How to Manage Kidney Transplant Recipients: Deciding Between Glomerular Filtration Rate-Estimating Equations, Creatinine Clearance and Albumin-Creatinine Ratio, or Albumin Excretion.

OBJECTIVES: Management of renal transplant recipients involves measuring glomerular filtration rate and albuminuria; however, data are conflicting on the use of estimating equations or creatinine clearance and albumin-creatinine ratio in early morning urine or albumin excretion in 24-hour urine. We aimed to determine the performance of creatinine clearance and 3 estimated creatinine-based formulas and compare the usefulness of albumin-creatinine ratio related to albumin excretion in kidney transplant patients. MATERIALS AND METHODS: This cross-sectional study examined 300 consecutive kidney transplant patients. Serum creatinine was measured with Cobas-8000 and albumin-creatinine ratio, and albumin excretion was measured with Cobas-C311 (Roche Diagnostics, Hitachi, Tokyo, Japan). We quantified bias and percent bias, Bland-Altman results, and concordances in the classification of chronic kidney disease between formulas and creatinine clearance. We also conducted linear regression analyses of all parameters and for cutoffs of 30 and 300 mg/24 hours and determined the ability of albumin-creatinine ratio to predict abnormal albumin excretion (receiver operator characteristic curve analysis). RESULTS: Bias (mL/min/1.73 m2), percent bias, and concordances between creatinine clearance and Cockcroft-Gault, Modification of Diet in Renal Disease, and Chronic Kidney Disease Epidemiology Colla-boration formulas in the classification of chronic kidney disease were as follows: 15.89, 20.91%, and 0.35; 20.52, 27.89%, and 0.21; and 18.24, 25.39%, and 0.27, respectively. Regression analyses showed a weak but significantly linear relationship for the cutoff values (P < .001). Receiver operator characteristic curve analyses showed areas under the curve of 0.957 and 0.997 at cutoffs of 30 and 300 mg/24 hours. In our patients, the cutoffs were 27 mg/g (88.38% sensitivity, 92.16% specificity) and 238 mg/g (80.00% sensitivity, 97.45% specificity). CONCLUSIONS: We suggest using estimating equations and albumin-creatinine ratio with caution. In routine management of patients with successive stable revisions, we recommended using the Cockcroft-Gault or Chronic Kidney Disease Epidemiology Collaboration formulas and albumin-creatinine ratio.

Comparison of two commercial embryo culture media (SAGE-1 step single medium vs. G1-PLUSTM/G2-PLUSTM sequential media): Influence on in vitro fertilization outcomes and human embryo quality.

OBJECTIVE: To compare embryo quality, fertilization, implantation, miscarriage and clinical pregnancy rates for embryos cultured in two different commercial culture media until D-2 or D-3. METHODS: In this retrospective study, we analyzed 189 cycles performed in 2016. Metaphase II oocytes were microinjected and allocated into single medium (SAGE 1-STEP, Origio) until transferred, frozen or discarded; or, if sequential media were used, the oocytes were cultured in G1-PLUSTM (Vitrolife) up to D-2 or D-3 and in G2-PLUSTM (Vitrolife) to transfer. On the following day, the oocytes were checked for normal fertilization and on D-2 and D-3 for morphological classification. Statistical analysis was performed using the chi-square and Mann-Whitney tests in PASW Statistics 18.0. RESULTS: The fertilization rates were 70.07% for single and 69.11% for sequential media (p=0.736). The mean number of embryos with high morphological quality (class A/B) was higher in the single medium than in the sequential media: D-2 [class A (190 vs. 107, p<0.001), B (133 vs. 118, p=0.018)]; D-3 [class A (40 vs. 19, p=0.048) but without differences in class B (40 vs. 49)]. Consequently, a higher number of embryos cultured in single medium were frozen: 197 (21.00%) vs. sequential: 102 (11.00%), p<0.001. No differences were found in implantation rates (30.16% vs. 25.57%, p=0.520), clinical pregnancy rates (55.88% vs. 41.05%, p=0.213), or miscarriage rates (14.29% vs. 9.52%, p=0.472). CONCLUSION: Embryo culture in single medium yields greater efficiency per cycle than in sequential media. Higher embryo quality and quantity were achieved, resulting in more frozen embryos. There were no differences in clinical pregnancy rates.

Primary hypolactasia diagnosis: Comparison between the gaxilose test, shortened lactose tolerance test, and clinical parameters corresponding to the C/T-13910 polymorphism.

BACKGROUND & AIMS: There is no consensus on the most accurate method to diagnose primary hypolactasia. We aimed to compare the diagnostic accuracy of the new gaxilose test with 2 traditional tests (lactose tolerance test and clinical criteria) for the diagnosis of primary hypolactasia using the C/T-13910 polymorphism as a reference standard. METHODS: Patients with a clinical suspicion of lactose intolerance were subjected to gaxilose tests, shortened lactose tolerance tests, and symptom questionnaires before and after overload with 50 g lactose and after a lactose-free diet. The diagnostic accuracy and degree of agreement and correlation were assessed using a genetic test (C/T-13910 polymorphism) as a reference standard and their respective 95% confidence intervals. RESULTS: Thirty consecutive patients (70% women) participated in the study. The genetic test confirmed the C/T-13910 polymorphism in 11 patients (36.8%). The presence of diarrhoea and the symptom score after lactose overload, along with the tolerance test, were the variables with the highest degree of agreement (κ > 0.60). Area under the ROC curve was >0.82 (p < 0.05), with sensitivity and specificity values of >0.80. However, the gaxilose test obtained lower values: κ, 0.47; area under curve, 0.75 (0.57-0.94); sensitivity, 0.82 (0.55-1); and specificity, 0.68 (0.45-0.92). The multivariate analysis showed an association between the post-overload symptom questionnaire and the results of the genetic test (odds ratio: 1.17; 1.04-1.31; p < 0.01). CONCLUSIONS: The presence of diarrhoea and the symptom score after overload with 50 g lactose showed a higher degree of agreement and diagnostic accuracy for primary hypolactasia than the gaxilose test when the genetic test is used as a reference standard.

Repercusión clínica en la seguridad del paciente de la comunicación de valores críticos de laboratorio / Clinical impact of laboratory critical values notification as a tool for patient safety

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Implantación y evaluación de un procedimiento de comunicación de valores críticos / Evaluation of a critical value reporting procedure

Objetivo. Evaluar la puesta en marcha de un procedimiento de comunicación de pruebas y valores críticos en el Hospital de Montilla (Empresa Pública Hospital Alto Guadalquivir), Montilla, Córdoba. Material y métodos. Se consensuó un catálogo de «pruebas y valores críticos» estableciendo como óptimo un tiempo de comunicación inferior a 30 minutos. Para identificarlos se crearon en el Sistema Informático de Laboratorio (Omega 3000, Roche Diagnostics) reglas automáticas que generan una prueba de aviso. El valor crítico se comprueba analíticamente conforme al procedimiento. Se establecen las responsabilidades en la comunicación y la relación de personas a avisar en cada supuesto. Para el registro se genera otra prueba que incluye quién comunica, a qué hora, el receptor y la recepción de la notificación («Read-back»). Como indicadores se establecieron: número de comunicaciones, tiempo de demora y efectos adversos por retraso. Resultados. Desde enero a septiembre de 2010 se han realizado 73 avisos por pruebas críticas y 354 por valores críticos (0,64% del total de peticiones) de los que 77 (22%) han correspondido a análisis de rutina y 277 (78%) a análisis de urgencias y consulta única. El aviso más frecuente fue por hiperpotasemia (15,8%). Conclusiones. La puesta en marcha del procedimiento ha generado un ligero aumento de la carga de trabajo en el laboratorio, pero ha supuesto una mayor diligencia clínica a la hora de generar acciones médicas inmediatas. Estas iniciativas generan cultura de seguridad para el paciente y los profesionales, creando sinergias beneficiosas en toda la organización (AU)

Objective. Analysis of running a critical value and a critical test reporting procedure in Montilla Hospital (Empresa Pública Hospital Alto Guadalquivir), Montilla, Córdoba (Spain). Material and method. The concept of critical tests and critical values were defined in a list approved by the physicians and based on the literature. The time of the notification was established as less than 30minutes. To identify critical values, some automatic rules were created to generate a notification test in the Laboratory Informatics System (Omega 3000, Roche Diagnostics). A critical value is checked under the appropriate specific procedure, which also establishes the responsibilities for communication and the priority of persons to be notified in each case. Another test is created to register the notification and must include: who notified, at what time and who received the notification («Read-back»). To control the quality of the process we considered: the number of notifications, the time delay in notifying a critical value and if there had been some adverse effects due to any delay. Results. From January to September in 2010 we have notified 73 critical tests and 354 critical values (0.64% of the analysis applications). We reported 77 (22%) critical values from outpatients and 277 (78%) from inpatients. The most frequent notification was due to hyperkalaemia (15.8%). Conclusions. The procedure has involved a slight increase in laboratory workload, but it has assumed more clinical diligence to make critical decisions. These initiatives generate a safety culture for the patient, the staff and good relationships in the organization (AU)