Ferric carboxymaltose-induced hypophosphataemia after kidney transplantation.

BACKGROUND: Ferric carboxymaltose (FCM) can induce hypophosphataemia in the general population and patients with chronic kidney disease (CKD). Less is known about the effect of FCM in the kidney transplant population. It has been suggested that fibroblast growth factor 23 (FGF-23)-mediated renal phosphate wasting may be the most likely cause of this phenomenon. In the current study, the effects of FCM on phosphate metabolism were studied in a cohort of kidney transplant recipients. METHODS: Two index patients receiving FCM are described. Additionally, data of 23 kidney transplant recipients who received a single dose of FCM intravenously between 1 January 2014 and 1 July 2015 were collected. Changes in the serum phosphate concentration were analysed in all subjects. Change in plasma FGF-23 concentrations was analysed in the index patients. RESULTS: In the two index patients an increase in FGF-23 and a decrease in phosphate concentrations were observed after FCM administration. In the 23 kidney transplant patients, median estimated glomerular filtration rate was 42 ml/min/1.73 m2 ( range 10-90 ml/ min/1.73 m2). Mean phosphate concentration before and after FCM administration was 1.05 ±; 0.35 mmol/l and 0.78 ±; 0.41 mmol/l, respectively (average decrease of 0.27 mmol/l; p = 0.003). In the total population, 13 (56.5%) patients showed a transient decline in phosphate concentration after FCM administration. Hypophosphataemia following FCM administration was severe (i.e. < 0.5 mmol/l) in 8 (34.8%) patients. CONCLUSION: Administration of a single dose of FCM may induce transient and mostly asymptomatic renal phosphate wasting and hypophosphataemia in kidney transplant recipients. This appears to be explained by an increase in FGF-23 concentration.

Practitioners and nondrug treatment of hypertension, effects of participating in a survey.

A nationwide survey in the Netherlands among 600 randomly sampled practitioners revealed that the advice (1) quit smoking, (2) reduce alcohol, (3) healthy diet, and (4) physical activities was only given by 76%, 26%, 44%, and 61% of the practitioners. To confirm these data, and to study the effects of the personal characteristics of the practitioners, and the effect of their participation in a survey. All general practitioners in the areas of Dordrecht in the Netherlands, with 350,000 inhabitants, were invited to participate. Self-administered questionnaires included questions about non-pharmaceutical treatment recommendations given, about blood pressure increasing factors including blood pressure increasing medicines, and healthy life style. After 1 year, the survey was repeated among the practitioners who completed the first one. The current survey produced a result largely similar to that of the nationwide survey. The combined results were as follows: among 281 practitioners a quit smoking advice was given by 82%, reduce alcohol advice by 47%, healthy diet advice by 51%, and physical activities advice by only 73% of the practitioners with 95% confidence intervals of, respectively, 75%-84%, 38%-49%, 41%-53%, and 64%-75%. Country physicians and older physicians were more active in giving nondrug treatments with P-values of <0.02 to <0.05. Increased blood pressure as a side effect of concomitant medications was virtually never addressed. After the survey, 26 practitioners (24.8%, P < 0.001) had started life style recommendations.

Prevalence of iatrogenic admissions to the Departments of Medicine/Cardiology/ Pulmonology in a 1,250 bed general hospital.

A recent meta-analysis in this journal showed incidences between 3.4 and 33.9%. Studies performed by pharmacists and epidemiologists produced lower incidences than internists' studies. We reassessed the prevalence of iatrogenic admissions in a study of internists. Iatrogenic disease was defined as adverse drug reactions according to the World Health Organization Definition and complications induced by non-drug medical interventions. Subsequent admissions at the Departments of Medicine/Cardiology/Pulmonology in a 1,250 bed general hospital in the Netherlands from May 2007 to August 2007 were studied. 2,000 consecutive admissions were studied: 576 (29%, 26-32%) were classified as possibly iatrogenic; out of these 380 (19%, 17-22%) as definitely iatrogenic, out of whom 229 (12%, 10-14%) had already been classified as iatrogenic by the admitting physicians. Patients with cardiac disease, hypertension, gastrointestinal conditions, anticoagulant treatment and use of NSAIDs were, particularly, at risk of iatrogenic admission with percentages of 22 (16-24), 13 (11-18), 12 (9-15), and 7 (5-11) %. An independent predictor of iatrogenic admissions was age with an odds ratio of 1.27 per 10 years (p = 0.0001). 1. At least 19% of admissions to the Departments of Internal Medicine/Cardiology/Pulmonology, and, maybe, even percentages up to 29% were due to adverse drug effects. 2. A large difference between the numbers of iatrogenic admission according to the physicians in charge of admission and the investigators, 229 versus 380 patients, was observed. 3. Most often iatrogenic admissions were observed with cardiac disease, hypertension, gastrointestinal conditions, anticoagulant treatment, and use of NSAIDs.

Meta-analysis of recent studies on patients admitted to hospital due to adverse drug effects.

The use of drugs has expanded during the previous decade. However, earlier studies on patients admitted for adverse drugs effects (ADEs) have been heterogeneous. The objectives of this study were to assess the number of recent admissions to hospital due to ADEs and to assess the degree of heterogeneity in recent studies. Prospective studies published in the past decade were therefore pooled and compared with the pooled results from earlier studies. The pooled overall percentage in recent studies (n = 20) was 5.4% (5.0 - 5.8) and this did not significantly differ from that in the earlier studies (n = 21, pooled percentage 4.7%, 3.1 - 6.2). The studies were clinically very heterogeneous with percentages of ADEs between 3.4 and 33.2%. The nature of the patient group could be held largely responsible for the clinical heterogeneity observed.

Accuracy assessments of quantitative diagnostic tests for clinical research.

BACKGROUND: Clinical research is impossible without accurate diagnostic tests. The methods for assessing accuracy of quantitative diagnostic tests are not routinely used by the scientific community. OBJECTIVE AND METHODS: To review the advantages and disadvantages of methods that could be used for that purpose. Using real data examples we review seven possible methods. RESULTS AND CONCLUSIONS: Simple linear regression testing the presence of a significant correlation between the new test data (x-axis data) and the control test data (y-axis data) is not accurate for testing the validity of a novel quantitative diagnostic test. Accurate methods using linear regression include the following. First, from y = a + b x, test the hypothesis that b is statistically significantly larger than zero, than test the hypothesis that b = 1.000 and a = 0.000. Second, if "the b = 1.000 and a = 0.000 hypothesis" cannot be confirmed, then use as criterion for validation a squared correlation-coefficient r2 or intraclass correlation of > 95%, or a relative residual variance of < 5%. If the new test is validated this way, then the predicted control-test-values are calculated from the equation y = a + bx. The above three methods assume uncertainty of the new test data, but not of the control test data. Deming regression, Passing-Bablok regression, paired Student's t-tests, and Altman-Bland plots assume uncertainty of both the new test and the control test. This is rarely a condition for validation, and carries the risk of unneeded loss of sensitivity of testing. However, if the control test is not the gold standard test and it is decided to account the uncertainty of the control test, then Passing-Bablok regression is the only method that adjusts for non-normal data as frequently observed in practice.

Lifestyle interventions in the management of hypertension: a survey based on the opinion of 105 practitioners.

BACKGROUND: Lifestyle interventions in the management of hypertension were beneficial in published studies. OBJECTIVE: To evaluate (1) which lifestyle recommendations are given by physicians and to what extent the possibility of drug-induced hypertension is addressed; (2) to study the characteristics of the physicians who more often perform lifestyle interventions. METHODS: General practitioners in the area of Dordrecht were asked whether or not they included lifestyle advice in the management of their patients' hypertension. RESULTS: Of the 176 physicians invited, 105 consented to take part. Measures to reduce body weight, stopping smoking, and physical exercise advice were given by 94, 92, and 92% of the physicians, respectively. Advice on psychological relaxation and reducing liquorice (Dutch: drop) intake was only given by 23 and 32%. Rural physicians were more active: they more often recommended quitting smoking (p<0.02), reducing weight (p<0.02), and participating in sporting activities (p<0.02). And so were older physicians: they more often recommended starting low-calorie diets (p<0.05), stopping liquorice consumption (p<0.04) and emphasised drug compliance (p<0.02). Increased blood pressure as a side effect of concomitant medications, other than nonsteroidal anti-inflammatory drugs and oral contraceptives, was virtually never addressed. CONCLUSIONS: (1) Advice to reduce body weight, stop smoking, and increase physical exercise are the only lifestyle recommendations routinely given, (2) rural physicians and older physicians were more active in giving non-drug treatments, (3) increased blood pressure as a side effect of medications was virtually never addressed. (Neth Heart J 2009;17:9-12.).