963 THE IMPACT OF AGE, SEX AND MORBIDITY COUNT ON EARLY TERMINATION: A META-ANALYSIS OF INDIVIDUAL PATIENT DATA FROM CLINICAL TRIALS

Introduction

Multimorbidity is found in around half of people with any long-term condition but is substantially less common in randomised controlled trials (‘trials’). Multimorbidity may diminish a participant’s ability to complete a trial. However, empirical estimates of the association between individual patient characteristics and early termination are lacking.

Method

Individual patient-level data were obtained from Phase 3/4 trials contained within two clinical trial repositories. Eligible trials for inclusion were identified according to pre-specified criteria (PROSPERO CRD42018048202). Within each trial, the association between morbidity count and early termination (failure for any reason to complete the final trial visit) was estimated in logistic regression models, adjusting for age and sex. These estimates were meta-analysed in Bayesian linear models, with partial pooling across index conditions and drug classes. Using these estimates, the impact of morbidity count on early termination was modelled for a set of notional trials.

Results

In 92 trials across 20 index conditions and 17 drug classes, the mean morbidity count ranged from 0.3–2.7. Neither age nor sex was associated with early termination (OR 1.04, 95% CI 0.98–1.11; OR 1.00, 95% PI 0.95–1.07 respectively). Morbidity count was associated with early termination (OR per additional morbidity: 1.11, 95% CI: 1.07 to 1.14). There was no evidence of non-linearity in the association between morbidity count and early termination, and there was minimal variation across drug classes and index conditions. For a notional trial with high level of early termination in individuals without multimorbidity, doubling the mean morbidity count from 1 to 2 increases risk of early termination from 29% to 31%.

Conclusion

Multimorbidity, irrespective of age and sex, is associated with a relatively modest increased odds of early termination of trial participation. The benefit of increased generalisability of trials by including patients with multimorbidity appears likely to outweigh the disadvantages of lower retention.

Proton pump inhibitor use and progression to major adverse renal events: a competing risk analysis

BACKGROUND

Proton pump inhibitors (PPIs) are associated with acute tubulointerstitial nephritis and there are reports associating their use with the development of chronic kidney disease (CKD).

AIM

To determine if PPI use is associated with major adverse renal events (MARE) in patients with CKD.

DESIGN

Observational cohort study comprising patients with CKD attending secondary care renal clinics from 1 January 2006 until 31 December 2016.

METHODS

We collated baseline clinical, socio-demographic and biochemical data at start of PPI (PPI group) or study inception (control group). MARE was considered a composite of doubling of creatinine or end-stage renal disease. Association between PPI exposure and progression to MARE was assessed by cause-specific hazards competing risk survival analysis.

RESULTS

There were 3824 patients with CKD included in the analyses of whom 1195 were prescribed a PPI. The PPI group was younger (64.8 vs. 67.0 years, P < 0.001), with lower estimated glomerular filtration rate (eGFR) (30 vs. 35 ml/min, P < 0.001) and more proteinuria (64 vs. 48 mg/mmol, P < 0.001). PPI use was associated with progression to MARE on multivariable adjustment (hazard ratio 1.13 [95% confidence interval 1.02-1.25], P = 0.021). Other factors significantly associated with progression to MARE were higher systolic blood pressure, lower eGFR, greater proteinuria, congestive cardiac failure and diabetes. Hypomagnesaemia was more common in the PPI group (39.5 vs. 18.9%, P < 0.001).

CONCLUSION

PPI use was associated with progression to MARE, but not death in patients with CKD after adjusting for factors known to predict declining renal function, including lower eGFR, proteinuria and comorbidities. A prospective cohort study is required to validate these findings.

The impact of coronary angiography on renal transplant function

INTRODUCTION

There may be reluctance to perform coronary angiography in kidney transplant patients due to perceived risk of iodinated contrast, despite an increased risk of cardiovascular disease compared with the general population.

AIM

We sought to determine if renal transplant function was adversely affected within 7, 30 and 180 days of coronary angiography.

DESIGN AND METHODS

Renal transplant recipients undergoing coronary angiography in a single centre (01/2006-02/2018) were identified retrospectively. Baseline and highest SCr within 7, 30 and 180 days of coronary angiography were extracted from the electronic patient record. Rise in creatinine >26 micromol/l was considered significant [equivalent to Acute Kidney Injury (AKI) Network criteria stage 1 AKI] and case note review performed to determine circumstance of renal decline.

RESULTS

There were 127 coronary angiographies conducted in 90 patients: 67.7% were male and mean age was 58.0 (±10.1) years. There was AKI within 7 days in 18.9% cases, but SCr returned to baseline within 7 days or there was an alternative explanation for AKI in 83.3% of these. In the remaining four cases, there was progressive decline in renal transplant function. In the absence of critical illness, no patient required dialysis or extended hospital stay for contrast-associated AKI.

CONCLUSIONS

In this cohort of renal transplant recipients undergoing coronary angiography, AKI occurred in a minority of cases, and in more than 95% of such cases this effect was transient, with progressive renal decline a rare and predictable event. Renal transplant should not be regarded as a contraindication to coronary angiography.

IgG4-related disease: a novel, important but easily missed condition

Immunoglobulin G4-related disease (IgG4-RD) is a multisystem, fibroinflammatory condition unrecognised in medical science until the last decade. It is characterised by progressive scarring and dysfunction of affected organs and tissues including the pancreas, hepatobiliary tree, kidneys, salivary glands, retroperitoneum and lungs. The diagnosis is made with the presence of numerous IgG4 positive plasma cells within a histologically-distinct chronic inflammatory process; most patients also have elevated serum IgG4. Though early cases were all identified in Japan, subsequent reports clearly demonstrate that IgG4-RD exists worldwide. There are no data confirming the prevalence of IgG4-RD in the West but it is thought to be very rare. Limited awareness of the condition and its heterogeneous presentation frequently results in misdiagnosis. Prompt and correct diagnosis is critical, as a rapid reversal of even advanced disease is often seen with corticosteroid therapy. We present three cases that illustrate some of the typical features of this condition.

Decreased use of cervical spine clearance in blunt trauma: the implication of the injury mechanism and distracting injury

BACKGROUND

Cervical spine injury (CSI) can be ruled out based on clinical examination and no X-ray is required if patient is awake, alert, and examinable. This is known as a clinical clearance (CC). Clinicians have decreased the use and reliance of CC and relied more upon X-ray, especially now that computerized tomography (CT) is fast and readily available. The objective of this study was to identify clinical factors, in particular, the injury mechanism and the distracting injuries, which may be associated with CSI. The knowledge may help to improve the use of CC.

METHODS

We retrospectively reviewed the records of all blunt trauma patients who were awake, alert, and examinable, with a Glasgow Coma Scale of 14-15, and who were admitted to our Level 1 Trauma Center during January 1 to December 31, 2005. We excluded patients who presented with gross neurological deficit or who died within 72 h. From the chart review, we collected the demographics; the injury severity score (ISS); the injury mechanism; the presence of distracting injuries (DI) which were defined as bony fractures (divided into upper body, lower body, or both); and the radiographs obtained. Patients who did not receive CC underwent a 3-view plain film X-ray, with or without CT scan. We then divided the group into those with CSI (Case) and those without (Control). We compared the two group variables and performed a multiple logistic regression analysis to identify clinical factors associated with CSI. Statistical significance was accepted with p-value <0.05.

RESULTS

Of the 985 patients evaluated, only 179 (18%) received CC. The remaining did not receive CC and went on to have radiographs. Of these, 76 were diagnosed CSI (Case). On a univariate analysis, the ISS, a motor vehicle collision (MVC) with rollover; MVC with rollover and ejection, the absence of DI, and a lower-body DI were significantly associated with CSI. However, on a multivariate analysis, only an MVC with rollover (odds ratio [OR], 2.326; 95% confidence interval [CI], 1.36-3.97) and a lower-body distracting injury (OR, 0.20; 95% CI, 0.07-0.55) were significantly associated with CSI.

CONCLUSION

The injury mechanism of MVC with rollover may prevent clinicians from utilizing CC, while the presence of a lower-body DI should not. A future and prospective study is needed to better understand the role of the injury mechanism and the distracting injury in relation to CSI.

Human immunodeficiency virus and drug misuse: the Edinburgh experience

During 1985 many drug abusers who lived in Edinburgh were found to be infected with the human immunodeficiency virus (HIV). As a result an alternative counselling and screening clinic for testing for antibodies to HIV was established for use by drug abusers. Four hundred and forty one patients were counselled in the first year, and over 60% were either drug abusers or their sexual contacts. One hundred and fourteen (26%) patients were positive for HIV antibody, and 100 (88%) of these were current or former drug abusers. The HIV seropositivity rate in drug abusers was 52% but was only 7% in their sexual contacts. Services were provided for these people as well as counselling before and after the test. The cost of this counselling service for the first year was 27,000 pounds or 61.22 pounds per patient. The unexpected mobility of 23% of the Edinburgh drug abusers, particularly to other areas of Britain, suggests that similar services need to be set up elsewhere.