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These findings illustrate that AKI is common among patients with sepsis in the ICU and patients may often present with AKI early after admission with sepsis. Acute kidney injury (AKI) is a common complication of sepsis and significantly influences patient outcomes [[4]]. While preventing AKI remains commendable, in those who ultimately develop sepsis, efforts to improve recovery and outcomes of AKI (i.e. consequences of AKI) are then more likely to be impactful than efforts to prevent SA-AKI [[10]]. The term sepsis-associated AKI (SA-AKI) serves as an operational unification of AKI within the context of sepsis. [Extracted from the article]

Importance: Contrast-associated acute kidney injury (AKI) is a common complication of coronary angiography and percutaneous coronary intervention (PCI) that has been associated with high costs and adverse long-term outcomes.Objective: To determine whether a multifaceted intervention is effective for the prevention of AKI after coronary angiography or PCI.Design, Setting, and Participants: A stepped-wedge, cluster randomized clinical trial was conducted in Alberta, Canada, that included all invasive cardiologists at 3 cardiac catheterization laboratories who were randomized to various start dates for the intervention between January 2018 and September 2019. Eligible patients were aged 18 years or older who underwent nonemergency coronary angiography, PCI, or both; who were not undergoing dialysis; and who had a predicted AKI risk of greater than 5%. Thirty-four physicians performed 7820 procedures among 7106 patients who met the inclusion criteria. Participant follow-up ended in November 2020.Interventions: During the intervention period, cardiologists received educational outreach, computerized clinical decision support on contrast volume and hemodynamic-guided intravenous fluid targets, and audit and feedback. During the control (preintervention) period, cardiologists provided usual care and did not receive the intervention.Main Outcomes and Measures: The primary outcome was AKI. There were 12 secondary outcomes, including contrast volume, intravenous fluid administration, and major adverse cardiovascular and kidney events. The analyses were conducted using time-adjusted models.Results: Of the 34 participating cardiologists who were divided into 8 clusters by practice group and center, the intervention group included 31 who performed 4327 procedures among 4032 patients (mean age, 70.3 [SD, 10.7] years; 1384 were women [32.0%]) and the control group included 34 who performed 3493 procedures among 3251 patients (mean age, 70.2 [SD, 10.8] years; 1151 were women [33.0%]). The incidence of AKI was 7.2% (310 events after 4327 procedures) during the intervention period and 8.6% (299 events after 3493 procedures) during the control period (between-group difference, -2.3% [95% CI, -0.6% to -4.1%]; odds ratio [OR], 0.72 [95% CI, 0.56 to 0.93]; P = .01). Of 12 prespecified secondary outcomes, 8 showed no significant difference. The proportion of procedures in which excessive contrast volumes were used was reduced to 38.1% during the intervention period from 51.7% during the control period (between-group difference, -12.0% [95% CI, -14.4% to -9.4%]; OR, 0.77 [95% CI, 0.65 to 0.90]; P = .002). The proportion of procedures in eligible patients in whom insufficient intravenous fluid was given was reduced to 60.8% during the intervention period from 75.1% during the control period (between-group difference, -15.8% [95% CI, -19.7% to -12.0%]; OR, 0.68 [95% CI, 0.53 to 0.87]; P = .002). There were no significant between-group differences in major adverse cardiovascular events or major adverse kidney events.Conclusions and Relevance: Among cardiologists randomized to an intervention including clinical decision support with audit and feedback, patients undergoing coronary procedures during the intervention period were less likely to develop AKI compared with those treated during the control period, with a time-adjusted absolute risk reduction of 2.3%. Whether this intervention would show efficacy outside this study setting requires further investigation.Trial Registration: ClinicalTrials.gov Identifier: NCT03453996. [ABSTRACT FROM AUTHOR]

Source Citation: Vazquez MA, Oliver G, Amarasingham R, et al; ICD-Pieces Study Group. Pragmatic trial of hospitalization rate in chronic kidney disease. N Engl J Med. 2024;390:1196-1206. 38598574 Clinical Impact Ratings: GIM/FP/GP: 6 out of 7 Cardiology: 5 out of 7 Endocrinology: 5 out of 7 Nephrology: 7 out of 7 [ABSTRACT FROM AUTHOR]

Low estradiol status is associated with increased cardiovascular risk. We sought to determine the association between heart rate variability (HRV), a marker of cardiovascular risk, at baseline and in response to stressor as a function of menopausal status, menstrual cycle phase and estradiol level. Forty‐one healthy women (13 postmenopausal, 28 premenopausal) were studied. Eleven premenopausal women were additionally studied in the high and low estradiol phases of the menstrual cycle. HRV was calculated by spectral power analysis (low Frequency (LF), high frequency (HF) and LF:HF) at baseline and in response to graded Angiotensin II (AngII) infusion. The primary outcomes were differences in HRV at baseline and in response to AngII. Compared to premenopausal women in the low estradiol phase, postmenopausal women demonstrated lower baseline LF (p = 0.01) and HF (p < 0.001) measures, which were not significant after adjustment for age and BMI. In response to AngII, a decrease in cardioprotective HRV (ΔHF = −0.43 ± 0.46 ln ms2, p = 0.005 vs. baseline) was observed in postmenopausal women versus premenopausal women. Baseline HRV parameters did not differ by menstrual phase in premenopausal women. During the low estradiol phase, no differences were observed in the HRV response to AngII challenge. In contrast, women in the high estradiol phase were unable to maintain HRV (ΔLF = −0.07 ± 0.46 ln ms2, p = 0.048 response vs. baseline, ΔHF = −0.33 ± 0.74 ln ms2, p = 0.048 response vs. baseline). No association was observed between any measure of HRV and estradiol level. Menopausal status and the high estradiol phase in premenopausal women were associated with reduced HRV, a marker of cardiovascular risk. Understanding the role of estradiol in the modulation of cardiac autonomic tone may help guide risk reduction strategies in women. [ABSTRACT FROM AUTHOR]

Background Young women with end-stage kidney disease (ESKD) have early menopause compared with women in the general population and the highest mortality among the dialysis population. We hypothesized that low estrogen status was associated with death in women with ESKD. Methods We measured estradiol and sex hormone levels in female ESKD patients initiating hemodialysis from 2005 to 2012 in four Canadian centers. We divided women into quintiles based on estradiol levels and tested for associations between the estradiol level and cardiovascular (CV), non-CV and all-cause mortality. Participants were further dichotomized by age. Results A total of 482 women (60 ± 15 years of age, 53% diabetic, estradiol 116 ± 161 pmol/L) were followed for a mean of 2.9 years, with 237 deaths (31% CV). Estradiol levels were as follows (mean ± standard deviation): Quintile 1: 19.3 ± 0.92 pmol/L; Quintile 2: 34.6 ± 6.6 pmol/L; Quintile 3: 63.8 ± 10.6 pmol/L; Quintile 4: 108.9 ± 19.3; Quintile 5: 355 ± 233 pmol/L. Compared with Quintile 1, women in Quintiles 4 and 5 had significantly higher adjusted all-cause mortality {hazard ratio [HR] 2.12 [95% confidence interval (CI) 1.38–3.25] and 1.92 [1.19–3.10], respectively}. Similarly, compared with Quintile 1, women in Quintile 5 had higher non-CV mortality [HR 2.16 (95% CI 1.18–3.96)]. No associations were observed between estradiol levels and CV mortality. When stratified by age, higher quintiles were associated with greater all-cause mortality (P for trend <0.001) and non-CV mortality (P for trend = 0.02), but not CV mortality in older women. Conclusions In women with ESKD treated with hemodialysis, higher estradiol levels were associated with greater all-cause and non-CV mortality. Further studies are required to determine the mechanism for the observed increased risk. [ABSTRACT FROM AUTHOR]

Background Improving recognition of patients at increased risk of acute kidney injury (AKI) in the community may facilitate earlier detection and implementation of proactive prevention measures that mitigate the impact of AKI. The aim of this study was to develop and externally validate a practical risk score to predict the risk of AKI in either hospital or community settings using routinely collected data. Methods Routinely collected linked datasets from Tayside, Scotland, were used to develop the risk score and datasets from Kent in the UK and Alberta in Canada were used to externally validate it. AKI was defined using the Kidney Disease: Improving Global Outcomes serum creatinine–based criteria. Multivariable logistic regression analysis was performed with occurrence of AKI within 1 year as the dependent variable. Model performance was determined by assessing discrimination (C-statistic) and calibration. Results The risk score was developed in 273 450 patients from the Tayside region of Scotland and externally validated into two populations: 218 091 individuals from Kent, UK and 1 173 607 individuals from Alberta, Canada. Four variables were independent predictors for AKI by logistic regression: older age, lower baseline estimated glomerular filtration rate, diabetes and heart failure. A risk score including these four variables had good predictive performance, with a C-statistic of 0.80 [95% confidence interval (CI) 0.80–0.81] in the development cohort and 0.71 (95% CI 0.70–0.72) in the Kent, UK external validation cohort and 0.76 (95% CI 0.75–0.76) in the Canadian validation cohort. Conclusion We have devised and externally validated a simple risk score from routinely collected data that can aid both primary and secondary care physicians in identifying patients at high risk of AKI. [ABSTRACT FROM AUTHOR]

Acute kidney injury (AKI), once viewed predominantly as a self-limited and reversible condition, is now recognized as a growing problem associated with significant risks of adverse long-term health outcomes. Many cohort studies have established important relationships between AKI and subsequent risks of recurrent AKI, hospital re-admission, morbidity and mortality from cardiovascular disease and cancer, as well as the development of chronic kidney disease and end-stage kidney disease. In both high-income countries (HICs) and low-income or middle-income countries (LMICs), several challenges exist in providing high-quality, patient-centered care following AKI. Despite advances in our understanding about the long-term risks following AKI, large gaps in knowledge remain about effective interventions that can improve the outcomes of patients. Therapies for high blood pressure, glycaemic control (for patients with diabetes), renin-angiotensin inhibition and statins might be important in improving long-term cardiovascular and kidney outcomes after AKI. Novel strategies that incorporate risk stratification approaches, educational interventions and new models of ambulatory care following AKI have been described, and some of these are now being implemented and evaluated in clinical studies in HICs. Care for AKI in LMICs must overcome additional barriers due to limited resources for diagnosis and management. [ABSTRACT FROM AUTHOR]

Background: Acute kidney injury (AKI) is associated with increased morbidity and mortality after liver resection. Patients with hepatocellular carcinoma (HCC) have a higher risk of AKI owing to the underlying association between hepatic and renal dysfunction. Use of the Acute Kidney Injury Network (AKIN) diagnostic criteria is recommended for patients with cirrhosis, but remains poorly studied following liver resection. We compared the prognostic value of the AKIN creatinine and urine output criteria in terms of postoperative outcomes following liver resection for HCC.Methods: All patients who underwent a liver resection for HCC from January 2010 to June 2016 were included. We used AKIN urine output and creatinine criteria to assess for AKI within 48 hours of surgery.Results: Eighty liver resections were performed during the study period. Cirrhosis was confirmed in 80%. Median hospital stay was 9 (interquartile range 7–12) days, and 30-day mortality was 2.5%. The incidence of AKI was higher based on the urine output than on the creatinine criterion (53.8% v. 20%), and was associated with prolonged hospitalization and 30-day postoperative mortality when defined by serum creatinine (hospital stay: 11.2 v. 20.1 d, p = 0.01; mortality: 12.5% v. 0%, p < 0.01), but not urine output (hospital stay: 15.6 v. 10 d, p = 0.05; mortality: 2.3% v. 2.7%, p > 0.99).Conclusion: The urine output criterion resulted in an overestimation of AKI and compromised the prognostic value of AKIN criteria. Revision may be required to account for the exacerbated physiologic postoperative reduction in urine output in patients with HCC. [ABSTRACT FROM AUTHOR]

Importance: Some patients will develop chronic kidney disease after a hospitalization with acute kidney injury; however, no risk-prediction tools have been developed to identify high-risk patients requiring follow-up.Objective: To derive and validate predictive models for progression of acute kidney injury to advanced chronic kidney disease.Design, Setting, and Participants: Data from 2 population-based cohorts of patients with a prehospitalization estimated glomerular filtration rate (eGFR) of more than 45 mL/min/1.73 m2 and who had survived hospitalization with acute kidney injury (defined by a serum creatinine increase during hospitalization > 0.3 mg/dL or > 50% of their prehospitalization baseline), were used to derive and validate multivariable prediction models. The risk models were derived from 9973 patients hospitalized in Alberta, Canada (April 2004-March 2014, with follow-up to March 2015). The risk models were externally validated with data from a cohort of 2761 patients hospitalized in Ontario, Canada (June 2004-March 2012, with follow-up to March 2013).Exposures: Demographic, laboratory, and comorbidity variables measured prior to discharge.Main Outcomes and Measures: Advanced chronic kidney disease was defined by a sustained reduction in eGFR less than 30 mL/min/1.73 m2 for at least 3 months during the year after discharge. All participants were followed up for up to 1 year.Results: The participants (mean [SD] age, 66 [15] years in the derivation and internal validation cohorts and 69 [11] years in the external validation cohort; 40%-43% women per cohort) had a mean (SD) baseline serum creatinine level of 1.0 (0.2) mg/dL and more than 20% had stage 2 or 3 acute kidney injury. Advanced chronic kidney disease developed in 408 (2.7%) of 9973 patients in the derivation cohort and 62 (2.2%) of 2761 patients in the external validation cohort. In the derivation cohort, 6 variables were independently associated with the outcome: older age, female sex, higher baseline serum creatinine value, albuminuria, greater severity of acute kidney injury, and higher serum creatinine value at discharge. In the external validation cohort, a multivariable model including these 6 variables had a C statistic of 0.81 (95% CI, 0.75-0.86) and improved discrimination and reclassification compared with reduced models that included age, sex, and discharge serum creatinine value alone (integrated discrimination improvement, 2.6%; 95% CI, 1.1%-4.0%; categorical net reclassification index, 13.5%; 95% CI, 1.9%-25.1%) or included age, sex, and acute kidney injury stage alone (integrated discrimination improvement, 8.0%; 95% CI, 5.1%-11.0%; categorical net reclassification index, 79.9%; 95% CI, 60.9%-98.9%).Conclusions and Relevance: A multivariable model using routine laboratory data was able to predict advanced chronic kidney disease following hospitalization with acute kidney injury. The utility of this model in clinical care requires further research. [ABSTRACT FROM AUTHOR]

Background: The implementation of new serum creatinine (SCr)-based criteria for acute kidney injury (AKI) has brought to light several areas of uncertainty in patients with cirrhosis. Study Design: Population-based cohort study. Setting & Participants: Adults with cirrhosis hospitalized between 2002–2012. Predictor: We aimed to address the prognostic implications of the new AKI criteria in cirrhosis. Outcomes: Baseline kidney function was defined from all outpatient SCr within 3 months before hospitalization. Cox proportional hazards models were fit to examine associations between AKI, renal recovery and all-cause mortality. Results: 4,733 patients were studied. The 30-day mortality was higher for participants with AKI (43.9% vs 8.5%; p-value<0.001), and increased with AKI severity. The highest incidence of AKI occurred when the lowest SCr within the three months prior to admission was used to define baseline. The hazard ratio for mortality using the lowest SCr within 3 months and the closest pre-admission SCr (definition suggested by the recent consensus guideline) were similar, validating the use of the latter measure. As compared to patients without AKI, stage 1 AKI with maximum SCr ≤132 mmol/L remained associated with a 3.5-fold increased hazard of death at 30 days (95% CI 2.6 to 4.7). Limitations: As an observational study, the results were vulnerable to residual confounding and ascertainment bias in the use of laboratory data to identify AKI. We did not have access to liver function or disease etiology variables and were unable to adjust for these in our analyses. Conclusions: These results confirm the graded relationship between AKI severity, renal recovery, and mortality and further clarify previously discordant reports about the prognostic relevance of new AKI criteria in patients with cirrhosis. [ABSTRACT FROM AUTHOR]

Purpose: Patient-reported outcome measures (PROMs) such as the Neurological Disorders Depression Inventory in Epilepsy (NDDI-E), a 6-item epilepsy-specific PROM, is used to screen for major depressive disorder symptoms for patients with epilepsy (PWE). The validity and interpretation of PROMs can be affected by differential item functioning (DIF), which occurs when subgroups of patients with the same underlying health status respond to and interpret questions about their health status differently. This study aims to determine whether NDDI-E items exhibit DIF and to identify subgroups of PWE that exhibit DIF in NDDI-E items.Data were from the Calgary Comprehensive Epilepsy Program database, a clinical registry of adult PWE in Calgary, Canada. A tree-based partial credit model based on recursive partitioning (PCTree) was used to identify subgroups that exhibit DIF on NDDI-E items using patients’ characteristics as covariates. Differences in the identified subgroups were characterized using multinomial logistic regression.Of the 1,576 patients in this cohort, 806 (51.1%) were female, and the median age was 38.0 years. PCTree identified four patient subgroups defined by employment status, age, and sex. Subgroup 1 were unemployed patients ≤ 26 years old, subgroup 2 were unemployed patients > 26 years, subgroup 3 were employed females, while subgroup 4 were employed male patients. The subgroups exhibited significant differences on education level, comorbidity index scores, marital status, type of epilepsy, and driving status.PWE differed in their interpretation and responses to questions about their depression symptoms, and these differences were a function of sociodemographic and clinical characteristics.Methods: Patient-reported outcome measures (PROMs) such as the Neurological Disorders Depression Inventory in Epilepsy (NDDI-E), a 6-item epilepsy-specific PROM, is used to screen for major depressive disorder symptoms for patients with epilepsy (PWE). The validity and interpretation of PROMs can be affected by differential item functioning (DIF), which occurs when subgroups of patients with the same underlying health status respond to and interpret questions about their health status differently. This study aims to determine whether NDDI-E items exhibit DIF and to identify subgroups of PWE that exhibit DIF in NDDI-E items.Data were from the Calgary Comprehensive Epilepsy Program database, a clinical registry of adult PWE in Calgary, Canada. A tree-based partial credit model based on recursive partitioning (PCTree) was used to identify subgroups that exhibit DIF on NDDI-E items using patients’ characteristics as covariates. Differences in the identified subgroups were characterized using multinomial logistic regression.Of the 1,576 patients in this cohort, 806 (51.1%) were female, and the median age was 38.0 years. PCTree identified four patient subgroups defined by employment status, age, and sex. Subgroup 1 were unemployed patients ≤ 26 years old, subgroup 2 were unemployed patients > 26 years, subgroup 3 were employed females, while subgroup 4 were employed male patients. The subgroups exhibited significant differences on education level, comorbidity index scores, marital status, type of epilepsy, and driving status.PWE differed in their interpretation and responses to questions about their depression symptoms, and these differences were a function of sociodemographic and clinical characteristics.Results: Patient-reported outcome measures (PROMs) such as the Neurological Disorders Depression Inventory in Epilepsy (NDDI-E), a 6-item epilepsy-specific PROM, is used to screen for major depressive disorder symptoms for patients with epilepsy (PWE). The validity and interpretation of PROMs can be affected by differential item functioning (DIF), which occurs when subgroups of patients with the same underlying health status respond to and interpret questions about their health status differently. This study aims to determine whether NDDI-E items exhibit DIF and to identify subgroups of PWE that exhibit DIF in NDDI-E items.Data were from the Calgary Comprehensive Epilepsy Program database, a clinical registry of adult PWE in Calgary, Canada. A tree-based partial credit model based on recursive partitioning (PCTree) was used to identify subgroups that exhibit DIF on NDDI-E items using patients’ characteristics as covariates. Differences in the identified subgroups were characterized using multinomial logistic regression.Of the 1,576 patients in this cohort, 806 (51.1%) were female, and the median age was 38.0 years. PCTree identified four patient subgroups defined by employment status, age, and sex. Subgroup 1 were unemployed patients ≤ 26 years old, subgroup 2 were unemployed patients > 26 years, subgroup 3 were employed females, while subgroup 4 were employed male patients. The subgroups exhibited significant differences on education level, comorbidity index scores, marital status, type of epilepsy, and driving status.PWE differed in their interpretation and responses to questions about their depression symptoms, and these differences were a function of sociodemographic and clinical characteristics.Conclusion: Patient-reported outcome measures (PROMs) such as the Neurological Disorders Depression Inventory in Epilepsy (NDDI-E), a 6-item epilepsy-specific PROM, is used to screen for major depressive disorder symptoms for patients with epilepsy (PWE). The validity and interpretation of PROMs can be affected by differential item functioning (DIF), which occurs when subgroups of patients with the same underlying health status respond to and interpret questions about their health status differently. This study aims to determine whether NDDI-E items exhibit DIF and to identify subgroups of PWE that exhibit DIF in NDDI-E items.Data were from the Calgary Comprehensive Epilepsy Program database, a clinical registry of adult PWE in Calgary, Canada. A tree-based partial credit model based on recursive partitioning (PCTree) was used to identify subgroups that exhibit DIF on NDDI-E items using patients’ characteristics as covariates. Differences in the identified subgroups were characterized using multinomial logistic regression.Of the 1,576 patients in this cohort, 806 (51.1%) were female, and the median age was 38.0 years. PCTree identified four patient subgroups defined by employment status, age, and sex. Subgroup 1 were unemployed patients ≤ 26 years old, subgroup 2 were unemployed patients > 26 years, subgroup 3 were employed females, while subgroup 4 were employed male patients. The subgroups exhibited significant differences on education level, comorbidity index scores, marital status, type of epilepsy, and driving status.PWE differed in their interpretation and responses to questions about their depression symptoms, and these differences were a function of sociodemographic and clinical characteristics. [ABSTRACT FROM AUTHOR]

The article describes the case of a 77-year-old woman who was diagnosed with hyponatremia and polyuria secondary to unilateral stenosis of the renal artery. Her symptoms included malaise, vomiting, and decreased oral intake. Findings on presentation included hypertension, hypovolemia, and an elevated serum creatinine level. The association between hyponatremic-hypertensive syndrome and elevated renin activity generated by the ischemic kidney is also explored.

The article focuses on a study to determine the association of age with the likelihood of treatment of kidney failure. A community-based cohort study of adults in Alberta, Canada, who had outpatient estimated glomerular filtration rate measured between May 1, 2002 and March 31, 2008 and who did not require renal replacement therapy at baseline, was conducted. Main outcomes included adjusted rates of treated kidney failure, untreated kidney failure and death. The study concluded that in Alberta, Canada, rates of untreated kidney failure are significantly higher in older compared with younger individuals.

Acute kidney injury (AKI) is associated with high morbidity and mortality and consumes substantial health-care resources, particularly when renal replacement therapy is required. Randomized controlled trials (RCTs) have not identified the optimal mode of renal replacement for AKI in terms of clinically relevant endpoints such as patient survival or recovery of renal function. As for other complex health interventions, the costs and consequences of AKI treatment are relevant to health-care providers and decision makers aiming to maximize health outcomes despite fixed health resources. Studies from several different centers suggest that continuous renal replacement therapy (CRRT) is more costly than intermittent hemodialysis and less economically attractive than even intensive intermittent dialysis. On the other hand, while the incremental costs of providing CRRT are significant, they remain relatively small compared with the projected costs of providing chronic dialysis to survivors who do not recover renal function. Even small differences in the risk of chronic dialysis in survivors are likely to determine the economic attractiveness of the different types of renal replacement therapies. To clarify the true incremental cost-effectiveness of these therapies, future RCTs should collect data on long-term survival, the need for chronic dialysis, and detailed information on costs. [ABSTRACT FROM AUTHOR]

Background: Administrative health care databases offer an efficient and accessible, though as-yet unvalidated, approach to studying outcomes of patients with chronic kidney disease and end-stage renal disease (ESRD). The objective of this study is to determine the validity of outpatient physician billing derived algorithms for defining chronic dialysis compared to a reference standard ESRD registry. Methods: A cohort of incident dialysis patients (Jan. 1 - Dec. 31, 2008) and prevalent chronic dialysis patients (Jan 1, 2008) was selected from a geographically inclusive ESRD registry and administrative database. Four administrative data definitions were considered: at least 1 outpatient claim, at least 2 outpatient claims, at least 2 outpatient claims at least 90 days apart, and continuous outpatient claims at least 90 days apart with no gap in claims greater than 21 days. Measures of agreement of the four administrative data definitions were compared to a reference standard (ESRD registry). Basic patient characteristics are compared between all 5 patient groups. Results: 1,118,097 individuals formed the overall population and 2,227 chronic dialysis patients were included in the ESRD registry. The three definitions requiring at least 2 outpatient claims resulted in kappa statistics between 0.60-0.80 indicating "substantial" agreement. "At least 1 outpatient claim" resulted in "excellent" agreement with a kappa statistic of 0.81. Conclusions: Of the four definitions, the simplest (at least 1 outpatient claim) performed comparatively to other definitions. The limitations of this work are the billing codes used are developed in Canada, however, other countries use similar billing practices and thus the codes could easily be mapped to other systems. Our reference standard ESRD registry may not capture all dialysis patients resulting in some misclassification. The registry is linked to on-going care so this is likely to be minimal. The definition utilized will vary with the research objective. [ABSTRACT FROM AUTHOR]

The article focuses on a study which investigated the association of estimated glomerular filtration rate (EGFR) and proteinuria with the risks of acute kidney injury and subsequent adverse clinical outcomes. Adults aged 18 years and more with a history of at least one outpatient measurement of serum creatinine and one of proteinuria within Alberta were considered in the study from May 1, 2002 to December 31, 2006. Results indicate that the risk of admission with acute kidney injury rose with the presence and severity of proteinuria and reduced eGFR.

To determine whether acute kidney injury results in later long-term decline in kidney function we measured changes in kidney function over a 3-year period in adults undergoing coronary angiography who had serum creatinine measurements as part of their clinical care. Acute kidney injury was categorized by the magnitude of increase in serum creatinine (mild (50-99% or 0.3 mg/dl) and moderate or severe (100%)) within 7 days of coronary angiography. Compared to patients without acute kidney injury, the adjusted odds of a sustained decline in kidney function at 3 months following angiography increased more than 4-fold for patients with mild to more than 17-fold for those with moderate or severe acute kidney injury. Among those with an estimated glomerular filtration rate after angiography less than 90 ml/min per 1.73 m2, the subsequent adjusted mean rate of decline in estimated glomerular filtration rate during long-term follow-up (all normalized to 1.73 m2 per year) was 0.2 ml/min in patients without acute kidney injury, 0.8 ml/min following mild injury, and 2.8 ml/min following moderate to severe acute kidney injury. Thus, acute kidney injury following coronary angiography is associated with a sustained loss and a larger rate of future decline in kidney function. [ABSTRACT FROM AUTHOR]

The article discusses possible techniques that can be applied for the early diagnosis and treatment of high-risk patients in order to reduce morbidity and mortality in chronic kidney disease. Chronic kidney disease is a condition characterized with sustained reduction in glomerular filtration rate or abnormalities in urinalysis, biopsy or imaging. It is found to be prevalent in developed countries but is unknown in developing countries. Early detection of chronic kidney disease can be done through population-based screening, screening for proteinuria and screening to detect glomerulonephritis. The prevention and therapeutic management of chronic kidney diseases are also explained.

Findings from observational studies have established that the arteriovenous fistula (AVF) is the preferred form of vascular access for chronic hemodialysis. Unfortunately, in a subset of patients with end-stage renal disease, an AVF cannot be placed or fails to mature. In these patients an alternate form of vascular access, either an arteriovenous graft (AVG) or central venous catheter (CVC) must be selected. In this review we discuss the findings and limitations of studies examining the effect of access type (AVG or CVC) on clinical endpoints including mortality, quality of life, occurrence of infections, as well as the impact of the different access types on resource requirements. Specifically, we examine whether findings from previous studies are valid and applicable to patients for whom an AVF is not possible, and outline the need for future randomized clinical trials addressing this question. [ABSTRACT FROM AUTHOR]

The article presents a cohort study which examines the risk of bloodstream infection in patients with chronic kidney disease (CKD) not treated with dialysis in Canada. A cohort of 25,675 patients age 66 years or older are required at least one outpatient serum creatinine measurement enabling estimation of glomerular filtration rate (eGFR) using the Modification of Diet in Renal Disease Study equation. Results reveal that older patients with CKD who did not receive dialysis are at increased risk of bloodstream infection and death.

Background: Catheter-related infections cause morbidity and mortality in patients undergoing hemodialysis. Purpose: To examine whether topical or intraluminal antibiotics reduce catheter-related bloodstream infection compared with no antibiotic therapy in adults undergoing hemodialysis. Data Sources: Electronic databases, trial registries, bibliographies, and conference proceedings up to October 2007, with no language restrictions. Study Selection: Two reviewers independently selected randomized, controlled trials using topical or intraluminal antibiotics for prophylaxis of infection in adults with catheters who are undergoing hemodialysis. Data Extraction: Two independent reviewers assessed studies for inclusion, quality, and extracted data. Data Synthesis: Fixed-effects models were used to estimate pooled rate ratios for outcomes. Topical antibiotics reduced the rate of bacteremia (rate ratio, 0.22 [95% CI, 0.12 to 0.40]; 0.10 vs. 0.45 case of bacteremia per 100 catheter-days), exit-site infection (rate ratio, 0.17 [CI, 0.08 to 0.38]; 0.06 vs. 0.41 case of infection per 100 catheter-days), need for catheter removal, and hospitalization for infection. Intraluminal antibiotics reduced the rate of bacteremia (rate ratio, 0.32 [CI, 0.22 to 0.47]; 0.12 vs. 0.32 case of bacteremia per 100 catheter-days) and need for catheter removal. Intraluminal antibiotics did not significantly reduce the rate of exit-site infection, and no hospitalization data were available for these agents. Limitations: The evidence base included only 16 trials, and most had less than 6 months of follow-up. Only one third of studies were blinded. Publication bias was evident. Conclusion: Both topical and intraluminal antibiotics reduced the rate of bacteremia as well as the need for catheter removal secondary to complications. Whether these strategies will lead to antimicrobial resistance and loss of efficacy over longer periods remains unclear. [ABSTRACT FROM AUTHOR]

Purpose: Patients with coronary artery disease (CAD) experience significant angina symptoms and lifestyle changes. Revascularization procedures can result in better patient-reported outcomes (PROs) than optimal medical therapy (OMT) alone. This study evaluates the impact of response shift (RS) on changes in PROs of patients with CAD across treatment strategies. Methods: Data were from patients with CAD in the Alberta Provincial Project on Outcome Assessment in Coronary Heart Disease (APPROACH) registry who completed the 16-item Canadian version of the Seattle Angina Questionnaire at 2 weeks and 1 year following a coronary angiogram. Multi-group confirmatory factor analysis (MG-CFA) was used to assess measurement invariance across treatment groups at week 2. Longitudinal MG-CFA was used to test for RS according to receipt of coronary artery bypass grafting (CABG), percutaneous coronary intervention (PCI), or optimal medical therapy (OMT) alone. Results: Of the 3116 patients included in the analysis, 443 (14.2%) received CABG, 2049(65.8%) PCI, and the remainder OMT alone. The MG-CFA revealed a partial-strong invariance across the treatment groups at 2 weeks (CFI = 0.98, RMSEA [90% CI] = 0.05 [0.03, 0.06]). Recalibration RS was detected on the Angina Symptoms and Burden subscale and its magnitude in the OMT, PCI, and CABG groups were 0.32, 0.28, and 0.53, respectively. After adjusting for RS effects, the estimated target changes were largest in the CABG group and negligible in the OMT group. Conclusion: Adjusting for RS is recommended in studies that use SAQ-CAN to assess changes in patients with CAD who have received revascularization versus OMT alone. [ABSTRACT FROM AUTHOR]

Purpose: Unsupervised item-response theory (IRT) models such as polytomous IRT based on recursive partitioning (IRTrees) and mixture IRT (MixIRT) models can be used to assess differential item functioning (DIF) in patient-reported outcome measures (PROMs) when the covariates associated with DIF are unknown a priori. This study examines the consistency of results for IRTrees and MixIRT models. Methods: Data were from 4478 individuals in the Alberta Provincial Project on Outcome Assessment in Coronary Heart Disease registry who received cardiac angiography in Alberta, Canada, and completed the Hospital Anxiety and Depression Scale (HADS) depression subscale items. The partial credit model (PCM) based on recursive partitioning (PCTree) and mixture PCM (MixPCM) were used to identify covariates associated with differential response patterns to HADS depression subscale items. Model covariates included demographic and clinical characteristics. Results: The median (interquartile range) age was 64.5(15.7) years, and 3522(78.5%) patients were male. The PCTree identified 4 terminal nodes (subgroups) defined by smoking status, age, and body mass index. A 3-class PCM fits the data well. The MixPCM latent classes were defined by age, disease indication, smoking status, comorbid diabetes, congestive heart failure, and chronic obstructive pulmonary disease. Conclusion: PCTree and MixPCM were not consistent in detecting covariates associated with differential interpretations of PROM items. Future research will use computer simulations to assess these models' Type I error and statistical power for identifying covariates associated with DIF. [ABSTRACT FROM AUTHOR]

Background There are no consensus definitions for evaluating kidney function recovery after acute kidney injury (AKI) and acute kidney disease (AKD), nor is it clear how recovery varies across populations and clinical subsets. We present a federated analysis of four population-based cohorts from Canada, Denmark and Scotland, 2011–18. Methods We identified incident AKD defined by serum creatinine changes within 48 h, 7 days and 90 days based on KDIGO AKI and AKD criteria. Separately, we applied changes up to 365 days to address widely used e-alert implementations that extend beyond the KDIGO AKI and AKD timeframes. Kidney recovery was based on resolution of AKD and a subsequent creatinine measurement below 1.2× baseline. We evaluated transitions between non-recovery, recovery and death up to 1 year; within age, sex and comorbidity subgroups; between subset AKD definitions; and across cohorts. Results There were 464 868 incident cases, median age 67–75 years. At 1 year, results were consistent across cohorts, with pooled mortalities for creatinine changes within 48 h, 7 days, 90 days and 365 days (and 95% confidence interval) of 40% (34%–45%), 40% (34%–46%), 37% (31%–42%) and 22% (16%–29%) respectively, and non-recovery of kidney function of 19% (15%–23%), 30% (24%–35%), 25% (21%–29%) and 37% (30%–43%), respectively. Recovery by 14 and 90 days was frequently not sustained at 1 year. Older males and those with heart failure or cancer were more likely to die than to experience sustained non-recovery, whereas the converse was true for younger females and those with diabetes. Conclusion Consistently across multiple cohorts, based on 1-year mortality and non-recovery, KDIGO AKD (up to 90 days) is at least prognostically similar to KDIGO AKI (7 days), and covers more people. Outcomes associated with AKD vary by age, sex and comorbidities such that older males are more likely to die, and younger females are less likely to recover. [ABSTRACT FROM AUTHOR]

Perioperative medicine is changing rapidly, and with this change comes the opportunity to improve upon current models of care delivery and integration within the health care system. Perioperative models of care are structured or conceptual arrangements for surgical patients before, during and after their surgery. Models of care such as the Perioperative Surgical Home and Enhanced Recovery After Surgery pathways are increasingly used to guide the structure of perioperative care delivery with an aim to improve patient outcomes and experience in Canadian settings. In this narrative review, we summarize the origins of these perioperative models of care. They are fundamentally different in scope and level of evidence. Both models have potential benefits and limitations to their broad implementation in our health care system. As currently developed, both models are limited in their application to patients with chronic disease. We discuss how these models of care can be used to develop integrated horizontal and vertical perioperative pathways in a Canadian setting. Such integration is a potential solution that will improve their applicability to patients with medically complex conditions and in times when health care systems are under pressure. We describe this approach using the example of patients with kidney failure receiving dialysis. [ABSTRACT FROM AUTHOR]

The article discusses research on the use of automated, electronic alerts in improving recognition and managing acute kidney injury. It references a study by F. P Wilson and colleague published in the periodical "Lancet." Topics include the primary outcome of the clinical trial, limitations of the trial design, and the finding that AKI alerts did not alter clinical outcomes.

Importance Higher levels of red cell distribution width (RDW) are associated with adverse outcomes, especially in selected cohorts with or at risk for chronic disease. Whether higher RDW or the related parameter standard deviation of the red blood cell distribution (SD-RBC) can predict a broader range of outcomes in the general population is unknown. Objective To evaluate the association of RDW and SD-RBC with the risk of adverse outcomes in people from the general population. Design Population-based retrospective cohort study. Setting Health care system in a Canadian province (Alberta). Participants All 3,156,863 adults living in Alberta, Canada with at least one measure of RDW and SDRBC between 2003 and 2016. Data were analyzed in September 2018. Exposure RDW and SD-RBC, classified into percentiles (<1, 1–5, 5–25, 25–75, 75–95, 95–99, >99). Main outcomes All-cause death, first myocardial infarction, first stroke or transient ischemic attack, placement into long-term care (LTC), progression to renal replacement therapy (initiation of chronic dialysis or pre-emptive kidney transplantation), incident solid malignancy, and first hospitalization during follow-up. Results Over median follow-up of 6.8 years, 209,991 of 3,156,863 participants (6.7%) died. The risk of death increased with increasing RDW percentile. After adjustment, and compared to RDW in the 25th to 75th percentiles, the risk of death was lower for participants in the <25th percentiles but higher for participants in the 75th-95th percentiles (HR 1.42, 95% CI 1.40,1.43), the 95th-99th percentiles (HR 1.86, 95% CI 1.83,1.89) and the >99th percentile (HR 2.18, 95% CI 2.12,2.23). Similar results were observed for MI, stroke/TIA, incident cancer, hospitalization and LTC placement, but no association was found between RDW and ESRD. Findings were generally similar for SD-RBC, except that all associations tended to be stronger than for RDW, and both lower and higher values of SD-RBC were independently associated with ESRD. Conclusion and relevance RDW and SD-RBC may be useful as prognostic markers for people in the general population, especially for outcomes related to chronic illness. SD-RBC may be superior to RDW. [ABSTRACT FROM AUTHOR]

Introduction: People with chronic medical conditions often take medications that improve long‐term outcomes but which can be harmful during acute illness. Guidelines recommend that healthcare providers offer instructions to temporarily stop these medications when patients are sick (i.e., sick days). We describe the experiences of patients managing sick days and of healthcare providers providing sick day guidance to their patients. Methods: We undertook a qualitative descriptive study. We purposively sampled patients and healthcare providers from across Canada. Adult patients were eligible if they took at least two medications for diabetes, heart disease, high blood pressure and/or kidney disease. Healthcare providers were eligible if they were practising in a community setting with at least 1 year of experience. Data were collected using virtual focus groups and individual phone interviews conducted in English. Team members analyzed transcripts using conventional content analysis. Results: We interviewed 48 participants (20 patients and 28 healthcare providers). Most patients were between 50 and 64 years of age and identified their health status as 'good'. Most healthcare providers were between 45 and 54 years of age and the majority practised as pharmacists in urban areas. We identified three overarching themes that summarize the experiences of patients and healthcare providers, largely suggesting a broad spectrum in approaches to managing sick days: Individualized Communication, Tailored Sick Day Practices, and Variation in Knowledge of Sick Day Practices and Relevant Resources. Conclusion: It is important to understand the perspectives of both patients and healthcare providers with respect to the management of sick days. This understanding can be used to improve care and outcomes for people living with chronic conditions during sick days. Patient or Public Contribution: Two patient partners were involved from proposal development to the dissemination of our findings, including manuscript development. Both patient partners took part in team meetings and contributed to team decision‐making. Patient partners also participated in data analysis by reviewing codes and theme development. Furthermore, patients living with various chronic conditions and healthcare providers participated in focus groups and individual interviews. [ABSTRACT FROM AUTHOR]

The article discusses a study on the association between kidney function and major bleeding in older patients with atrial fibrillation starting warfarin treatment in Alberta. It presents the factors measured in the study including the outcome measure such as admission to hospital or visit to an emergency department for major bleeding. It also notes that the study focused on the safety and not efficacy of warfarin treatment by kidney function in these patients.

Background: The prevalence of menopause in women with or at risk of chronic kidney disease is increasing globally. Although international guidelines on menopause recommend the use of postmenopausal hormone therapy with or without selective estrogen receptor modulators for control of vasomotor symptoms, the effects of these treatments on kidney function and albuminuria are unclear. Furthermore, women with chronic kidney disease are at significantly increased risk of venous thromboembolism and malignancy, well-documented adverse effects of postmenopausal hormone therapy. Our study aims to establish the effect of these treatments on kidney function and albuminuria in women, as well as determine the safety of these treatments in the chronic kidney disease population. Methods: We will conduct a systematic review and meta-analysis addressing the effect and safety of postmenopausal hormone therapy and selective estrogen receptor modulators on kidney outcomes in women. We plan to search for published (MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials (CENTRAL), tables of contents of relevant journals) and unpublished (ongoing studies, conference proceedings) studies in all languages examining the effect of postmenopausal hormone therapy, including selective estrogen receptor modulators, on kidney function and albuminuria, as well as the risk of adverse outcomes of these treatments in women with chronic kidney disease. Two independent investigators will screen identified abstracts and select studies that examine the effect of postmenopausal hormone therapy and selective estrogen receptor modulators on kidney outcomes in the general population or adverse outcomes in the chronic kidney disease population. Data on study population, intervention, outcomes, as well as study quality and risk of bias will be independently extracted from each eligible study. Along with descriptive presentation of data, outcome measures will be presented as meta-analyses using a random effects model. Planned subgroup analyses will be completed, and meta-regression will be performed if significant heterogeneity is noted. Discussion: By examining the effects of postmenopausal hormone therapy and selective estrogen receptor modulators on kidney function and albuminuria, the results of this systematic review and meta-analysis will inform management of postmenopausal women in the general population. Furthermore, it will evaluate the safety, including the risks of known adverse outcomes of postmenopausal hormone therapy and selective estrogen receptor modulators, in the already vulnerable chronic kidney disease population. Systematic review registration: PROSPERO CRD42016050651 [ABSTRACT FROM AUTHOR]

Background: People with kidney failure receiving dialysis (CKD‐G5D) are more likely to undergo surgery and experience poorer postoperative outcomes than those without kidney failure. In this scoping review, we aimed to systematically identify and summarize perioperative strategies, protocols, pathways, and interventions that have been studied or implemented for people with CKD‐G5D. Methods: We searched MEDLINE, EMBASE, CINAHL Plus, Cochrane Database of Systematic Reviews, and Cochrane Controlled Trials registry (inception to February 2020), in addition to an extensive grey literature search, for sources that reported on a perioperative strategy to guide management for people with CKD‐G5D. We summarized the overall study characteristics and perioperative management strategies and identified evidence gaps based on surgery type and perioperative domain. Publication trends over time were assessed, stratified by surgery type and study design. Results: We included 183 studies; the most common study design was a randomized controlled trial (27%), with 67% of publications focused on either kidney transplantation or dialysis vascular access. Transplant‐related studies often focused on fluid and volume management strategies and risk stratification, whereas dialysis vascular access studies focused most often on imaging. The number of publications increased over time, across all surgery types, though driven by non‐randomized study designs. Conclusions: Despite many current gaps in perioperative research for patients with CKD‐G5D, evidence generation supporting perioperative management is increasing, with recent growth driven primarily by non‐randomized studies. Our review may inform organization of evidence‐based strategies into perioperative care pathways where evidence is available while also highlighting gaps that future perioperative research can address. [ABSTRACT FROM AUTHOR]

Background Using a community-based cohort we sought to investigate the association between change in estimated glomerular filtration rate (eGFR) and risk of incident cardiovascular disease including congestive heart failure (CHF), acute myocardial infarction (AMI), and stroke. Methods We identified 479,126 adults without a history of cardiovascular disease who had at least 3 outpatient eGFR measurements over a 4 year period in Alberta, Canada. Change in eGFR was estimated as the absolute annual rate of change (categorized as ≤− 5, − 4, − 3, − 2, − 1, 0, 1, 2, 3, 4, and ≥ 5 mL/min/1.73 m 2 /year). In a sensitivity analysis we also estimated change as the annual percentage change (categorized as ≤− 7, − 6 to − 5, − 4 to − 3, − 2 to − 1, 0, 1 to 2, 3 to 4, 5 to 6, and ≥ 7%/year). The adjusted risk of incident CHF, AMI, and stroke associated with each category of change in eGFR was estimated, using no change in eGFR as the reference, Results There were 2622 (0.6%) CHF, 3463 (0.7%) AMI, and 2768 (0.6%) stroke events over a median follow-up of 2.5 years. Compared to participants with stable eGFR, those with the greatest decline (≤− 5 mL/min/1.73 m 2 /year) had more than a two-fold increased risk of CHF (HR 2.57; 95% CI: 2.28 to 2.89). Risk for AMI and stroke was increased by 31% and 29%, respectively. After adjusting for the last eGFR at the end of the accrual period, the observed association remained significantly higher for CHF but diminished for AMI and stroke. A similar pattern was observed when change in eGFR was quantified as annual percentage change. Conclusion In this large community-based cohort, we observed that a declining eGFR was associated with an increased risk of CHF, AMI, and stroke. However, when the risk of CVD events was adjusted for the last eGFR measurement, decline in eGFR per se was no longer associated with increased risk of AMI or stroke, and the association with CHF remained significant but was attenuated. These results demonstrate the importance of monitoring change in eGFR over time to improve cardiovascular risk prognostication. [ABSTRACT FROM AUTHOR]

The article presents information on a cohort study conducted at Alberta, Canada to evaluate renal outcomes in invasive versus conservative management of acute coronary syndrome. It informs that people who received early invasive management for the syndrome were prone to develop acute kidney injury. The results manifest that no acute kidney injury required dialysis or progressed to end stage renal disease.

Introduction: Information on early, guideline discordant referrals in nephrology is limited. Our objective was to investigate trends in referral patterns to nephrology for patients with chronic kidney disease (CKD). Methods: Retrospective cohort study of adults with ≥1 visits to a nephrologist from primary care with ≥1 serum creatinine and/or urine protein measurement <180 days before index nephrology visit, from 2006 and 2019 in Alberta, Canada. Guideline discordant referrals were those that did not meet ≥1 of: Estimated glomerular filtration rate (eGFR) ˂ 30 mL/min/1.73m2, persistent albuminuria (ACR ≥ 300 mg/g, PCR ≥ 500 mg/g, or Udip ≥ 2+), or progressive and persistent decline in eGFR until index nephrology visit (≥ 5 mL/min/1.73m2). Results: Of 69,372 patients with CKD, 28,518 (41%) were referred in a guideline concordant manner. The overall rate of first outpatient visits to nephrology increased from 2006 to 2019, although guideline discordant referrals showed a greater increase (trend 21.9 per million population/year, 95% confidence interval 4.3, 39.4) versus guideline concordant referrals (trend 12.4 per million population/year, 95% confidence interval 5.7, 19.0). The guideline concordant cohort were more likely to be on renin-angiotensin system blockers or beta blockers (hazard ratio 1.14, 95% confidence interval 1.12, 1.16), and had a higher risk of CKD progression (hazard ratio 1.09, 95% confidence interval 1.06, 1.13), kidney failure (hazard ratio 7.65, 95% confidence interval 6.83, 8.56), cardiovascular event (hazard ratio 1.40, 95% confidence interval 1.35,1.45) and mortality (hazard ratio 1.58, 95% confidence interval 1.52, 1.63). Conclusions: A significant proportion nephrology referrals from primary care were not consistent with current guideline-recommended criteria for referral. Further work is needed to identify quality improvement initiatives aimed at enhancing referral patterns of patients with CKD. [ABSTRACT FROM AUTHOR]

Background: The growing burden associated with population aging, dementia and multimorbidity poses potential challenges for the sustainability of health systems worldwide. We sought to examine how the intersection among age, dementia and greater multimorbidity is associated with health care costs. Methods: We did a retrospective population-based cohort study in Alberta, Canada, with adults aged 65 years and older between April 2003 and March 2017. We identified 31 morbidities using algorithms (30 algorithms were validated), which were applied to administrative health data, and assessed costs associated with hospital admission, provider billing, ambulatory care, medications and long-term care (LTC). Actual costs were used for provider billing and medications; estimated costs for inpatient and ambulatory patients were based on the Canadian Institute for Health Information's resource intensive weights and Alberta's cost of a standard hospital stay. Costs for LTC were based on an estimated average daily cost. Results: There were 827 947 people in the cohort. Dementia was associated with higher mean annual total costs and individual mean component costs for almost all age categories and number of comorbidities categories (differences in total costs ranged from $27 598 to $54 171). Similarly, increasing number of morbidities was associated with higher mean total costs and component costs (differences in total costs ranged from $4597 to $10 655 per morbidity). Increasing age was associated with higher total costs for people with and without dementia, driven by increasing LTC costs (differences in LTC costs ranged from $115 to $9304 per age category). However, there were no consistent trends between age and non-LTC costs among people with dementia. When costs attributable to LTC were excluded, older age tended to be associated with lower costs among people with dementia (differences in non-LTC costs ranged from -$857 to -$7365 per age category). Interpretation: Multimorbidity, older age and dementia were all associated with increased use of LTC and thus health care costs, but some costs among people with dementia decreased at older ages. These findings illustrate the complexity of projecting the economic consequences of the aging population, which must account for the interplay between multimorbidity and dementia. [ABSTRACT FROM AUTHOR]

Systematic reviews are an ideal way of summarizing evidence from primary studies. While systematic reviews of randomized trials are broadly used to summarize benefits and harms of interventions, systematic reviews of observational studies are useful to summarize data on prevalence of risk factors in a population, distribution of outcomes or associations of different risk factors with outcomes. Also, systematic reviews can be useful to clarify potential reasons for conflicting data found in primary studies and explore sources of heterogeneity (variation in primary study data) to better understand epidemiological data and generate hypotheses for candidate interventions to improve outcomes. Summarizing data from observational studies in systematic reviews is a powerful tool to distil existing prognostic evidence in specific settings and inform patients and healthcare providers. In this article, we describe how to critically appraise the methods, interpret the results and apply the findings of a systematic review of observational (prognostic) studies. [ABSTRACT FROM AUTHOR]

Purpose: The Seattle Angina Questionnaire (SAQ) is a widely used patient-reported measure of health status in patients with coronary artery disease. Comparisons of SAQ scores amongst population groups and over time rely on the assumption that its factorial structure is invariant. This study evaluates the measurement invariance of the SAQ across different demographic and clinical groups and over time. Methods: Data were obtained from the Alberta Provincial Project on Outcome Assessment in Coronary Heart Disease registry, a registry of patients who received coronary angiogram in Alberta, Canada. The study cohort consists of adult patients who completed the paper-based version of the 16-item Canadian version of the SAQ (SAQ-CAN) 2 weeks and 1-year post-coronary angiogram between 2009 and 2016. Multi-group confirmatory factor analysis was used to assess configural, weak, strong, and strict measurement invariance across age groups, sex, angina type, treatment, and over time. Model fit was assessed using the comparative fit index and root mean square error of approximation. Results: Of the 8101 patients included in these analysis, 1300 (16.1%) were at least 75 years old, while 1755 (21.7%) were female, 5154 (63.6%) were diagnosed with acute coronary syndrome, 1177 (14.5%) received coronary artery bypass graft treatment, and 3279 had complete data on the SAQ-CAN at both occasions. There was evidence of strict invariance across age, sex, and angina type, and treatment groups, but partial strict invariance was established over time. Conclusion: SAQ-CAN can be used to compare the health status of coronary artery disease patients across population groups and over time. [ABSTRACT FROM AUTHOR]

Background and aims: Delayed post-polypectomy bleeding (DPPB) is a commonly described adverse event following polypectomy. Prophylactic clipping may prevent DPPB in some patient subgroups. We performed a meta-analysis to assess both the efficacy and real-world effectiveness of prophylactic clipping. Methods: We performed a database search through March 2020 for clinical trials or observational studies assessing prophylactic clipping and DPPB. Pooled risk ratios (RR) were calculated using random effects models. Subgroup, sensitivity, and meta-regression analyses were performed to elucidate clinical or methodological factors associated with effects on outcomes. Results: A total of 2771 citations were screened, with 11 randomized controlled trials (RCTs) and 9 observational studies included, representing 24,670 colonoscopies. DPPB occurred in 2.0% of patients overall. The pooled RR of DPPB was 0.47 (95% CI 0.29–0.77) from RCTs enrolling only patients with polyps ≥ 20 mm. Remaining pooled RCT data did not demonstrate a benefit for clipping. The pooled RR of DPPB was 0.96 (95% CI 0.61–1.51) from observational studies including all polyp sizes. For patients with proximal polyps of any size, the RR was 0.73 (95% CI 0.33–1.62) from RCTs. Meta-regression confirmed that polyp size ≥ 20 mm significantly influenced the effect of clipping on DPPB. Conclusion: Pooled evidence demonstrates a benefit when clipping polyps measuring ≥ 20 mm, especially in the proximal colon. In lower-risk subgroups, prophylactic clipping likely results in little to no difference in DPPB. [ABSTRACT FROM AUTHOR]

In the past two decades, a substantial increase in the incidence of acute kidney injury (AKI) and kidney injury requiring dialysis has occurred in North America. This increase has coincided with an increase in the incidence of end-stage renal disease (ESRD), which has exceeded that expected based upon the prevalence of chronic kidney disease (CKD). In order to better understand the association between these conditions, there has been a proliferation of studies that have examined the risks of incident and progressive CKD following AKI. Animal studies have shown that failed differentiation of epithelial cells following renal ischaemia-reperfusion injury might lead to tubulointerstitial fibrosis, supporting a biological mechanism linking AKI and CKD. Strong and consistent associations between AKI and incident CKD, progression of CKD and incident ESRD have also been shown in epidemiological studies. In this Review, we summarize the wealth of available data on the relationship between AKI and CKD, and discuss the implications of these findings for the long-term clinical management of patients following AKI. We also identify areas of active investigation and future directions for research. [ABSTRACT FROM AUTHOR]

Acute kidney injury (AKI) is common after surgery and associated with increased mortality, costs, and lengths of hospitalization. We examined associations between angiotensin-converting enzyme inhibitor (ACEI)/angiotensin receptor blocker (ARB), diuretic, or nonsteroidal anti-inflammatory drug (NSAID) use after major surgery and AKI. We conducted a nested case-control study of patients who underwent major cardiac, thoracic, general, or vascular surgery in Calgary, Alberta, Canada. Cases with AKI were matched on age, gender, and surgery type with up to five controls without AKI within 30-d after surgery. Adjusted odds ratios (ORs) for AKI were determined based on postoperative administration of ACEIs/ARBs, diuretics, or NSAIDs. Among 33,648 patients in the cohort, 2911 cases with AKI were matched to 9309 controls without AKI. Postoperative diuretic [OR = 1.96; 95% confidence interval (CI) = 1.68-2.29], but not ACEI/ARB (OR = 0.83; 95% CI = 0.72-0.95) or NSAID (OR = 1.12; 95% CI = 0.96-1.31), use was independently associated with higher odds of AKI (including stages 1 and 2/3 AKI) after all types of major surgery. There were increased adjusted odds of AKI 1 to 5 d after first exposure to diuretics and 1 d after first exposure to NSAIDs (but not after later exposures). Relationships between ACEI/ARB use and AKI varied by surgery type (p-interaction = 0.004), with lower odds of AKI observed among ACEI/ARB use after cardiac surgery (OR = 0.70; 95% CI = 0.57-0.81), but no difference after other major surgeries. Postoperative administration of diuretics and NSAIDs was associated with increased odds of AKI after major surgery. These findings characterize potentially modifiable medication exposures associated with AKI after surgery. [ABSTRACT FROM AUTHOR]

Objectives: Despite advances in medical therapy, reperfusion, and mechanical support, cardiogenic shock remains associated with excess morbidity and mortality. Accurate risk stratification may improve patient management. We compared the accuracy of established risk scores for cardiogenic shock. Methods: Patients admitted to tertiary care center cardiac care units in the province of Alberta in 2015 were assessed for cardiogenic shock. The Acute Physiology and Chronic Health Evaluation-II (APACHE-II), CardShock, intra-aortic balloon pump (IABP) Shock II, and sepsis-related organ failure assessment (SOFA) risk scores were compared. Receiver operating characteristic curves were used to assess discrimination of in-hospital mortality and compared using DeLong's method. Calibration was assessed using the Hosmer-Lemeshow goodness-of-fit test. Results: The study included 3021 patients, among whom 510 (16.9%) had cardiogenic shock. Patients with cardiogenic shock had longer median hospital stays (median 11.0 vs 4.1 days, P < .001) and were more likely to die (29.0% vs 2.5%, P < .001). All risk scores were adequately calibrated for predicting hospital morality except for the APACHE-II score (Hosmer-Lemeshow P < .001). Discrimination of in-hospital mortality with the APACHE-II (area under the curve [AUC]: 0.72, 95% confidence interval [CI]: 0.66-0.76) and IABP-Shock II (AUC: 0.73, 95% CI: 0.68-0.77) scores were similar, while the CardShock (AUC: 0.76, 95% CI: 0.72-0.81) and SOFA (AUC: 0.76, 95%CI: 0.72-0.81) scores had better discrimination for predicting in-hospital mortality. Conclusions: In a real-world population of patients with cardiogenic shock, existing risk scores had modest prognostic accuracy, with no clear superior score. Further investigation is required to improve the discriminative abilities of existing models or establish novel methods. [ABSTRACT FROM AUTHOR]

Background: Patients with chronic kidney disease (CKD) and heart disease face challenging treatment decisions. We sought to explore the perceptions of patients and physicians about shared decision-making for coronary procedures for people with CKD, as well as opinions about strategies and tools to improve these decisions. Methods: We partnered with 4 patients with CKD and 1 caregiver to design and conduct a qualitative descriptive study using semi-structured interviews and content analysis. Patient participants with CKD and either acute coronary syndrome or cardiac catheterization in the preceding year were recruited from a provincial cardiac registry, cardiology wards and clinics in Calgary between March and September 2018. Cardiologists from the region also participated in the study. Data analysis emphasized identifying, organizing and describing themes found within the data. Results: Twenty patients with CKD and 10 cardiologists identified several complexities related to bidirectional information exchange needed for shared decision-making. Themes identified by both patients and physicians included challenges synthesizing best evidence, variable patient knowledge seeking, timeliness in the acute care setting and influence of roles on decision-making. Themes identified by physicians related to processes and tools to help support shared decision-making in this setting included personalization to reflect the variability of risks and heterogeneity of patient preferences as well as allowing for physicians to share their clinical judgment. Interpretation: There are complexities related to bidirectional information exchange between patients with CKD and their physicians for shared decision-making about coronary procedures. Processes and tools to facilitate shared decision-making in this setting require personalization and need to be time sensitive. [ABSTRACT FROM AUTHOR]

Background: In studies showing associations between ambient air pollution and myocardial infarction (MI), data have been lacking on the inherent spatial variability of air pollution. The aim of this study was to determine whether the long-term spatial distribution of air pollution influences short-term temporal associations between air pollution and admission to hospital for MI. Methods: We identified adults living in Calgary who were admitted to hospital for an MI between 2004 and 2012. We evaluated associations between short-term exposure to air pollution (ozone [O3], nitrogen dioxide [NO2], sulfur dioxide [SO2], carbon monoxide [CO], particulate matter < 10 μm in diameter [PM10] and particulate matter < 2.5 μm in diameter [PM2.5]), and hospital admissions for MI using a time-stratified, case-crossover study design. Air Quality Health Index (AQHI) scores were calculated from a composition of O3, NO2 and PM2.5. Conditional logistic regression models were stratified by low, medium and high levels of neighbourhood NO2 concentrations derived from land use regression models; results of these analyses are presented as odds ratios (ORs) with 95% confidence intervals (CIs). Results: From 2004 to 2012, 6142 MIs were recorded in Calgary. Individuals living in neighbourhoods with higher long-term air pollution concentrations were more likely to be admitted to hospital for MI after short-term elevations in air pollution (e.g., 5-day average NO2: OR 1.20, 95% CI 1.03–1.40, per interquartile range [IQR]) as compared with regions with lower air pollution (e.g., 5-day average NO2: OR 0.90, 95% CI 0.78–1.04, per IQR). In high NO2 tertiles, the AQHI score was associated with MI (e.g., 5-day average OR 1.13, 95% CI 1.02–1.24, per IQR; 3-day average OR 1.13, 95% CI 1.04–1.23, per IQR). Interpretation: Our results show that the effect of air pollution on hospital admissions for MI was stronger in areas with higher NO2 concentrations than that in areas with lower NO2 concentrations. Individuals living in neighbourhoods with higher traffic-related pollution should be advised of the health risks and be attentive to special air quality warnings. [ABSTRACT FROM AUTHOR]

INTRODUCTION: Delayed postpolypectomy bleeding (DPPB) is a relatively common adverse event. Evidence is conflicting on the efficacy of prophylactic clipping to prevent DPPB, and real-world effectiveness data are lacking. We aimed to determine the effectiveness of prophylactic clipping in preventing DPPB in a large screening-related cohort. METHODS: We manually reviewed records of patients who underwent polypectomy from 2008 to 2014 at a screening facility. Endoscopist-, patient- and polyp-related data were collected. The primary outcome was DPPB within 30 days. All unplanned healthcare visits were reviewed; DPPB cases were adjudicated by committee using a criterion-based lexicon. Multivariable logistic regression was performed, yielding adjusted odds ratios (AORs) for the association between clipping and DPPB. Secondary analyses were performed on procedures where one polyp was removed, in addition to propensity score-matched and subgroup analyses. RESULTS: In total, 8,366 colonoscopies involving polypectomy were analyzed, yielding 95 DPPB events. Prophylactic clipping was not associated with reduced DPPB (AOR 1.27; 0.83-1.96). These findings were similar in the single-polyp cohort (n = 3,369, AOR 1.07; 0.50-2.31). In patients with one proximal polyp ≥20 mm removed, there was a nonsignificant AOR with clipping of 0.55 (0.10-2.66). Clipping was not associated with a protective benefit in the propensity score-matched or other subgroup analyses. DISCUSSION: In this large cohort study, prophylactic clipping was not associated with lower DPPB rates. Endoscopists should not routinely use prophylactic clipping in most patients. Additional effectiveness and cost-effectiveness studies are required in patients with proximal lesions ≥20 mm, in whom there may be a role for prophylactic clipping. [ABSTRACT FROM AUTHOR]

Purpose: Perceived social support is known to be an important predictor of health outcomes in patients with acute coronary syndrome (ACS). This study investigates patterns of longitudinal trajectories of patient-reported perceived social support in individuals with ACS.Methods: Data are from 3013 patients from the Alberta Provincial Project for Outcome Assessment in Coronary Heart Disease registry who had their first cardiac catheterization between 2004 and 2011. Perceived social support was assessed using the 19-item Medical Outcomes Study Social Support Survey (MOS) 2 weeks, 1 year, and 3 years post catheterization. Group-based trajectory analysis based on longitudinal multiple imputation model was used to identify distinct subgroups of trajectories of perceived social support over a 3-year follow-up period.Results: Three distinct social support trajectory subgroups were identified, namely: "High" social support group (60%), "Intermediate" social support group (30%), and "Low" social support subgroup (10%). Being female (OR = 1.67; 95% CI = [1.18-2.36]), depression (OR = 8.10; 95% CI = [4.27-15.36]) and smoking (OR = 1.70; 95% CI = [1.23-2.35]) were predictors of the differences among these trajectory subgroups.Conclusion: Although the majority of ACS patients showed increased or fairly stable trajectories of social support, about 10% of the cohort reported declining social support. These findings can inform targeted psycho-social interventions to improve their perceived social support and health outcomes. [ABSTRACT FROM AUTHOR]

Abstract: Cardiovascular disease has been identified as one of the late complications of cancer therapy. The purpose of this study was to quantify the long‐term risk of cardiovascular mortality among lymphoma survivors relative to that of the general population. A systematic review and meta‐analysis were conducted. Articles were identified in November 2016 by searching EMBASE, MEDLINE, and CINAHL databases. Observational studies were included if they assessed cardiovascular mortality in patients with lymphoma who survived for at least 5 years from time of diagnosis or if they had a median follow‐up of 10 years. A pooled standardized mortality ratio (SMR) was estimated using a DerSimonian and Laird random‐effects model. The Q and I2 statistics were used to assess heterogeneity. Funnel plots and Begg's and Egger's tests were used to evaluate publication bias. Of the 7450 articles screened, 27 studies were included in the systematic review representing 46 829 Hodgkin and 14 764 non‐Hodgkin lymphoma survivors. The pooled number of deaths attributable to cardiovascular disease among Hodgkin and non‐Hodgkin disease was estimated to be 7.31 (95% CI: 5.29‐10.10; I2 = 95.4%) and 5.35 (95% CI: 2.55‐11.24; I2 = 94.0%) times that of the general population, respectively. This association was greater among Hodgkin lymphoma survivors treated before the age of 21 (pooled SMR = 13.43; 95% CI: 9.22‐19.57; I2 = 78.9%). There was a high degree of heterogeneity and a high risk of bias due to confounding in this body of literature. Lymphoma survivors have an increased risk of fatal cardiovascular events compared to the general population and should be targeted for cardiovascular screening and prevention campaigns. [ABSTRACT FROM AUTHOR]

Inflammation is an integral component of many diseases, including chronic kidney disease (CKD). ASC (apoptosis-associated speck-like protein containing CARD, also PYCARD) is the key inflammasome adaptor protein in the innate immune response. Since ASC specks, a macromolecular condensate of ASC protein, can be released by inflammasome-activated cells into the extracellular space to amplify inflammatory responses, the ASC protein could be an important biomarker in diagnostic applications. Herein, we describe the development and validation of a multiple reaction monitoring mass spectrometry (MRM-MS) assay for the accurate quantification of ASC in human biospecimens. Limits of detection and quantification for the signature DLLLQALR peptide (used as surrogate for the target ASC protein) were determined by the method of standard addition using synthetic isotope-labeled internal standard (SIS) peptide and urine matrix from a healthy donor (LOQ was 8.25 pM, with a ~ 1000-fold linear range). We further quantified ASC in the urine of CKD patients (8.4 ± 1.3 ng ASC/ml urine, n = 13). ASC was positively correlated with proteinuria and urinary IL-18 in CKD samples but not with urinary creatinine. Unfortunately, the ASC protein is susceptible to degradation, and patient urine that was thawed and refrozen lost 85% of the ASC signal. In summary, the MRM-MS assay provides a robust means to quantify ASC in biological samples, including clinical biospecimens; however, sample collection and storage conditions will have a critical impact on assay reliability. [ABSTRACT FROM AUTHOR]