Nasrollah Ghahramani

The assessment, serial evaluation, and subsequent sequelae of acute kidney injury (ASSESS-AKI) study: design and methods

BackgroundThe incidence of acute kidney injury (AKI) has been increasing over time and is associated with a high risk of short-term death. Previous studies on hospital-acquired AKI have important methodological limitations, especially their retrospective study designs and limited ability to control for potential confounding factors.MethodsThe Assessment, Serial Evaluation, and Subsequent Sequelae of Acute Kidney Injury (ASSESS-AKI) Study was established to examine how a hospitalized episode of AKI independently affects the risk of chronic kidney disease development and progression, cardiovascular events, death, and other important patient-centered outcomes. This prospective study will enroll a cohort of 1100 adult participants with a broad range of AKI and matched hospitalized participants without AKI at three Clinical Research Centers, as well as 100 children undergoing cardiac surgery at three Clinical Research Centers. Participants will be followed for up to four years, and will undergo serial evaluation during the index hospitalization, at three months post-hospitalization, and at annual clinic visits, with telephone interviews occurring during the intervening six-month intervals. Biospecimens will be collected at each visit, along with information on lifestyle behaviors, quality of life and functional status, cognitive function, receipt of therapies, interim renal and cardiovascular events, electrocardiography and urinalysis.ConclusionsASSESS-AKI will characterize the short-term and long-term natural history of AKI, evaluate the incremental utility of novel blood and urine biomarkers to refine the diagnosis and prognosis of AKI, and identify a subset of high-risk patients who could be targeted for future clinical trials to improve outcomes after AKI.

Risk of fractures after renal transplantation in the United States.

Background. Although it is known that the incidence of fracture events is increased in renal transplantation recipients, the timing and the factors associated with risk of fractures are less well understood. The objective of this study was to estimate the time to fracture in renal transplantation recipients and to determine whether risk was associated with patient and transplantation characteristics. Methods. Using the U. S. Renal Data System, we retrospectively studied 68,814 patients, who underwent renal transplantation between 1988 and 1998. Fractures were identified from International Classification of Diseases, Ninth Revision, Clinical Modification diagnosis codes in billing data. Time to first fracture was modeled during the first 5 years posttransplant using the Kaplan-Meier method and Cox proportional hazards models. Results. Of the patients who underwent transplantation, 22.5% developed a fracture within 5 years. Woman (hazard ratio [HR] 1.36, P<0.0001), patients older than 45 years of age (HR 1.14, P<0.0001) especially older than 65 years (HR 1.69, P<0.0001), and whites (HR 1.28, P<0.0001) were at increased risk of a fracture. Additionally, receipt of a deceased donor kidney (HR 1.30, P<0.0001), increased human leukocyte antigen mismatches (HR 1.09, P<0.014), diabetes (HR 1.88, P<0.0001), pretransplant dialysis (HR 1.08, P<0.0001), and an aggressive induction immunosuppression regimen (HR 1.14, P<0.0001) all significantly increased risk of fracture events during the first 5 years. Conclusions. In addition to patient demographic features, donor factors, including suboptimal organ quality and the need for more intense immunosuppression, were associated with an increased risk of fractures during the first 5 years after a renal transplant.

Incentives for organ donation: proposed standards for an internationally acceptable system.

Incentives for organ donation, currently prohibited in most countries, may increase donation and save lives. Discussion of incentives has focused on two areas: (1) whether or not there are ethical principles that justify the current prohibition and (2) whether incentives would do more good than harm. We herein address the second concern and propose for discussion standards and guidelines for an acceptable system of incentives for donation. We believe that if systems based on these guidelines were developed, harms would be no greater than those to todays conventional donors. Ultimately, until there are trials of incentives, the question of benefits and harms cannot be satisfactorily answered.

A systematic review of continuous renal replacement therapy and intermittent haemodialysis in management of patients with acute renal failure.

Background:  Acute renal failure (ARF) still bears a poor prognosis with mortality rates up to 70% and the ideal form of renal replacement therapy (RRT) remains controversial. The purpose of this study was to conduct a systematic review and meta‐analysis of all randomized controlled trials (RCT) to examine the effect of dialysis modality (IHD: Intermittent haemodialysis; CRRT: continuous renal replacement therapy) on survival of patients with ARF and to also study the effect of each modality on dialysis dependence (DD).

User Satisfaction with Computerized Order Entry System and Its Effect on Workplace Level of Stress

To evaluate the impact of Computerized Provider Order Entry (CPOE) on workplace stress and overall job performance, as perceived by medical students, housestaff, attending physicians and nurses, after CPOE implementation at Penn State—Milton S. Hershey Medical Center, an academic tertiary care facility, in 2005. Using an online survey, the authors studied attitudes towards CPOE among 862 health care professionals. The main outcome measures were job performance and perceived stress levels. Statistical analyses were conducted using the Statistical Analytical Software (SAS Inc, Carey, NC). A total of 413 respondents completed the entire survey (47.9 % response rate). Respondents in the younger age group were more familiar with the system, used it more frequently, and were more satisfied with it. Interns and residents were the most satisfied groups with the system, while attending physicians expressed the least satisfaction. Attending physicians and fellows found the system least user friendly compared with other groups, and also tended to express more stress and frustration with the system. Participants with previous CPOE experience were more familiar with the system, would use the system more frequently and were more likely to perceive the system as user friendly. User satisfaction with CPOE increases by familiarity and frequent use of the system. Improvement in system characteristics and avoidance of confusing terminology and inconsistent display of data is expected to enhance user satisfaction. Training in the use of CPOE should start early, ideally integrated into medical and nursing school curricula and form a continuous, long-term and user-specific process. This is expected to increase familiarity with the system, reducing stress and leading to improved user satisfaction and to subsequent enhanced safety and efficiency.

Postrenal transplant improvement of sexual function.

RESULTS The majority (81.8%) of the patients were within the age range of 21 to 49 years. Thirty patients (32.3%) were unmarried, and 63 (67.7%) married. Among males, 75% claimed complete lack of libido or potency prior to renal transplantation and during the period of dialysis. A significant improvement in libido and sexual potency was noted by 90% of the males. A significant improvement within the first month was noted by 48% patients, and 82% within the first six months. Among the females, 70% had complete loss of libido in the period of maintenance dialysis, while following transplantation, 85% of these women rated themselves as having a normal libido. Amenorrhea prior to transplantation was reported by 69.7% of the female patients.

Comparative Effects of Silymarin and Vitamin E Supplementation on Oxidative Stress Markers, and Hemoglobin Levels Among Patients on Hemodialysis

Background: The incidence of accelerated atherosclerosis among patients on hemodialysis is very high and oxidative stress (OS) is a potentially major contributor to their morbidity and mortality. Objective: To evaluate the effects of Silymarin and/or vitamin E on OS markers and hemoglobin levels in patients on hemodialysis. Methods: Eighty patients on hemodialysis were randomized into four groups: Group 1 received silymarin 140 mg 3 times daily; Group 2 received vitamin E 400 IU/day; Group 3 received silymarin 140 mg 3 times daily and vitamin E 400 IU/day; and Group 4 was the control. Samples were obtained at baseline and on day 21 for measurement of malondialdehyde (MDA), red blood cell (RBC) glutathione peroxidase (GPX), and hemoglobin. Results: Combination of silymarin and vitamin E led to a reduction in the MDA levels (7.84 ± 1.84 vs. 9.20 ± 2.74 nmol/mL; p = 0.008). There was a significant increase in RBC GPX levels in all treatment groups compared with controls after 3 weeks. This was more pronounced in the group receiving combination compared with the group receiving vitamin E or the control group (5.78 ± 3.51, 4.22 ± 1.63, and 3.16 ± 1.89 IU/grHb, respectively; p < 0.001). There was also a significant increase in mean hemoglobin of all treatment groups compared with the control. Conclusions: Oral supplementation with silymarin and vitamin E leads to reduction in MDA, increase in RBC GPX, and increase in hemoglobin levels in patients with end-stage renal disease. Studies with larger sample sizes and longer follow-up are required to investigate the effect of silymarin on cardiovascular outcomes and erythropoietin requirement.

Perioperative Use of Continuous Renal Replacement Therapy for Orthotopic Liver Transplantation

PURPOSE We present a retrospective study describing the perioperative use of continuous renal replacement therapy (CRRT) for orthotopic liver transplantation (OLT). MATERIALS AND METHODS We retrospectively reviewed the clinical course of patients who underwent OLT with the perioperative use of CRRT. The following variables were recorded: Gender, age, indication for transplantation, time when CRRT was initiated, postoperative need for CRRT, and the patient and organ (liver, kidneys) outcome up to 1 year after transplantation. RESULTS Among 105 patients who underwent OLT from 2006 to 2010; we used CRRT in 12 cases (11.4%) perioperatively, including 9 (8.3%) patients intraoperatively. Perioperative CRRT was employed for volume, electrolyte, and/or pH management. All patients who underwent CRRT perioperatively were alive at 1 month, 10 (83.3%), at 3 and 6 months and 9 (75%) at 1 year after OLT. Only 1 surviving patient (8.3%) required renal replacement therapy at 1 month after surgery. Renal replacement therapy was not required in any surviving patient up to 12 months posttransplantation. CONCLUSION Perioperative and especially intraoperative use of CRRT therapy can potentially improve the outcomes of patients undergoing OLT.

Immune functional assay for immunosuppressive management in post‐transplant malignancy

Uemura T, Riley TR, Khan A, Hollenbeak C, Schreibman I, Ghahramani N, Reeves B, Domen RE, Zander DS, Kadry Z. Immune functional assay for immunosuppressive management in post‐transplant malignancy.
Clin Transplant 2011: 25: E32–E37.

Living unrelated kidney donor transplantation in Iran

In the September and November 2006 issues of Nature Clinical Practice Nephrology, two articles regarding living unrelated kidney donor transplantation alluded to the practices in Iran. Having served in the planning, supervision and implementation of various aspects of health care in Iran, including organ transplantation (ANH), and as transplant nephrologists who have actively participated in the care of transplanted patients in Iran (ANH and NG), we feel obligated to elucidate the realities surrounding organ transplantation in Iran. So that unbiased researchers are provided with information to judge for themselves.