Kim Cheema

BACKGROUND: Acute kidney injury (AKI) is a serious complication of major noncardiac surgery. Risk prediction models for AKI following noncardiac surgery may be useful for identifying high-risk patients to target with prevention strategies. METHODS: We conducted a systematic review of risk prediction models for AKI following major noncardiac surgery. MEDLINE, EMBASE, BIOSIS Previews and Web of Science were searched for articles that (i) developed or validated a prediction model for AKI following major noncardiac surgery or (ii) assessed the impact of a model for predicting AKI following major noncardiac surgery that has been implemented in a clinical setting. RESULTS: We identified seven models from six articles that described a risk prediction model for AKI following major noncardiac surgeries. Three studies developed prediction models for AKI requiring renal replacement therapy following liver transplantation, three derived prediction models for AKI based on the Risk, Injury, Failure, Loss of kidney function, End-stage kidney disease (RIFLE) criteria following liver resection and one study developed a prediction model for AKI following major noncardiac surgical procedures. The final models included between 4 and 11 independent variables, and c-statistics ranged from 0.79 to 0.90. None of the models were externally validated. CONCLUSIONS: Risk prediction models for AKI after major noncardiac surgery are available; however, these models lack validation, studies of clinical implementation and impact analyses. Further research is needed to develop, validate and study the clinical impact of such models before broad clinical uptake.

OBJECTIVES: To analyse the current evidence for the management of lupus nephritis (LN) informing the 2019 update of the EULAR/European Renal Association-European Dialysis and Transplant Association recommendations. METHODS: According to the EULAR standardised operating procedures, a PubMed systematic literature review was performed, from January 1, 2012 to December 31, 2018. Since this was an update of the 2012 recommendations, the final level of evidence (LoE) and grading of recommendations considered the total body of evidence, including literature prior to 2012. RESULTS: We identified 387 relevant articles. High-quality randomised evidence supports the use of immunosuppressive treatment for class III and class IV LN (LoE 1a), and moderate-level evidence supports the use of immunosuppressive treatment for pure class V LN with nephrotic-range proteinuria (LoE 2b). Treatment should aim for at least 25% reduction in proteinuria at 3 months, 50% at 6 months and complete renal response (<500-700 mg/day) at 12 months (LoE 2a-2b). High-quality evidence supports the use of mycophenolate mofetil/mycophenolic acid (MMF/MPA) or low-dose intravenous cyclophosphamide (CY) as initial treatment of active class III/IV LN (LoE 1a). Combination of tacrolimus with MMF/MPA and high-dose CY are alternatives in specific circumstances (LoE 1a). There is low-quality level evidence to guide optimal duration of immunosuppression in LN (LoE 3). In end-stage kidney disease, all methods of kidney replacement treatment can be used, with transplantation having the most favourable outcomes (LoE 2b). CONCLUSIONS: There is high-quality evidence to guide the initial and subsequent phases of class III/IV LN treatment, but low-to-moderate quality evidence to guide treatment of class V LN, monitoring and optimal duration of immunosuppression.

QUALITY ISSUE: Research indicates that 10% of patients are harmed by healthcare but data that can be used in real time to improve safety are not routinely available. INITIAL ASSESSMENT: We identified the need for a prospective safety measurement system that healthcare professionals can use to improve safety locally, regionally and nationally. CHOICE OF SOLUTION: We designed, developed and implemented a national tool, named the NHS Safety Thermometer (NHS ST) with the goal of measuring the prevalence of harm from pressure ulcers, falls, urinary tract infection in patients with catheters and venous thromboembolism on one day each month for all NHS patients. IMPLEMENTATION: The NHS ST survey instrument was developed in a learning collaborative involving 161 organizations (e.g. hospitals and other delivery organizations) using a Plan, Do, Study, Act method. EVALUATION: Testing of operational definitions, technical capability and use were conducted and feedback systems were established by site coordinators in each participating organization. During the 17-month pilot, site coordinators reported a total of 73,651 patient entries. LESSONS LEARNED: It is feasible to obtain national data through standardized reporting by site coordinators at the point of care. Some caution is required in interpreting data and work is required locally to ensure data collection systems are robust and data collectors were trained. Sampling is an important strategy to optimize efficiency and reduce the burden of measurement.