The effect of low-dose furosemide in critically ill patients with early acute kidney injury: A pilot randomized blinded controlled trial (the SPARK study)

Purpose Furosemide is commonly prescribed in acute kidney injury (AKI). Prior studies have found conflicting findings on whether furosemide modifies the course and outcome of AKI. Methods Pilot multi-center randomized blinded placebo-controlled trial in adult patients with AKI admitted to three intensive care units. Participants were randomly allocated to furosemide bolus and infusion or 0.9% saline placebo. Primary endpoint was worsening AKI, defined by the RIFLE criteria. Secondary endpoints were kidney recovery, renal replacement therapy (RRT) and adverse events. Results The trial was terminated after enrollment of 73 participants (37 to furosemide and 36 to placebo). Mean (SD) age was 61.7 (14.3), 79.5% were medical admissions, mean (SD) APACHE II score was 26.6 (7.8), 90.4% received mechanical ventilation and 61.6% received vasoactives. Groups were similar at baseline. No differences were found in the proportion with worsening AKI (43.2% vs. 37.1%, p = 0.6), kidney recovery (29.7% vs. 42.9%, p = 0.3), or RRT (27.0% s. 28.6%, p = 0.8). Adverse events, mostly electrolyte abnormalities, were more common in furosemide-treated patients (p < 0.001). Protocol deviations were common, due often to supplementary furosemide. Conclusions In this pilot trial, furosemide did not reduce the rate of worsening AKI, improve recovery or reduce RRT; however, was associated with greater electrolyte abnormalities. Trial registration ClinicalTrials.gov Identifier: NCT00978354 registered September 9, 2014

Routine use of post-bronchodilator testing in pulmonary function testing labs

Purpose: Pulmonary function tests (PFTs), including spirometry with and without post-bronchodilator (post-BD) testing, are frequently performed in the assessment of asthma, along with other obstructive airway disorders. Multiple publications over the past 15 years have noted that one in three physician-diagnosed asthma cases are not in fact asthma. In this quality assurance project, we assess whether PFT labs in Alberta have policies on post-BD testing, as extraneous and unnecessary use of post-BD testing can lead to wasted staff and patient time and unnecessary expenses to the health care system. Methods: We reviewed, in collaboration with the College of Physicians and Surgeons of Alberta and Alberta Medical Association, all PFT labs in the province of Alberta (hospital-based private not-for-profit [NFP] and private for-profit [FP] labs). This health policy study of PFT labs involved identifying the proportions and regional distribution of NFP and private FP labs in the province of Alberta while assessing post-BD policies. Each PFT lab was asked for their policy regarding spirometry and asthma diagnosis from May 1 to August 31, 2017. Results: A total of 92 PFT labs were identified in Alberta, 74 of which were private FP (independent) labs, while 18 were private NFP (public) hospital-based labs. Policies were as follows: (i) post-BD policy existed (and if so routinely performed / not routinely done); (ii) no post-BD policy; and (iii) lab chose not to participate. All 18 hospital labs responded: 10 had no policy; six had a policy or algorithm; one did not perform post-BD testing (exercise testing) and one had multiple testing sites. Of the private FP labs, three had relevant policies and/or algorithm and 10 had none. No information was provided from 61 labs. Access to PFT labs in Northern Alberta was limited. Conclusions: Lab policies surrounding post-BD testing were found to be heterogeneous in Alberta. Low response rates, despite the use of a systems approach and requests in writing and in person from FP labs, were notable. Development of a standardized policy across the province would be beneficial. Further higher-level review of the appropriateness of post-BD use in both FP and NFP PFT labs is needed