Focal Spot, Spring 2007

https://digitalcommons.wustl.edu/focal_spot_archives/1105/thumbnail.jp

Focal Spot, Winter 2005/2006

https://digitalcommons.wustl.edu/focal_spot_archives/1101/thumbnail.jp

Comparative Effectiveness of 12 Treatment Strategies for Preventing Contrast-Induced Acute Kidney Injury: A Systematic Review and Bayesian Network Meta-analysis

Background: To simultaneously evaluate the relative efficacy of multiple pharmacologic strategies for preventing contrast-induced acute kidney injury (AKI).  Study Design: Systematic review containing a Bayesian network meta-analysis of randomized controlled trials.  Setting & Population: Participants undergoing diagnostic and/or interventional procedures with contrast media.  Selection Criteria for Studies: Randomized controlled trials comparing the active drug treatments with each other or with hydration alone.  Intervention: Any of the following drugs in combination with hydration: N-acetylcysteine (NAC), theophylline (aminophylline), fenoldopam, iloprost, alprostadil, prostaglandin E1, statins, statins plus NAC, bicarbonate sodium, bicarbonate sodium plus NAC, ascorbic acid (vitamin C), tocopherol (vitamin E), α-lipoic acid, atrial natriuretic peptide, B-type natriuretic peptide, and carperitide.  Outcomes: The occurrence of contrast-induced AKI.  Results: The trial network included 150 trials with 31,631 participants and 4,182 contrast-induced AKI events assessing 12 different interventions. Compared to hydration, ORs (95% credible intervals) for contrast-induced AKI were 0.31 (0.14-0.60) for high-dose statin plus NAC, 0.37 (0.19-0.64) for high-dose statin alone, 0.37 (0.17-0.72) for prostaglandins, 0.48 (0.26-0.82) for theophylline, 0.62 (0.40-0.88) for bicarbonate sodium plus NAC, 0.67 (0.54-0.81) for NAC alone, 0.64 (0.41-0.95) for vitamins and analogues, 0.70 (0.29-1.37) for natriuretic peptides, 0.69 (0.31-1.37) for fenoldopam, 0.78 (0.59-1.01) for bicarbonate sodium, and 0.98 (0.41-2.07) for low-dose statin. High-dose statin plus NAC or high-dose statin alone were likely to be ranked the best or the second best for preventing contrast-induced AKI. The overall results were not materially changed in metaregressions or subgroup and sensitivity analyses.  Limitations: Patient-level data were unavailable; unable to include some treatment agents; low event rates; imbalanced distribution of participants among treatment strategies.  Conclusions: High-dose statins plus hydration with or without NAC might be the preferred treatment strategy to prevent contrast-induced AKI in patients undergoing diagnostic and/or interventional procedures requiring contrast media

Transjugular intrahepatic portosystemic stent-shunts: a new option in portal hypertension.

These guidelines on transjugular intrahepatic portosystemic stent-shunt (TIPSS) in the management of portal hypertension have been commissioned by the Clinical Services and Standards Committee (CSSC) of the British Society of Gastroenterology (BSG) under the auspices of the Liver Section of the BSG. The guidelines are new and have been produced in collaboration with the British Society of Interventional Radiology (BSIR) and British Association of the Study of the Liver (BASL). The guidelines development group comprises elected members of the BSG Liver Section, representation from BASL, a nursing representative and two patient representatives. The quality of evidence and grading of recommendations was appraised using the GRADE system. These guidelines are aimed at healthcare professionals considering referring a patient for a TIPSS. They comprise the following subheadings: indications; patient selection; procedural details; complications; and research agenda. They are not designed to address: the management of the underlying liver disease; the role of TIPSS in children; or complex technical and procedural aspects of TIPSS.</jats:p

Precision Nephrology Is a Non-Negligible State of Mind in Clinical Research:Remember the Past to Face the Future

CKD is a major public health problem. It is characterized by a multitude of risk factors that, when aggregated, can strongly modify outcome. While major risk factors, namely, albuminuria and low estimated glomerular filtration rate (eGFR) have been well analyzed, a large variability in disease progression still remains. This happens because (1) the weight of each risk factor varies between populations (general population or CKD cohort), countries, and single individuals and (2) response to nephroprotective drugs is so heterogeneous that a non-negligible part of patients maintains a high cardiorenal risk despite optimal treatment. Precision nephrology aims at individualizing cardiorenal prognosis and therapy. The purpose of this review is to focus on the risk stratification in different areas, such as clinical practice, population research, and interventional trials, and to describe the strategies used in observational or experimental studies to afford individual-level evidence. The future of precision nephrology is also addressed. Observational studies can in fact provide more adequate findings by collecting more information on risk factors and building risk prediction models that can be applied to each individual in a reliable fashion. Similarly, new clinical trial designs can reduce the individual variability in response to treatment and improve individual outcomes

Expanding Use of Sodium-Glucose Cotransporter-2 Inhibitor (SGLT2i) In Managing Patients with Diabetes and Chronic Kidney Disease in Primary Care

Practice Problem: In 2022, the addendum of standards of medical care in diabetes management was annotated to recommend the broader use of sodium-glucose cotransporter 2 inhibitors (SGLT2i) to treat patients with Type 2 diabetes mellitus (DM) and diabetic nephropathy. Despite the Department of Veterans Affairs’ (VA) efforts to include SLGT2i as a formulary, non-restrictive prescription in the primary care ordering menu, the overall utilization rates of SGLT2i remained relatively low in primary care. PICOT: The PICOT question that guided this project was: In patients with DM and chronic kidney disease (CKD) (P), how does an evidence-based guideline algorithm bundle (I) compared to standard care (C) affect providers’ adherence and prescribing practices of including SGLT2 inhibitors (O) within 10 weeks (T)? Evidence: An extensive evidence literature review supported that the algorithm approach with current guidelines has allowed clinicians to identify patients eligible for SGLT2i was based on comprehensive risk assessment with various comorbidities and risk factors. The guideline-based algorithm was a quick reference guide to provide clarity and indication for patients with the most significant potential benefits from SGLT2i therapy. Intervention: The algorithm bundle, designed to reflect the current guidelines, was intended to enhance primary care clinicians\u27 prescribing confidence in SGLT2i and guide better decision-making. The algorithm bundle comprised the physical laminated algorithm card, embedded reminder in the e-prescribing menu, and a focused education session for the primary care providers. Outcome: The project outcomes reflected that the algorithm bundle has clinical significance in improving prescribers’ knowledge of SGLT2i agents and practice compliance, as evidenced by a rise in SGLT2i prescriptions. Conclusion: The algorithm bundle intervention in this project resonates with the American Diabetic Association’s (2022) latest recommendation to widen indications for using SGLT2 to optimize the management of DM and CKD patients. The evidence supports using a guideline-based algorithm to guide clinicians with a comprehensive assessment of high-risk patients and a better decision-making tool. Continued efforts to educate and audit primary care providers are essential to identify potential knowledge gaps and to sustain practice compliance of using SGLT2i as part of the standard of care

Chronic kidney disease : a clinical model of premature vascular aging

Patients with chronic kidney disease (CKD) are prone to develop an accelerated vascular aging phenotype characterized by vascular calcification (VC), a major culprit of cardiovascular complications and premature death. While VC has been recognized as an active pathophysiologic process with involvement of specific mediators and effectors, the coexistence of traditional risk factors (i.e., high age, diabetes, hypertension, dyslipidemia), inflammaging stimuli and pharmacological interventions (e.g., phosphate binders, warfarin and statin therapy) adds to the complexity of the course and consequences of different types of VC (e.g., intima and media VC, micro- and macrocalcification) in the context of CKD. This work attempts to further explore the prognostic value, predictive markers as well as collateral therapeutic consequence of VC in uremic milieu. Study I explores the associations of the composites of coronary artery calcium (CAC) score, i.e., CAC density and CAC volume, with mortality risk in patients with CKD stage 5 (CKD G5). We found that while mortality risk increases with higher CAC score and CAC volume, CAC density shows an inverse-J shaped pattern, with the crude mortality rate being highest in the middle tertile of CAC density. Study II evaluates the overlapping presence of aortic valve calcium (AVC) and CAC and the prognostic value of AVC in CKD5 patients. We found a more common overlap of AVC and CAC in CKD G5 than that observed in general population. High AVC score is associated with increased all-cause mortality independent of presence of CAC, traditional risk factors and inflammation. Study III investigates phenotypic factors associated with the presence of biopsy-verified media VC in CKD G5 patients using the relaxed linear separability feature selection model. We identified through a mapping and ranking process, 17 features including novel biomarkers and traditional risk factors that can differentiate patients with media VC from those without. These results, if confirmed, may inform future investigations on media VC without the need of arterial biopsies. Study IV assesses the association of commonly prescribed phosphate binder sevelamer with gut microbial metabolites in CKD G5 patients. We found that sevelamer therapy associates with increased gut-derived uremic toxins and poor vitamin K status, suggesting potential tradeoffs of sevelamer therapy in CKD. Study V explores the plausible association between plasma dephosphorylated-uncarboxylated matrix Gla-protein (dp-ucMGP, a circulating marker of functional vitamin K deficiency), VC and mortality in CKD G5 patients. We found an independent association between high dpucMGP levels and increased mortality risk that is not modified by presence of CAC and AVC in CKD G5

Technical recommendations for clinical translation of renal MRI: a consensus project of the Cooperation in Science and Technology Action PARENCHIMA.

PURPOSE: The potential of renal MRI biomarkers has been increasingly recognised, but clinical translation requires more standardisation. The PARENCHIMA consensus project aims to develop and apply a process for generating technical recommendations on renal MRI. METHODS: A task force was formed in July 2018 focused on five methods. A draft process for attaining consensus was distributed publicly for consultation and finalised at an open meeting (Prague, October 2018). Four expert panels completed surveys between October 2018 and March 2019, discussed results and refined the surveys at a face-to-face meeting (Aarhus, March 2019) and completed a second round (May 2019). RESULTS: A seven-stage process was defined: (1) formation of expert panels; (2) definition of the context of use; (3) literature review; (4) collection and comparison of MRI protocols; (5) consensus generation by an approximate Delphi method; (6) reporting of results in vendor-neutral and vendor-specific terms; (7) ongoing review and updating. Application of the process resulted in 166 consensus statements. CONCLUSION: The process generated meaningful technical recommendations across very different MRI methods, while allowing for improvement and refinement as open issues are resolved. The results are likely to be widely supported by the renal MRI community and thereby promote more harmonisation