Erythropoiesis-stimulating agents for preventing acute kidney injury.

BACKGROUND: Acute kidney injury (AKI) is characterised by a rapid decline in kidney function and is caused by a variety of clinical conditions. The incidence of AKI in hospitalised adults is high. In animal studies, erythropoiesis-stimulating agents (ESA) have been shown to act as a novel nephroprotective agent against ischaemic, toxic, and septic AKI by inhibiting apoptosis, promoting cell proliferation, and inducing antioxidant and anti-inflammatory responses. As a result, ESAs may reduce the incidence of AKI in humans. Randomised controlled trials (RCTs) have been conducted on the efficacy and safety of ESAs, but no prior systematic reviews exist that comprehensively examine ESAs with respect to AKI prevention, although the effectiveness of these agents has been examined for a range of other diseases and clinical situations. OBJECTIVES: This review aimed to look at the benefits and harms of ESAs for preventing AKI in the context of any health condition. SEARCH METHODS: We searched the Cochrane Kidney and Transplant Register of Studies up to 30 August 2024 through contact with the Information Specialist using search terms relevant to this review. Studies in the Register are identified through searches of CENTRAL, MEDLINE, and EMBASE, conference proceedings, the International Clinical Trials Registry Platform (ICTRP) Search Portal and ClinicalTrials.gov. SELECTION CRITERIA: We included RCTs and quasi-RCTs (in which allocation to treatment was based on alternate assignment or order of medical records, admission dates, date of birth or other non-random methods) that compared ESAs with placebo or standard care in people at risk of AKI. DATA COLLECTION AND ANALYSIS: Three authors independently extracted data and assessed the risk of bias for included studies. We used random-effects model meta-analyses to perform quantitative synthesis of the data. We used the I2 statistic to measure heterogeneity amongst the studies in each analysis. We indicated summary estimates as a risk ratio (RR) for dichotomous outcomes and mean difference (MD) for continuous outcomes with their 95% confidence interval (CI). We assessed the certainty of the evidence for each main outcome using the Grades of Recommendation, Assessment, Development, and Evaluation (GRADE) approach. MAIN RESULTS: A total of 20 studies (36 records, 5348 participants) were included. The number of participants ranged from 10 to 1302, and most studies were carried out in single centres (13/20). All the included studies compared ESAs to placebo or usual care. Many of the studies were judged to have unclear or high risk of reporting bias, but were at low risk for other types of bias. ESAs, when compared to control interventions, may make little or no difference to the risk of AKI (18 studies, 5314 participants: RR 0.97, 95% CI 0.85 to 1.10; I² = 19%; moderate-certainty evidence), death (18 studies, 5263 participants: RR 0.92, 95% CI 0.80 to 1.06; I² = 0%; moderate-certainty evidence), or the initiation of dialysis (14 studies, 2059 participants: RR 1.16, 95% CI 0.90 to 1.51; I² = 0%; low-certainty evidence). Even with standardised measurement of AKI, the studies showed no difference in results between different routes of administration (subcutaneous or intravenous), background diseases (cardiac surgeries, children or neonates, other adults at risk of AKI), or duration or dose of ESA. ESAs may make little or no difference to the risk of thrombosis when compared to control interventions (8 studies, 3484 participants: RR 0.92, 95% CI 0.68 to 1.24; I² = 0%). Similarly, there were probably no differences in kidney function measures and adverse events such as myocardial infarction, stroke or hypertension. However, this may be due to the low incidence of these adverse events. AUTHORS' CONCLUSIONS: In patients at risk of AKI, ESAs probably do not reduce the risk of AKI or death and may not reduce the need for starting dialysis. Similarly, there were probably no differences in kidney function measures and adverse events such as thrombosis, myocardial infarction, stroke or hypertension. There are currently two ongoing studies that have either not been completed or published, and it is unclear whether they will change the results. Caution should be exercised when using ESAs to prevent AKI.

Use of an iPad App (Aid for Decision-making in Occupational Choice) for Collaborative Goal Setting in Interprofessional Rehabilitation: Qualitative Descriptive Study.

BACKGROUND: Goal setting is a key part of the rehabilitation process. The use of technology and electronic tools such as smartphone apps and websites has been suggested as a way of improving the engagement of users in meaningful goal setting and facilitating shared decision-making between patients and health professionals. OBJECTIVE: This study aims to describe experiences of health professionals and patients in the use of the English language version of the iPad app Aid for Decision-making in Occupational Choice (ADOC) to facilitate collaborative goal setting in rehabilitation. METHODS: We recruited participants from 3 acute and postacute care rehabilitation wards in both public and private organizations in New Zealand. Participants were registered allied health professionals, including physiotherapists, occupational therapists, and speech-language therapists, who engage in goal setting as part of their normal work, and their adult patients. We collected data via semistructured interviews to gather information about the experiences of the participants in the use of ADOC for goal setting. Data were analyzed with thematic analysis. RESULTS: A total of 8 health professionals and 8 patients participated in the study. Six main themes emerged from the data: changing patients' perspective on what is possible, changing health professionals' perspective on what is important, facilitating shared decision-making, lack of guides for users, logistic and organizational barriers, and app-related and technical issues. CONCLUSIONS: Health professionals and patients found ADOC to be a valuable tool when setting shared rehabilitation goals. The use of ADOC promoted a patient-centered approach that empowered patients to engage in collaborative goal setting. The technological limitations of the app that negatively impacted experiences can be addressed in the future implementation of ADOC in rehabilitation settings.

Aldosterone antagonists for people with chronic kidney disease requiring dialysis.

BACKGROUND: People with chronic kidney disease (CKD) requiring dialysis are at a particularly high risk of cardiovascular death and morbidity. Several clinical studies suggested that aldosterone antagonists would be a promising treatment option for people undergoing dialysis. However, the clinical efficacy and potential harm of aldosterone antagonists for people with CKD on dialysis has yet to be determined. OBJECTIVES: This review aimed to evaluate the benefits and harms of aldosterone antagonists, both non-selective (spironolactone) and selective (eplerenone), in comparison to control (placebo or standard care) in people with CKD requiring haemodialysis (HD) or peritoneal dialysis (PD). SEARCH METHODS: We searched the Cochrane Kidney and Transplant Register of Studies up to 5 August 2020 using search terms relevant to this review. Studies in the Register are identified through searches of CENTRAL, MEDLINE, and EMBASE, conference proceedings, the International Clinical Trials Register (ICTRP) Search Portal and ClinicalTrials.gov. SELECTION CRITERIA: We included parallel randomised controlled trials (RCTs), cross-over RCTs, and quasi-RCTs (where group allocation is by a method that is not truly random, such as alternation, assignment based on alternate medical records, date of birth, case record number, or other predictable methods) that compared aldosterone antagonists with placebo or standard care in people with CKD requiring dialysis. DATA COLLECTION AND ANALYSIS: Two review authors independently extracted data and assessed risk of bias for included studies. We used a random-effects model meta-analysis to perform a quantitative synthesis of the data. We used the I² statistic to measure heterogeneity among the studies in each analysis. We indicated summary estimates as a risk ratio (RR) for dichotomous outcomes, mean difference (MD) for continuous outcomes, or standardised mean differences (SMD) if different scales were used, with their 95% confidence interval (CI). We assessed the certainty of the evidence for each of the main outcomes using the GRADE (Grades of Recommendation, Assessment, Development, and Evaluation) approach. MAIN RESULTS: We included 16 studies (14 parallel RCTs and two cross-over RCTs) involving a total of 1446 participants. Thirteen studies compared spironolactone to placebo or standard care and one study compared eplerenone to a placebo. Most included studies had an unclear or high risk of bias. Compared to control, aldosterone antagonists probably reduced the risk of death (any cause) for people with CKD requiring dialysis (9 studies, 1119 participants: RR 0.45, 95% CI 0.30 to 0.67; I² = 0%; moderate certainty of evidence). Aldosterone antagonist probably decreased the risk of death due to cardiovascular disease (6 studies, 908 participants: RR 0.37, 95% CI 0.22 to 0.64; I² = 0%; moderate certainty of evidence) and cardiovascular and cerebrovascular morbidity (3 studies, 328 participants: RR 0.38, 95% CI 0.18 to 0.76; I² = 0%; moderate certainty of evidence). While aldosterone antagonists probably increased risk of gynaecomastia compared with control (4 studies, 768 participants: RR 5.95, 95% CI 1.93 to 18.3; I² = 0%; moderate certainty of evidence), aldosterone antagonists may make little or no difference to the risk of hyperkalaemia (9 studies, 981 participants: RR 1.41, 95% CI 0.72 to 2.78; I² = 47%; low certainty of evidence). Aldosterone antagonists had a marginal effect on left ventricular mass among participants undergoing dialysis (8 studies, 633 participants: SMD -0.42, 95% CI -0.78 to 0.05; I² = 77%). In people with CKD requiring dialysis received aldosterone antagonists compared to control, there were 72 fewer deaths from all causes per 1000 participants (95% CI 47 to 98) with a number needed to treat for an additional beneficial outcome (NNTB) of 14 (95% CI 10 to 21) and for gynaecomastia were 26 events per 1000 participants (95% CI 15 to 39) with a number need to treat for an additional harmful outcome (NNTH) of 38 (95% CI 26 to 68). AUTHORS' CONCLUSIONS: Based on moderate certainty of the evidence, aldosterone antagonists probably reduces the risk of all-cause and cardiovascular death and probably reduces morbidity due to cardiovascular and cerebrovascular disease in people with CKD requiring dialysis. For the adverse effect of gynaecomastia, the risk was increased compared to control. For this outcome, the absolute risk was lower than the absolute risk of death. It is hoped the three large ongoing studies will provide better certainty of evidence.

Whakawhanaungatanga: the importance of culturally meaningful connections to improve uptake of pulmonary rehabilitation by Maori with COPD - a qualitative study.

BACKGROUND: Pulmonary rehabilitation is known to improve function and quality of life for people with chronic obstructive pulmonary disease (COPD). However, little research has been conducted on the influence of culture on experiences of pulmonary rehabilitation. This study examined factors influencing uptake of pulmonary rehabilitation by Maori with COPD in New Zealand. METHOD: Grounded theory nested within kaupapa Maori methodology. Transcripts were analyzed from interviews and focus groups with 15 Maori and ten New Zealand non-Maori invited to attend pulmonary rehabilitation for COPD. Maori participants had either attended a mainstream hospital-based program, a community-based program designed "by Maori, for Maori", or had experienced both. RESULTS: Several factors influencing uptake of pulmonary rehabilitation were common to all participants regardless of ethnicity: 1) participants' past experiences (eg, of exercise; of health care systems), 2) attitudes and expectations, 3) access issues (eg, time, transport, and conflicting responsibilities), and 4) initial program experiences. These factors were moderated by the involvement of family and peers, interactions with health professionals, the way information on programs was presented, and by new illness events. For Maori, however, several additional factors were also identified relating to cultural experiences of pulmonary rehabilitation. In particular, Maori participants placed high value on whakawhanaungatanga: the making of culturally meaningful connections with others. Culturally appropriate communication and relationship building was deemed so important by some Maori participants that when it was absent, they felt strongly discouraged to attend pulmonary rehabilitation. Only the more holistic services offered a program in which they felt culturally safe and to which they were willing to return for ongoing rehabilitation. CONCLUSION: Lack of attention to cultural factors in the delivery of pulmonary rehabilitation may be a barrier to its uptake by indigenous, minority ethnic groups, such as New Zealand Maori. Indigenous-led or culturally responsive health care interventions for COPD may provide a solution to this issue.

Interventions for sexual dysfunction in people with chronic obstructive pulmonary disease (COPD).

BACKGROUND: People with chronic obstructive pulmonary disease (COPD) are believed be at higher risk of problems with sexual function than age-matched peers. Problems with sexuality or sexual function associated with COPD may arise as a results of hormonal, physiological, or psychological problems, or as a result of changes in intimate relationships arising from the chronic nature of the condition. OBJECTIVES: To evaluate the effectiveness of interventions for sexual dysfunction in people with COPD. SEARCH METHODS: We searched the Cochrane Airways Group's Specialised Register on 8 July 2015 and conducted supplementary searches of the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, four other databases, and two trials registers to July 2015, together with reference checking, citation searching, and contact with study authors to identify additional studies. We used no language or date restrictions. SELECTION CRITERIA: Randomised controlled trials (RCTs), cluster RCTs, and quasi-RCTs evaluating the effects of pharmacological, mechanical, psychological, or educational interventions to address problems with sexual well-being in people with COPD and their partners. DATA COLLECTION AND ANALYSIS: Two review authors independently reviewed search results against predetermined inclusion criteria. Two review authors independently extracted data and assessed risk of bias for included studies. We contacted study authors for additional information. MAIN RESULTS: We included two studies involving a total of 48 participants. One of these studies (an RCT) investigated the effect of a pharmacological intervention (testosterone therapy) compared to a placebo over a four-month period. The other study (a quasi-RCT) compared one month of long-term oxygen therapy to a single 24-hour dose of oxygen therapy over a one-month period. Both studies only included men with moderate to very severe COPD (mean FEV1% across both studies 41%; standard deviation (SD) 11.7%) who were under the age of 74 (mean age across both studies 65 years; SD 7.1). We found low-quality evidence that testosterone therapy for men with COPD results in improvements in erectile function, but no evidence of effect regarding overall satisfaction with sexual function. There is insufficient data to draw conclusions regarding the possibility of adverse events arising from testosterone therapy for COPD or the effect of oxygen therapy on erectile dysfunction. Neither study provided additional data on sexual function, other than erectile function. AUTHORS' CONCLUSIONS: There is currently insufficient evidence from clinical trials at present to inform the best way of providing interventions to improve sexual function and sexual satisfaction for people with COPD and their partners. Consequently, clinicians need to rely on clinical trials involving people without COPD and expert opinion in order to guide clinical practice in this area. Considerably more trials need to be conducted in this area of clinical practice.

ANTECEDENTES: Se considera que los pacientes con enfermedad pulmonar obstructiva crónica (EPOC) tienen un mayor riesgo de problemas con la función sexual que sus pares igualados por la edad. Los problemas con la sexualidad o la función sexual asociados con la EPOC pueden surgir como resultado de problemas hormonales, fisiológicos o psicológicos, o como resultado de los cambios en las relaciones íntimas que aparecen por la naturaleza crónica de la afección. OBJETIVOS: Evaluar la efectividad de las intervenciones para la disfunción sexual en los pacientes con EPOC. MÉTODOS DE BÚSQUEDA: Se buscó en el registro especializado del Grupo Cochrane de Vías Respiratorias (Cochrane Airways Group) el 8 de julio de 2015 y se realizaron búsquedas suplementarias en el Registro Cochrane Central de Ensayos Controlados (Cochrane Central Register of Controlled Trials) (CENTRAL), MEDLINE, EMBASE, en otras cuatro bases de datos y en otros dos registros hasta julio 2015, junto con la verificación de las referencias, la búsqueda de citas y el contacto con autores de estudios para identificar estudios adicionales. No se aplicó ninguna restricción de idioma o de fecha. CRITERIOS DE SELECCIÓN: Ensayos controlados aleatorios (ECA), ECA grupales y ensayos controlados cuasialeatorios que evaluaron los efectos de las intervenciones farmacológicas, mecánicas, psicológicas o educacionales para enfrentar los problemas con el bienestar sexual en pacientes con EPOC y sus parejas. OBTENCIÓN Y ANÁLISIS DE LOS DATOS: Dos revisores de manera independiente examinaron los resultados de la búsqueda contra los criterios predeterminados de inclusión. Dos autores de la revisión, de forma independiente, extrajeron los datos y evaluaron el riesgo de sesgo de los estudios incluidos. Se contactó con los autores de los estudios para obtener información adicional. RESULTADOS PRINCIPALES: Se incluyeron dos estudios con un total de 48 participantes. Uno de estos estudios (un ECA) investigó el efecto de una intervención farmacológica (tratamiento con testosterona) comparada con placebo durante un período de cuatro meses. El otro estudio (un ensayo controlado cuasialeatorio) comparó un mes de oxigenoterapia a largo plazo con una dosis única de 24 horas de oxigenoterapia durante un período de un mes. Ambos estudios solamente incluyeron hombres con EPOC moderada a muy grave (VEF1% medio en ambos estudios 41%; desviación estándar [DE] 11,7%) que tenían menos de 74 años (edad promedio en ambos estudios 65 años; DE 7,1). Se encontraron pruebas de baja calidad de que el tratamiento con testosterona en los hombres con EPOC da lugar a mejorías en la función eréctil, pero no se obtuvieron pruebas del efecto con respecto a la satisfacción general con la función sexual. No hay datos suficientes para establecer conclusiones con respecto a la posibilidad de eventos adversos con el tratamiento con testosterona para la EPOC o el efecto de la oxigenoterapia sobre la disfunción eréctil. Ningún estudio proporcionó datos adicionales sobre la función sexual, aparte de la función eréctil. CONCLUSIONES DE LOS AUTORES: Actualmente no hay pruebas suficientes de ensayos clínicos que informen la mejor manera de proporcionar intervenciones para mejorar la función sexual y la satisfacción sexual de los pacientes con EPOC y sus parejas. Por lo tanto, los médicos deben depender de ensayos clínicos que incluyen pacientes sin EPOC y de la opinión de expertos para guiar la práctica clínica en esta área. Es necesario realizar muchos más ensayos en esta área de la práctica clínica.