This week’s announcement by the HRC of Feasibility Study and Emerging Researcher grants have many great projects. Two in particular are worth crowing about (because they have some relationship to kidneys and they involve two excellent people). I have put summaries in their own words below, but first my comments.
Dr Palmer (Department of Medicine, University of Otago Christchurch), who has appeared on this blog site before, conducts what in the trade are called “meta-analyses” and “systematic reviews.” Simply put, these are methods to extract the best possible evidence from all the studies that have been done for the effectiveness of a treatment. Just as one person may toss a coin 4 times in a row and get 4 heads, so too can any one trial give a mistaken impression that a treatment is efficacious (or not) when it really isn’t (or is). By pooling together many treatments Suetonia provides the very best quality evidence available. Given that Chronic Kidney Disease affects a large and growing proportion of us, knowing which treatments have the best outcomes is of national significance, not merely to our health but also to the national budget. A particular problem is that after a trial it can be many many years until meaningful health outcomes are know (e.g. if the treatment delays dialysis need or reduces mortality). Suetonia’s study will assess the effectiveness of surrogate endpoints for clinical trials. Surrogate endpoints, such as plasma creatinine which I’ve discussed many time in this blog, are physiologically related to the functioning of an organ or to a disease state as well as statistically associated with future hard outcomes. However, their use in trials is limited by how well they are associated and how they are used. I look forward to finding out what Suetonia discovers.
Mrs Rachael Parke (Auckland DHB) is an experienced nurse undertaking a PhD. Ensuring patients have adequate fluids on board is particularly crucial to the kidneys and other organs. Obviously with surgery any blood loss needs to be compensated for. However, there are also physiological changes in where fluid is distributed throughout the body. Cardiopulmonary bypass, used in cardiac surgery, is a particular risk factor for Acute Kidney Injury. In the past the practice has been to give large amounts of fluid in order to ensure adequate fluid is given. However, recent research has shown that too much fluid can have a negative impact (increased mortality). A more restrictive fluid regime may have very meaningful outcomes. Rachael is investigating, in a randomised controlled trial, if restricting fluid improves outcomes. The outcome she is most interested in is how long patients stay in the hospital. This is a very practical outcome for both patient and budget. I am particularly pleased that this study is nurse-led. Nurses play an incredibly important role in research as well as patient management.
In their own words:
Dr Suetonia Palmer: Making better clinical decisions to prevent kidney disease
More than ten percent of adults will develop chronic kidney disease. The effectiveness of many treatments used to improve outcomes in kidney disease is tested against surrogate (indirect) markers of health (e.g., cholesterol levels or blood pressure).
Unexpectedly, subsequent systematic analysis has identified little evidence to show that treatment strategies based on these surrogate markers translate to improved health for patients. Serum creatinine and proteinuria levels are commonly-used markers of kidney function to guide treatment.
The research involves using systematic review methods to summarise the quality of evidence for using proteinuria and serum creatinine as markers of treatment effectiveness in clinical trials. It will be determined whether using these markers to guide clinical care improves patient health or, conversely, leads to treatment-related harm or excessive use of ineffective medication.
These summaries will help clinicians and patients make better shared decisions about which therapeutic strategies actually improve clinical outcomes in kidney disease.
Mrs Rachel Parke: Fluid therapy after cardiac surgery – A feasibility study
Following cardiac surgery, patients receive large amounts of fluid in the intensive care unit. This may cause problems with wound healing and delay hospital discharge. A planned randomised controlled trial of a restrictive fluid regime as compared to a more liberal approach utilising advance hemodynamic monitoring, aims to reduce the amount of fluid patients receive and reduce hospital length of stay. This feasibility study aims to determine whether this nurse-led protocol is practicable and feasible and will help answer the research question. This study is simple and inexpensive and if it demonstrates a decreased length of hospital stay then this will represent a significant benefit for both individual patients and the health system.