Evaluation of biomarkers of cell cycle arrest and inflammation in prediction of dialysis or recovery after kidney transplantation.

Early prediction of delayed graft function (DGF) after kidney transplantation would facilitate patient management. Cell cycle arrest and inflammation are implicated in the pathogenesis of DGF. We assessed the utility of two novel acute kidney injury (AKI) biomarkers, urinary tissue inhibitor of metalloproteinases-2 (TIMP-2) and insulin-like growth factor-binding protein 7 (IGFBP7), and five inflammatory markers to predict DGF following deceased-donor kidney transplantation. Serial urine concentrations of TIMP-2 and IGFBP7 were measured immediately after transplantation in 56 recipients along with vascular endothelial growth factor-A (VEGF-A), macrophage migration inhibitory factor (MIF), monocyte chemotactic protein-1 (MCP-1), trefoil factor 3 (TFF3) and chemokine (C-X-C) ligand 16 (CXCL16). Delayed graft function (DGF) was defined as requirement for dialysis within 7 days. Integrated discrimination improvement analysis was used to evaluate whether these biomarkers enhanced prediction of DGF independently of a validated clinical risk prediction model. DGF occurred in 22 patients (39%). At 4 h after kidney reperfusion, the area under the receiver operator characteristic curve (AUC) for VEGF-A was good (AUC > 0.80); for TIMP-2, IGFBP7 and [TIMP-2] × [IGFBP7] fair (AUCs 0.70-0.79); and for MIF, MCP-1, TFF3 and CXCL16 poor (AUC < 0.70). Only TIMP-2 and VEGF significantly enhanced the DGF prediction at 4 and 12 h. The cell cycle arrest marker urinary TIMP-2 and the inflammatory biomarker VEGF-A are potentially useful adjuncts to clinical data for early prediction of DGF.

Starting a care improvement journey: focusing on the essentials of bedside nursing care in an Australian teaching hospital.

AIMS AND OBJECTIVES: To evaluate and improve patient assessment practices, care practices, recognition of patient deterioration and communication in the acute ward environment. BACKGROUND: A growing recognition of patient safety-related concerns in acute hospitals, a nursing shortage and a reduction in availability of skill and experience levels at the bedside led a group of clinicians to explore the issues that impacted on patient care at a ward level within their organisation. DESIGN: Multimethod practice development study. This paper reports phase one of concept development. METHOD: A practice review was conducted using clinical audit processes that examined practice and documentation in relation to patient assessment parameters and care planning, specifically identifying whether changes in clinical parameters were identified and acted on. RESULTS: Results highlighted a clear discrepancy between the care that was identified on the nursing care plan and the care the patient was receiving. Actions as a result of the disappointing audit results included changes to education programmes, strategies to improve critical discussion regarding clinical practices and the development of assessable domains of nursing care that were relevant and realistic to ward-based nurses. CONCLUSION: The results enabled the identification of eight domains of care and associated care outcomes that target strategies for care improvement. Emancipatory practice development methodology will be used to further progress this work and ensure successful implementation into clinical units. RELEVANCE TO CLINICAL PRACTICE: This paper examines the critical discussions, audit processes and actions that took place, leading to the development of care outcomes for nurses.

Clusterin in kidney transplantation: novel biomarkers versus serum creatinine for early prediction of delayed graft function.

BACKGROUND AND OBJECTIVES: Current methods for rapid detection of delayed graft function (DGF) after kidney transplantation are unreliable. Urinary clusterin is a biomarker of kidney injury but its utility for prediction of graft dysfunction is unknown. METHODS: In a single-center, prospective cohort study of renal transplant recipients (N=81), urinary clusterin was measured serially between 4 hr and 7 days after transplantation. The utility of clusterin for prediction of DGF (hemodialysis within 7 days of transplantation) was compared with urinary interleukin (IL)-18, neutrophil gelatinase-associated lipocalin (NGAL), kidney injury molecule-1, serum creatinine, and clinical variables. RESULTS: At 4 hr after reperfusion, anuria was highly specific, but of low sensitivity for detection of DGF. At 4 hr, receiver operating characteristic analysis suggested that urinary clusterin, IL-18, kidney injury molecule-1, and NGAL concentration were predictive of DGF. After adjusting for preoperative clinical variables and anuria, clusterin and IL-18 independently enhanced the clinical model for prediction of DGF. Kidney injury molecule-1 only modestly improved the prediction of DGF, whereas NGAL, serum creatinine, and the creatinine reduction ratio did not improve on the clinical model. At 12 hr, the creatinine reduction ratio independently predicted DGF. CONCLUSION: Both urinary clusterin and IL-18 are useful biomarkers and may allow triaging of patients with DGF within 4 hr of transplantation. Relative performance of biomarkers for prediction of graft function is time-dependant. Early and frequent measurements of serum creatinine and calculation of the creatinine reduction ratio also predict DGF within 12 hr of reperfusion.

Removal of urinary catheters: midnight vs 0600 hours.

In the fields of both nursing and medicine there is a dearth of published literature on the optimum time to remove indwelling urinary catheters (IDCs) following urological surgery. Tradition seems to be in favour of removing IDCs at 0600 hours despite a lack of evidence to support this practice. This study was undertaken to determine whether midnight removal of IDCs resulted in patients' resuming normal voiding patterns. A prospective clinical trial was conducted to determine the impact midnight removal of urinary catheters would have on the patients' voiding pattern, and subsequent discharge from hospital. One hundred and sixty patients were entered into the study. The patients were allocated at random to have their urinary catheter removed either at midnight or at 0600 hours. Patients who had their catheters removed at midnight passed a greater volume of urine with both their first (268 ml compared with 177 ml; P<0.0001) and second voids (322 ml compared with 195 ml; P<0.0001) than their counterparts in the 0600 group. This permitted earlier discharge from hospital. The results reported in this study support the findings of earlier research that midnight removal of IDC leads to an earlier resumption of normal voiding patterns, permits earlier discharge from hospital and appears to reduce patients' anxiety. The recommendation from this study is that there should be a change in hospital policy so that the majority of IDCs are removed at midnight.