRD42021252290.
People with kidney failure rely on central venous catheters to facilitate life-sustaining hemodialysis treatments. Unfortunately, hemodialysis catheters are a common source of problematic bloodstream infections. Quality improvement programs have effectively prevented catheter-related infections in intensive care units, but it is unclear whether they can be adapted to patients using hemodialysis catheters in the community. In a systematic review that included 21 studies, we found that most quality improvement programs were reported to be successful. However, the findings were mixed among higher-quality studies, and overall the quality of evidence was low. Ongoing quality improvement programs should be complemented by more high-quality research.
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Background Urine dipsticks, an inexpensive accessible test for proteinuria, are widely advocated for mass screening; however, their diagnostic accuracy in the general community is largely unknown. ...Study Design Evaluation of diagnostic test accuracy in a cross-sectional cohort. Setting & Participants AusDiab, a representative survey of Australian adults 25 years and older (conducted in 1999/2000). Stratified cluster random sampling from 11,247 individuals participating in the biomedical examination; complete urinalysis data available for 10,944. Index Test Urine dipsticks (Bayer Multistix), with a positive result defined as ≥1+ or trace or higher protein. Reference Test Albumin-creatinine ratio (ACR), measured on a random spot urine sample. Reference test positivity was defined as ACR ≥30 mg/g or ACR ≥300 mg/g. Results Numbers of participants with ACR <30, 30-300, and ≥300 mg/g were 10,219 (93.4%), 634 (5.8%), and 91 (0.8%), respectively. The area under the receiver operating characteristic curve (AUC) for dipstick detection of ACR ≥30 mg/g was 0.8451 ± 0.0129 (SE) in men and 0.7775 ± 0.0131 in women ( P < 0.001). The AUROC for dipstick detection of ACR ≥300 mg/g was 0.9904 ± 0.0030 in men and 0.9950 ± 0.0016 in women ( P = 0.02). Dipstick result ≥1+ identified ACR ≥30 mg/g with 57.8% sensitivity (95% CI, 54.1%-61.4%) and 95.4% specificity (95% CI, 95.0%-95.8%) and identified ACR ≥300 mg/g with 98.9% sensitivity (99% CI, 92.1%-100%) and 92.6% specificity (99% CI, 92.0%-93.3%). A dipstick result of trace or higher identified ACR ≥30 mg/g with 69.4% sensitivity (95% CI, 65.9%-72.7%) and 86.8% specificity (95% CI, 86.1%-87.4%) and identified ACR ≥300 mg/g with 100% sensitivity (99% CI, 94.3%-100%) and 83.7% specificity (99% CI, 82.8%-84.6%). A negative dipstick result (less than trace) had a negative predictive value of 97.6% (95% CI, 97.2%-97.9%) for ACR ≥30 mg/g and a negative predictive value of 100% (99% CI, 99.9%-100%) for ACR ≥300 mg/g. The probability of an ACR ≥30 mg/g confirmed on laboratory investigation was 47.2% (95% CI, 43.9%-50.5%) based on a dipstick result ≥1+ and 27.1% (95% CI, 25.1%-29.2%) based on a trace or higher result. Limitations Isolated urine samples precluded assessment of test reproducibility. Urine specific gravity and pH were not recorded; therefore, the effect of urine concentration on test performance was not assessed. Conclusions A dipstick test result <1+ or less than trace has a high negative predictive value in the general community setting, with minimal risk of a missed diagnosis of macroalbuminuria. High false-positive rates emphasize the need for laboratory confirmation of positive results.
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