How the websites of high-volume US centers address the risks of living kidney donation.

BACKGROUND: The websites of US transplant centers may be a source of information about the renal risks of potential living kidney donors. METHODS: To include only likely best practices, we surveyed websites of centers that performed at least 50 living donor kidney transplants per year. We tabulated how risks were conveyed regarding loss of eGFR at donation, the adequacy of long-term ESRD risk data, long-term donor mortality, minority donor ESRD risk, concerns about hyperfiltration injury versus the risk of end-stage kidney diseases, comparisons of ESRD risks in donors to population risks, the increased risks of younger donors, an effect of the donation itself to increase risk, quantifying risks over specific intervals, and a lengthening list of small post-donation medical risks and metabolic changes of uncertain significance. RESULTS: While websites had no formal obligation to address donor risks, many offered abundant information. Some conveyed OPTN-mandated requirements for counseling individual donor candidates. While actual wording often varied, there was general agreement on many issues. We occasionally noted clear-cut differences among websites in risk characterization and other outliers. CONCLUSIONS: The websites of the most active US centers offer insights into how transplant professionals view living kidney donor risk. Website content may merit further study.

"You can't get there from here": Critical obstacles to current estimates of the ESRD risks of young living kidney donors.

Short studies that generate lifetime end-stage renal disease (ESRD) risks for young living kidney donors have conflicted with the knowledge and practice of nontransplant specialists. A widely accepted online risk calculator (OLRC) is no exception. It uses 6.4 year observations and an ostensibly empiric methodology to predict low lifetime risks for normal young candidates. But the nonspecific ESRD risk factors identified in this study are likely features of kidney diseases that were already underway at study entry. No practicing nephrologist would use their absence to predict any specific kidney disease that had yet to begin, which is essential for excluding high-risk individuals. The OLRC's risk estimates are particularly low because it also does not assign to young adults about 70% of the lifetime ESRD that they will experience as they age, which is part of their risk. It reinforces traditional concepts of low donor risk, minimizing the potential relevance of recent, sometimes concerning, long-term outcome data. These data suggest many similarities between postdonation ESRD and ESRD in the general population, about which much is already known. Despite our best efforts, the heterogeneity and exponential accumulation of end-stage kidney diseases over time prevent long-term predictions of risk for young kidney donors.

Moving closer to understanding the risks of living kidney donation.

Recent studies from the United States and Norway have suggested an unexpected 8- to 11-fold relative risk of ESRD after kidney donation, but a low long-term absolute risk. Abundant renal epidemiologic data predict that these studies have underestimated long-term risk. The 1% lifetime post-donation risk in the US study requires medical screening to predict ESRD in 96 of 100 candidates. This is particularly unlikely in the 30-35% of candidates under age 35, half of whose lifetime ESRD will occur after age 64. Many experts have attributed the increased relative risks in these studies to loss of GFR at donation, which ultimately means that high-normal pre-donation GFRs will reduce absolute post-donation risks. The 8- to 11-fold relative risks predict implausible risks of uninephrectomy in the general population, but lower estimates still result in very high risks for black donors. Young vs. older age, low vs. high-normal pre-donation GFRs, black race, and an increased relative risk of donation all predict highly variable individual risks, not a single "low" or "1%" risk as these studies suggest. A uniform, ethically defensible donor selection protocol would accept older donors with many minor medical abnormalities but protect from donation many currently acceptable younger, black, and/or low GFR candidates.

ECD kidney transplantation outcomes are improved when matching donors to recipients using a novel creatinine clearance match ratio (CCMR).

Improved outcomes have been associated with various methods of size matching between expanded criteria (ECD) donors and recipients. A novel method for improved functional based matching was developed utilizing manipulation of Cockcroft-Gault estimated creatinine clearances for donor and recipient. We hypothesized that optimal clearance-based matches would have superior outcomes for both immediate graft function and long-term graft survival. For the analysis, recipients of ECD kidneys in the Scientific Registry of Transplant Recipients (SRTR) transplanted between October 1, 1987 and August 31, 2011 were included. Univariate and multivariate analyses predicted the hazard ratio of graft failure and the odds ratio of requiring dialysis within the first week. A total of 25,640 ECD kidney transplants were analyzed. On multivariate analysis, higher creatinine clearance match ratio (CCMR) was associated with increased graft failure and odds of requiring dialysis within the first week (comparing highest ratio quintile versus lowest ratio quintile: HR 1.43, p < 0.001; OR 2.08, p < 0.001). This study suggests that ECD kidneys have improved outcomes when the recipient/donor CCMR is optimized.

Steroid-free chronic immunosuppression in renal transplantation.

PURPOSE OF REVIEW: Over the past two decades, steroid-free immunosuppression has become more widespread, but improvements in long-term kidney transplant survival have been modest, mandating scrutiny of our chronic regimens. RECENT FINDINGS: Current studies and commentary cautiously conclude that steroid-free regimens in low-risk patients seem acceptable for up to 5 years, although most studies are shorter. Patients who will develop chronic rejection cannot be identified prospectively and usually return to steroids. One center continues to report long-term steroid-free results that are comparable to or better than national Scientific Registry of Renal Transplant Recipients (SRTR) outcomes, even with 'older' drugs cyclosporine and azathioprine, reaffirming the need for well designed prospective studies. Some authorities question whether minimal side effects with current regimens justify steroid elimination. In low-risk populations, 'steroid-type' studies probably would suggest no short-term benefit of tacrolimus over cyclosporine, or mycophenolate over azathioprine. SUMMARY: The data justifying steroid-free immunosuppression continue to be suboptimal. A larger question is whether to treat an entire population at medical risk or just the higher-risk subgroup that declares itself in the short term. 'Subgroup therapy' might well produce the same quandaries if applied to other accepted transplant immunosuppression.

Interdialytic creatinine change versus predialysis creatinine as indicators of nutritional status in maintenance hemodialysis.

BACKGROUND: Protein-energy wasting is common in patients on maintenance hemodialysis and is strongly associated with poor quality of life and mortality. However, clinical assessment of protein-energy wasting remains difficult. Predialysis creatinine levels are associated with mortality risk but may be influenced by both muscle mass and dialysis dose. This might be overcome by examining the rate of rise in creatinine between dialysis sessions. METHODS: We conducted an observational cohort study among 81 patients on maintenance hemodialysis at our Veterans Affairs unit. Predialysis serum creatinine and change in serum creatinine between midweek dialysis sessions served as the predictor variables of interest and clinically available proxies of nutritional status and time to mortality served as the outcome variables. Linear regression and Cox proportional hazards models evaluated relationships, respectively. RESULTS: The mean age of the study participants was 63 ± 10 years, 77 (95%) were male, mean body mass index was 27 ± 6 kg/m(2) and 69% had diabetes. Median follow-up time was 13 months, during which 12 patients (15%) died. Interdialytic change in serum creatinine showed a strong direct correlation with predialysis serum creatinine (R = 0.96). Higher levels of both markers were associated with younger age, less residual urine volume and higher serum albumin, serum phosphorus and normalized protein catabolic rate (P < 0.05 for all). Both markers were approximately equally strongly associated with mortality. For example, compared to the highest predialysis creatinine tertile, participants in the lowest tertile (<6 mg/dL) had 5.5-fold [95% confidence interval (CI) 1.1, 26.6] higher risk of death. Similarly, participants in the lowest tertile of interdialytic change in creatinine (change <3.7 mg/dL/48 h), had 5.0-fold (95% CI 1.0, 24.4) higher death risk. CONCLUSIONS: Predialysis creatinine and interdialytic change in creatinine are both strongly associated with proxies of nutritional status and mortality in hemodialysis patients and are highly correlated. Interdialytic change in creatinine provided little additional information about nutritional status or mortality risk above and beyond predialysis creatinine levels alone.

Clinical practice guideline: benign paroxysmal positional vertigo.

OBJECTIVES: This guideline provides evidence-based recommendations on managing benign paroxysmal positional vertigo (BPPV), which is the most common vestibular disorder in adults, with a lifetime prevalence of 2.4 percent. The guideline targets patients aged 18 years or older with a potential diagnosis of BPPV, evaluated in any setting in which an adult with BPPV would be identified, monitored, or managed. This guideline is intended for all clinicians who are likely to diagnose and manage adults with BPPV. PURPOSE: The primary purposes of this guideline are to improve quality of care and outcomes for BPPV by improving the accurate and efficient diagnosis of BPPV, reducing the inappropriate use of vestibular suppressant medications, decreasing the inappropriate use of ancillary tests such as radiographic imaging and vestibular testing, and to promote the use of effective repositioning maneuvers for treatment. In creating this guideline, the American Academy of Otolaryngology-Head and Neck Surgery Foundation selected a panel representing the fields of audiology, chiropractic medicine, emergency medicine, family medicine, geriatric medicine, internal medicine, neurology, nursing, otolaryngology-head and neck surgery, physical therapy, and physical medicine and rehabilitation. RESULTS: The panel made strong recommendations that 1) clinicians should diagnose posterior semicircular canal BPPV when vertigo associated with nystagmus is provoked by the Dix-Hallpike maneuver. The panel made recommendations against 1) radiographic imaging, vestibular testing, or both in patients diagnosed with BPPV, unless the diagnosis is uncertain or there are additional symptoms or signs unrelated to BPPV that warrant testing; and 2) routinely treating BPPV with vestibular suppressant medications such as antihistamines or benzodiazepines. The panel made recommendations that 1) if the patient has a history compatible with BPPV and the Dix-Hallpike test is negative, clinicians should perform a supine roll test to assess for lateral semicircular canal BPPV; 2) clinicians should differentiate BPPV from other causes of imbalance, dizziness, and vertigo; 3) clinicians should question patients with BPPV for factors that modify management including impaired mobility or balance, CNS disorders, lack of home support, and increased risk for falling; 4) clinicians should treat patients with posterior canal BPPV with a particle repositioning maneuver (PRM); 5) clinicians should reassess patients within 1 month after an initial period of observation or treatment to confirm symptom resolution; 6) clinicians should evaluate patients with BPPV who are initial treatment failures for persistent BPPV or underlying peripheral vestibular or CNS disorders; and 7) clinicians should counsel patients regarding the impact of BPPV on their safety, the potential for disease recurrence, and the importance of follow-up. The panel offered as options that 1) clinicians may offer vestibular rehabilitation, either self-administered or with a clinician, for the initial treatment of BPPV and 2) clinicians may offer observation as initial management for patients with BPPV and with assurance of follow-up. The panel made no recommendation concerning audiometric testing in patients diagnosed with BPPV. DISCLAIMER: This clinical practice guideline is not intended as a sole source of guidance in managing benign paroxysmal positional vertigo. Rather, it is designed to assist clinicians by providing an evidence-based framework for decision-making strategies. The guideline is not intended to replace clinical judgement or establish a protocol for all individuals with this condition, and may not provide the only appropriate approach to diagnosing and managing this problem.

Clinical Practice Guideline: Benign Paroxysmal Positional Vertigo (Update) Executive Summary.

The American Academy of Otolaryngology-Head and Neck Surgery Foundation has published a supplement to this issue of Otolaryngology-Head and Neck Surgery featuring the "Clinical Practice Guideline: Benign Paroxysmal Positional Vertigo (Update)." To assist in implementing the guideline recommendations, this article summarizes the rationale, purpose, and key action statements. The 14 recommendations developed emphasize diagnostic accuracy and efficiency, reducing the inappropriate use of vestibular suppressant medications, decreasing the inappropriate use of ancillary testing, and increasing the appropriate therapeutic repositioning maneuvers. An updated guideline is needed due to new clinical trials, new systematic reviews, and the lack of consumer participation in the initial guideline development group.

Clinical Practice Guideline: Benign Paroxysmal Positional Vertigo (Update).

Objective This update of a 2008 guideline from the American Academy of Otolaryngology-Head and Neck Surgery Foundation provides evidence-based recommendations to benign paroxysmal positional vertigo (BPPV), defined as a disorder of the inner ear characterized by repeated episodes of positional vertigo. Changes from the prior guideline include a consumer advocate added to the update group; new evidence from 2 clinical practice guidelines, 20 systematic reviews, and 27 randomized controlled trials; enhanced emphasis on patient education and shared decision making; a new algorithm to clarify action statement relationships; and new and expanded recommendations for the diagnosis and management of BPPV. Purpose The primary purposes of this guideline are to improve the quality of care and outcomes for BPPV by improving the accurate and efficient diagnosis of BPPV, reducing the inappropriate use of vestibular suppressant medications, decreasing the inappropriate use of ancillary testing such as radiographic imaging, and increasing the use of appropriate therapeutic repositioning maneuvers. The guideline is intended for all clinicians who are likely to diagnose and manage patients with BPPV, and it applies to any setting in which BPPV would be identified, monitored, or managed. The target patient for the guideline is aged ≥18 years with a suspected or potential diagnosis of BPPV. The primary outcome considered in this guideline is the resolution of the symptoms associated with BPPV. Secondary outcomes considered include an increased rate of accurate diagnoses of BPPV, a more efficient return to regular activities and work, decreased use of inappropriate medications and unnecessary diagnostic tests, reduction in recurrence of BPPV, and reduction in adverse events associated with undiagnosed or untreated BPPV. Other outcomes considered include minimizing costs in the diagnosis and treatment of BPPV, minimizing potentially unnecessary return physician visits, and maximizing the health-related quality of life of individuals afflicted with BPPV. Action Statements The update group made strong recommendations that clinicians should (1) diagnose posterior semicircular canal BPPV when vertigo associated with torsional, upbeating nystagmus is provoked by the Dix-Hallpike maneuver, performed by bringing the patient from an upright to supine position with the head turned 45° to one side and neck extended 20° with the affected ear down, and (2) treat, or refer to a clinician who can treat, patients with posterior canal BPPV with a canalith repositioning procedure. The update group made a strong recommendation against postprocedural postural restrictions after canalith repositioning procedure for posterior canal BPPV. The update group made recommendations that the clinician should (1) perform, or refer to a clinician who can perform, a supine roll test to assess for lateral semicircular canal BPPV if the patient has a history compatible with BPPV and the Dix-Hallpike test exhibits horizontal or no nystagmus; (2) differentiate, or refer to a clinician who can differentiate, BPPV from other causes of imbalance, dizziness, and vertigo; (3) assess patients with BPPV for factors that modify management, including impaired mobility or balance, central nervous system disorders, a lack of home support, and/or increased risk for falling; (4) reassess patients within 1 month after an initial period of observation or treatment to document resolution or persistence of symptoms; (5) evaluate, or refer to a clinician who can evaluate, patients with persistent symptoms for unresolved BPPV and/or underlying peripheral vestibular or central nervous system disorders; and (6) educate patients regarding the impact of BPPV on their safety, the potential for disease recurrence, and the importance of follow-up. The update group made recommendations against (1) radiographic imaging for a patient who meets diagnostic criteria for BPPV in the absence of additional signs and/or symptoms inconsistent with BPPV that warrant imaging, (2) vestibular testing for a patient who meets diagnostic criteria for BPPV in the absence of additional vestibular signs and/or symptoms inconsistent with BPPV that warrant testing, and (3) routinely treating BPPV with vestibular suppressant medications such as antihistamines and/or benzodiazepines. The guideline update group provided the options that clinicians may offer (1) observation with follow-up as initial management for patients with BPPV and (2) vestibular rehabilitation, either self-administered or with a clinician, in the treatment of BPPV.