Diagnostic sensitivity and false positive AKI alerts through unlinking of an integrated Grampian biochemistry service

ReportPublisher PD

Review of land flow accounting methods and recommendations for further development

Robust land footprint indicators can potentially extend the consumption-based resource use indicator of the German sustainability strategy, which focuses on abiotic resources including fossil fuels, metals, and construction and industrial minerals and decidedly excludes biotic resources. Various approaches exist for quantifying the land embodied in international trade flows and consumption, i.e. the land footprint. These can be classified into a) environmental-economic accounting approaches, applying input-output analysis and tracking supply chains in monetary values, b) physical accounting approaches, using an accounting framework based on data for production, trade and utilization of agricultural and forestry commodities and tracking supply chains in physical units, and c) hybrid accounting, combining elements from both environmental-economic and physical accounting. The results of recent studies vary widely, indicating a lack of robustness and thus hampering their application in policy making. This report provides an in-depth review of the current state of the art in measuring land footprints. We identify differences in available accounting methods and indicate their shortcomings, which are mainly attributable to the product and supply chain coverage and detail, and biases introduced by the use of monetary flows as a proxy for actual physical flows. We offer options and give clear recommendations for the further development of actual and virtual global biomass and land flow accounting methods, particularly highlighting the advantages of hybrid accounting approaches as a framework for the robust and transparent assessment of land footprints associated with global biomass flows

A real-world assessment of mycophenolate mofetil for remission induction in eosinophilic granulomatosis with polyangiitis

Funding This study was not supported with specific funding.Peer reviewedPublisher PD

Intermediate and Long-Term Outcomes of Survivors of Acute Kidney Injury Episodes

Background The long-term prognosis after acute kidney injury (AKI) is variable. It is unclear how the prognosis of AKI and its relationship to prognostic factors (baseline kidney function, AKI severity, prior AKI episodes, and recovery of kidney function) change as follow-up progresses. Study Design Observational cohort study. Setting & Participants The Grampian Laboratory Outcomes Morbidity and Mortality Study II (GLOMMS-II) is a large regional population cohort with complete serial biochemistry and outcome data capture through data linkage. From GLOMMS-II, we followed up 17,630 patients hospitalized in 2003 through to 2013. Predictors AKI identified using KDIGO (Kidney Disease: Improving Global Outcomes) serum creatinine criteria, characterized by baseline kidney function (estimated glomerular filtration rate [eGFR] ≥ 60, 45-59, 30-44, and <30 mL/min/1.73 m2), AKI severity (KDIGO stage), 90-day recovery of kidney function, and prior AKI episodes. Outcomes Intermediate- (30-364 days) and long-term (1-10 years) mortality and long-term renal replacement therapy. Measurements Poisson regression in time discrete intervals. Multivariable Cox regression for those at risk in the intermediate and long term, adjusted for age, sex, baseline comorbid conditions, and acute admission circumstances. Results Of 17,630 patients followed up for a median of 9.0 years, 9,251 died. Estimated incidences of hospital AKI were 8.4% and 17.6% for baseline eGFRs ≥ 60 and <60 mL/min/1.73 m2, respectively. Intermediate-term (30-364 days) adjusted mortality HRs for AKI versus no AKI were 2.48 (95% CI, 2.15-2.88), 2.50 (95% CI, 2.04-3.06), 1.90 (95% CI, 1.51-2.39), and 1.63 (95% CI, 1.20-2.22) for eGFRs ≥ 60, 45 to 59, 30 to 44, and <30 mL/min/1.73 m2, respectively. Among 1-year survivors, long-term HRs were attenuated: 1.44 (95% CI, 1.31-1.58), 1.25 (95% CI, 1.09-1.43), 1.21 (95% CI, 1.03-1.42), and 1.08 (95% CI, 0.85-1.36), respectively. The excess long-term hazards in AKI were lower for lower baseline eGFRs (P for interaction = 0.01). Limitations Nonprotocolized observational data. No adjustment for albuminuria. Conclusions The prognostic importance of a discrete AKI episode lessens over time. Baseline kidney function is of greater long-term importance

Acute kidney injury as an independent risk factor for unplanned 90-day hospital readmissions

Background Reducing readmissions is an international priority in healthcare. Acute kidney injury (AKI) is common, serious and also a global concern. This analysis evaluates AKI as a candidate risk factor for unplanned readmissions and determines the reasons for readmissions. Methods GLOMMS-II is a large population cohort from one health authority in Scotland, combining hospital episode data and complete serial biochemistry results through data-linkage. 16453 people (2623 with AKI and 13830 without AKI) from GLOMMS-II who survived an index hospital admission in 2003 were used to identify the causes of and predict readmissions. The main outcome was “unplanned readmission or death” within 90 days of discharge. In a secondary analysis, the outcome was limited to readmissions with acute pulmonary oedema. 26 candidate predictors during the index admission included AKI (defined and staged 1–3 using an automated e-alert algorithm), prior AKI episodes, baseline kidney function, index admission circumstances and comorbidities. Prediction models were developed and assessed using multivariable logistic regression (stepwise variable selection), C statistics, bootstrap validation and decision curve analysis. Results Three thousand sixty-five (18.6%) patients had the main outcome (2702 readmitted, 363 died without readmission). The outcome was strongly predicted by AKI. Multivariable odds ratios for AKI stage 3; 2 and 1 (vs no AKI) were 2.80 (2.22–3.53); 2.23 (1.85–2.68) and 1.50 (1.33–1.70). Acute pulmonary oedema was the reason for readmission in 26.6% with AKI and eGFR < 60; and 4.0% with no AKI and eGFR ≥ 60. The best stepwise model from all candidate predictors had a C statistic of 0.698 for the main outcome. In a secondary analysis, a model for readmission with acute pulmonary oedema had a C statistic of 0.853. In decision curve analysis, AKI improved clinical utility when added to any model, although the incremental benefit was small when predicting the main outcome. Conclusions AKI is a strong, consistent and independent risk factor for unplanned readmissions – particularly readmissions with acute pulmonary oedema. Pre-emptive planning at discharge should be considered to minimise avoidable readmissions in this high risk group

Acute kidney injury—how does automated detection perform?

Background Early detection of acute kidney injury (AKI) is important for safe clinical practice. NHS England is implementing a nationwide automated AKI detection system based on changes in blood creatinine. Little has been reported on the similarities and differences of AKI patients detected by this algorithm and other definitions of AKI in the literature. Methods We assessed the NHS England AKI algorithm and other definitions using routine biochemistry in our own health authority in Scotland in 2003 (adult population 438 332). Linked hospital episode codes (ICD-10) were used to identify patients where AKI was a major clinical diagnosis. We compared how well the algorithm detected this subset of AKI patients in comparison to other definitions of AKI. We also evaluated the potential ‘alert burden’ from using the NHS England algorithm in comparison to other AKI definitions. Results Of 127 851 patients with at least one blood test in 2003, the NHS England AKI algorithm identified 5565 patients. The combined NHS England algorithm criteria detected 91.2% (87.6–94.0) of patients who had an ICD-10 AKI code and this was better than any individual AKI definition. Some of those not captured could be identified by algorithm modifications to identify AKI in retrospect after recovery, but this would not be practical in real-time. Any modifications also increased the number of alerted patients (2-fold in the most sensitive model). Conclusions The NHS England AKI algorithm performs well as a diagnostic adjunct in clinical practice. In those without baseline data, AKI may only be seen in biochemistry in retrospect, therefore proactive clinical care remains essential. An alternative algorithm could increase the diagnostic sensitivity, but this would also produce a much greater burden of patient alerts

KDIGO-based acute kidney injury criteria operate differently in hospitals and the community—findings from a large population cohort

Background Early recognition of acute kidney injury (AKI) is important. It frequently develops first in the community. KDIGO-based AKI e-alert criteria may help clinicians recognize AKI in hospitals, but their suitability for application in the community is unknown. Methods In a large renal cohort (n = 50 835) in one UK health authority, we applied the NHS England AKI ‘e-alert’ criteria to identify and follow three AKI groups: hospital-acquired AKI (HA-AKI), community-acquired AKI admitted to hospital within 7 days (CAA-AKI) and community-acquired AKI not admitted within 7 days (CANA-AKI). We assessed how AKI criteria operated in each group, based on prior blood tests (number and time lag). We compared 30-day, 1- and 5-year mortality, 90-day renal recovery and chronic renal replacement therapy (RRT). Results In total, 4550 patients met AKI e-alert criteria, 61.1% (2779/4550) with HA-AKI, 22.9% (1042/4550) with CAA-AKI and 16.0% (729/4550) with CANA-AKI. The median number of days since last blood test differed between groups (1, 52 and 69 days, respectively). Thirty-day mortality was similar for HA-AKI and CAA-AKI, but significantly lower for CANA-AKI (24.2, 20.2 and 2.6%, respectively). Five-year mortality was high in all groups, but followed a similar pattern (67.1, 64.7 and 46.2%). Differences in 5-year mortality among those not admitted could be explained by adjusting for comorbidities and restricting to 30-day survivors (hazard ratio 0.91, 95% confidence interval 0.80–1.04, versus hospital AKI). Those with CANA-AKI (versus CAA-AKI) had greater non-recovery at 90 days (11.8 versus 3.5%, P < 0.001) and chronic RRT at 5 years (3.7 versus 1.2%, P < 0.001). Conclusions KDIGO-based AKI criteria operate differently in hospitals and in the community. Some patients may not require immediate admission but are at substantial risk of a poor long-term outcome

Hip fracture incidence and mortality in chronic kidney disease

Background: Individuals on renal replacement therapy (RRT) have increased fracture risk, but risk in less advanced chronic kidney disease (CKD) is unclear. Objective: To investigate CKD associations with hip fracture incidence and mortality. Design: Record linkage cohort study (GLOMMS-II).Setting Single health region in Scotland. Participants: All individuals (>5 years) with sustained CKD stage 3-5 and those on RRT, and a 20% random sample of those with normal renal function, in the resident population in 2003. Outcome measures: Outcomes were (i) incident hip fracture measured with (a) admissions or (b) deaths, with at least 5.5 years follow-up; and (ii) post-hip fracture mortality. Unadjusted and adjusted, incident (IRR) and mortality (MRR) rate ratios, were calculated using Poisson regression. Results: Of 39 630 individuals identified in 2003 (41% males, mean age 63.3 years), 19 537 had CKD stage 3-5, 345 were on RRT, and 19 748 had normal eGFR. Hip fracture incidence, measured by admissions, was increased in CKD stage 3-5 (compared to normal eGFR), both overall (adjusted IRR 1.49 [95% CI, 1.24-1.79]) and for individual CKD stages 3a, 3b and 4. Hip fracture incidence, measured using deaths, was increased in those with CKD stage 3b and 4. Post-hip fracture mortality, was only increased in CKD stage 4. There was only a small number of individuals and events for CKD stage 5, resulting in insufficient statistical power. Conclusion: Hip fracture incidence was higher in CKD stage 3-5 compared to normal eGFR. Post-hip fracture mortality was only increased in CKD Stage 4. Reducing hip fracture incidence in CKD through regular fall and fracture risk review, should reduce overall deaths after hip fracture in the population

A menedzser újszerű szerepe az ezredforduló társadalmában

Hosmer-Lemeshow test standardised for sample size for model of 90 day readmission with acute pulmonary oedema with plots of quintiles of observed and predicted risk. (PDF 43 kb

Post-discharge kidney function is associated with subsequent ten-year renal progression risk among survivors of acute kidney injury

The extent to which renal progression after acute kidney injury (AKI) arises from an initial step drop in kidney function (incomplete recovery), or from a long-term trajectory of subsequent decline, is unclear. This makes it challenging to plan or time post-discharge follow-up. This study of 14651 hospital survivors in 2003 (1966 with AKI, 12685 no AKI) separates incomplete recovery from subsequent renal decline by using the post-discharge estimated glomerular filtration rate (eGFR) rather than the pre-admission as a new reference point for determining subsequent renal outcomes. Outcomes were sustained 30% renal decline and de novo CKD stage 4, followed from 2003-2013. Death was a competing risk. Overall, death was more common than subsequent renal decline (37.5% vs 11.3%) and CKD stage 4 (4.5%). Overall, 25.7% of AKI patients had non-recovery. Subsequent renal decline was greater after AKI (vs no AKI) (14.8% vs 10.8%). Renal decline after AKI (vs no AKI) was greatest among those with higher post-discharge eGFRs with multivariable hazard ratios of 2.29 (1.88-2.78); 1.50 (1.13-2.00); 0.94 (0.68-1.32) and 0.95 (0.64-1.41) at eGFRs of 60 or more; 45-59; 30-44 and under 30, respectively. The excess risk after AKI persisted over ten years of study, irrespective of AKI severity, or post-episode proteinuria. Thus, even if post-discharge kidney function returns to normal, hospital admission with AKI is associated with increased renal progression that persists for up to ten years. Follow-up plans should avoid false reassurance when eGFR after AKI returns to normal.The extent to which renal progression after acute kidney injury (AKI) arises from an initial step drop in kidney function (incomplete recovery), or from a long-term trajectory of subsequent decline, is unclear. This makes it challenging to plan or time post-discharge follow-up. This study of 14651 hospital survivors in 2003 (1966 with AKI, 12685 no AKI) separates incomplete recovery from subsequent renal decline by using the post-discharge estimated glomerular filtration rate (eGFR) rather than the pre-admission as a new reference point for determining subsequent renal outcomes. Outcomes were sustained 30% renal decline and de novo CKD stage 4, followed from 2003-2013. Death was a competing risk. Overall, death was more common than subsequent renal decline (37.5% vs 11.3%) and CKD stage 4 (4.5%). Overall, 25.7% of AKI patients had non-recovery. Subsequent renal decline was greater after AKI (vs no AKI) (14.8% vs 10.8%). Renal decline after AKI (vs no AKI) was greatest among those with higher post-discharge eGFRs with multivariable hazard ratios of 2.29 (1.88-2.78); 1.50 (1.13-2.00); 0.94 (0.68-1.32) and 0.95 (0.64-1.41) at eGFRs of 60 or more; 45-59; 30-44 and under 30, respectively. The excess risk after AKI persisted over ten years of study, irrespective of AKI severity, or post-episode proteinuria. Thus, even if post-discharge kidney function returns to normal, hospital admission with AKI is associated with increased renal progression that persists for up to ten years. Follow-up plans should avoid false reassurance when eGFR after AKI returns to normal