Is estimated glomerular filtration rate superior to serum creatinine in predicting mortality on the waiting list for liver transplantation?

Serum creatinine is an important prognostic indicator in patients on the liver transplant waiting-list, being a component of the Model for End Stage Liver Disease (MELD) score. However, creatinine is influenced by age, gender and race, and in this role may disadvantage some individuals. The Modification of Diet in Renal Disease (MDRD) estimated glomerular filtration rate (eGFR) takes into account these variables and may be a superior measure of renal function. Our aim was to examine whether the MDRD 4-variable, 5-variable and 6-variable eGFRs are superior to serum creatinine in predicting 3-month waiting-list mortality in patients with end-stage liver disease. This was a retrospective single-centre study of 427 adults listed for first liver transplantation. The median listing MDRD 4-variable, 5-variable and 6-variable eGFR was 69, 71 and 73 ml/min/1.73 m(2) , respectively. The median listing serum creatinine was 89 µm. MDRD 4-variable (P = 0.002), 5-variable (P < 0.001) and 6-variable eGFR (P < 0.001), and serum creatinine (P < 0.001), were all predictors of mortality on the transplant waiting-list. Of the three MDRD equations, the 6-variable eGFR was the better prognostic indicator. The substitution of 6-variable eGFR for serum creatinine did not improve the prognostic accuracy of the MELD (P = 0.825) and UK score for Patients with End-Stage Liver Disease (P = 0.781) scores. In conclusion the MDRD eGFR is comparable, but not superior to serum creatinine, in predicting death within 3 months of listing for liver transplantation.

Protocol and Fidelity Monitoring Plan for Four Supports. A Multicenter Trial of an Intervention to Support Surrogate Decision Makers in Intensive Care Units.

Individuals acting as surrogate decision makers for critically ill patients frequently struggle in this role and experience high levels of long-term psychological distress. Prior interventions designed to improve the sharing of information by the clinical team with surrogate decision makers have demonstrated little effect on surrogates' outcomes or clinical decisions. In this report, we describe the study protocol and corresponding intervention fidelity monitoring plan for a multicenter randomized clinical trial testing the impact of a multifaceted surrogate support intervention (Four Supports) on surrogates' psychological distress, the quality of decisions about goals of care, and healthcare use. We will randomize the surrogates of 300 incapacitated critically ill patients at high risk of death and/or severe long-term functional impairment to receive the Four Supports intervention or an education control. The Four Supports intervention adds to the intensive care unit (ICU) team a trained interventionist (family support specialist) who delivers four types of protocolized support-emotional support; communication support; decisional support; and, if indicated, anticipatory grief support-to surrogates through daily interactions during the ICU stay. The primary outcome is surrogates' symptoms of anxiety and depression at 6-month follow-up, measured with the Hospital Anxiety and Depression Scale. Prespecified secondary outcome measures are the Patient Perception of Patient Centeredness Scale (modified for use with surrogates) and Impact of Event Scale scores at 3- and 6-month follow-up, respectively, together with ICU and hospital lengths of stay and total hospital cost among decedents. The fidelity monitoring plan entails establishing and measuring adherence to the intervention using multiple measurement methods, including daily checklists and coding of audiorecorded encounters. This approach to intervention fidelity may benefit others designing and testing behavioral interventions in the ICU setting. Clinical trial registered with www.clinicaltrials.gov (NCT01982877).