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Jayne D, Walsh M, Merkel PA, Peh CA, Szpirt W, Puéchal X, Fujimoto S, Hawley C, Khalidi N, Jones R, Flossmann O, Wald R, Girard L, Levin A, Gregorini G, Harper L, Clark W, Pagnoux C, Specks U, Smyth L, Ito-Ihara T, de Zoysa J, Brezina B, Mazzetti A, McAlear CA, Reidlinger D, Mehta S, Ives N, Brettell EA, Jarrett H, Wheatley K, Broadhurst E, Casian A, Pusey CD. Plasma exchange and glucocorticoids to delay death or end-stage renal disease in anti-neutrophil cytoplasm antibody-associated vasculitis: PEXIVAS non-inferiority factorial RCT. Health Technol Assess 2022; 26:1-60. [PMID: 36155131 DOI: 10.3310/pnxb5040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Anti-neutrophil cytoplasm antibody-associated vasculitis is a multisystem, autoimmune disease that causes organ failure and death. Physical removal of pathogenic autoantibodies by plasma exchange is recommended for severe presentations, along with high-dose glucocorticoids, but glucocorticoid toxicity contributes to morbidity and mortality. The lack of a robust evidence base to guide the use of plasma exchange and glucocorticoid dosing contributes to variation in practice and suboptimal outcomes. OBJECTIVES We aimed to determine the clinical efficacy of plasma exchange in addition to immunosuppressive therapy and glucocorticoids with respect to death and end-stage renal disease in patients with severe anti-neutrophil cytoplasm antibody-associated vasculitis. We also aimed to determine whether or not a reduced-dose glucocorticoid regimen was non-inferior to a standard-dose regimen with respect to death and end-stage renal disease. DESIGN This was an international, multicentre, open-label, randomised controlled trial. Patients were randomised in a two-by-two factorial design to receive either adjunctive plasma exchange or no plasma exchange, and either a reduced or a standard glucocorticoid dosing regimen. All patients received immunosuppressive induction therapy with cyclophosphamide or rituximab. SETTING Ninety-five hospitals in Europe, North America, Australia/New Zealand and Japan participated. PARTICIPANTS Participants were aged ≥ 16 years with a diagnosis of granulomatosis with polyangiitis or microscopic polyangiitis, and either proteinase 3 anti-neutrophil cytoplasm antibody or myeloperoxidase anti-neutrophil cytoplasm antibody positivity, and a glomerular filtration rate of < 50 ml/minute/1.73 m2 or diffuse alveolar haemorrhage attributable to active anti-neutrophil cytoplasm antibody-associated vasculitis. INTERVENTIONS Participants received seven sessions of plasma exchange within 14 days or no plasma exchange. Oral glucocorticoids commenced with prednisolone 1 mg/kg/day and were reduced over different lengths of time to 5 mg/kg/day, such that cumulative oral glucocorticoid exposure in the first 6 months was 50% lower in patients allocated to the reduced-dose regimen than in those allocated to the standard-dose regimen. All patients received the same glucocorticoid dosing from 6 to 12 months. Subsequent dosing was at the discretion of the treating physician. PRIMARY OUTCOME The primary outcome was a composite of all-cause mortality and end-stage renal disease at a common close-out when the last patient had completed 10 months in the trial. RESULTS The study recruited 704 patients from June 2010 to September 2016. Ninety-nine patients died and 138 developed end-stage renal disease, with the primary end point occurring in 209 out of 704 (29.7%) patients: 100 out of 352 (28%) in the plasma exchange group and 109 out of 352 (31%) in the no plasma exchange group (adjusted hazard ratio 0.86, 95% confidence interval 0.65 to 1.13; p = 0.3). In the per-protocol analysis for the non-inferiority glucocorticoid comparison, the primary end point occurred in 92 out of 330 (28%) patients in the reduced-dose group and 83 out of 325 (26%) patients in the standard-dose group (partial-adjusted risk difference 0.023, 95% confidence interval 0.034 to 0.08; p = 0.5), thus meeting our non-inferiority hypothesis. Serious infections in the first year occurred in 96 out of 353 (27%) patients in the reduced-dose group and in 116 out of 351 (33%) patients in the standard-dose group. The rate of serious infections at 1 year was lower in the reduced-dose group than in the standard-dose group (incidence rate ratio 0.69, 95% confidence interval 0.52 to 0.93; p = 0.016). CONCLUSIONS Plasma exchange did not prolong the time to death and/or end-stage renal disease in patients with anti-neutrophil cytoplasm antibody-associated vasculitis with severe renal or pulmonary involvement. A reduced-dose glucocorticoid regimen was non-inferior to a standard-dose regimen and was associated with fewer serious infections. FUTURE WORK A meta-analysis examining the effects of plasma exchange on kidney outcomes in anti-neutrophil cytoplasm antibody-associated vasculitis is planned. A health-economic analysis of data collected in this study to examine the impact of both plasma exchange and reduced glucocorticoid dosing is planned to address the utility of plasma exchange for reducing early end-stage renal disease rates. Blood and tissue samples collected in the study will be examined to identify predictors of response to plasma exchange in anti-neutrophil cytoplasm in antibody-associated vasculitis. The benefits associated with reduced glucocorticoid dosing will inform future studies of newer therapies to permit further reduction in glucocorticoid exposure. Data from this study will contribute to updated management recommendations for anti-neutrophil cytoplasm antibody-associated vasculitis. LIMITATIONS This study had an open-label design which may have permitted observer bias; however, the nature of the end points, end-stage renal disease and death, would have minimised this risk. Despite being, to our knowledge, the largest ever trial in anti-neutrophil cytoplasm antibody-associated vasculitis, there was an insufficient sample size to assess clinically useful benefits on the separate components of the primary end-point: end-stage renal disease and death. Use of a fixed-dose plasma exchange regimen determined by consensus rather than data-driven dose ranging meant that some patients may have been underdosed, thus reducing the therapeutic impact. In particular, no biomarkers have been identified to help determine dosing in a particular patient, although this is one of the goals of the biomarker plan of this study. TRIAL REGISTRATION This trial is registered as ISRCTN07757494, EudraCT 2009-013220-24 and Clinicaltrials.gov NCT00987389. FUNDING This project was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 26, No. 38. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- David Jayne
- Department of Medicine, University of Cambridge, Cambridge, UK
| | - Michael Walsh
- Department of Nephrology, McMaster University, Hamilton, ON, Canada
| | - Peter A Merkel
- Department of Rheumatology, University of Pennsylvania, Philadelphia, PA, USA
| | - Chen Au Peh
- Royal Adelaide Hospital, Adelaide, SA, Australia
| | - Wladimir Szpirt
- Department of Nephrology, Rigshospitalet, Copenhagen, Denmark
| | - Xavier Puéchal
- National Referral Centre for Rare Systemic Autoimmune Diseases, Cochin Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Shouichi Fujimoto
- Department of Hemovascular Medicine and Artificial Organs, Faculty of Medicine, University of Miyazaki, Miyazaki, Japan
| | - Carmel Hawley
- Department of Nephrology, The University of Queensland, Brisbane, QLD, Australia
| | - Nader Khalidi
- Department of Rheumatology, McMaster University, Hamilton, ON, Canada
| | - Rachel Jones
- Renal Unit, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | | | - Ron Wald
- Department of Rheumatology, St Michael's Hospital, Toronto, ON, Canada
| | - Louis Girard
- Department of Nephrology, University of Calgary, Calgary, AB, Canada
| | - Adeera Levin
- Department of Nephrology, St Paul's Hospital, Vancouver, BC, Canada
| | - Gina Gregorini
- Department of Nephrology, Azienda Ospedaliera Spedali Civili di Brescia, Brescia, Italy
| | - Lorraine Harper
- Department of Nephrology, University of Birmingham, Birmingham, UK
| | - William Clark
- Department of Nephrology, University of Western Ontario, London, ON, Canada
| | - Christian Pagnoux
- Department of Rheumatology, Mount Sinai Hospital, Toronto, ON, Canada
| | - Ulrich Specks
- Department of Pulmonary Medicine, Mayo Clinic, Rochester, MN, USA
| | - Lucy Smyth
- Department of Nephrology, The Royal Devon and Exeter Hospital, Exeter, UK
| | - Toshiko Ito-Ihara
- Clinical and Translational Research Centre, Kyoto Prefecture University of Medicine, Kyoto, Japan
| | - Janak de Zoysa
- Department of Nephrology, North Shore Hospital, Auckland, New Zealand
| | - Biljana Brezina
- Renal Unit, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Andrea Mazzetti
- The Research Institute, St Joseph's Healthcare, Hamilton, ON, Canada
| | - Carol A McAlear
- Department of Rheumatology, University of Pennsylvania, Philadelphia, PA, USA
| | - Donna Reidlinger
- Australasian Kidney Trials Network, The University of Queensland, Brisbane, QLD, Australia
| | - Samir Mehta
- Birmingham Clinical Trials Unit, University of Birmingham, Birmingham, UK
| | - Natalie Ives
- Birmingham Clinical Trials Unit, University of Birmingham, Birmingham, UK
| | | | - Hugh Jarrett
- Birmingham Clinical Trials Unit, University of Birmingham, Birmingham, UK
| | - Keith Wheatley
- Cancer Research UK Clinical Trials Unit, University of Birmingham, Birmingham, UK
| | | | - Alina Casian
- Department of Medicine, University of Cambridge, Cambridge, UK
| | - Charles D Pusey
- Department of Nephrology, Imperial College London, London, UK
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Afentou N, Frew E, Mehta S, Ives NJ, Woolley RL, Brettell EA, Khan AR, Milford DV, Bockenhauer D, Saleem MA, Hall AS, Koziell A, Maxwell H, Hegde S, Finlay E, Gilbert RD, Jones C, McKeever K, Cook W, Webb NJA, Christian MT. Economic Evaluation of Using Daily Prednisolone versus Placebo at the Time of an Upper Respiratory Tract Infection for the Management of Children with Steroid-Sensitive Nephrotic Syndrome: A Model-Based Analysis. Pharmacoecon Open 2022; 6:605-617. [PMID: 35733076 PMCID: PMC9283622 DOI: 10.1007/s41669-022-00334-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Accepted: 03/28/2022] [Indexed: 06/15/2023]
Abstract
BACKGROUND Childhood steroid-sensitive nephrotic syndrome is a frequently relapsing disease with significant short- and long-term complications, leading to high healthcare costs and reduced quality of life for patients. The majority of relapses are triggered by upper respiratory tract infections (URTIs) and evidence shows that daily low-dose prednisolone at the time of infection may reduce the risk of relapse. OBJECTIVE The aim of this study was to assess the cost effectiveness of a 6-day course of low-dose prednisolone at the start of a URTI when compared with placebo. METHODS A state-transition Markov model was developed to conduct a cost-utility analysis with the outcome measured in quality-adjusted life-years (QALYs). Resource use and outcome data were derived from the PREDNOS2 trial. The analysis was performed from a UK National Health Service perspective and the results were extrapolated to adulthood. Model parameter and structural uncertainty were assessed using sensitivity analyses. RESULTS The base-case results showed that administering low-dose prednisolone at the time of a URTI generated more QALYs and a lower mean cost at 1 year compared with placebo. In the long-term, low-dose prednisolone was associated with a cost saving (£176) and increased effectiveness (0.01 QALYs) compared with placebo and thus remained the dominant treatment option. These findings were robust to all sensitivity analyses. CONCLUSION A 6-day course of low-dose prednisolone at the time of a URTI in children with steroid-sensitive nephrotic syndrome has the potential to reduce healthcare costs and improve quality of life compared with placebo.
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Affiliation(s)
- Nafsika Afentou
- Health Economics Unit, University of Birmingham, Birmingham, UK
| | - Emma Frew
- Health Economics Unit, University of Birmingham, Birmingham, UK.
| | - Samir Mehta
- Birmingham Clinical Trials Unit, University of Birmingham, Birmingham, UK
| | - Natalie J Ives
- Birmingham Clinical Trials Unit, University of Birmingham, Birmingham, UK
| | - Rebecca L Woolley
- Birmingham Clinical Trials Unit, University of Birmingham, Birmingham, UK
| | | | - Adam R Khan
- Birmingham Clinical Trials Unit, University of Birmingham, Birmingham, UK
| | - David V Milford
- Department of Paediatric Nephrology, Birmingham Children's Hospital, Birmingham, UK
| | - Detlef Bockenhauer
- Department of Renal Medicine, University College London, London, UK
- Department of Paediatric Nephrology, Great Ormond Street Hospital for Children, London, UK
| | - Moin A Saleem
- School of Clinical Sciences, University of Bristol, Bristol, UK
- Department of Paediatric Nephrology, Bristol Royal Hospital for Children, Bristol, UK
| | | | - Ania Koziell
- Child Health Clinical Academic Group, King's College London, London, UK
- Department of Paediatric Nephrology, Evelina Children's Hospital, London, UK
| | - Heather Maxwell
- Department of Paediatric Nephrology, Royal Hospital for Sick Children, Glasgow, UK
| | - Shivaram Hegde
- Department of Paediatric Nephrology, University Hospital of Wales, Cardiff, UK
| | - Eric Finlay
- Department of Paediatric Nephrology, Leeds Children's Hospital, Leeds, UK
| | - Rodney D Gilbert
- Department of Paediatric Nephrology, Southampton Children's Hospital, Southampton, UK
| | - Caroline Jones
- Department of Paediatric Nephrology, Alder Hey Children's Hospital, Liverpool, UK
| | - Karl McKeever
- Department of Paediatric Nephrology, Royal Hospital for Sick Children, Belfast, UK
| | - Wendy Cook
- Nephrotic Syndrome Trust (NeST), Taunton, UK
| | - Nicholas J A Webb
- Department of Paediatric Nephrology, University of Manchester, Manchester, UK
- Academic Health Science Centre, Royal Manchester Children's Hospital, Manchester, UK
| | - Martin T Christian
- Department of Paediatric Nephrology, Nottingham Children's Hospital, Nottingham, UK
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3
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Christian MT, Webb NJA, Mehta S, Woolley RL, Afentou N, Frew E, Brettell EA, Khan AR, Milford DV, Bockenhauer D, Saleem MA, Hall AS, Koziell A, Maxwell H, Hegde S, Prajapati H, Gilbert RD, Jones C, McKeever K, Cook W, Ives N. Evaluation of Daily Low-Dose Prednisolone During Upper Respiratory Tract Infection to Prevent Relapse in Children With Relapsing Steroid-Sensitive Nephrotic Syndrome: The PREDNOS 2 Randomized Clinical Trial. JAMA Pediatr 2022; 176:236-243. [PMID: 34928294 PMCID: PMC8689426 DOI: 10.1001/jamapediatrics.2021.5189] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
IMPORTANCE In children with corticosteroid-sensitive nephrotic syndrome, many relapses are triggered by upper respiratory tract infections. Four small studies found that administration of daily low-dose prednisolone for 5 to 7 days at the time of an upper respiratory tract infection reduced the risk of relapse, but the generalizability of their findings is limited by location of the studies and selection of study population. OBJECTIVE To investigate the use of daily low-dose prednisolone for the treatment of upper respiratory tract infection-related relapses. DESIGN, SETTING, AND PARTICIPANTS This double-blind, placebo-controlled randomized clinical trial (Prednisolone in Nephrotic Syndrome [PREDNOS] 2) evaluated 365 children with relapsing steroid-sensitive nephrotic syndrome with and without background immunosuppressive treatment at 122 pediatric departments in the UK from February 1, 2013, to January 31, 2020. Data from the modified intention-to-treat population were analyzed from July 1, 2020, to December 31, 2020. INTERVENTIONS At the start of an upper respiratory tract infection, children received 6 days of prednisolone, 15 mg/m2 daily, or matching placebo preparation. Those already taking alternate-day prednisolone rounded their daily dose using trial medication to the equivalent of 15 mg/m2 daily or their alternate-day dose, whichever was greater. MAIN OUTCOMES AND MEASURES The primary outcome was the incidence of first upper respiratory tract infection-related relapse. Secondary outcomes included overall rate of relapse, changes in background immunosuppressive treatment, cumulative dose of prednisolone, rates of serious adverse events, incidence of corticosteroid adverse effects, and quality of life. RESULTS The modified intention-to-treat analysis population comprised 271 children (mean [SD] age, 7.6 [3.5] years; 174 [64.2%] male), with 134 in the prednisolone arm and 137 in the placebo arm. The number of patients experiencing an upper respiratory tract infection-related relapse was 56 of 131 (42.7%) in the prednisolone arm and 58 of 131 (44.3%) in the placebo arm (adjusted risk difference, -0.02; 95% CI, -0.14 to 0.10; P = .70). No evidence was found that the treatment effect differed according to background immunosuppressive treatment. No significant differences were found in secondary outcomes between the treatment arms. A post hoc subgroup analysis assessing the primary outcome in 54 children of South Asian ethnicity (risk ratio, 0.66; 95% CI, 0.40-1.10) vs 208 children of other ethnicity (risk ratio, 1.11; 95% CI, 0.81-1.54) found no difference in efficacy of intervention in those of South Asian ethnicity (test for interaction P = .09). CONCLUSIONS AND RELEVANCE The results of PREDNOS 2 suggest that administering 6 days of daily low-dose prednisolone at the time of an upper respiratory tract infection does not reduce the risk of relapse of nephrotic syndrome in children in the UK. Further work is needed to investigate interethnic differences in treatment response. TRIAL REGISTRATION isrctn.org Identifier: ISRCTN10900733; EudraCT 2012-003476-39.
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Affiliation(s)
- Martin T. Christian
- Department of Paediatric Nephrology, Nottingham Children’s Hospital, Nottingham, UK
| | - Nicholas J. A. Webb
- Department of Paediatric Nephrology, University of Manchester, Manchester Academic Health Science Centre, Royal Manchester Children’s Hospital, Manchester, UK
| | - Samir Mehta
- Birmingham Clinical Trials Unit, University of Birmingham, Birmingham, UK
| | - Rebecca L. Woolley
- Birmingham Clinical Trials Unit, University of Birmingham, Birmingham, UK
| | - Nafsika Afentou
- Health Economics Unit, University of Birmingham, Birmingham, UK
| | - Emma Frew
- Health Economics Unit, University of Birmingham, Birmingham, UK
| | | | - Adam R. Khan
- Birmingham Clinical Trials Unit, University of Birmingham, Birmingham, UK
| | - David V. Milford
- Department of Paediatric Nephrology, Birmingham Children’s Hospital, Birmingham, UK
| | - Detlef Bockenhauer
- Department of Renal Medicine, University College London, London, UK,Department of Paediatric Nephrology, Great Ormond Street Hospital for Children, London, UK
| | - Moin A. Saleem
- Department of Glomerular Cell Biology, Bristol Medical School, University of Bristol, Bristol, UK,Department of Paediatric Nephrology, Bristol Royal Hospital for Children, Bristol, UK
| | | | - Ania Koziell
- Child Health Clinical Academic Group, King’s College London, London, UK,Department of Paediatric Nephrology, Evelina Children’s Hospital, London, UK
| | - Heather Maxwell
- Department of Paediatric Nephrology, Royal Hospital for Sick Children, Glasgow, UK
| | - Shivaram Hegde
- Department of Paediatric Nephrology, University Hospital of Wales, Cardiff, UK
| | - Hitesh Prajapati
- Department of Paediatric Nephrology, Leeds Children’s Hospital, Leeds, UK
| | - Rodney D. Gilbert
- Department of Paediatric Nephrology, Southampton Children’s Hospital, Southampton, UK
| | - Caroline Jones
- Department of Paediatric Nephrology, Alder Hey Children’s Hospital, Liverpool, UK
| | - Karl McKeever
- Department of Paediatric Nephrology, Royal Hospital for Sick Children, Belfast, UK
| | | | - Natalie Ives
- Birmingham Clinical Trials Unit, University of Birmingham, Birmingham, UK
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4
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Christian MT, Webb NJA, Woolley RL, Afentou N, Mehta S, Frew E, Brettell EA, Khan AR, Milford DV, Bockenhauer D, Saleem MA, Hall AS, Koziell A, Maxwell H, Hegde S, Finlay ER, Gilbert RD, Jones C, McKeever K, Cook W, Ives N. Daily low-dose prednisolone to prevent relapse of steroid-sensitive nephrotic syndrome in children with an upper respiratory tract infection: PREDNOS2 RCT. Health Technol Assess 2022; 26:1-94. [DOI: 10.3310/wtfc5658] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
Background
Most children with steroid-sensitive nephrotic syndrome have relapses that are triggered by upper respiratory tract infections. Four small trials, mostly in children already taking maintenance corticosteroid in countries of different upper respiratory tract infection epidemiology, showed that giving daily low-dose prednisone/prednisolone for 5–7 days during an upper respiratory tract infection reduces the risk of relapse.
Objectives
To determine if these findings were replicated in a large UK population of children with relapsing steroid-sensitive nephrotic syndrome on different background medication or none.
Design
A randomised double-blind placebo-controlled trial, including a cost-effectiveness analysis.
Setting
A total of 122 UK paediatric departments, of which 91 recruited patients.
Participants
A total of 365 children with relapsing steroid-sensitive nephrotic syndrome (mean age 7.6 ± 3.5 years) were randomised (1 : 1) according to a minimisation algorithm based on background treatment. Eighty children completed 12 months of follow-up without an upper respiratory tract infection. Thirty-two children were withdrawn from the trial (14 prior to an upper respiratory tract infection), leaving a modified intention-to-treat analysis population of 271 children (134 and 137 children in the prednisolone and placebo arms, respectively).
Interventions
At the start of an upper respiratory tract infection, children received 6 days of prednisolone (15 mg/m2) or an equivalent dose of placebo.
Main outcome measures
The primary outcome was the incidence of first upper respiratory tract infection-related relapse following any upper respiratory tract infection over 12 months. The secondary outcomes were the overall rate of relapse, changes in background treatment, cumulative dose of prednisolone, rates of serious adverse events, incidence of corticosteroid adverse effects, change in Achenbach Child Behaviour Checklist score and quality of life. Analysis was by intention-to-treat principle. The cost-effectiveness analysis used trial data and a decision-analytic model to estimate quality-adjusted life-years and costs at 1 year, which were then extrapolated over 16 years.
Results
There were 384 upper respiratory tract infections and 82 upper respiratory tract infection-related relapses in the prednisolone arm, and 407 upper respiratory tract infections and 82 upper respiratory tract infection-related relapses in the placebo arm. The number of patients experiencing an upper respiratory tract infection-related relapse was 56 (42.7%) and 58 (44.3%) in the prednisolone and placebo arms, respectively (adjusted risk difference –0.024, 95% confidence interval –0.14 to 0.09; p = 0.70). There was no evidence that the treatment effect differed when data were analysed according to background treatment. There were no significant differences in secondary outcomes between treatment arms. Giving daily prednisolone at the time of an upper respiratory tract infection was associated with increased quality-adjusted life-years (0.9427 vs. 0.9424) and decreased average costs (£252 vs. £254), when compared with standard care. The cost saving was driven by background therapy and hospitalisations after relapse. The finding was robust to sensitivity analysis.
Limitations
A larger number of children than expected did not have an upper respiratory tract infection and the sample size attrition rate was adjusted accordingly during the trial.
Conclusions
The clinical analysis indicated that giving 6 days of daily low-dose prednisolone at the time of an upper respiratory tract infection does not reduce the risk of relapse of steroid-sensitive nephrotic syndrome in UK children. However, there was an economic benefit from costs associated with background therapy and relapse, and the health-related quality-of-life impact of having a relapse.
Future work
Further work is needed to investigate the clinical and health economic impact of relapses, interethnic differences in treatment response, the effect of different corticosteroid regimens in treating relapses, and the pathogenesis of individual viral infections and their effect on steroid-sensitive nephrotic syndrome.
Trial registration
Current Controlled Trials ISRCTN10900733 and EudraCT 2012-003476-39.
Funding
This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 26, No. 3. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Martin T Christian
- Department of Paediatric Nephrology, Nottingham Children’s Hospital, Nottingham, UK
| | - Nicholas JA Webb
- Department of Paediatric Nephrology, University of Manchester, Academic Health Science Centre, Royal Manchester Children’s Hospital, Manchester, UK
| | - Rebecca L Woolley
- Birmingham Clinical Trials Unit, University of Birmingham, Birmingham, UK
| | - Nafsika Afentou
- Health Economics Unit, University of Birmingham, Birmingham, UK
| | - Samir Mehta
- Birmingham Clinical Trials Unit, University of Birmingham, Birmingham, UK
| | - Emma Frew
- Health Economics Unit, University of Birmingham, Birmingham, UK
| | | | - Adam R Khan
- Birmingham Clinical Trials Unit, University of Birmingham, Birmingham, UK
| | - David V Milford
- Department of Paediatric Nephrology, Birmingham Children’s Hospital, Birmingham, UK
| | - Detlef Bockenhauer
- Department of Renal Medicine, University College London, Department of Paediatric Nephrology, Great Ormond Street Hospital for Children, London, UK
| | - Moin A Saleem
- School of Clinical Sciences, University of Bristol, Department of Paediatric Nephrology, Bristol Royal Hospital for Children, Bristol, UK
| | | | - Ania Koziell
- Child Health Clinical Academic Group, King’s College London, Department of Paediatric Nephrology, Evelina London Children’s Hospital, London, UK
| | - Heather Maxwell
- Department of Paediatric Nephrology, Royal Hospital for Sick Children, Glasgow, UK
| | - Shivaram Hegde
- Department of Paediatric Nephrology, University Hospital of Wales, Cardiff, UK
| | - Eric R Finlay
- Department of Paediatric Nephrology, Leeds Children’s Hospital, Leeds, UK
| | - Rodney D Gilbert
- Department of Paediatric Nephrology, Southampton Children’s Hospital, Southampton, UK
| | - Caroline Jones
- Department of Paediatric Nephrology, Alder Hey Children’s Hospital, Liverpool, UK
| | - Karl McKeever
- Department of Paediatric Nephrology, Royal Hospital for Sick Children, Belfast, UK
| | - Wendy Cook
- Nephrotic Syndrome Trust (NeST), Taunton, UK
| | - Natalie Ives
- Birmingham Clinical Trials Unit, University of Birmingham, Birmingham, UK
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5
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Jones RA, Barratt J, Brettell EA, Cockwell P, Dalton RN, Deeks JJ, Eaglestone G, Pellatt-Higgins T, Kalra PA, Khunti K, Morris FS, Ottridge RS, Sitch AJ, Stevens PE, Sharpe CC, Sutton AJ, Taal MW, Lamb EJ. Biological variation of cardiac troponins in chronic kidney disease. Ann Clin Biochem 2020; 57:162-169. [DOI: 10.1177/0004563220906431] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Background Patients with chronic kidney disease often have increased plasma cardiac troponin concentration in the absence of myocardial infarction. Incidence of myocardial infarction is high in this population, and diagnosis, particularly of non ST-segment elevation myocardial infarction (NSTEMI), is challenging. Knowledge of biological variation aids understanding of serial cardiac troponin measurements and could improve interpretation in clinical practice. The National Academy of Clinical Biochemistry (NACB) recommended the use of a 20% reference change value in patients with kidney failure. The aim of this study was to calculate the biological variation of cardiac troponin I and cardiac troponin T in patients with moderate chronic kidney disease (glomerular filtration rate [GFR] 30–59 mL/min/1.73 m2). Methods and results Plasma samples were obtained from 20 patients (median GFR 43.0 mL/min/1.73 m2) once a week for four consecutive weeks. Cardiac troponin I (Abbott ARCHITECT® i2000SR, median 4.3 ng/L, upper 99th percentile of reference population 26.2 ng/L) and cardiac troponin T (Roche Cobas® e601, median 11.8 ng/L, upper 99th percentile of reference population 14 ng/L) were measured in duplicate using high-sensitivity assays. After outlier removal and log transformation, 18 patients’ data were subject to ANOVA, and within-subject (CVI), between-subject (CVG) and analytical (CVA) variation calculated. Variation for cardiac troponin I was 15.0%, 105.6%, 8.3%, respectively, and for cardiac troponin T 7.4%, 78.4%, 3.1%, respectively. Reference change values for increasing and decreasing troponin concentrations were +60%/–38% for cardiac troponin I and +25%/–20% for cardiac troponin T. Conclusions The observed reference change value for cardiac troponin T is broadly compatible with the NACB recommendation, but for cardiac troponin I, larger changes are required to define significant change. The incorporation of separate RCVs for cardiac troponin I and cardiac troponin T, and separate RCVs for rising and falling concentrations of cardiac troponin, should be considered when developing guidance for interpretation of sequential cardiac troponin measurements.
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Affiliation(s)
- RA Jones
- Clinical Biochemistry, East Kent Hospitals University NHS Foundation Trust, Canterbury, UK
| | - J Barratt
- University Hospitals of Leicester, Leicester, UK
| | - EA Brettell
- Birmingham Clinical Trials Unit, Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - P Cockwell
- Renal Medicine, Queen Elizabeth Hospital Birmingham and Institute of Inflammation and Ageing, University of Birmingham, Birmingham, UK
| | - RN Dalton
- Evelina London Children’s Hospital, London, UK
| | - JJ Deeks
- Birmingham Clinical Trials Unit, Institute of Applied Health Research, University of Birmingham, Birmingham, UK
- Test Evaluation Research Group, University of Birmingham, Birmingham, UK
- NIHR Birmingham Biomedical Research Centre, University of Birmingham and University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - G Eaglestone
- Kent Kidney Care Centre, East Kent Hospitals University NHS Foundation Trust, Canterbury, UK
| | - T Pellatt-Higgins
- Centre for Health Services Studies, University of Kent, Canterbury, UK
| | - PA Kalra
- Salford Royal NHS Foundation Trust, Salford, UK
| | - K Khunti
- University of Leicester, Leicester, UK
| | - FS Morris
- Kent Kidney Care Centre, East Kent Hospitals University NHS Foundation Trust, Canterbury, UK
| | - RS Ottridge
- Birmingham Clinical Trials Unit, Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - AJ Sitch
- Test Evaluation Research Group, University of Birmingham, Birmingham, UK
- NIHR Birmingham Biomedical Research Centre, University of Birmingham and University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - PE Stevens
- Kent Kidney Care Centre, East Kent Hospitals University NHS Foundation Trust, Canterbury, UK
| | - CC Sharpe
- King’s College London & King’s College Hospital NHS Foundation Trust, London, UK
| | - AJ Sutton
- Institute of Health Economics (IHE), Edmonton, Canada
| | - MW Taal
- Division of Medical Sciences and Graduate Entry Medicine, University of Nottingham, Royal Derby Hospital, Derby, UK
| | - EJ Lamb
- Clinical Biochemistry, East Kent Hospitals University NHS Foundation Trust, Canterbury, UK
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Lamb EJ, Sitch AJ, Barratt J, Brettell EA, Cockwell P, Dalton RN, Deeks JJ, Eaglestone G, Pellatt-Higgins T, Kalra PA, Khunti K, Loud FC, Morris FS, Ottridge RS, Stevens PE, Sharpe CC, Sutton AJ, Taal MW, Rowe C. The authors reply. Kidney Int 2020; 97:214-215. [PMID: 31901344 DOI: 10.1016/j.kint.2019.10.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2019] [Accepted: 10/21/2019] [Indexed: 11/26/2022]
Affiliation(s)
- Edmund J Lamb
- Department of Clinical Biochemistry, East Kent Hospitals University NHS Foundation Trust, Canterbury, Kent, United Kingdom.
| | - Alice J Sitch
- Test Evaluation Research Group, University of Birmingham, Birmingham, United Kingdom; NIHR Birmingham Biomedical Research Centre, University of Birmingham and University Hospitals Birmingham NHS Foundation Trust, Birmingham, United Kingdom
| | | | - Elizabeth A Brettell
- Birmingham Clinical Trials Unit, Institute of Applied Health Research, University of Birmingham, Birmingham, United Kingdom
| | - Paul Cockwell
- Renal Medicine, Queen Elizabeth Hospital Birmingham, University of Birmingham, Birmingham, United Kingdom
| | - R Neil Dalton
- Evelina London Children's Hospital, London, United Kingdom
| | - Jon J Deeks
- Test Evaluation Research Group, University of Birmingham, Birmingham, United Kingdom; NIHR Birmingham Biomedical Research Centre, University of Birmingham and University Hospitals Birmingham NHS Foundation Trust, Birmingham, United Kingdom; Birmingham Clinical Trials Unit, Institute of Applied Health Research, University of Birmingham, Birmingham, United Kingdom
| | - Gillian Eaglestone
- Kent Kidney Care Centre, East Kent Hospitals University NHS Foundation Trust, Canterbury, Kent, United Kingdom
| | | | - Philip A Kalra
- Salford Royal NHS Foundation Trust, Salford, United Kingdom
| | | | | | - Frances S Morris
- Kent Kidney Care Centre, East Kent Hospitals University NHS Foundation Trust, Canterbury, Kent, United Kingdom
| | - Ryan S Ottridge
- Birmingham Clinical Trials Unit, Institute of Applied Health Research, University of Birmingham, Birmingham, United Kingdom
| | - Paul E Stevens
- Kent Kidney Care Centre, East Kent Hospitals University NHS Foundation Trust, Canterbury, Kent, United Kingdom
| | - Claire C Sharpe
- King's College London & King's College Hospital NHS Foundation Trust, London, United Kingdom
| | - Andrew J Sutton
- Leeds Institute of Health Sciences, University of Leeds, Leeds, United Kingdom
| | | | - Ceri Rowe
- Department of Clinical Biochemistry, East Kent Hospitals University NHS Foundation Trust, Canterbury, Kent, United Kingdom
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Webb NJ, Woolley RL, Lambe T, Frew E, Brettell EA, Barsoum EN, Trompeter RS, Cummins C, Wheatley K, Ives NJ. Sixteen-week versus standard eight-week prednisolone therapy for childhood nephrotic syndrome: the PREDNOS RCT. Health Technol Assess 2019; 23:1-108. [PMID: 31156083 DOI: 10.3310/hta23260] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND The optimal corticosteroid regimen for treating the presenting episode of steroid-sensitive nephrotic syndrome (SSNS) remains uncertain. Most UK centres use an 8-week regimen, despite previous systematic reviews indicating that longer regimens reduce the risk of relapse and frequently relapsing nephrotic syndrome (FRNS). OBJECTIVES The primary objective was to determine whether or not an extended 16-week course of prednisolone increases the time to first relapse. The secondary objectives were to compare the relapse rate, FRNS and steroid-dependent nephrotic syndrome (SDNS) rates, requirement for alternative immunosuppressive agents and corticosteroid-related adverse events (AEs), including adverse behaviour and costs. DESIGN Randomised double-blind parallel-group placebo-controlled trial, including a cost-effectiveness analysis. SETTING One hundred and twenty-five UK paediatric departments. PARTICIPANTS Two hundred and thirty-seven children presenting with a first episode of SSNS. Participants aged between 1 and 15 years were randomised (1 : 1) according to a minimisation algorithm to ensure balance of ethnicity (South Asian, white or other) and age (≤ 5 or ≥ 6 years). INTERVENTIONS The control group (n = 118) received standard course (SC) prednisolone therapy: 60 mg/m2/day of prednisolone in weeks 1-4, 40 mg/m2 of prednisolone on alternate days in weeks 5-8 and matching placebo on alternate days in weeks 9-18 (total 2240 mg/m2). The intervention group (n = 119) received extended course (EC) prednisolone therapy: 60 mg/m2/day of prednisolone in weeks 1-4; started at 60 mg/m2 of prednisolone on alternate days in weeks 5-16, tapering by 10 mg/m2 every 2 weeks (total 3150 mg/m2). MAIN OUTCOME MEASURES The primary outcome measure was time to first relapse [Albustix® (Siemens Healthcare Limited, Frimley, UK)-positive proteinuria +++ or greater for 3 consecutive days or the presence of generalised oedema plus +++ proteinuria]. The secondary outcome measures were relapse rate, incidence of FRNS and SDNS, other immunosuppressive therapy use, rates of serious adverse events (SAEs) and AEs and the incidence of behavioural change [using Achenbach Child Behaviour Checklist (ACBC)]. A comprehensive cost-effectiveness analysis was performed. The analysis was by intention to treat. Participants were followed for a minimum of 24 months. RESULTS There was no significant difference in time to first relapse between the SC and EC groups (hazard ratio 0.87, 95% confidence interval 0.65 to 1.17; log-rank p = 0.3). There were also no differences in the incidence of FRNS (SC 50% vs. EC 53%; p = 0.7), SDNS (44% vs. 42%; p = 0.8) or requirement for other immunosuppressive therapy (56% vs. 54%; p = 0.8). The total prednisolone dose received following completion of study medication was 5475 mg vs. 6674 mg (p = 0.07). SAE rates were not significantly different (25% vs. 17%; p = 0.1) and neither were AEs, except poor behaviour (yes/no), which was less frequent with EC treatment. There were no differences in ACBC scores. EC therapy was associated with a mean increase in generic health benefit [0.0162 additional quality-adjusted life-years (QALYs)] and cost savings (£4369 vs. £2696). LIMITATIONS Study drug formulation may have prevented some younger children who were unable to swallow whole or crushed tablets from participating. CONCLUSIONS This trial has not shown any clinical benefit for EC prednisolone therapy in UK children. The cost-effectiveness analysis suggested that EC therapy may be cheaper, with the possibility of a small QALY benefit. FUTURE WORK Studies investigating EC versus SC therapy in younger children and further cost-effectiveness analyses are warranted. TRIAL REGISTRATION Current Controlled Trials ISRCTN16645249 and EudraCT 2010-022489-29. FUNDING This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 23, No. 26. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Nicholas Ja Webb
- Department of Paediatric Nephrology, University of Manchester, Manchester Academic Health Science Centre, Royal Manchester Children's Hospital, Manchester, UK
| | - Rebecca L Woolley
- Birmingham Clinical Trials Unit, University of Birmingham, Birmingham, UK
| | - Tosin Lambe
- Health Economics Unit, University of Birmingham, Birmingham, UK
| | - Emma Frew
- Health Economics Unit, University of Birmingham, Birmingham, UK
| | | | - Emma N Barsoum
- Birmingham Clinical Trials Unit, University of Birmingham, Birmingham, UK
| | | | - Carole Cummins
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Keith Wheatley
- Cancer Research UK Clinical Trials Unit, University of Birmingham, Birmingham, UK
| | - Natalie J Ives
- Birmingham Clinical Trials Unit, University of Birmingham, Birmingham, UK
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Webb NJA, Woolley RL, Lambe T, Frew E, Brettell EA, Barsoum EN, Trompeter RS, Cummins C, Deeks JJ, Wheatley K, Ives NJ. Long term tapering versus standard prednisolone treatment for first episode of childhood nephrotic syndrome: phase III randomised controlled trial and economic evaluation. BMJ 2019; 365:l1800. [PMID: 31335316 PMCID: PMC6531851 DOI: 10.1136/bmj.l1800] [Citation(s) in RCA: 36] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/01/2019] [Indexed: 12/01/2022]
Abstract
OBJECTIVE To determine whether extending initial prednisolone treatment from eight to 16 weeks in children with idiopathic steroid sensitive nephrotic syndrome improves the pattern of disease relapse. DESIGN Double blind, parallel group, phase III randomised placebo controlled trial, including a cost effectiveness analysis. SETTING 125 UK National Health Service district general hospitals and tertiary paediatric nephrology centres. PARTICIPANTS 237 children aged 1-14 years with a first episode of steroid sensitive nephrotic syndrome. INTERVENTIONS Children were randomised to receive an extended 16 week course of prednisolone (total dose 3150 mg/m2) or a standard eight week course of prednisolone (total dose 2240 mg/m2). The drug was supplied as 5 mg tablets alongside matching placebo so that participants in both groups received the same number of tablets at any time point in the study. A minimisation algorithm ensured balanced treatment allocation by ethnicity (South Asian, white, or other) and age (5 years or less, 6 years or more). MAIN OUTCOME MEASURES The primary outcome measure was time to first relapse over a minimum follow-up of 24 months. Secondary outcome measures were relapse rate, incidence of frequently relapsing nephrotic syndrome and steroid dependent nephrotic syndrome, use of alternative immunosuppressive treatment, rates of adverse events, behavioural change using the Achenbach child behaviour checklist, quality adjusted life years, and cost effectiveness from a healthcare perspective. Analysis was by intention to treat. RESULTS No significant difference was found in time to first relapse (hazard ratio 0.87, 95% confidence interval 0.65 to 1.17, log rank P=0.28) or in the incidence of frequently relapsing nephrotic syndrome (extended course 60/114 (53%) v standard course 55/109 (50%), P=0.75), steroid dependent nephrotic syndrome (48/114 (42%) v 48/109 (44%), P=0.77), or requirement for alternative immunosuppressive treatment (62/114 (54%) v 61/109 (56%), P=0.81). Total prednisolone dose after completion of the trial drug was 6674 mg for the extended course versus 5475 mg for the standard course (P=0.07). There were no statistically significant differences in serious adverse event rates (extended course 19/114 (17%) v standard course 27/109 (25%), P=0.13) or adverse event rates, with the exception of behaviour, which was poorer in the standard course group. Scores on the Achenbach child behaviour checklist did not, however, differ. Extended course treatment was associated with a mean increase in generic quality of life (0.0162 additional quality adjusted life years, 95% confidence interval -0.005 to 0.037) and cost savings (difference -£1673 ($2160; €1930), 95% confidence interval -£3455 to £109). CONCLUSIONS Clinical outcomes did not improve when the initial course of prednisolone treatment was extended from eight to 16 weeks in UK children with steroid sensitive nephrotic syndrome. However, evidence was found of a short term health economic benefit through reduced resource use and increased quality of life. TRIAL REGISTRATION ISRCTN16645249; EudraCT 2010-022489-29.
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Affiliation(s)
- Nicholas J A Webb
- Department of Paediatric Nephrology, Royal Manchester Children's Hospital, Manchester, UK
- Manchester Academic Health Science Centre, University of Manchester, Manchester M13 9PL, UK
| | - Rebecca L Woolley
- Birmingham Clinical Trials Unit, Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Tosin Lambe
- Health Economics Unit, Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Emma Frew
- Health Economics Unit, Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Elizabeth A Brettell
- Birmingham Clinical Trials Unit, Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Emma N Barsoum
- Birmingham Clinical Trials Unit, Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | | | - Carole Cummins
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Jonathan J Deeks
- Birmingham Clinical Trials Unit, Institute of Applied Health Research, University of Birmingham, Birmingham, UK
- NIHR Birmingham Biomedical Research Centre, University Hospitals Birmingham NHS Foundation Trust and University of Birmingham, Birmingham, UK
| | - Keith Wheatley
- Cancer Research UK Clinical Trials Unit, University of Birmingham, Birmingham, UK
| | - Natalie J Ives
- Birmingham Clinical Trials Unit, Institute of Applied Health Research, University of Birmingham, Birmingham, UK
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Lambe T, Frew E, Ives NJ, Woolley RL, Cummins C, Brettell EA, Barsoum EN, Webb NJA. Mapping the Paediatric Quality of Life Inventory (PedsQL™) Generic Core Scales onto the Child Health Utility Index-9 Dimension (CHU-9D) Score for Economic Evaluation in Children. Pharmacoeconomics 2018; 36:451-465. [PMID: 29264866 DOI: 10.1007/s40273-017-0600-7] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
BACKGROUND The Paediatric Quality of Life Inventory (PedsQL™) questionnaire is a widely used, generic instrument designed for measuring health-related quality of life (HRQoL); however, it is not preference-based and therefore not suitable for cost-utility analysis. The Child Health Utility Index-9 Dimension (CHU-9D), however, is a preference-based instrument that has been primarily developed to support cost-utility analysis. OBJECTIVE This paper presents a method for estimating CHU-9D index scores from responses to the PedsQL™ using data from a randomised controlled trial of prednisolone therapy for treatment of childhood corticosteroid-sensitive nephrotic syndrome. METHODS HRQoL data were collected from children at randomisation, week 16, and months 12, 18, 24, 36 and 48. Observations on children aged 5 years and older were pooled across all data collection timepoints and were then randomised into an estimation (n = 279) and validation (n = 284) sample. A number of models were developed using the estimation data before internal validation. The best model was chosen using multi-stage selection criteria. RESULTS Most of the models developed accurately predicted the CHU-9D mean index score. The best performing model was a generalised linear model (mean absolute error = 0.0408; mean square error = 0.0035). The proportion of index scores deviating from the observed scores by < 0.03 was 53%. CONCLUSIONS The mapping algorithm provides an empirical tool for estimating CHU-9D index scores and for conducting cost-utility analyses within clinical studies that have only collected PedsQL™ data. It is valid for children aged 5 years or older. Caution should be exercised when using this with children younger than 5 years, older adolescents (> 13 years) or patient groups with particularly poor quality of life. ISRCTN REGISTRY NO 16645249.
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Affiliation(s)
- Tosin Lambe
- Health Economics Unit, Institute of Applied Health Research, University of Birmingham, Edgbaston, Birmingham, UK
| | - Emma Frew
- Health Economics Unit, Institute of Applied Health Research, University of Birmingham, Edgbaston, Birmingham, UK.
| | - Natalie J Ives
- Birmingham Clinical Trials Unit, University of Birmingham, Birmingham, UK
| | - Rebecca L Woolley
- Birmingham Clinical Trials Unit, University of Birmingham, Birmingham, UK
| | - Carole Cummins
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | | | - Emma N Barsoum
- Birmingham Clinical Trials Unit, University of Birmingham, Birmingham, UK
| | - Nicholas J A Webb
- Department of Paediatric Nephrology and NIHR Manchester Clinical Research Facility, Manchester Academic Health Science Centre, Royal Manchester Children's Hospital, Manchester, UK
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Bhandari S, Ives N, Brettell EA, Valente M, Cockwell P, Topham PS, Cleland JG, Khwaja A, El Nahas M. Multicentre randomized controlled trial of angiotensin-converting enzyme inhibitor/angiotensin receptor blocker withdrawal in advanced renal disease: the STOP-ACEi trial. Nephrol Dial Transplant 2016; 31:255-61. [PMID: 26429974 PMCID: PMC4725389 DOI: 10.1093/ndt/gfv346] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2015] [Accepted: 08/28/2015] [Indexed: 01/13/2023] Open
Abstract
BACKGROUND Blood pressure (BP) control and reduction of urinary protein excretion using agents that block the renin-angiotensin aldosterone system are the mainstay of therapy for chronic kidney disease (CKD). Research has confirmed the benefits in mild CKD, but data on angiotensin-converting enzyme inhibitor (ACEi) or angiotensin receptor blocker (ARB) use in advanced CKD are lacking. In the STOP-ACEi trial, we aim to confirm preliminary findings which suggest that withdrawal of ACEi/ARB treatment can stabilize or even improve renal function in patients with advanced progressive CKD. METHODS The STOP-ACEi trial (trial registration: current controlled trials, ISRCTN62869767) is an investigator-led multicentre open-label, randomized controlled clinical trial of 410 participants with advanced (Stage 4 or 5) progressive CKD receiving ACEi, ARBs or both. Patients will be randomized in a 1:1 ratio to either discontinue ACEi, ARB or combination of both (experimental arm) or continue ACEi, ARB or combination of both (control arm). Patients will be followed up at 3 monthly intervals for 3 years. The primary outcome measure is eGFR at 3 years. Secondary outcome measures include the number of renal events, participant quality of life and physical functioning, hospitalization rates, BP and laboratory measures, including serum cystatin-C. Safety will be assessed to ensure that withdrawal of these treatments does not cause excess harm or increase mortality or cardiovascular events such as heart failure, myocardial infarction or stroke. RESULTS The rationale and trial design are presented here. The results of this trial will show whether discontinuation of ACEi/ARBs can improve or stabilize renal function in patients with advanced progressive CKD. It will show whether this simple intervention can improve laboratory and clinical outcomes, including progression to end-stage renal disease, without causing an increase in cardiovascular events.
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Affiliation(s)
- Sunil Bhandari
- Department of Renal Medicine, Hull and East Yorkshire Hospitals NHS Trust, Kingston upon Hull, UK
- Hull York Medical School, East Yorkshire, UK
| | - Natalie Ives
- Birmingham Clinical Trials Unit, University of Birmingham, Birmingham, UK
| | | | - Marie Valente
- Birmingham Clinical Trials Unit, University of Birmingham, Birmingham, UK
| | - Paul Cockwell
- Department of Renal Medicine, Queen Elizabeth Hospital, Birmingham, UK
| | - Peter S. Topham
- Department of Renal Medicine, Leicester General Hospital, Leicester, UK
| | - John G. Cleland
- National Heart & Lung Institute, Imperial College London, London, UK
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Webb NJA, Frew E, Brettell EA, Milford DV, Bockenhauer D, Saleem MA, Christian M, Hall AS, Koziell A, Maxwell H, Hegde S, Finlay ER, Gilbert RD, Booth J, Jones C, McKeever K, Cook W, Ives NJ. Short course daily prednisolone therapy during an upper respiratory tract infection in children with relapsing steroid-sensitive nephrotic syndrome (PREDNOS 2): protocol for a randomised controlled trial. Trials 2014; 15:147. [PMID: 24767719 PMCID: PMC4030532 DOI: 10.1186/1745-6215-15-147] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2013] [Accepted: 04/03/2014] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Relapses of childhood steroid-sensitive nephrotic syndrome (SSNS) are treated with a 4- to 8-week course of high-dose oral prednisolone, which may be associated with significant adverse effects. There is a clear association between upper respiratory tract infection (URTI) and relapse development. Previous studies in developing nations have suggested that introducing a 5- to 7-day course of daily prednisolone during an URTI may prevent a relapse developing and the need for a treatment course of high-dose prednisolone. The aim of PREDNOS 2 is to evaluate the effectiveness of a 6-day course of daily prednisolone therapy during an URTI in reducing the development of a subsequent relapse in a developed nation. METHODS/DESIGN The subjects will be 300 children with relapsing SSNS (≥2 relapses in preceding year), who will be randomised to receive either a 6-day course of daily prednisolone or no change to their current therapy (with the use of placebo to double blind) each time they develop an URTI over 12 months. A strict definition for URTI will be used. Subjects will be reviewed at 3, 6, 9 and 12 months to capture data regarding relapse history, ongoing therapy and adverse effect profile, including behavioural problems and quality of life. A formal health economic analysis will also be performed. The primary end point of the study will be the incidence of URTI-related relapse (3 days of Albustix +++) following the first infection during the 12-month follow-up period. DNA and RNA samples will be collected to identify a potential genetic cause for the disease. Subjects will be recruited from over 100 UK centres with the assistance of the Medicines for Children Research Network.PREDNOS 2 is funded by the National Institute for Health Research Health Technology Assessment Programme (11/129/261). DISCUSSION We propose that PREDNOS 2 will be a pivotal study that will inform the future standard of care for children with SSNS. If it is possible to reduce the disease relapse rate effectively and safely, this will reduce the morbidity and cost associated with drug treatment, notwithstanding hospital admission and parental absence from employment. TRIAL REGISTRATION Current Controlled Trials (ISRCTN10900733).
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Affiliation(s)
- Nicholas J A Webb
- Department of Paediatric Nephrology and NIHR/Wellcome Trust Children's Clinical Research Facility, University of Manchester, Manchester Academic Health Science Centre, Royal Manchester Children's Hospital, Manchester, UK.
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12
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Lamb EJ, Brettell EA, Cockwell P, Dalton N, Deeks JJ, Harris K, Higgins T, Kalra PA, Khunti K, Loud F, Ottridge RS, Sharpe CC, Sitch AJ, Stevens PE, Sutton AJ, Taal MW. The eGFR-C study: accuracy of glomerular filtration rate (GFR) estimation using creatinine and cystatin C and albuminuria for monitoring disease progression in patients with stage 3 chronic kidney disease--prospective longitudinal study in a multiethnic population. BMC Nephrol 2014; 15:13. [PMID: 24423077 PMCID: PMC3898236 DOI: 10.1186/1471-2369-15-13] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2013] [Accepted: 01/09/2014] [Indexed: 12/26/2022] Open
Abstract
BACKGROUND Uncertainty exists regarding the optimal method to estimate glomerular filtration rate (GFR) for disease detection and monitoring. Widely used GFR estimates have not been validated in British ethnic minority populations. METHODS/DESIGN Iohexol measured GFR will be the reference against which each estimating equation will be compared. The estimating equations will be based upon serum creatinine and/or cystatin C. The eGFR-C study has 5 components: 1) A prospective longitudinal cohort study of 1300 adults with stage 3 chronic kidney disease followed for 3 years with reference (measured) GFR and test (estimated GFR [eGFR] and urinary albumin-to-creatinine ratio) measurements at baseline and 3 years. Test measurements will also be undertaken every 6 months. The study population will include a representative sample of South-Asians and African-Caribbeans. People with diabetes and proteinuria (ACR ≥30 mg/mmol) will comprise 20-30% of the study cohort.2) A sub-study of patterns of disease progression of 375 people (125 each of Caucasian, Asian and African-Caribbean origin; in each case containing subjects at high and low risk of renal progression). Additional reference GFR measurements will be undertaken after 1 and 2 years to enable a model of disease progression and error to be built.3) A biological variability study to establish reference change values for reference and test measures.4) A modelling study of the performance of monitoring strategies on detecting progression, utilising estimates of accuracy, patterns of disease progression and estimates of measurement error from studies 1), 2) and 3).5) A comprehensive cost database for each diagnostic approach will be developed to enable cost-effectiveness modelling of the optimal strategy.The performance of the estimating equations will be evaluated by assessing bias, precision and accuracy. Data will be modelled as a linear function of time utilising all available (maximum 7) time points compared with the difference between baseline and final reference values. The percentage of participants demonstrating large error with the respective estimating equations will be compared. Predictive value of GFR estimates and albumin-to-creatinine ratio will be compared amongst subjects that do or do not show progressive kidney function decline. DISCUSSION The eGFR-C study will provide evidence to inform the optimal GFR estimate to be used in clinical practice. TRIAL REGISTRATION ISRCTN42955626.
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Affiliation(s)
- Edmund J Lamb
- Clinical Biochemistry, East Kent Hospitals University NHS Foundation Trust, Canterbury, Kent CT1 3NG, UK
| | - Elizabeth A Brettell
- Birmingham Clinical Trials Unit, School of Cancer Sciences, Robert Aitken Institute, University of Birmingham, Birmingham B15 2TT, UK
| | - Paul Cockwell
- University Hospitals Birmingham NHS Foundation Trust, Birmingham B15 2TT, UK
| | | | - Jon J Deeks
- Birmingham Clinical Trials Unit, School of Cancer Sciences, Robert Aitken Institute, University of Birmingham, Birmingham B15 2TT, UK
- Test Evaluation Research Group, School of Health and Population Sciences, Public Health Building, University of Birmingham, Birmingham, B15 2TT, UK
| | - Kevin Harris
- University Hospitals of Leicester, Leicester, UK
| | - Tracy Higgins
- Centre for Health Services Studies, University of Kent, Canterbury CT2 7NF, UK
| | | | | | - Fiona Loud
- British Kidney Patient Association, Hampshire, UK
| | - Ryan S Ottridge
- Birmingham Clinical Trials Unit, School of Cancer Sciences, Robert Aitken Institute, University of Birmingham, Birmingham B15 2TT, UK
| | - Claire C Sharpe
- King’s College London & King’s College Hospital NHS Foundation Trust SE5 9RJ, London, UK
| | - Alice J Sitch
- Test Evaluation Research Group, School of Health and Population Sciences, Public Health Building, University of Birmingham, Birmingham, B15 2TT, UK
| | - Paul E Stevens
- Kent Kidney Care Centre, East Kent Hospitals University NHS Foundation Trust, Canterbury, Kent CT1 3NG, UK
| | - Andrew J Sutton
- Health Economics Unit, School of Health and Population Sciences, Occupational Health Building, University of Birmingham, Birmingham B15 2TT, UK
| | - Maarten W Taal
- Royal Derby Hospital, Uttoxeter Road, Derby DE22 3NE, UK
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