Effect of multiple episodes of Acute Kidney Injury on mortality:an observational study

Background Patients who survive an episode of acute kidney injury (AKI) are more likely to have further episodes of AKI. AKI is associated with increased mortality, with a further increase with recurrent episodes. It is not clear whether this is due to AKI or as a result of other patient characteristics. The aim of this study was to establish whether recurrence of AKI is an independent risk factor for mortality or if excess mortality is explained by other factors. Methods This observational cohort study included adult people from the Tayside region of Scotland, with an episode of AKI between 1 January 2009 and 31 December 2009. AKI was defined using the creatinine-based Kidney Disease: Improving Global Outcomes definition. Associations between recurrent AKI and mortality were examined using a Cox proportional hazards model. Results Survival was worse in the group identified to have recurrent AKI compared with those with a single episode of AKI [hazard ratio = 1.49, 95% confidence interval (CI) 1.37–1.63; P

Conducting and reporting trials for older people

Randomised controlled trials provide the most rigorous test of efficacy and effectiveness for interventions used in healthcare. They underpin much of clinical practice, yet older people are often excluded from studies, resulting in uncertainty about risks and benefits of new treatments. Encouraging inclusion of older people in randomised controlled trials and reporting of trial results in a rigorous manner is a key function of clinical geriatrics journals such as Age and Ageing. This article provides practical advice on how to report randomised controlled trials that are targeted at older people. Some of these issues are generic, but there are specific requirements which apply to most studies of older people. Recording and reporting basic characteristics of recruits in terms of physical function, cognition, comorbidity and/or frailty is vital to allow proper interpretation of the external validity of the trial. Adverse effects should include consideration of common geriatric problems including falls. Authors should follow the CONSORT reporting guidelines (CONsolidated Standards Of Reporting Trials) to enhance the transparency and quality of their manuscript

Should chronic metabolic acidosis be treated in older people with chronic kidney disease?

Metabolic acidosis is common in advanced chronic kidney disease, and has been associated with a range of physiological derangements of importance to the health of older people. These include associations with skeletal muscle weakness, cardiovascular risk factors, and bone and mineral disorders that may lead to fragility fractures. Although metabolic acidosis is associated with accelerated decline in kidney function, end stage renal failure is a much less common outcome in older, frail patients than cardiovascular death. Correction of metabolic acidosis using bicarbonate therapy is commonly employed, but the existing evidence is insufficient to know whether such therapy is of net benefit to older people. Bicarbonate is bulky and awkward to take, may impose additional sodium load with effects on fluid retention and blood pressure, and may cause gastrointestinal side effects. Trial data to date suggests potential benefits of bicarbonate therapy on progression of renal disease and nutrition, but trials have not as yet been published examining the effect of bicarbonate therapy across a range of domains relevant to the health of older people. Fortunately, a number of trials are now underway that should allow us to ascertain whether bicarbonate therapy can improve physical function, quality of life, vascular, bone and kidney health in older people, and hence decide whether any benefits seen outweigh adverse effects and additional treatment burden in this vulnerable group of patients

Selecting Potential Pharmacological Interventions in Sarcopenia

Sarcopenia of age is prevalent and costly and proven pharmacological interventions are currently lacking. The pathophysiology of sarcopenia is incompletely understood but appears to involve multiple pathways, including inflammation, hormonal dysregulation, impaired regeneration, mitochondrial dysfunction and denervation. There are several ways in which we might select potential pharmacological interventions for testing in clinical trials. These include a 'bottom-up' approach using basic science to elucidate the molecular processes involved and identify potential targets from this knowledge-a strategy that has led to the development of myostatin inhibitors. A 'top-down' approach might use observational data to examine the association between physical function and use of certain medications, such as the association between angiotensin-converting enzyme inhibitors with slower decline in physical function. Once a pharmacological intervention has been proposed, efficacy must be demonstrated in this complex multi-morbid population. Both muscle mass and muscle function need to be measured as outcomes, but these outcomes require large sample sizes and sufficient follow-up to detect change. Biomarkers that can predict the response of sarcopenia to intervention after a short time would greatly assist our ability to select candidate interventions in short proof-of-concept trials. Further development of trial methods is required to accelerate progress in this important area of medicine for older people.</p

Social, environmental and psychological factors associated with objective physical activity levels in the over 65s

Objective: To assess physical activity levels objectively using accelerometers in community dwelling over 65 s and to examine associations with health, social, environmental and psychological factors. Design: Cross sectional survey. Setting: 17 general practices in Scotland, United Kingdom. Participants: Random sampling of over 65 s registered with the practices in four strata young-old (65–80 years), old-old (over 80 years), more affluent and less affluent groups. Main Outcome Measures: Accelerometry counts of activity per day. Associations between activity and Theory of Planned Behaviour variables, the physical environment, health, wellbeing and demographic variables were examined with multiple regression analysis and multilevel modelling. Results: 547 older people (mean (SD) age 79(8) years, 54% female) were analysed representing 94% of those surveyed. Accelerometry counts were highest in the affluent younger group, followed by the deprived younger group, with lowest levels in the deprived over 80 s group. Multiple regression analysis showed that lower age, higher perceived behavioural control, the physical function subscale of SF-36, and having someone nearby to turn to were all independently associated with higher physical activity levels (R2 = 0.32). In addition, hours of sunshine were independently significantly associated with greater physical activity in a multilevel model. Conclusions: Other than age and hours of sunlight, the variables identified are modifiable, and provide a strong basis for the future development of novel multidimensional interventions aimed at increasing activity participation in later life.Peer reviewe

Research note – barriers and solutions to linking and using health and social care data in Scotland

Integration of health and social care will require integrated data to drive service evaluation, design, joint working and research. We describe the results of a Scottish meeting of key stakeholders in this area. Potential uses for linked data included understanding client populations, mapping trajectories of dependency, identifying at risk groups, predicting required capacity for future service provision, and research to better understand the reciprocal interactions between health, social circumstances and care. Barriers to progress included lack of analytical capacity, incomplete understanding of data provenance and quality, intersystem incompatibility and issues of consent for data sharing. Potential solutions included better understanding the content, quality and provenance of social care data; investment in analytical capacity; improving communication between data providers and users in health and social care; clear guidance to systems developers and procurers; and enhanced engagement with the public. We plan a website for communication across Scotland on health and social care data linkage, educational resources for front line staff and researchers, plus further events for training and information dissemination. We believe that these processes hold lessons for other countries with an interest in linking health and social care data, as well as for cross-sector data linkage initiatives in general.</p

Effect of allopurinol on phosphocreatine recovery and muscle function in older people with impaired physical function:a randomised controlled trial

Background: Allopurinol has vascular antioxidant effects and participates in purinergic signalling within muscle. We tested whether allopurinol could improve skeletal muscle energetics and physical function in older people with impaired physical performance. Methods: We conducted a randomised, double blind, parallel group, placebo-controlled trial, comparing 20 weeks of allopurinol 600 mg once daily versus placebo. We recruited community-dwelling participants aged 65 and over with baseline 6-min walk distance of &lt;400 m and no contraindications to magnetic resonance imaging scanning. Outcomes were measured at baseline and 20 weeks. The primary outcome was post-exercise phosphocreatine (PCr) recovery rate measured using 31P magnetic resonance spectroscopy of the calf. Secondary outcomes included 6-min walk distance, short physical performance battery (SPPB), lean body mass measured by bioimpedance, endothelial function and quality of life. Results: In total, 124 participants were randomised, mean age 80 (SD 6) years. A total of 59 (48%) were female, baseline 6-min walk distance was 293 m (SD 80 m) and baseline SPPB was 8.5 (SD 2.0). Allopurinol did not significantly improve PCr recovery rate (treatment effect 0.10 units [95% CI, −0.07 to 0.27], P = 0.25). No significant changes were seen in endothelial function, quality of life, lean body mass or SPPB. Allopurinol improved 6-min walk distance (treatment effect 25 m [95% 4–46, P = 0.02]). This was more pronounced in those with high baseline oxidative stress and urate. Conclusion: Allopurinol improved 6-min walk distance but not PCr recovery rate in older people with impaired physical function. Antioxidant strategies to improve muscle function for older people may need to be targeted at subgroups with high baseline oxidative stress. </p