Prevention of Contrast-Induced Acute Kidney Injury: Is Simple Oral Hydration Similar To Intravenous? A Systematic Review of the Evidence

Background

Pre-procedural intravenous fluid administration is an effective prophylaxis measure for contrast-induced acute kidney injury. For logistical ease, the oral route is an alternative to the intravenous. The objective of this study was to compare the efficacy of the oral to the intravenous route in prevention of contrast-induced acute kidney injury.

Study Design

A systematic review and meta-analysis of randomised trials with a stratified analysis and metaregression. Databases included MEDLINE (1950 to November 23 2011), EMBASE (1947 to week 47 2011), Cochrane CENTRAL (3^rd quarter 2011). Two reviewers identified relevant trials and abstracted data.

Settings and Population

Trials including patients undergoing a contrast enhanced procedure.

Selection Criteria

Randomised controlled trial; adult (>18 years) population; comparison of oral versus intravenous volume expansion.

Intervention

Oral route of volume expansion compared to the intravenous route.

Outcomes

Any measure of acute kidney injury, need for renal replacement therapy, hospitalization and death.

Results

Six trials including 513 patients met inclusion criteria. The summary odds ratio was 1.19 (95% CI 0.46, 3.10, p = 0.73) suggesting no difference between the two routes of volume expansion. There was significant heterogeneity (Cochran’s Q = 11.65, p = 0.04; I² = 57). In the stratified analysis, inclusion of the five studies with a prespecified oral volume expansion protocol resulted in a shift towards oral volume expansion (OR 0.75, 95% CI 0.37, 1.50, p = 0.42) and also resolved the heterogeneity (Q = 3.19, P = 0.53; I² = 0).

Limitations

Small number of studies identified; lack of hard clinical outcomes.

Conclusion

The oral route may be as effective as the intravenous route for volume expansion for contrast-induced acute kidney injury prevention. Adequately powered trials with hard endpoints should be done given the potential advantages of oral (e.g. reduced patient burden and cost) over intravenous volume expansion.     

Evidence-Based Laboratory Medicine: Is It Working in Practice?

The principles of Evidence-Based Medicine have been established for about two decades, with the need for evidence-based clinical practice now being accepted in most health systems around the world. These principles can be employed in laboratory medicine. The key steps in evidence-based practice, namely (i) formulating the question; (ii) searching for evidence; (iii) appraising evidence; (iv) applying evidence; and (v) assessing the experience are all accepted but, as yet, translation into daily clinical and laboratory practice has been slow. Furthermore, the demand for evidence-based laboratory medicine (EBLM) has been slow to develop.There are many contrasting observations about laboratory medicine, for example (i) there is too much testing vs insufficient testing; (ii) testing is expensive vs laboratories are expected to generate income; and (iii) test results have little impact on outcomes vs test results are crucial to clinical decision making. However, there is little evidence to support any of these observations. Integrating the principles of EBLM into routine practice will help to resolve some of these issues by identifying (a) where laboratory medicine fits into the care pathway; (b) where testing is appropriate; (c) the nature and quality of evidence required to demonstrate the clinical utility of a test; (d) how the test result impacts on clinical actions; (e) where changes in the care pathway will occur; and (f) where benefit/value can be achieved. These answers will help to establish the culture of EBLM in clinical and laboratory practice.     

Data Acquisition for Conservation Assessments: Is the Effort Worth It?

When identifying conservation priorities, the accuracy of conservation assessments is constrained by the quality of data available. Despite previous efforts exploring how to deal with imperfect datasets, little is known about how data uncertainty translates into errors in conservation planning outcomes. Here, we evaluate the magnitude of commission and omission error, effectiveness and efficiency of conservation planning outcomes derived from three datasets with increasing data quality. We demonstrate that investing in data acquisition might not always be the best strategy as the magnitude of errors introduced by new sites/species can exceed the benefits gained. There was a trade-off between effectiveness and efficiency due to poorly sampled rare species. Given that data acquisition is limited by the high cost and time required, we recommend focusing on improving the quality of data for those species with the highest level of uncertainty (rare species) when acquiring new data.     

Microtubule Flux: What Is It Good for?

During mitosis in a eukaryotic cell, microtubule subunits continuously move towards spindle poles. A new study has revealed that inhibiting this microtubule flux in mammalian cells has no major effects on chromosome movements; it does, however, increase the probability of erroneous chromosome segregation.     

Study on the Effect of Kidney Transplantation on the Health of the Patients’ Offspring: A Report on 252 Chinese Children

Even though the incidence of pregnancies in the female recipients is lower and also chronic renal disease in male patients is associated with impaired spermatogenesis, the health of the children born to these patients was not studied. In this report, we discuss information on the growth and development of offspring of 248 male and female kidney recipient patients. Physical and routine clinical measurements of the 252 offspring (129 male and 123 female) born to these transplantation patients were made along with the intelligence tests. In some of these children chest X-ray and immune indices were assessed. Among the recipients, 219 males fathered 223 children with an average birth weight of 3,255 ± 374 g and 29 female recipients gave birth to 29 children with an average birth weight of 2,923 ± 551. While most of these children were normal, we noticed a case of soft double toe, a case of short tongue tie, five cases of marginal mental retardation, three cases of proteinuria, six cases of microscopic hematuria, 15 cases of low hemoglobin, and 21 cases with recurrent respiratory tract infections. We conclude that kidney transplantation has no significant impact on the growth, development, health, and intelligence of the offspring born to recipients.     

Sex: Is Giardia Doing It in the Dark?

The protist Giardia has long been considered strictly asexual. Now genes specific for meiotic recombination have been found in the Giardia genome, but their consequences for genetics, epidemiology and evolution remain unknown.     

Is It Benign or Is It a Pariah? Empirical Evidence for the Impact of the Common Myna (Acridotheres tristis) on Australian Birds

There is widespread concern over the impact of introduced species on biodiversity, but the magnitude of these impacts can be variable. Understanding the impact of an introduced species is essential for effective management. However, empirical evidence of the impact of an introduced species can be difficult to obtain, especially when the impact is through competition. Change in species abundance is often slow and gradual, coinciding with environmental change. As a result, negative impacts on native species through competition are poorly documented. An example of the difficulties associated with obtaining empirical evidence of impact due to competition comes from work on the Common Myna (Acridotheres tristis). The species is listed in the World's top 100 worst invaders, despite a lack of empirical evidence of its negative impacts on native species. We assessed the impact of the Common Myna on native bird abundance, using long-term data both pre and post its invasion. At the outset of our investigation, we postulated that Common Myna establishment would negatively affect the abundance of other cavity-nesting species and bird species that are smaller than it. We found a negative relationship between the establishment of the Common Myna and the long-term abundance of three cavity-nesting species (Sulphur-crested Cockatoo, Crimson Rosella, Laughing Kookaburra) and eight small bird species (Striated Paradoxes, Rufous Whistler, Willie Wagtail, Grey Fantail, Magpie-lark, House Sparrow, Silvereye, Common Blackbird). To the best of our knowledge, this finding has never previously been demonstrated at the population level. We discuss the key elements of our success in finding empirical evidence of a species impact and the implications for prioritisation of introduced species for management. Specifically, prioritization of the Common Myna for management over other species still remains a contentious issue.     

Corneal Transplantation in Disease Affecting Only One Eye: Does It Make a Difference to Habitual Binocular Viewing?

Background

Clarity of the transplanted tissue and restoration of visual acuity are the two primary metrics for evaluating the success of corneal transplantation. Participation of the transplanted eye in habitual binocular viewing is seldom evaluated post-operatively. In unilateral corneal disease, the transplanted eye may remain functionally inactive during binocular viewing due to its suboptimal visual acuity and poor image quality, vis-à-vis the healthy fellow eye.

Methods and Findings

This study prospectively quantified the contribution of the transplanted eye towards habitual binocular viewing in 25 cases with unilateral transplants [40yrs (IQR: 32–42yrs) and 25 age-matched controls [30yrs (25–37yrs)]. Binocular functions including visual field extent, high-contrast logMAR acuity, suppression threshold and stereoacuity were assessed using standard psychophysical paradigms. Optical quality of all eyes was determined from wavefront aberrometry measurements.Binocular visual field expanded by a median 21% (IQR: 18–29%) compared to the monocular field of cases and controls (p = 0.63). Binocular logMAR acuity [0.0 (0.0–0.0)] almost always followed the fellow eye’s acuity [0.00 (0.00 –-0.02)] (r = 0.82), independent of the transplanted eye’s acuity [0.34 (0.2–0.5)] (r = 0.04). Suppression threshold and stereoacuity were poorer in cases [30.1% (13.5–44.3%); 620.8arc sec (370.3–988.2arc sec)] than in controls [79% (63.5–100%); 16.3arc sec (10.6–25.5arc sec)] (p<0.001). Higher-order wavefront aberrations of the transplanted eye [0.34μ (0.21–0.51μ)] were higher than the fellow eye [0.07μ (0.05–0.11μ)] (p<0.001) and their reduction with RGP contact lenses [0.09μ (0.08–0.12μ)] significantly improved the suppression threshold [65% (50–72%)] and stereoacuity [56.6arc sec (47.7–181.6arc sec)] (p<0.001).

Conclusions

In unilateral corneal disease, the transplanted eye does participate in gross binocular viewing but offers limited support to fine levels of binocularity. Improvement in the transplanted eye’s optics enhances its participation in binocular viewing. Current metrics of this treatment success can expand to include measures of binocularity to assess the functional benefit of the transplantation process in unilateral corneal disease.     

Genomic Heritability: What Is It?

Whole-genome regression methods are being increasingly used for the analysis and prediction of complex traits and diseases. In human genetics, these methods are commonly used for inferences about genetic parameters, such as the amount of genetic variance among individuals or the proportion of phenotypic variance that can be explained by regression on molecular markers. This is so even though some of the assumptions commonly adopted for data analysis are at odds with important quantitative genetic concepts. In this article we develop theory that leads to a precise definition of parameters arising in high dimensional genomic regressions; we focus on the so-called genomic heritability: the proportion of variance of a trait that can be explained (in the population) by a linear regression on a set of markers. We propose a definition of this parameter that is framed within the classical quantitative genetics theory and show that the genomic heritability and the trait heritability parameters are equal only when all causal variants are typed. Further, we discuss how the genomic variance and genomic heritability, defined as quantitative genetic parameters, relate to parameters of statistical models commonly used for inferences, and indicate potential inferential problems that are assessed further using simulations. When a large proportion of the markers used in the analysis are in LE with QTL the likelihood function can be misspecified. This can induce a sizable finite-sample bias and, possibly, lack of consistency of likelihood (or Bayesian) estimates. This situation can be encountered if the individuals in the sample are distantly related and linkage disequilibrium spans over short regions. This bias does not negate the use of whole-genome regression models as predictive machines; however, our results indicate that caution is needed when using marker-based regressions for inferences about population parameters such as the genomic heritability.     

Angiotensin in the Kidney: A Key to Understanding Hypertension?

A crosstransplantation study between genetically matched angiotensin AT1 receptor knockout and wild-type mice revealed that renal AT1 receptors are required for the development of angiotensin II-induced hypertension (). However, in this experimental setting, hypertension-related left ventricular hypertrophy seemed to depend on blood pressure elevation rather than on the expression of AT1 receptors in the heart.     

Thermal Biofeedback for Primary Raynaud’s Phenomenon: A Review of the Literature

The clinical presentation of primary Raynaud’s phenomenon (RP) derives from various pathogenic triggers. The use of thermal biofeedback (TBF) may be of benefit in reducing the severity and frequency of attacks. This article summarizes the relevant research regarding the pathophysiology of primary RP and mechanism of TBF for RP. Systematic reviews of the efficacy of TBF for RP and treatment guidelines for clinicians are provided. The panel concludes that the level of evidence for TBF efficacy is categorized as Level IV: efficacious. The rationale, based on three randomized controlled trials conducted in independent laboratories, demonstrated “superiority or equivalence” of treatments that include TBF. However, randomly controlled trials (RCT) with positive clinical outcomes tended to be small. A large RCT with negative results did not effectively teach handwarming skills. Procedures for reviewing and rating of the levels of evidence of efficacy of studies was based on the Template for Developing Guidelines for the Evaluation of the Clinical Efficacy of Psychophysiological Interventions developed by the joint task force of the AAPB and the Society for Neuronal Regulation (SNR).