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Lassen MCH, Johansen ND, Modin D, Nealon J, Samson S, Dufournet M, Loiacono MM, Larsen CS, Jensen AMR, Landler NE, Claggett BL, Solomon SD, Landray MJ, Gislason GH, Køber L, Jensen JUS, Sivapalan P, Vestergaard LS, Krause TG, Biering-Sørensen T. Effects of high-dose versus standard-dose quadrivalent influenza vaccine among patients with diabetes: A post-hoc analysis of the DANFLU-1 trial. Diabetes Obes Metab 2024; 26:1821-1829. [PMID: 38586966 DOI: 10.1111/dom.15498] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2023] [Revised: 01/25/2024] [Accepted: 01/31/2024] [Indexed: 04/09/2024]
Abstract
AIM High-dose quadrivalent influenza vaccine (QIV-HD) has been shown to be more effective than standard-dose (QIV-SD) in reducing influenza infection, but whether diabetes status affects relative vaccine effectiveness (rVE) is unknown. We aimed to assess rVE on change in glycated haemoglobin [HbA1c (∆HbA1c)], incident diabetes, total all-cause hospitalizations (first + recurrent), and a composite of all-cause mortality and hospitalization for pneumonia or influenza. METHODS DANFLU-1 was a pragmatic, open-label trial randomizing adults (65-79 years) 1:1 to QIV-HD or QIV-SD during the 2021/22 influenza season. Cox proportional hazards regression was used to estimate rVE against incident diabetes and the composite endpoint, negative binomial regression to estimate rVE against all-cause hospitalizations, and ANCOVA when assessing rVE against ∆HbA1c. RESULTS Of the 12 477 participants, 1162 (9.3%) had diabetes at baseline. QIV-HD, compared with QIV-SD, was associated with a reduction in the rate of all-cause hospitalizations irrespective of diabetes [overall: 647 vs. 742 events, incidence rate ratio (IRR): 0.87, 95% CI (0.76-0.99); diabetes: 93 vs. 118 events, IRR: 0.80, 95% CI (0.55-1.15); without diabetes: 554 vs. 624 events, IRR: 0.88, 95% CI (0.76-1.01), pinteraction = 0.62]. Among those with diabetes, QIV-HD was associated with a lower risk of the composite outcome [2 vs. 11 events, HR: 0.18, 95% CI (0.04-0.83)] but had no effect on ∆HbA1c; QIV-HD adjusted mean difference: ∆ + 0.2 mmol/mol, 95% CI (-0.9 to 1.2). QIV-HD did not affect the risk of incident diabetes [HR 1.18, 95% CI (0.94-1.47)]. CONCLUSIONS In this post-hoc analysis, QIV-HD versus QIV-SD was associated with an increased rVE against the composite of all-cause death and hospitalization for pneumonia/influenza, and the all-cause hospitalization rate irrespective of diabetes status.
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Affiliation(s)
- Mats C Højbjerg Lassen
- Department of Cardiology, Copenhagen University Hospital-Herlev and Gentofte, Copenhagen, Denmark
- Center for Translational Cardiology and Pragmatic Randomized Trials, Department of Biomedical Sciences, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
- Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Niklas Dyrby Johansen
- Department of Cardiology, Copenhagen University Hospital-Herlev and Gentofte, Copenhagen, Denmark
- Center for Translational Cardiology and Pragmatic Randomized Trials, Department of Biomedical Sciences, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Daniel Modin
- Department of Cardiology, Copenhagen University Hospital-Herlev and Gentofte, Copenhagen, Denmark
- Center for Translational Cardiology and Pragmatic Randomized Trials, Department of Biomedical Sciences, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | | | | | | | | | - Carsten Schade Larsen
- Department of Clinical Medicine-Department of Infectious Diseases, Aarhus University Hospital, Aarhus, Denmark
| | - Anne Marie Reimer Jensen
- Department of Cardiology, Copenhagen University Hospital-Herlev and Gentofte, Copenhagen, Denmark
- Center for Translational Cardiology and Pragmatic Randomized Trials, Department of Biomedical Sciences, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Nino Emanuel Landler
- Department of Cardiology, Copenhagen University Hospital-Herlev and Gentofte, Copenhagen, Denmark
- Center for Translational Cardiology and Pragmatic Randomized Trials, Department of Biomedical Sciences, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Brian L Claggett
- Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Scott D Solomon
- Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Martin J Landray
- Clinical Trial Service Unit and Epidemiological Studies Unit, Nuffield Department of Public Health, University of Oxford, Oxford, UK
- Big Data Institute, University of Oxford, Oxford, UK
| | - Gunnar H Gislason
- Department of Cardiology, Copenhagen University Hospital-Herlev and Gentofte, Copenhagen, Denmark
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
- The Danish Heart Foundation, Copenhagen, Denmark
- The National Institute of Public Health, University of Southern Denmark, Copenhagen, Denmark
| | - Lars Køber
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
- Department of Cardiology, Copenhagen University Hospital-Rigshospitalet, Copenhagen, Denmark
| | - Jens Ulrik Stæhr Jensen
- Respiratory Medicine Section, Department of Medicine, Copenhagen University Hospital-Herlev and Gentofte, Copenhagen, Denmark
| | - Pradeesh Sivapalan
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
- Respiratory Medicine Section, Department of Medicine, Copenhagen University Hospital-Herlev and Gentofte, Copenhagen, Denmark
| | | | - Tyra Grove Krause
- Epidemiological Infectious Disease Preparedness, Statens Serum Institut, Copenhagen, Denmark
| | - Tor Biering-Sørensen
- Department of Cardiology, Copenhagen University Hospital-Herlev and Gentofte, Copenhagen, Denmark
- Center for Translational Cardiology and Pragmatic Randomized Trials, Department of Biomedical Sciences, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
- Department of Cardiology, Copenhagen University Hospital-Rigshospitalet, Copenhagen, Denmark
- Steno Diabetes Center Copenhagen, Herlev, Denmark
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2
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Mayne KJ, Staplin N, Keane DF, Wanner C, Brenner S, Cejka V, Stegbauer J, Judge PK, Preiss D, Emberson J, Trinca D, Dayanandan R, Lee R, Nolan J, Omata A, Green JB, Cherney DZI, Hooi LS, Pontremoli R, Tuttle KR, Lees JS, Mark PB, Davies SJ, Hauske SJ, Steubl D, Brückmann M, Landray MJ, Baigent C, Haynes R, Herrington WG. Effects of Empagliflozin on Fluid Overload, Weight, and Blood Pressure in CKD. J Am Soc Nephrol 2024; 35:202-215. [PMID: 38082486 PMCID: PMC7615589 DOI: 10.1681/asn.0000000000000271] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2023] [Accepted: 10/26/2023] [Indexed: 02/03/2024] Open
Abstract
SIGNIFICANCE STATEMENT SGLT2 inhibitors reduce risk of kidney progression, AKI, and cardiovascular disease, but the mechanisms of benefit are incompletely understood. Bioimpedance spectroscopy can estimate body water and fat mass. One quarter of the EMPA-KIDNEY bioimpedance substudy CKD population had clinically significant levels of bioimpedance-derived "Fluid Overload" at recruitment. Empagliflozin induced a prompt and sustained reduction in "Fluid Overload," irrespective of sex, diabetes, and baseline N-terminal pro B-type natriuretic peptide or eGFR. No significant effect on bioimpedance-derived fat mass was observed. The effects of SGLT2 inhibitors on body water may be one of the contributing mechanisms by which they mediate effects on cardiovascular risk. BACKGROUND CKD is associated with fluid excess that can be estimated by bioimpedance spectroscopy. We aimed to assess effects of sodium glucose co-transporter 2 inhibition on bioimpedance-derived "Fluid Overload" and adiposity in a CKD population. METHODS EMPA-KIDNEY was a double-blind placebo-controlled trial of empagliflozin 10 mg once daily in patients with CKD at risk of progression. In a substudy, bioimpedance measurements were added to the main trial procedures at randomization and at 2- and 18-month follow-up visits. The substudy's primary outcome was the study-average difference in absolute "Fluid Overload" (an estimate of excess extracellular water) analyzed using a mixed model repeated measures approach. RESULTS The 660 substudy participants were broadly representative of the 6609-participant trial population. Substudy mean baseline absolute "Fluid Overload" was 0.4±1.7 L. Compared with placebo, the overall mean absolute "Fluid Overload" difference among those allocated empagliflozin was -0.24 L (95% confidence interval [CI], -0.38 to -0.11), with similar sized differences at 2 and 18 months, and in prespecified subgroups. Total body water differences comprised between-group differences in extracellular water of -0.49 L (95% CI, -0.69 to -0.30, including the -0.24 L "Fluid Overload" difference) and a -0.30 L (95% CI, -0.57 to -0.03) difference in intracellular water. There was no significant effect of empagliflozin on bioimpedance-derived adipose tissue mass (-0.28 kg [95% CI, -1.41 to 0.85]). The between-group difference in weight was -0.7 kg (95% CI, -1.3 to -0.1). CONCLUSIONS In a broad range of patients with CKD, empagliflozin resulted in a sustained reduction in a bioimpedance-derived estimate of fluid overload, with no statistically significant effect on fat mass. TRIAL REGISTRATION Clinicaltrials.gov: NCT03594110 ; EuDRACT: 2017-002971-24 ( https://eudract.ema.europa.eu/ ).
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Affiliation(s)
- Kaitlin J Mayne
- Medical Research Council Population Health Research Unit, Clinical Trial Service Unit and Epidemiological Studies Unit (CTSU), Nuffield Department of Population Health, University of Oxford, Oxford, United Kingdom
- School of Cardiovascular and Metabolic Health, College of Medical and Veterinary Life Sciences, University of Glasgow, Glasgow, United Kingdom
| | - Natalie Staplin
- Medical Research Council Population Health Research Unit, Clinical Trial Service Unit and Epidemiological Studies Unit (CTSU), Nuffield Department of Population Health, University of Oxford, Oxford, United Kingdom
| | - David F Keane
- CÚRAM SFI Research Centre for Medical Devices, HRB-Clinical Research Facility Galway, National University of Ireland Galway, Galway, Ireland
| | - Christoph Wanner
- Medical Research Council Population Health Research Unit, Clinical Trial Service Unit and Epidemiological Studies Unit (CTSU), Nuffield Department of Population Health, University of Oxford, Oxford, United Kingdom
| | | | | | - Johannes Stegbauer
- Department of Nephrology, Medical Faculty, University Hospital Düsseldorf, Heinrich-Heine-University Düsseldorf, Düsseldorf, Germany
- CARID, Cardiovascular Research Institute Düsseldorf, Medical Faculty and University Hospital Düsseldorf, Heinrich-Heine-University Düsseldorf, Dusseldorf, Germany
| | - Parminder K Judge
- Medical Research Council Population Health Research Unit, Clinical Trial Service Unit and Epidemiological Studies Unit (CTSU), Nuffield Department of Population Health, University of Oxford, Oxford, United Kingdom
- Oxford Kidney Unit, Oxford University Hospitals NHS Foundation Trust, Oxford, United Kingdom
| | - David Preiss
- Medical Research Council Population Health Research Unit, Clinical Trial Service Unit and Epidemiological Studies Unit (CTSU), Nuffield Department of Population Health, University of Oxford, Oxford, United Kingdom
| | - Jonathan Emberson
- Medical Research Council Population Health Research Unit, Clinical Trial Service Unit and Epidemiological Studies Unit (CTSU), Nuffield Department of Population Health, University of Oxford, Oxford, United Kingdom
| | - Daniele Trinca
- Leeds Teaching Hospitals NHS Trust, Leeds, United Kingdom
| | - Rejive Dayanandan
- Medical Research Council Population Health Research Unit, Clinical Trial Service Unit and Epidemiological Studies Unit (CTSU), Nuffield Department of Population Health, University of Oxford, Oxford, United Kingdom
| | - Ryonfa Lee
- Medical Research Council Population Health Research Unit, Clinical Trial Service Unit and Epidemiological Studies Unit (CTSU), Nuffield Department of Population Health, University of Oxford, Oxford, United Kingdom
| | - John Nolan
- Medical Research Council Population Health Research Unit, Clinical Trial Service Unit and Epidemiological Studies Unit (CTSU), Nuffield Department of Population Health, University of Oxford, Oxford, United Kingdom
| | - Akiko Omata
- Medical Research Council Population Health Research Unit, Clinical Trial Service Unit and Epidemiological Studies Unit (CTSU), Nuffield Department of Population Health, University of Oxford, Oxford, United Kingdom
| | | | | | - Lai Seong Hooi
- Department of Medicine and Haemodialysis Unit, Sultanah Aminah Hospital, Johor Bahru, Malaysia
| | - Roberto Pontremoli
- Università degli Studi and IRCCS Ospedale Policlinico San Martino di Genova, Genoa, Italy
| | - Katherine R Tuttle
- Providence Inland Northwest Health, University of Washington, Spokane, Washington
| | - Jennifer S Lees
- School of Cardiovascular and Metabolic Health, College of Medical and Veterinary Life Sciences, University of Glasgow, Glasgow, United Kingdom
| | - Patrick B Mark
- School of Cardiovascular and Metabolic Health, College of Medical and Veterinary Life Sciences, University of Glasgow, Glasgow, United Kingdom
| | - Simon J Davies
- School of Medicine, Keele University, Newcastle, United Kingdom
| | - Sibylle J Hauske
- Boehringer Ingelheim International GmbH, Ingelheim upon Rhein, Germany
- The Fifth Department of Medicine, University Medical Center Mannheim, Mannheim, Germany
| | - Dominik Steubl
- Boehringer Ingelheim International GmbH, Ingelheim upon Rhein, Germany
- University of Heidelberg, Mannheim, Germany
- Department of Nephrology, Hospital Rechts der Isar, Technical University of Munich, Munich, Germany
| | - Martina Brückmann
- Boehringer Ingelheim International GmbH, Ingelheim upon Rhein, Germany
- The First Department of Medicine, University Medical Center Mannheim, Mannheim, Germany
| | - Martin J Landray
- Medical Research Council Population Health Research Unit, Clinical Trial Service Unit and Epidemiological Studies Unit (CTSU), Nuffield Department of Population Health, University of Oxford, Oxford, United Kingdom
| | - Colin Baigent
- Medical Research Council Population Health Research Unit, Clinical Trial Service Unit and Epidemiological Studies Unit (CTSU), Nuffield Department of Population Health, University of Oxford, Oxford, United Kingdom
| | - Richard Haynes
- Medical Research Council Population Health Research Unit, Clinical Trial Service Unit and Epidemiological Studies Unit (CTSU), Nuffield Department of Population Health, University of Oxford, Oxford, United Kingdom
- Oxford Kidney Unit, Oxford University Hospitals NHS Foundation Trust, Oxford, United Kingdom
| | - William G Herrington
- Medical Research Council Population Health Research Unit, Clinical Trial Service Unit and Epidemiological Studies Unit (CTSU), Nuffield Department of Population Health, University of Oxford, Oxford, United Kingdom
- Oxford Kidney Unit, Oxford University Hospitals NHS Foundation Trust, Oxford, United Kingdom
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3
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Horby PW, Peto L, Staplin N, Campbell M, Pessoa-Amorim G, Mafham M, Emberson JR, Stewart R, Prudon B, Uriel A, Green CA, Dhasmana DJ, Malein F, Majumdar J, Collini P, Shurmer J, Yates B, Baillie JK, Buch MH, Day J, Faust SN, Jaki T, Jeffery K, Juszczak E, Knight M, Lim WS, Montgomery A, Mumford A, Rowan K, Thwaites G, Haynes R, Landray MJ. Dimethyl fumarate in patients admitted to hospital with COVID-19 (RECOVERY): a randomised, controlled, open-label, platform trial. Nat Commun 2024; 15:924. [PMID: 38296965 PMCID: PMC10831058 DOI: 10.1038/s41467-023-43644-x] [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] [Received: 06/15/2023] [Accepted: 11/15/2023] [Indexed: 02/02/2024] Open
Abstract
Dimethyl fumarate (DMF) inhibits inflammasome-mediated inflammation and has been proposed as a treatment for patients hospitalised with COVID-19. This randomised, controlled, open-label platform trial (Randomised Evaluation of COVID-19 Therapy [RECOVERY]), is assessing multiple treatments in patients hospitalised for COVID-19 (NCT04381936, ISRCTN50189673). In this assessment of DMF performed at 27 UK hospitals, adults were randomly allocated (1:1) to either usual standard of care alone or usual standard of care plus DMF. The primary outcome was clinical status on day 5 measured on a seven-point ordinal scale. Secondary outcomes were time to sustained improvement in clinical status, time to discharge, day 5 peripheral blood oxygenation, day 5 C-reactive protein, and improvement in day 10 clinical status. Between 2 March 2021 and 18 November 2021, 713 patients were enroled in the DMF evaluation, of whom 356 were randomly allocated to receive usual care plus DMF, and 357 to usual care alone. 95% of patients received corticosteroids as part of routine care. There was no evidence of a beneficial effect of DMF on clinical status at day 5 (common odds ratio of unfavourable outcome 1.12; 95% CI 0.86-1.47; p = 0.40). There was no significant effect of DMF on any secondary outcome.
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Affiliation(s)
- Peter W Horby
- Pandemic Sciences Institute, Nuffield Department of Medicine, University of Oxford, Oxford, UK.
- International Severe Acute Respiratory and Emerging Infections Consortium (ISARIC), University of Oxford, Oxford, UK.
| | - Leon Peto
- Nuffield Department of Population Health, University of Oxford, Oxford, UK
- Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Natalie Staplin
- Nuffield Department of Population Health, University of Oxford, Oxford, UK
- MRC Population Health Research Unit, University of Oxford, Oxford, UK
| | - Mark Campbell
- Nuffield Department of Population Health, University of Oxford, Oxford, UK
- Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | | | - Marion Mafham
- Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Jonathan R Emberson
- Nuffield Department of Population Health, University of Oxford, Oxford, UK
- MRC Population Health Research Unit, University of Oxford, Oxford, UK
| | - Richard Stewart
- Milton Keynes University Hospital NHS Foundation Trust, Milton Keynes, UK
| | - Benjamin Prudon
- North Tees and Hartlepool NHS Foundation Trust, Stockton-on-Tees, UK
| | - Alison Uriel
- Manchester University NHS Foundation Trust, Manchester, UK
| | | | - Devesh J Dhasmana
- Victoria Hospital Kirkcaldy, NHS Fife, Kirkcaldy, UK
- School of Medicine, University of St Andrews, St Andrews, UK
| | - Flora Malein
- Liverpool University Hospitals NHS Foundation Trust, Liverpool, UK
| | | | - Paul Collini
- Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | | | - Bryan Yates
- Northumbria Healthcare NHS Foundation Trust, Northumberland, UK
| | | | - Maya H Buch
- Centre for Musculoskeletal Research, University of Manchester, Manchester, UK
| | - Jeremy Day
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
- Oxford University Clinical Research Unit, Ho Chi Minh City, Viet Nam
| | - Saul N Faust
- NIHR Southampton Clinical Research Facility and Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust and University of Southampton, Southampton, UK
| | - Thomas Jaki
- University of Regensburg, Regensburg, Germany
- MRC Biostatistics Unit, University of Cambridge, Cambridge, UK
| | - Katie Jeffery
- Oxford University Hospitals NHS Foundation Trust, Oxford, UK
- Radcliffe Department of Medicine, University of Oxford, Oxford, UK
| | - Edmund Juszczak
- School of Medicine, University of Nottingham, Nottingham, UK
| | - Marian Knight
- Nuffield Department of Population Health, University of Oxford, Oxford, UK
- National Perinatal Epidemiology Unit, University of Oxford, Oxford, UK
| | - Wei Shen Lim
- School of Medicine, University of Nottingham, Nottingham, UK
- Respiratory Medicine Department, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Alan Montgomery
- School of Medicine, University of Nottingham, Nottingham, UK
| | - Andrew Mumford
- School of Cellular and Molecular Medicine, University of Bristol, Bristol, UK
| | - Kathryn Rowan
- Intensive Care National Audit & Research Centre, London, UK
| | - Guy Thwaites
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
- Oxford University Clinical Research Unit, Ho Chi Minh City, Viet Nam
| | - Richard Haynes
- Nuffield Department of Population Health, University of Oxford, Oxford, UK
- Oxford University Hospitals NHS Foundation Trust, Oxford, UK
- MRC Population Health Research Unit, University of Oxford, Oxford, UK
| | - Martin J Landray
- Nuffield Department of Population Health, University of Oxford, Oxford, UK
- Oxford University Hospitals NHS Foundation Trust, Oxford, UK
- MRC Population Health Research Unit, University of Oxford, Oxford, UK
- NIHR Oxford Biomedical Research Centre, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
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4
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Johansen ND, Modin D, Skaarup KG, Nealon J, Samson S, Dufournet M, Loiacono MM, Harris RC, Larsen CS, Jensen AMR, Landler NE, Claggett BL, Solomon SD, Landray MJ, Gislason GH, Køber L, Jensen JUS, Sivapalan P, Vestergaard LS, Valentiner-Branth P, Krause TG, Biering-Sørensen T. Effectiveness of high-dose versus standard-dose quadrivalent influenza vaccine against recurrent hospitalizations and mortality in relation to influenza circulation: A post-hoc analysis of the DANFLU-1 randomized clinical trial. Clin Microbiol Infect 2024:S1198-743X(24)00039-9. [PMID: 38286177 DOI: 10.1016/j.cmi.2024.01.017] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2023] [Revised: 01/18/2024] [Accepted: 01/23/2024] [Indexed: 01/31/2024]
Abstract
OBJECTIVES To evaluate the relative effectiveness of high-dose quadrivalent influenza vaccine (QIV-HD) versus standard-dose quadrivalent influenza vaccine (QIV-SD) against recurrent hospitalizations and its potential variation in relation to influenza circulation. METHODS We did a post-hoc analysis of a pragmatic, open-label, randomized trial of QIV-HD versus QIV-SD performed during the 2021-2022 influenza season among adults aged 65-79 years. Participants were enrolled in October 2021-November, 2021 and followed for outcomes from 14 days postvaccination until 31 May, 2022. We investigated the following outcomes: Hospitalizations for pneumonia or influenza, respiratory hospitalizations, cardio-respiratory hospitalizations, cardiovascular hospitalizations, all-cause hospitalizations, and all-cause death. Outcomes were analysed as recurrent events. Cumulative numbers of events were assessed weekly. Cumulative relative effectiveness estimates were calculated and descriptively compared with influenza circulation. The trial is registered at Clinicaltrials.gov: NCT05048589. RESULTS Among 12,477 randomly assigned participants, receiving QIV-HD was associated with lower incidence rates of hospitalizations for pneumonia or influenza (10 vs. 33 events, incidence rate ratio [IRR] 0.30 [95% CI, 0.14-0.64]; p 0.002) and all-cause hospitalizations (647 vs. 742 events, IRR 0.87 [95% CI, 0.76-0.99]; p 0.032) compared with QIV-SD. Trends favouring QIV-HD were consistently observed over time including in the period before active influenza transmission; i.e. while the first week with a ≥10% influenza test positivity rate was calendar week 10, 2022, the first statistically significant reduction in hospitalizations for pneumonia or influenza was already observed by calendar week 3, 2022 (5 vs. 15 events, IRR 0.33 [95% CI, 0.11-0.94]; p 0.037). DISCUSSION In a post-hoc analysis, QIV-HD was associated with lower incidence rates of hospitalizations for pneumonia or influenza and all-cause hospitalizations compared with QIV-SD, with trends evident independent of influenza circulation levels. Our exploratory results correspond to a number needed to treat of 65 (95% CI 35-840) persons vaccinated with QIV-HD compared with QIV-SD to prevent one additional all-cause hospitalization per season. Further research is needed to confirm these hypothesis-generating findings.
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Affiliation(s)
- Niklas Dyrby Johansen
- Department of Cardiology, Copenhagen University Hospital-Herlev and Gentofte, Copenhagen, Denmark; Department of Biomedical Sciences, Faculty of Health and Medical Sciences, Center for Translational Cardiology and Pragmatic Randomized Trials, University of Copenhagen, Denmark
| | - Daniel Modin
- Department of Cardiology, Copenhagen University Hospital-Herlev and Gentofte, Copenhagen, Denmark; Department of Biomedical Sciences, Faculty of Health and Medical Sciences, Center for Translational Cardiology and Pragmatic Randomized Trials, University of Copenhagen, Denmark
| | - Kristoffer Grundtvig Skaarup
- Department of Cardiology, Copenhagen University Hospital-Herlev and Gentofte, Copenhagen, Denmark; Department of Biomedical Sciences, Faculty of Health and Medical Sciences, Center for Translational Cardiology and Pragmatic Randomized Trials, University of Copenhagen, Denmark
| | - Joshua Nealon
- School of Public Health, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Pokfulam, China
| | | | | | | | | | - Carsten Schade Larsen
- Department of Clinical Medicine, Department of Infectious Diseases, Aarhus University Hospital, Aarhus, Denmark
| | - Anne Marie Reimer Jensen
- Department of Cardiology, Copenhagen University Hospital-Herlev and Gentofte, Copenhagen, Denmark; Department of Biomedical Sciences, Faculty of Health and Medical Sciences, Center for Translational Cardiology and Pragmatic Randomized Trials, University of Copenhagen, Denmark
| | - Nino Emanuel Landler
- Department of Cardiology, Copenhagen University Hospital-Herlev and Gentofte, Copenhagen, Denmark; Department of Biomedical Sciences, Faculty of Health and Medical Sciences, Center for Translational Cardiology and Pragmatic Randomized Trials, University of Copenhagen, Denmark
| | - Brian L Claggett
- Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Scott D Solomon
- Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Martin J Landray
- Clinical Trial Service Unit and Epidemiological Studies Unit, Nuffield Department of Public Health, University of Oxford, Oxford, United Kingdom; Big Data Institute, University of Oxford, Oxford, United Kingdom
| | - Gunnar H Gislason
- Department of Cardiology, Copenhagen University Hospital-Herlev and Gentofte, Copenhagen, Denmark; Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Denmark; The Danish Heart Foundation, Copenhagen, Denmark; The National Institute of Public Health, University of Southern Denmark, Copenhagen, Denmark
| | - Lars Køber
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Denmark; Department of Cardiology, Copenhagen University Hospital-Rigshospitalet, Copenhagen, Denmark
| | - Jens Ulrik Stæhr Jensen
- Department of Medicine, Respiratory Medicine Section, Copenhagen University Hospital-Herlev and Gentofte, Copenhagen, Denmark
| | - Pradeesh Sivapalan
- Department of Medicine, Respiratory Medicine Section, Copenhagen University Hospital-Herlev and Gentofte, Copenhagen, Denmark
| | | | - Palle Valentiner-Branth
- Epidemiological Infectious Disease Preparedness, Statens Serum Institut, Copenhagen, Denmark
| | - Tyra Grove Krause
- Epidemiological Infectious Disease Preparedness, Statens Serum Institut, Copenhagen, Denmark
| | - Tor Biering-Sørensen
- Department of Cardiology, Copenhagen University Hospital-Herlev and Gentofte, Copenhagen, Denmark; Department of Biomedical Sciences, Faculty of Health and Medical Sciences, Center for Translational Cardiology and Pragmatic Randomized Trials, University of Copenhagen, Denmark.
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5
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Staplin N, Haynes R, Judge PK, Wanner C, Green JB, Emberson J, Preiss D, Mayne KJ, Ng SYA, Sammons E, Zhu D, Hill M, Stevens W, Wallendszus K, Brenner S, Cheung AK, Liu ZH, Li J, Hooi LS, Liu WJ, Kadowaki T, Nangaku M, Levin A, Cherney D, Maggioni AP, Pontremoli R, Deo R, Goto S, Rossello X, Tuttle KR, Steubl D, Petrini M, Seidi S, Landray MJ, Baigent C, Herrington WG, Abat S, Abd Rahman R, Abdul Cader R, Abdul Hafidz MI, Abdul Wahab MZ, Abdullah NK, Abdul-Samad T, Abe M, Abraham N, Acheampong S, Achiri P, Acosta JA, Adeleke A, Adell V, Adewuyi-Dalton R, Adnan N, Africano A, Agharazii M, Aguilar F, Aguilera A, Ahmad M, Ahmad MK, Ahmad NA, Ahmad NH, Ahmad NI, Ahmad Miswan N, Ahmad Rosdi H, Ahmed I, Ahmed S, Ahmed S, Aiello J, Aitken A, AitSadi R, Aker S, Akimoto S, Akinfolarin A, Akram S, Alberici F, Albert C, Aldrich L, Alegata M, Alexander L, Alfaress S, Alhadj Ali M, Ali A, Ali A, Alicic R, Aliu A, Almaraz R, Almasarwah R, Almeida J, Aloisi A, Al-Rabadi L, Alscher D, Alvarez P, Al-Zeer B, Amat M, Ambrose C, Ammar H, An Y, Andriaccio L, Ansu K, Apostolidi A, Arai N, Araki H, Araki S, Arbi A, Arechiga O, Armstrong S, Arnold T, Aronoff S, Arriaga W, Arroyo J, Arteaga D, Asahara S, Asai A, Asai N, Asano S, Asawa M, Asmee MF, Aucella F, Augustin M, Avery A, Awad A, Awang IY, Awazawa M, Axler A, Ayub W, Azhari Z, Baccaro R, Badin C, Bagwell B, Bahlmann-Kroll E, Bahtar AZ, Baigent C, Bains D, Bajaj H, Baker R, Baldini E, Banas B, Banerjee D, Banno S, Bansal S, Barberi S, Barnes S, Barnini C, Barot C, Barrett K, Barrios R, Bartolomei Mecatti B, Barton I, Barton J, Basily W, Bavanandan S, Baxter A, Becker L, Beddhu S, Beige J, Beigh S, Bell S, Benck U, Beneat A, Bennett A, Bennett D, Benyon S, Berdeprado J, Bergler T, Bergner A, Berry M, Bevilacqua M, Bhairoo J, Bhandari S, Bhandary N, Bhatt A, Bhattarai M, Bhavsar M, Bian W, Bianchini F, Bianco S, Bilous R, Bilton J, Bilucaglia D, Bird C, Birudaraju D, Biscoveanu M, Blake C, Bleakley N, Bocchicchia K, Bodine S, Bodington R, Boedecker S, Bolduc M, Bolton S, Bond C, Boreky F, Boren K, Bouchi R, Bough L, Bovan D, Bowler C, Bowman L, Brar N, Braun C, Breach A, Breitenfeldt M, Brenner S, Brettschneider B, Brewer A, Brewer G, Brindle V, Brioni E, Brown C, Brown H, Brown L, Brown R, Brown S, Browne D, Bruce K, Brueckmann M, Brunskill N, Bryant M, Brzoska M, Bu Y, Buckman C, Budoff M, Bullen M, Burke A, Burnette S, Burston C, Busch M, Bushnell J, Butler S, Büttner C, Byrne C, Caamano A, Cadorna J, Cafiero C, Cagle M, Cai J, Calabrese K, Calvi C, Camilleri B, Camp S, Campbell D, Campbell R, Cao H, Capelli I, Caple M, Caplin B, Cardone A, Carle J, Carnall V, Caroppo M, Carr S, Carraro G, Carson M, Casares P, Castillo C, Castro C, Caudill B, Cejka V, Ceseri M, Cham L, Chamberlain A, Chambers J, Chan CBT, Chan JYM, Chan YC, Chang E, Chang E, Chant T, Chavagnon T, Chellamuthu P, Chen F, Chen J, Chen P, Chen TM, Chen Y, Chen Y, Cheng C, Cheng H, Cheng MC, Cherney D, Cheung AK, Ching CH, Chitalia N, Choksi R, Chukwu C, Chung K, Cianciolo G, Cipressa L, Clark S, Clarke H, Clarke R, Clarke S, Cleveland B, Cole E, Coles H, Condurache L, Connor A, Convery K, Cooper A, Cooper N, Cooper Z, Cooperman L, Cosgrove L, Coutts P, Cowley A, Craik R, Cui G, Cummins T, Dahl N, Dai H, Dajani L, D'Amelio A, Damian E, Damianik K, Danel L, Daniels C, Daniels T, Darbeau S, Darius H, Dasgupta T, Davies J, Davies L, Davis A, Davis J, Davis L, Dayanandan R, Dayi S, Dayrell R, De Nicola L, Debnath S, Deeb W, Degenhardt S, DeGoursey K, Delaney M, Deo R, DeRaad R, Derebail V, Dev D, Devaux M, Dhall P, Dhillon G, Dienes J, Dobre M, Doctolero E, Dodds V, Domingo D, Donaldson D, Donaldson P, Donhauser C, Donley V, Dorestin S, Dorey S, Doulton T, Draganova D, Draxlbauer K, Driver F, Du H, Dube F, Duck T, Dugal T, Dugas J, Dukka H, Dumann H, Durham W, Dursch M, Dykas R, Easow R, Eckrich E, Eden G, Edmerson E, Edwards H, Ee LW, Eguchi J, Ehrl Y, Eichstadt K, Eid W, Eilerman B, Ejima Y, Eldon H, Ellam T, Elliott L, Ellison R, Emberson J, Epp R, Er A, Espino-Obrero M, Estcourt S, Estienne L, Evans G, Evans J, Evans S, Fabbri G, Fajardo-Moser M, Falcone C, Fani F, Faria-Shayler P, Farnia F, Farrugia D, Fechter M, Fellowes D, Feng F, Fernandez J, Ferraro P, Field A, Fikry S, Finch J, Finn H, Fioretto P, Fish R, Fleischer A, Fleming-Brown D, Fletcher L, Flora R, Foellinger C, Foligno N, Forest S, Forghani Z, Forsyth K, Fottrell-Gould D, Fox P, Frankel A, Fraser D, Frazier R, Frederick K, Freking N, French H, Froment A, Fuchs B, Fuessl L, Fujii H, Fujimoto A, Fujita A, Fujita K, Fujita Y, Fukagawa M, Fukao Y, Fukasawa A, Fuller T, Funayama T, Fung E, Furukawa M, Furukawa Y, Furusho M, Gabel S, Gaidu J, Gaiser S, Gallo K, Galloway C, Gambaro G, Gan CC, Gangemi C, Gao M, Garcia K, Garcia M, Garofalo C, Garrity M, Garza A, Gasko S, Gavrila M, Gebeyehu B, Geddes A, Gentile G, George A, George J, Gesualdo L, Ghalli F, Ghanem A, Ghate T, Ghavampour S, Ghazi A, Gherman A, Giebeln-Hudnell U, Gill B, Gillham S, Girakossyan I, Girndt M, Giuffrida A, Glenwright M, Glider T, Gloria R, Glowski D, Goh BL, Goh CB, Gohda T, Goldenberg R, Goldfaden R, Goldsmith C, Golson B, Gonce V, Gong Q, Goodenough B, Goodwin N, Goonasekera M, Gordon A, Gordon J, Gore A, Goto H, Goto S, Goto S, Gowen D, Grace A, Graham J, Grandaliano G, Gray M, Green JB, Greene T, Greenwood G, Grewal B, Grifa R, Griffin D, Griffin S, Grimmer P, Grobovaite E, Grotjahn S, Guerini A, Guest C, Gunda S, Guo B, Guo Q, Haack S, Haase M, Haaser K, Habuki K, Hadley A, Hagan S, Hagge S, Haller H, Ham S, Hamal S, Hamamoto Y, Hamano N, Hamm M, Hanburry A, Haneda M, Hanf C, Hanif W, Hansen J, Hanson L, Hantel S, Haraguchi T, Harding E, Harding T, Hardy C, Hartner C, Harun Z, Harvill L, Hasan A, Hase H, Hasegawa F, Hasegawa T, Hashimoto A, Hashimoto C, Hashimoto M, Hashimoto S, Haskett S, Hauske SJ, Hawfield A, Hayami T, Hayashi M, Hayashi S, Haynes R, Hazara A, Healy C, Hecktman J, Heine G, Henderson H, Henschel R, Hepditch A, Herfurth K, Hernandez G, Hernandez Pena A, Hernandez-Cassis C, Herrington WG, Herzog C, Hewins S, Hewitt D, Hichkad L, Higashi S, Higuchi C, Hill C, Hill L, Hill M, Himeno T, Hing A, Hirakawa Y, Hirata K, Hirota Y, Hisatake T, Hitchcock S, Hodakowski A, Hodge W, Hogan R, Hohenstatt U, Hohenstein B, Hooi L, Hope S, Hopley M, Horikawa S, Hosein D, Hosooka T, Hou L, Hou W, Howie L, Howson A, Hozak M, Htet Z, Hu X, Hu Y, Huang J, Huda N, Hudig L, Hudson A, Hugo C, Hull R, Hume L, Hundei W, Hunt N, Hunter A, Hurley S, Hurst A, Hutchinson C, Hyo T, Ibrahim FH, Ibrahim S, Ihana N, Ikeda T, Imai A, Imamine R, Inamori A, Inazawa H, Ingell J, Inomata K, Inukai Y, Ioka M, Irtiza-Ali A, Isakova T, Isari W, Iselt M, Ishiguro A, Ishihara K, Ishikawa T, Ishimoto T, Ishizuka K, Ismail R, Itano S, Ito H, Ito K, Ito M, Ito Y, Iwagaitsu S, Iwaita Y, Iwakura T, Iwamoto M, Iwasa M, Iwasaki H, Iwasaki S, Izumi K, Izumi K, Izumi T, Jaafar SM, Jackson C, Jackson Y, Jafari G, Jahangiriesmaili M, Jain N, Jansson K, Jasim H, Jeffers L, Jenkins A, Jesky M, Jesus-Silva J, Jeyarajah D, Jiang Y, Jiao X, Jimenez G, Jin B, Jin Q, Jochims J, Johns B, Johnson C, Johnson T, Jolly S, Jones L, Jones L, Jones S, Jones T, Jones V, Joseph M, Joshi S, Judge P, Junejo N, Junus S, Kachele M, Kadowaki T, Kadoya H, Kaga H, Kai H, Kajio H, Kaluza-Schilling W, Kamaruzaman L, Kamarzarian A, Kamimura Y, Kamiya H, Kamundi C, Kan T, Kanaguchi Y, Kanazawa A, Kanda E, Kanegae S, Kaneko K, Kaneko K, Kang HY, Kano T, Karim M, Karounos D, Karsan W, Kasagi R, Kashihara N, Katagiri H, Katanosaka A, Katayama A, Katayama M, Katiman E, Kato K, Kato M, Kato N, Kato S, Kato T, Kato Y, Katsuda Y, Katsuno T, Kaufeld J, Kavak Y, Kawai I, Kawai M, Kawai M, Kawase A, Kawashima S, Kazory A, Kearney J, Keith B, Kellett J, Kelley S, Kershaw M, Ketteler M, Khai Q, Khairullah Q, Khandwala H, Khoo KKL, Khwaja A, Kidokoro K, Kielstein J, Kihara M, Kimber C, Kimura S, Kinashi H, Kingston H, Kinomura M, Kinsella-Perks E, Kitagawa M, Kitajima M, Kitamura S, Kiyosue A, Kiyota M, Klauser F, Klausmann G, Kmietschak W, Knapp K, Knight C, Knoppe A, Knott C, Kobayashi M, Kobayashi R, Kobayashi T, Koch M, Kodama S, Kodani N, Kogure E, Koizumi M, Kojima H, Kojo T, Kolhe N, Komaba H, Komiya T, Komori H, Kon SP, Kondo M, Kondo M, Kong W, Konishi M, Kono K, Koshino M, Kosugi T, Kothapalli B, Kozlowski T, Kraemer B, Kraemer-Guth A, Krappe J, Kraus D, Kriatselis C, Krieger C, Krish P, Kruger B, Ku Md Razi KR, Kuan Y, Kubota S, Kuhn S, Kumar P, Kume S, Kummer I, Kumuji R, Küpper A, Kuramae T, Kurian L, Kuribayashi C, Kurien R, Kuroda E, Kurose T, Kutschat A, Kuwabara N, Kuwata H, La Manna G, Lacey M, Lafferty K, LaFleur P, Lai V, Laity E, Lambert A, Landray MJ, Langlois M, Latif F, Latore E, Laundy E, Laurienti D, Lawson A, Lay M, Leal I, Leal I, Lee AK, Lee J, Lee KQ, Lee R, Lee SA, Lee YY, Lee-Barkey Y, Leonard N, Leoncini G, Leong CM, Lerario S, Leslie A, Levin A, Lewington A, Li J, Li N, Li X, Li Y, Liberti L, Liberti ME, Liew A, Liew YF, Lilavivat U, Lim SK, Lim YS, Limon E, Lin H, Lioudaki E, Liu H, Liu J, Liu L, Liu Q, Liu WJ, Liu X, Liu Z, Loader D, Lochhead H, Loh CL, Lorimer A, Loudermilk L, Loutan J, Low CK, Low CL, Low YM, Lozon Z, Lu Y, Lucci D, Ludwig U, Luker N, Lund D, Lustig R, Lyle S, Macdonald C, MacDougall I, Machicado R, MacLean D, Macleod P, Madera A, Madore F, Maeda K, Maegawa H, Maeno S, Mafham M, Magee J, Maggioni AP, Mah DY, Mahabadi V, Maiguma M, Makita Y, Makos G, Manco L, Mangiacapra R, Manley J, Mann P, Mano S, Marcotte G, Maris J, Mark P, Markau S, Markovic M, Marshall C, Martin M, Martinez C, Martinez S, Martins G, Maruyama K, Maruyama S, Marx K, Maselli A, Masengu A, Maskill A, Masumoto S, Masutani K, Matsumoto M, Matsunaga T, Matsuoka N, Matsushita M, Matthews M, Matthias S, Matvienko E, Maurer M, Maxwell P, Mayne KJ, Mazlan N, Mazlan SA, Mbuyisa A, McCafferty K, McCarroll F, McCarthy T, McClary-Wright C, McCray K, McDermott P, McDonald C, McDougall R, McHaffie E, McIntosh K, McKinley T, McLaughlin S, McLean N, McNeil L, Measor A, Meek J, Mehta A, Mehta R, Melandri M, Mené P, Meng T, Menne J, Merritt K, Merscher S, Meshykhi C, Messa P, Messinger L, Miftari N, Miller R, Miller Y, Miller-Hodges E, Minatoguchi M, Miners M, Minutolo R, Mita T, Miura Y, Miyaji M, Miyamoto S, Miyatsuka T, Miyazaki M, Miyazawa I, Mizumachi R, Mizuno M, Moffat S, Mohamad Nor FS, Mohamad Zaini SN, Mohamed Affandi FA, Mohandas C, Mohd R, Mohd Fauzi NA, Mohd Sharif NH, Mohd Yusoff Y, Moist L, Moncada A, Montasser M, Moon A, Moran C, Morgan N, Moriarty J, Morig G, Morinaga H, Morino K, Morisaki T, Morishita Y, Morlok S, Morris A, Morris F, Mostafa S, Mostefai Y, Motegi M, Motherwell N, Motta D, Mottl A, Moys R, Mozaffari S, Muir J, Mulhern J, Mulligan S, Munakata Y, Murakami C, Murakoshi M, Murawska A, Murphy K, Murphy L, Murray S, Murtagh H, Musa MA, Mushahar L, Mustafa R, Mustafar R, Muto M, Nadar E, Nagano R, Nagasawa T, Nagashima E, Nagasu H, Nagelberg S, Nair H, Nakagawa Y, Nakahara M, Nakamura J, Nakamura R, Nakamura T, Nakaoka M, Nakashima E, Nakata J, Nakata M, Nakatani S, Nakatsuka A, Nakayama Y, Nakhoul G, Nangaku M, Naverrete G, Navivala A, Nazeer I, Negrea L, Nethaji C, Newman E, Ng SYA, Ng TJ, Ngu LLS, Nimbkar T, Nishi H, Nishi M, Nishi S, Nishida Y, Nishiyama A, Niu J, Niu P, Nobili G, Nohara N, Nojima I, Nolan J, Nosseir H, Nozawa M, Nunn M, Nunokawa S, Oda M, Oe M, Oe Y, Ogane K, Ogawa W, Ogihara T, Oguchi G, Ohsugi M, Oishi K, Okada Y, Okajyo J, Okamoto S, Okamura K, Olufuwa O, Oluyombo R, Omata A, Omori Y, Ong LM, Ong YC, Onyema J, Oomatia A, Oommen A, Oremus R, Orimo Y, Ortalda V, Osaki Y, Osawa Y, Osmond Foster J, O'Sullivan A, Otani T, Othman N, Otomo S, O'Toole J, Owen L, Ozawa T, Padiyar A, Page N, Pajak S, Paliege A, Pandey A, Pandey R, Pariani H, Park J, Parrigon M, Passauer J, Patecki M, Patel M, Patel R, Patel T, Patel Z, Paul R, Paul R, Paulsen L, Pavone L, Peixoto A, Peji J, Peng BC, Peng K, Pennino L, Pereira E, Perez E, Pergola P, Pesce F, Pessolano G, Petchey W, Petr EJ, Pfab T, Phelan P, Phillips R, Phillips T, Phipps M, Piccinni G, Pickett T, Pickworth S, Piemontese M, Pinto D, Piper J, Plummer-Morgan J, Poehler D, Polese L, Poma V, Pontremoli R, Postal A, Pötz C, Power A, Pradhan N, Pradhan R, Preiss D, Preiss E, Preston K, Prib N, Price L, Provenzano C, Pugay C, Pulido R, Putz F, Qiao Y, Quartagno R, Quashie-Akponeware M, Rabara R, Rabasa-Lhoret R, Radhakrishnan D, Radley M, Raff R, Raguwaran S, Rahbari-Oskoui F, Rahman M, Rahmat K, Ramadoss S, Ramanaidu S, Ramasamy S, Ramli R, Ramli S, Ramsey T, Rankin A, Rashidi A, Raymond L, Razali WAFA, Read K, Reiner H, Reisler A, Reith C, Renner J, Rettenmaier B, Richmond L, Rijos D, Rivera R, Rivers V, Robinson H, Rocco M, Rodriguez-Bachiller I, Rodriquez R, Roesch C, Roesch J, Rogers J, Rohnstock M, Rolfsmeier S, Roman M, Romo A, Rosati A, Rosenberg S, Ross T, Rossello X, Roura M, Roussel M, Rovner S, Roy S, Rucker S, Rump L, Ruocco M, Ruse S, Russo F, Russo M, Ryder M, Sabarai A, Saccà C, Sachson R, Sadler E, Safiee NS, Sahani M, Saillant A, Saini J, Saito C, Saito S, Sakaguchi K, Sakai M, Salim H, Salviani C, Sammons E, Sampson A, Samson F, Sandercock P, Sanguila S, Santorelli G, Santoro D, Sarabu N, Saram T, Sardell R, Sasajima H, Sasaki T, Satko S, Sato A, Sato D, Sato H, Sato H, Sato J, Sato T, Sato Y, Satoh M, Sawada K, Schanz M, Scheidemantel F, Schemmelmann M, Schettler E, Schettler V, Schlieper GR, Schmidt C, Schmidt G, Schmidt U, Schmidt-Gurtler H, Schmude M, Schneider A, Schneider I, Schneider-Danwitz C, Schomig M, Schramm T, Schreiber A, Schricker S, Schroppel B, Schulte-Kemna L, Schulz E, Schumacher B, Schuster A, Schwab A, Scolari F, Scott A, Seeger W, Seeger W, Segal M, Seifert L, Seifert M, Sekiya M, Sellars R, Seman MR, Shah S, Shah S, Shainberg L, Shanmuganathan M, Shao F, Sharma K, Sharpe C, Sheikh-Ali M, Sheldon J, Shenton C, Shepherd A, Shepperd M, Sheridan R, Sheriff Z, Shibata Y, Shigehara T, Shikata K, Shimamura K, Shimano H, Shimizu Y, Shimoda H, Shin K, Shivashankar G, Shojima N, Silva R, Sim CSB, Simmons K, Sinha S, Sitter T, Sivanandam S, Skipper M, Sloan K, Sloan L, Smith R, Smyth J, Sobande T, Sobata M, Somalanka S, Song X, Sonntag F, Sood B, Sor SY, Soufer J, Sparks H, Spatoliatore G, Spinola T, Squyres S, Srivastava A, Stanfield J, Staplin N, Staylor K, Steele A, Steen O, Steffl D, Stegbauer J, Stellbrink C, Stellbrink E, Stevens W, Stevenson A, Stewart-Ray V, Stickley J, Stoffler D, Stratmann B, Streitenberger S, Strutz F, Stubbs J, Stumpf J, Suazo N, Suchinda P, Suckling R, Sudin A, Sugamori K, Sugawara H, Sugawara K, Sugimoto D, Sugiyama H, Sugiyama H, Sugiyama T, Sullivan M, Sumi M, Suresh N, Sutton D, Suzuki H, Suzuki R, Suzuki Y, Suzuki Y, Suzuki Y, Swanson E, Swift P, Syed S, Szerlip H, Taal M, Taddeo M, Tailor C, Tajima K, Takagi M, Takahashi K, Takahashi K, Takahashi M, Takahashi T, Takahira E, Takai T, Takaoka M, Takeoka J, Takesada A, Takezawa M, Talbot M, Taliercio J, Talsania T, Tamori Y, Tamura R, Tamura Y, Tan CHH, Tan EZZ, Tanabe A, Tanabe K, Tanaka A, Tanaka A, Tanaka N, Tang S, Tang Z, Tanigaki K, Tarlac M, Tatsuzawa A, Tay JF, Tay LL, Taylor J, Taylor K, Taylor K, Te A, Tenbusch L, Teng KS, Terakawa A, Terry J, Tham ZD, Tholl S, Thomas G, Thong KM, Tietjen D, Timadjer A, Tindall H, Tipper S, Tobin K, Toda N, Tokuyama A, Tolibas M, Tomita A, Tomita T, Tomlinson J, Tonks L, Topf J, Topping S, Torp A, Torres A, Totaro F, Toth P, Toyonaga Y, Tripodi F, Trivedi K, Tropman E, Tschope D, Tse J, Tsuji K, Tsunekawa S, Tsunoda R, Tucky B, Tufail S, Tuffaha A, Turan E, Turner H, Turner J, Turner M, Tuttle KR, Tye YL, Tyler A, Tyler J, Uchi H, Uchida H, Uchida T, Uchida T, Udagawa T, Ueda S, Ueda Y, Ueki K, Ugni S, Ugwu E, Umeno R, Unekawa C, Uozumi K, Urquia K, Valleteau A, Valletta C, van Erp R, Vanhoy C, Varad V, Varma R, Varughese A, Vasquez P, Vasseur A, Veelken R, Velagapudi C, Verdel K, Vettoretti S, Vezzoli G, Vielhauer V, Viera R, Vilar E, Villaruel S, Vinall L, Vinathan J, Visnjic M, Voigt E, von-Eynatten M, Vourvou M, Wada J, Wada J, Wada T, Wada Y, Wakayama K, Wakita Y, Wallendszus K, Walters T, Wan Mohamad WH, Wang L, Wang W, Wang X, Wang X, Wang Y, Wanner C, Wanninayake S, Watada H, Watanabe K, Watanabe K, Watanabe M, Waterfall H, Watkins D, Watson S, Weaving L, Weber B, Webley Y, Webster A, Webster M, Weetman M, Wei W, Weihprecht H, Weiland L, Weinmann-Menke J, Weinreich T, Wendt R, Weng Y, Whalen M, Whalley G, Wheatley R, Wheeler A, Wheeler J, Whelton P, White K, Whitmore B, Whittaker S, Wiebel J, Wiley J, Wilkinson L, Willett M, Williams A, Williams E, Williams K, Williams T, Wilson A, Wilson P, Wincott L, Wines E, Winkelmann B, Winkler M, Winter-Goodwin B, Witczak J, Wittes J, Wittmann M, Wolf G, Wolf L, Wolfling R, Wong C, Wong E, Wong HS, Wong LW, Wong YH, Wonnacott A, Wood A, Wood L, Woodhouse H, Wooding N, Woodman A, Wren K, Wu J, Wu P, Xia S, Xiao H, Xiao X, Xie Y, Xu C, Xu Y, Xue H, Yahaya H, Yalamanchili H, Yamada A, Yamada N, Yamagata K, Yamaguchi M, Yamaji Y, Yamamoto A, Yamamoto S, Yamamoto S, Yamamoto T, Yamanaka A, Yamano T, Yamanouchi Y, Yamasaki N, Yamasaki Y, Yamasaki Y, Yamashita C, Yamauchi T, Yan Q, Yanagisawa E, Yang F, Yang L, Yano S, Yao S, Yao Y, Yarlagadda S, Yasuda Y, Yiu V, Yokoyama T, Yoshida S, Yoshidome E, Yoshikawa H, Young A, Young T, Yousif V, Yu H, Yu Y, Yuasa K, Yusof N, Zalunardo N, Zander B, Zani R, Zappulo F, Zayed M, Zemann B, Zettergren P, Zhang H, Zhang L, Zhang L, Zhang N, Zhang X, Zhao J, Zhao L, Zhao S, Zhao Z, Zhong H, Zhou N, Zhou S, Zhu D, Zhu L, Zhu S, Zietz M, Zippo M, Zirino F, Zulkipli FH. Effects of empagliflozin on progression of chronic kidney disease: a prespecified secondary analysis from the empa-kidney trial. Lancet Diabetes Endocrinol 2024; 12:39-50. [PMID: 38061371 PMCID: PMC7615591 DOI: 10.1016/s2213-8587(23)00321-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2023] [Revised: 10/24/2023] [Accepted: 10/25/2023] [Indexed: 12/23/2023]
Abstract
BACKGROUND Sodium-glucose co-transporter-2 (SGLT2) inhibitors reduce progression of chronic kidney disease and the risk of cardiovascular morbidity and mortality in a wide range of patients. However, their effects on kidney disease progression in some patients with chronic kidney disease are unclear because few clinical kidney outcomes occurred among such patients in the completed trials. In particular, some guidelines stratify their level of recommendation about who should be treated with SGLT2 inhibitors based on diabetes status and albuminuria. We aimed to assess the effects of empagliflozin on progression of chronic kidney disease both overall and among specific types of participants in the EMPA-KIDNEY trial. METHODS EMPA-KIDNEY, a randomised, controlled, phase 3 trial, was conducted at 241 centres in eight countries (Canada, China, Germany, Italy, Japan, Malaysia, the UK, and the USA), and included individuals aged 18 years or older with an estimated glomerular filtration rate (eGFR) of 20 to less than 45 mL/min per 1·73 m2, or with an eGFR of 45 to less than 90 mL/min per 1·73 m2 with a urinary albumin-to-creatinine ratio (uACR) of 200 mg/g or higher. We explored the effects of 10 mg oral empagliflozin once daily versus placebo on the annualised rate of change in estimated glomerular filtration rate (eGFR slope), a tertiary outcome. We studied the acute slope (from randomisation to 2 months) and chronic slope (from 2 months onwards) separately, using shared parameter models to estimate the latter. Analyses were done in all randomly assigned participants by intention to treat. EMPA-KIDNEY is registered at ClinicalTrials.gov, NCT03594110. FINDINGS Between May 15, 2019, and April 16, 2021, 6609 participants were randomly assigned and then followed up for a median of 2·0 years (IQR 1·5-2·4). Prespecified subgroups of eGFR included 2282 (34·5%) participants with an eGFR of less than 30 mL/min per 1·73 m2, 2928 (44·3%) with an eGFR of 30 to less than 45 mL/min per 1·73 m2, and 1399 (21·2%) with an eGFR 45 mL/min per 1·73 m2 or higher. Prespecified subgroups of uACR included 1328 (20·1%) with a uACR of less than 30 mg/g, 1864 (28·2%) with a uACR of 30 to 300 mg/g, and 3417 (51·7%) with a uACR of more than 300 mg/g. Overall, allocation to empagliflozin caused an acute 2·12 mL/min per 1·73 m2 (95% CI 1·83-2·41) reduction in eGFR, equivalent to a 6% (5-6) dip in the first 2 months. After this, it halved the chronic slope from -2·75 to -1·37 mL/min per 1·73 m2 per year (relative difference 50%, 95% CI 42-58). The absolute and relative benefits of empagliflozin on the magnitude of the chronic slope varied significantly depending on diabetes status and baseline levels of eGFR and uACR. In particular, the absolute difference in chronic slopes was lower in patients with lower baseline uACR, but because this group progressed more slowly than those with higher uACR, this translated to a larger relative difference in chronic slopes in this group (86% [36-136] reduction in the chronic slope among those with baseline uACR <30 mg/g compared with a 29% [19-38] reduction for those with baseline uACR ≥2000 mg/g; ptrend<0·0001). INTERPRETATION Empagliflozin slowed the rate of progression of chronic kidney disease among all types of participant in the EMPA-KIDNEY trial, including those with little albuminuria. Albuminuria alone should not be used to determine whether to treat with an SGLT2 inhibitor. FUNDING Boehringer Ingelheim and Eli Lilly.
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Judge PK, Staplin N, Mayne KJ, Wanner C, Green JB, Hauske SJ, Emberson JR, Preiss D, Ng SYA, Roddick AJ, Sammons E, Zhu D, Hill M, Stevens W, Wallendszus K, Brenner S, Cheung AK, Liu ZH, Li J, Hooi LS, Liu WJ, Kadowaki T, Nangaku M, Levin A, Cherney D, Maggioni AP, Pontremoli R, Deo R, Goto S, Rossello X, Tuttle KR, Steubl D, Massey D, Landray MJ, Baigent C, Haynes R, Herrington WG, Abat S, Abd Rahman R, Abdul Cader R, Abdul Hafidz MI, Abdul Wahab MZ, Abdullah NK, Abdul-Samad T, Abe M, Abraham N, Acheampong S, Achiri P, Acosta JA, Adeleke A, Adell V, Adewuyi-Dalton R, Adnan N, Africano A, Agharazii M, Aguilar F, Aguilera A, Ahmad M, Ahmad MK, Ahmad NA, Ahmad NH, Ahmad NI, Ahmad Miswan N, Ahmad Rosdi H, Ahmed I, Ahmed S, Ahmed S, Aiello J, Aitken A, AitSadi R, Aker S, Akimoto S, Akinfolarin A, Akram S, Alberici F, Albert C, Aldrich L, Alegata M, Alexander L, Alfaress S, Alhadj Ali M, Ali A, Ali A, Alicic R, Aliu A, Almaraz R, Almasarwah R, Almeida J, Aloisi A, Al-Rabadi L, Alscher D, Alvarez P, Al-Zeer B, Amat M, Ambrose C, Ammar H, An Y, Andriaccio L, Ansu K, Apostolidi A, Arai N, Araki H, Araki S, Arbi A, Arechiga O, Armstrong S, Arnold T, Aronoff S, Arriaga W, Arroyo J, Arteaga D, Asahara S, Asai A, Asai N, Asano S, Asawa M, Asmee MF, Aucella F, Augustin M, Avery A, Awad A, Awang IY, Awazawa M, Axler A, Ayub W, Azhari Z, Baccaro R, Badin C, Bagwell B, Bahlmann-Kroll E, Bahtar AZ, Baigent C, Bains D, Bajaj H, Baker R, Baldini E, Banas B, Banerjee D, Banno S, Bansal S, Barberi S, Barnes S, Barnini C, Barot C, Barrett K, Barrios R, Bartolomei Mecatti B, Barton I, Barton J, Basily W, Bavanandan S, Baxter A, Becker L, Beddhu S, Beige J, Beigh S, Bell S, Benck U, Beneat A, Bennett A, Bennett D, Benyon S, Berdeprado J, Bergler T, Bergner A, Berry M, Bevilacqua M, Bhairoo J, Bhandari S, Bhandary N, Bhatt A, Bhattarai M, Bhavsar M, Bian W, Bianchini F, Bianco S, Bilous R, Bilton J, Bilucaglia D, Bird C, Birudaraju D, Biscoveanu M, Blake C, Bleakley N, Bocchicchia K, Bodine S, Bodington R, Boedecker S, Bolduc M, Bolton S, Bond C, Boreky F, Boren K, Bouchi R, Bough L, Bovan D, Bowler C, Bowman L, Brar N, Braun C, Breach A, Breitenfeldt M, Brenner S, Brettschneider B, Brewer A, Brewer G, Brindle V, Brioni E, Brown C, Brown H, Brown L, Brown R, Brown S, Browne D, Bruce K, Brueckmann M, Brunskill N, Bryant M, Brzoska M, Bu Y, Buckman C, Budoff M, Bullen M, Burke A, Burnette S, Burston C, Busch M, Bushnell J, Butler S, Büttner C, Byrne C, Caamano A, Cadorna J, Cafiero C, Cagle M, Cai J, Calabrese K, Calvi C, Camilleri B, Camp S, Campbell D, Campbell R, Cao H, Capelli I, Caple M, Caplin B, Cardone A, Carle J, Carnall V, Caroppo M, Carr S, Carraro G, Carson M, Casares P, Castillo C, Castro C, Caudill B, Cejka V, Ceseri M, Cham L, Chamberlain A, Chambers J, Chan CBT, Chan JYM, Chan YC, Chang E, Chang E, Chant T, Chavagnon T, Chellamuthu P, Chen F, Chen J, Chen P, Chen TM, Chen Y, Chen Y, Cheng C, Cheng H, Cheng MC, Cherney D, Cheung AK, Ching CH, Chitalia N, Choksi R, Chukwu C, Chung K, Cianciolo G, Cipressa L, Clark S, Clarke H, Clarke R, Clarke S, Cleveland B, Cole E, Coles H, Condurache L, Connor A, Convery K, Cooper A, Cooper N, Cooper Z, Cooperman L, Cosgrove L, Coutts P, Cowley A, Craik R, Cui G, Cummins T, Dahl N, Dai H, Dajani L, D'Amelio A, Damian E, Damianik K, Danel L, Daniels C, Daniels T, Darbeau S, Darius H, Dasgupta T, Davies J, Davies L, Davis A, Davis J, Davis L, Dayanandan R, Dayi S, Dayrell R, De Nicola L, Debnath S, Deeb W, Degenhardt S, DeGoursey K, Delaney M, Deo R, DeRaad R, Derebail V, Dev D, Devaux M, Dhall P, Dhillon G, Dienes J, Dobre M, Doctolero E, Dodds V, Domingo D, Donaldson D, Donaldson P, Donhauser C, Donley V, Dorestin S, Dorey S, Doulton T, Draganova D, Draxlbauer K, Driver F, Du H, Dube F, Duck T, Dugal T, Dugas J, Dukka H, Dumann H, Durham W, Dursch M, Dykas R, Easow R, Eckrich E, Eden G, Edmerson E, Edwards H, Ee LW, Eguchi J, Ehrl Y, Eichstadt K, Eid W, Eilerman B, Ejima Y, Eldon H, Ellam T, Elliott L, Ellison R, Emberson J, Epp R, Er A, Espino-Obrero M, Estcourt S, Estienne L, Evans G, Evans J, Evans S, Fabbri G, Fajardo-Moser M, Falcone C, Fani F, Faria-Shayler P, Farnia F, Farrugia D, Fechter M, Fellowes D, Feng F, Fernandez J, Ferraro P, Field A, Fikry S, Finch J, Finn H, Fioretto P, Fish R, Fleischer A, Fleming-Brown D, Fletcher L, Flora R, Foellinger C, Foligno N, Forest S, Forghani Z, Forsyth K, Fottrell-Gould D, Fox P, Frankel A, Fraser D, Frazier R, Frederick K, Freking N, French H, Froment A, Fuchs B, Fuessl L, Fujii H, Fujimoto A, Fujita A, Fujita K, Fujita Y, Fukagawa M, Fukao Y, Fukasawa A, Fuller T, Funayama T, Fung E, Furukawa M, Furukawa Y, Furusho M, Gabel S, Gaidu J, Gaiser S, Gallo K, Galloway C, Gambaro G, Gan CC, Gangemi C, Gao M, Garcia K, Garcia M, Garofalo C, Garrity M, Garza A, Gasko S, Gavrila M, Gebeyehu B, Geddes A, Gentile G, George A, George J, Gesualdo L, Ghalli F, Ghanem A, Ghate T, Ghavampour S, Ghazi A, Gherman A, Giebeln-Hudnell U, Gill B, Gillham S, Girakossyan I, Girndt M, Giuffrida A, Glenwright M, Glider T, Gloria R, Glowski D, Goh BL, Goh CB, Gohda T, Goldenberg R, Goldfaden R, Goldsmith C, Golson B, Gonce V, Gong Q, Goodenough B, Goodwin N, Goonasekera M, Gordon A, Gordon J, Gore A, Goto H, Goto S, Goto S, Gowen D, Grace A, Graham J, Grandaliano G, Gray M, Green JB, Greene T, Greenwood G, Grewal B, Grifa R, Griffin D, Griffin S, Grimmer P, Grobovaite E, Grotjahn S, Guerini A, Guest C, Gunda S, Guo B, Guo Q, Haack S, Haase M, Haaser K, Habuki K, Hadley A, Hagan S, Hagge S, Haller H, Ham S, Hamal S, Hamamoto Y, Hamano N, Hamm M, Hanburry A, Haneda M, Hanf C, Hanif W, Hansen J, Hanson L, Hantel S, Haraguchi T, Harding E, Harding T, Hardy C, Hartner C, Harun Z, Harvill L, Hasan A, Hase H, Hasegawa F, Hasegawa T, Hashimoto A, Hashimoto C, Hashimoto M, Hashimoto S, Haskett S, Hauske SJ, Hawfield A, Hayami T, Hayashi M, Hayashi S, Haynes R, Hazara A, Healy C, Hecktman J, Heine G, Henderson H, Henschel R, Hepditch A, Herfurth K, Hernandez G, Hernandez Pena A, Hernandez-Cassis C, Herrington WG, Herzog C, Hewins S, Hewitt D, Hichkad L, Higashi S, Higuchi C, Hill C, Hill L, Hill M, Himeno T, Hing A, Hirakawa Y, Hirata K, Hirota Y, Hisatake T, Hitchcock S, Hodakowski A, Hodge W, Hogan R, Hohenstatt U, Hohenstein B, Hooi L, Hope S, Hopley M, Horikawa S, Hosein D, Hosooka T, Hou L, Hou W, Howie L, Howson A, Hozak M, Htet Z, Hu X, Hu Y, Huang J, Huda N, Hudig L, Hudson A, Hugo C, Hull R, Hume L, Hundei W, Hunt N, Hunter A, Hurley S, Hurst A, Hutchinson C, Hyo T, Ibrahim FH, Ibrahim S, Ihana N, Ikeda T, Imai A, Imamine R, Inamori A, Inazawa H, Ingell J, Inomata K, Inukai Y, Ioka M, Irtiza-Ali A, Isakova T, Isari W, Iselt M, Ishiguro A, Ishihara K, Ishikawa T, Ishimoto T, Ishizuka K, Ismail R, Itano S, Ito H, Ito K, Ito M, Ito Y, Iwagaitsu S, Iwaita Y, Iwakura T, Iwamoto M, Iwasa M, Iwasaki H, Iwasaki S, Izumi K, Izumi K, Izumi T, Jaafar SM, Jackson C, Jackson Y, Jafari G, Jahangiriesmaili M, Jain N, Jansson K, Jasim H, Jeffers L, Jenkins A, Jesky M, Jesus-Silva J, Jeyarajah D, Jiang Y, Jiao X, Jimenez G, Jin B, Jin Q, Jochims J, Johns B, Johnson C, Johnson T, Jolly S, Jones L, Jones L, Jones S, Jones T, Jones V, Joseph M, Joshi S, Judge P, Junejo N, Junus S, Kachele M, Kadowaki T, Kadoya H, Kaga H, Kai H, Kajio H, Kaluza-Schilling W, Kamaruzaman L, Kamarzarian A, Kamimura Y, Kamiya H, Kamundi C, Kan T, Kanaguchi Y, Kanazawa A, Kanda E, Kanegae S, Kaneko K, Kaneko K, Kang HY, Kano T, Karim M, Karounos D, Karsan W, Kasagi R, Kashihara N, Katagiri H, Katanosaka A, Katayama A, Katayama M, Katiman E, Kato K, Kato M, Kato N, Kato S, Kato T, Kato Y, Katsuda Y, Katsuno T, Kaufeld J, Kavak Y, Kawai I, Kawai M, Kawai M, Kawase A, Kawashima S, Kazory A, Kearney J, Keith B, Kellett J, Kelley S, Kershaw M, Ketteler M, Khai Q, Khairullah Q, Khandwala H, Khoo KKL, Khwaja A, Kidokoro K, Kielstein J, Kihara M, Kimber C, Kimura S, Kinashi H, Kingston H, Kinomura M, Kinsella-Perks E, Kitagawa M, Kitajima M, Kitamura S, Kiyosue A, Kiyota M, Klauser F, Klausmann G, Kmietschak W, Knapp K, Knight C, Knoppe A, Knott C, Kobayashi M, Kobayashi R, Kobayashi T, Koch M, Kodama S, Kodani N, Kogure E, Koizumi M, Kojima H, Kojo T, Kolhe N, Komaba H, Komiya T, Komori H, Kon SP, Kondo M, Kondo M, Kong W, Konishi M, Kono K, Koshino M, Kosugi T, Kothapalli B, Kozlowski T, Kraemer B, Kraemer-Guth A, Krappe J, Kraus D, Kriatselis C, Krieger C, Krish P, Kruger B, Ku Md Razi KR, Kuan Y, Kubota S, Kuhn S, Kumar P, Kume S, Kummer I, Kumuji R, Küpper A, Kuramae T, Kurian L, Kuribayashi C, Kurien R, Kuroda E, Kurose T, Kutschat A, Kuwabara N, Kuwata H, La Manna G, Lacey M, Lafferty K, LaFleur P, Lai V, Laity E, Lambert A, Landray MJ, Langlois M, Latif F, Latore E, Laundy E, Laurienti D, Lawson A, Lay M, Leal I, Leal I, Lee AK, Lee J, Lee KQ, Lee R, Lee SA, Lee YY, Lee-Barkey Y, Leonard N, Leoncini G, Leong CM, Lerario S, Leslie A, Levin A, Lewington A, Li J, Li N, Li X, Li Y, Liberti L, Liberti ME, Liew A, Liew YF, Lilavivat U, Lim SK, Lim YS, Limon E, Lin H, Lioudaki E, Liu H, Liu J, Liu L, Liu Q, Liu WJ, Liu X, Liu Z, Loader D, Lochhead H, Loh CL, Lorimer A, Loudermilk L, Loutan J, Low CK, Low CL, Low YM, Lozon Z, Lu Y, Lucci D, Ludwig U, Luker N, Lund D, Lustig R, Lyle S, Macdonald C, MacDougall I, Machicado R, MacLean D, Macleod P, Madera A, Madore F, Maeda K, Maegawa H, Maeno S, Mafham M, Magee J, Maggioni AP, Mah DY, Mahabadi V, Maiguma M, Makita Y, Makos G, Manco L, Mangiacapra R, Manley J, Mann P, Mano S, Marcotte G, Maris J, Mark P, Markau S, Markovic M, Marshall C, Martin M, Martinez C, Martinez S, Martins G, Maruyama K, Maruyama S, Marx K, Maselli A, Masengu A, Maskill A, Masumoto S, Masutani K, Matsumoto M, Matsunaga T, Matsuoka N, Matsushita M, Matthews M, Matthias S, Matvienko E, Maurer M, Maxwell P, Mayne KJ, Mazlan N, Mazlan SA, Mbuyisa A, McCafferty K, McCarroll F, McCarthy T, McClary-Wright C, McCray K, McDermott P, McDonald C, McDougall R, McHaffie E, McIntosh K, McKinley T, McLaughlin S, McLean N, McNeil L, Measor A, Meek J, Mehta A, Mehta R, Melandri M, Mené P, Meng T, Menne J, Merritt K, Merscher S, Meshykhi C, Messa P, Messinger L, Miftari N, Miller R, Miller Y, Miller-Hodges E, Minatoguchi M, Miners M, Minutolo R, Mita T, Miura Y, Miyaji M, Miyamoto S, Miyatsuka T, Miyazaki M, Miyazawa I, Mizumachi R, Mizuno M, Moffat S, Mohamad Nor FS, Mohamad Zaini SN, Mohamed Affandi FA, Mohandas C, Mohd R, Mohd Fauzi NA, Mohd Sharif NH, Mohd Yusoff Y, Moist L, Moncada A, Montasser M, Moon A, Moran C, Morgan N, Moriarty J, Morig G, Morinaga H, Morino K, Morisaki T, Morishita Y, Morlok S, Morris A, Morris F, Mostafa S, Mostefai Y, Motegi M, Motherwell N, Motta D, Mottl A, Moys R, Mozaffari S, Muir J, Mulhern J, Mulligan S, Munakata Y, Murakami C, Murakoshi M, Murawska A, Murphy K, Murphy L, Murray S, Murtagh H, Musa MA, Mushahar L, Mustafa R, Mustafar R, Muto M, Nadar E, Nagano R, Nagasawa T, Nagashima E, Nagasu H, Nagelberg S, Nair H, Nakagawa Y, Nakahara M, Nakamura J, Nakamura R, Nakamura T, Nakaoka M, Nakashima E, Nakata J, Nakata M, Nakatani S, Nakatsuka A, Nakayama Y, Nakhoul G, Nangaku M, Naverrete G, Navivala A, Nazeer I, Negrea L, Nethaji C, Newman E, Ng SYA, Ng TJ, Ngu LLS, Nimbkar T, Nishi H, Nishi M, Nishi S, Nishida Y, Nishiyama A, Niu J, Niu P, Nobili G, Nohara N, Nojima I, Nolan J, Nosseir H, Nozawa M, Nunn M, Nunokawa S, Oda M, Oe M, Oe Y, Ogane K, Ogawa W, Ogihara T, Oguchi G, Ohsugi M, Oishi K, Okada Y, Okajyo J, Okamoto S, Okamura K, Olufuwa O, Oluyombo R, Omata A, Omori Y, Ong LM, Ong YC, Onyema J, Oomatia A, Oommen A, Oremus R, Orimo Y, Ortalda V, Osaki Y, Osawa Y, Osmond Foster J, O'Sullivan A, Otani T, Othman N, Otomo S, O'Toole J, Owen L, Ozawa T, Padiyar A, Page N, Pajak S, Paliege A, Pandey A, Pandey R, Pariani H, Park J, Parrigon M, Passauer J, Patecki M, Patel M, Patel R, Patel T, Patel Z, Paul R, Paul R, Paulsen L, Pavone L, Peixoto A, Peji J, Peng BC, Peng K, Pennino L, Pereira E, Perez E, Pergola P, Pesce F, Pessolano G, Petchey W, Petr EJ, Pfab T, Phelan P, Phillips R, Phillips T, Phipps M, Piccinni G, Pickett T, Pickworth S, Piemontese M, Pinto D, Piper J, Plummer-Morgan J, Poehler D, Polese L, Poma V, Pontremoli R, Postal A, Pötz C, Power A, Pradhan N, Pradhan R, Preiss D, Preiss E, Preston K, Prib N, Price L, Provenzano C, Pugay C, Pulido R, Putz F, Qiao Y, Quartagno R, Quashie-Akponeware M, Rabara R, Rabasa-Lhoret R, Radhakrishnan D, Radley M, Raff R, Raguwaran S, Rahbari-Oskoui F, Rahman M, Rahmat K, Ramadoss S, Ramanaidu S, Ramasamy S, Ramli R, Ramli S, Ramsey T, Rankin A, Rashidi A, Raymond L, Razali WAFA, Read K, Reiner H, Reisler A, Reith C, Renner J, Rettenmaier B, Richmond L, Rijos D, Rivera R, Rivers V, Robinson H, Rocco M, Rodriguez-Bachiller I, Rodriquez R, Roesch C, Roesch J, Rogers J, Rohnstock M, Rolfsmeier S, Roman M, Romo A, Rosati A, Rosenberg S, Ross T, Rossello X, Roura M, Roussel M, Rovner S, Roy S, Rucker S, Rump L, Ruocco M, Ruse S, Russo F, Russo M, Ryder M, Sabarai A, Saccà C, Sachson R, Sadler E, Safiee NS, Sahani M, Saillant A, Saini J, Saito C, Saito S, Sakaguchi K, Sakai M, Salim H, Salviani C, Sammons E, Sampson A, Samson F, Sandercock P, Sanguila S, Santorelli G, Santoro D, Sarabu N, Saram T, Sardell R, Sasajima H, Sasaki T, Satko S, Sato A, Sato D, Sato H, Sato H, Sato J, Sato T, Sato Y, Satoh M, Sawada K, Schanz M, Scheidemantel F, Schemmelmann M, Schettler E, Schettler V, Schlieper GR, Schmidt C, Schmidt G, Schmidt U, Schmidt-Gurtler H, Schmude M, Schneider A, Schneider I, Schneider-Danwitz C, Schomig M, Schramm T, Schreiber A, Schricker S, Schroppel B, Schulte-Kemna L, Schulz E, Schumacher B, Schuster A, Schwab A, Scolari F, Scott A, Seeger W, Seeger W, Segal M, Seifert L, Seifert M, Sekiya M, Sellars R, Seman MR, Shah S, Shah S, Shainberg L, Shanmuganathan M, Shao F, Sharma K, Sharpe C, Sheikh-Ali M, Sheldon J, Shenton C, Shepherd A, Shepperd M, Sheridan R, Sheriff Z, Shibata Y, Shigehara T, Shikata K, Shimamura K, Shimano H, Shimizu Y, Shimoda H, Shin K, Shivashankar G, Shojima N, Silva R, Sim CSB, Simmons K, Sinha S, Sitter T, Sivanandam S, Skipper M, Sloan K, Sloan L, Smith R, Smyth J, Sobande T, Sobata M, Somalanka S, Song X, Sonntag F, Sood B, Sor SY, Soufer J, Sparks H, Spatoliatore G, Spinola T, Squyres S, Srivastava A, Stanfield J, Staplin N, Staylor K, Steele A, Steen O, Steffl D, Stegbauer J, Stellbrink C, Stellbrink E, Stevens W, Stevenson A, Stewart-Ray V, Stickley J, Stoffler D, Stratmann B, Streitenberger S, Strutz F, Stubbs J, Stumpf J, Suazo N, Suchinda P, Suckling R, Sudin A, Sugamori K, Sugawara H, Sugawara K, Sugimoto D, Sugiyama H, Sugiyama H, Sugiyama T, Sullivan M, Sumi M, Suresh N, Sutton D, Suzuki H, Suzuki R, Suzuki Y, Suzuki Y, Suzuki Y, Swanson E, Swift P, Syed S, Szerlip H, Taal M, Taddeo M, Tailor C, Tajima K, Takagi M, Takahashi K, Takahashi K, Takahashi M, Takahashi T, Takahira E, Takai T, Takaoka M, Takeoka J, Takesada A, Takezawa M, Talbot M, Taliercio J, Talsania T, Tamori Y, Tamura R, Tamura Y, Tan CHH, Tan EZZ, Tanabe A, Tanabe K, Tanaka A, Tanaka A, Tanaka N, Tang S, Tang Z, Tanigaki K, Tarlac M, Tatsuzawa A, Tay JF, Tay LL, Taylor J, Taylor K, Taylor K, Te A, Tenbusch L, Teng KS, Terakawa A, Terry J, Tham ZD, Tholl S, Thomas G, Thong KM, Tietjen D, Timadjer A, Tindall H, Tipper S, Tobin K, Toda N, Tokuyama A, Tolibas M, Tomita A, Tomita T, Tomlinson J, Tonks L, Topf J, Topping S, Torp A, Torres A, Totaro F, Toth P, Toyonaga Y, Tripodi F, Trivedi K, Tropman E, Tschope D, Tse J, Tsuji K, Tsunekawa S, Tsunoda R, Tucky B, Tufail S, Tuffaha A, Turan E, Turner H, Turner J, Turner M, Tuttle KR, Tye YL, Tyler A, Tyler J, Uchi H, Uchida H, Uchida T, Uchida T, Udagawa T, Ueda S, Ueda Y, Ueki K, Ugni S, Ugwu E, Umeno R, Unekawa C, Uozumi K, Urquia K, Valleteau A, Valletta C, van Erp R, Vanhoy C, Varad V, Varma R, Varughese A, Vasquez P, Vasseur A, Veelken R, Velagapudi C, Verdel K, Vettoretti S, Vezzoli G, Vielhauer V, Viera R, Vilar E, Villaruel S, Vinall L, Vinathan J, Visnjic M, Voigt E, von-Eynatten M, Vourvou M, Wada J, Wada J, Wada T, Wada Y, Wakayama K, Wakita Y, Wallendszus K, Walters T, Wan Mohamad WH, Wang L, Wang W, Wang X, Wang X, Wang Y, Wanner C, Wanninayake S, Watada H, Watanabe K, Watanabe K, Watanabe M, Waterfall H, Watkins D, Watson S, Weaving L, Weber B, Webley Y, Webster A, Webster M, Weetman M, Wei W, Weihprecht H, Weiland L, Weinmann-Menke J, Weinreich T, Wendt R, Weng Y, Whalen M, Whalley G, Wheatley R, Wheeler A, Wheeler J, Whelton P, White K, Whitmore B, Whittaker S, Wiebel J, Wiley J, Wilkinson L, Willett M, Williams A, Williams E, Williams K, Williams T, Wilson A, Wilson P, Wincott L, Wines E, Winkelmann B, Winkler M, Winter-Goodwin B, Witczak J, Wittes J, Wittmann M, Wolf G, Wolf L, Wolfling R, Wong C, Wong E, Wong HS, Wong LW, Wong YH, Wonnacott A, Wood A, Wood L, Woodhouse H, Wooding N, Woodman A, Wren K, Wu J, Wu P, Xia S, Xiao H, Xiao X, Xie Y, Xu C, Xu Y, Xue H, Yahaya H, Yalamanchili H, Yamada A, Yamada N, Yamagata K, Yamaguchi M, Yamaji Y, Yamamoto A, Yamamoto S, Yamamoto S, Yamamoto T, Yamanaka A, Yamano T, Yamanouchi Y, Yamasaki N, Yamasaki Y, Yamasaki Y, Yamashita C, Yamauchi T, Yan Q, Yanagisawa E, Yang F, Yang L, Yano S, Yao S, Yao Y, Yarlagadda S, Yasuda Y, Yiu V, Yokoyama T, Yoshida S, Yoshidome E, Yoshikawa H, Young A, Young T, Yousif V, Yu H, Yu Y, Yuasa K, Yusof N, Zalunardo N, Zander B, Zani R, Zappulo F, Zayed M, Zemann B, Zettergren P, Zhang H, Zhang L, Zhang L, Zhang N, Zhang X, Zhao J, Zhao L, Zhao S, Zhao Z, Zhong H, Zhou N, Zhou S, Zhu D, Zhu L, Zhu S, Zietz M, Zippo M, Zirino F, Zulkipli FH. Impact of primary kidney disease on the effects of empagliflozin in patients with chronic kidney disease: secondary analyses of the EMPA-KIDNEY trial. Lancet Diabetes Endocrinol 2024; 12:51-60. [PMID: 38061372 DOI: 10.1016/s2213-8587(23)00322-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2023] [Revised: 10/24/2023] [Accepted: 10/25/2023] [Indexed: 12/23/2023]
Abstract
BACKGROUND The EMPA-KIDNEY trial showed that empagliflozin reduced the risk of the primary composite outcome of kidney disease progression or cardiovascular death in patients with chronic kidney disease mainly through slowing progression. We aimed to assess how effects of empagliflozin might differ by primary kidney disease across its broad population. METHODS EMPA-KIDNEY, a randomised, controlled, phase 3 trial, was conducted at 241 centres in eight countries (Canada, China, Germany, Italy, Japan, Malaysia, the UK, and the USA). Patients were eligible if their estimated glomerular filtration rate (eGFR) was 20 to less than 45 mL/min per 1·73 m2, or 45 to less than 90 mL/min per 1·73 m2 with a urinary albumin-to-creatinine ratio (uACR) of 200 mg/g or higher at screening. They were randomly assigned (1:1) to 10 mg oral empagliflozin once daily or matching placebo. Effects on kidney disease progression (defined as a sustained ≥40% eGFR decline from randomisation, end-stage kidney disease, a sustained eGFR below 10 mL/min per 1·73 m2, or death from kidney failure) were assessed using prespecified Cox models, and eGFR slope analyses used shared parameter models. Subgroup comparisons were performed by including relevant interaction terms in models. EMPA-KIDNEY is registered with ClinicalTrials.gov, NCT03594110. FINDINGS Between May 15, 2019, and April 16, 2021, 6609 participants were randomly assigned and followed up for a median of 2·0 years (IQR 1·5-2·4). Prespecified subgroupings by primary kidney disease included 2057 (31·1%) participants with diabetic kidney disease, 1669 (25·3%) with glomerular disease, 1445 (21·9%) with hypertensive or renovascular disease, and 1438 (21·8%) with other or unknown causes. Kidney disease progression occurred in 384 (11·6%) of 3304 patients in the empagliflozin group and 504 (15·2%) of 3305 patients in the placebo group (hazard ratio 0·71 [95% CI 0·62-0·81]), with no evidence that the relative effect size varied significantly by primary kidney disease (pheterogeneity=0·62). The between-group difference in chronic eGFR slopes (ie, from 2 months to final follow-up) was 1·37 mL/min per 1·73 m2 per year (95% CI 1·16-1·59), representing a 50% (42-58) reduction in the rate of chronic eGFR decline. This relative effect of empagliflozin on chronic eGFR slope was similar in analyses by different primary kidney diseases, including in explorations by type of glomerular disease and diabetes (p values for heterogeneity all >0·1). INTERPRETATION In a broad range of patients with chronic kidney disease at risk of progression, including a wide range of non-diabetic causes of chronic kidney disease, empagliflozin reduced risk of kidney disease progression. Relative effect sizes were broadly similar irrespective of the cause of primary kidney disease, suggesting that SGLT2 inhibitors should be part of a standard of care to minimise risk of kidney failure in chronic kidney disease. FUNDING Boehringer Ingelheim, Eli Lilly, and UK Medical Research Council.
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Harper C, Mafham M, Herrington W, Staplin N, Stevens W, Wallendszus K, Haynes R, Landray MJ, Parish S, Bowman L, Armitage J. Reliability of major bleeding events in UK routine data versus clinical trial adjudicated follow-up data. Heart 2023; 109:1467-1472. [PMID: 37270201 PMCID: PMC10511984 DOI: 10.1136/heartjnl-2023-322616] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2023] [Accepted: 05/16/2023] [Indexed: 06/05/2023] Open
Abstract
OBJECTIVE To assess how reliable UK routine data are for ascertaining major bleeding events compared with adjudicated follow-up. METHODS The ASCEND (A Study of Cardiovascular Events iN Diabetes) primary prevention trial randomised 15 480 UK people with diabetes to aspirin versus matching placebo. The primary safety outcome was major bleeding (including intracranial haemorrhage, sight-threatening eye bleeding, serious gastrointestinal bleeding and other major bleeding (epistaxis, haemoptysis, haematuria, vaginal and other bleeding)) ascertained by direct-participant mail-based follow-up, with >90% of outcomes undergoing adjudication. Nearly all participants were linked to routinely collected hospitalisation and death data (ie, routine data). An algorithm categorised bleeding events from routine data as major/minor. Kappa statistics were used to assess agreement between data sources, and randomised comparisons were re-run using routine data. RESULTS When adjudicated follow-up and routine data were compared, there was agreement for 318 major bleeding events, with routine data identifying 281 additional-potential events, and not identifying 241 participant-reported events (kappa 0.53, 95% CI 0.49 to 0.57). Repeating ASCEND's randomised comparisons using routine data only found estimated relative and absolute effects of allocation to aspirin versus placebo on major bleeding similar to adjudicated follow-up (adjudicated follow-up: aspirin 314 (4.1%) vs placebo 245 (3.2%); rate ratio (RR) 1.29, 95% CI 1.09 to 1.52; absolute excess +6.3/5000 person-years (mean SE±2.1); vs routine data: 327 (4.2%) vs 272 (3.5%); RR 1.21, 95% CI 1.03 to 1.41; absolute excess +5.0/5000 (±2.2)). CONCLUSIONS Analyses of the ASCEND randomised trial found that major bleeding events ascertained via UK routine data sources provided relative and absolute treatment effects similar to adjudicated follow-up. TRIAL REGISTRATION NUMBER ISRCTN60635500; NCT00135226.
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Affiliation(s)
- Charlie Harper
- Medical Research Council Population Health Research Unit at the University of Oxford, Nuffield Department of Population Health (NDPH), University of Oxford, Oxford, UK
- Clinical Trial Service Unit and Epidemiological Studies Unit (CTSU), NDPH, University of Oxford, Oxford, UK
| | - Marion Mafham
- Clinical Trial Service Unit and Epidemiological Studies Unit (CTSU), NDPH, University of Oxford, Oxford, UK
| | - William Herrington
- Medical Research Council Population Health Research Unit at the University of Oxford, Nuffield Department of Population Health (NDPH), University of Oxford, Oxford, UK
- Clinical Trial Service Unit and Epidemiological Studies Unit (CTSU), NDPH, University of Oxford, Oxford, UK
| | - Natalie Staplin
- Medical Research Council Population Health Research Unit at the University of Oxford, Nuffield Department of Population Health (NDPH), University of Oxford, Oxford, UK
- Clinical Trial Service Unit and Epidemiological Studies Unit (CTSU), NDPH, University of Oxford, Oxford, UK
| | - William Stevens
- Medical Research Council Population Health Research Unit at the University of Oxford, Nuffield Department of Population Health (NDPH), University of Oxford, Oxford, UK
- Clinical Trial Service Unit and Epidemiological Studies Unit (CTSU), NDPH, University of Oxford, Oxford, UK
| | - Karl Wallendszus
- Medical Research Council Population Health Research Unit at the University of Oxford, Nuffield Department of Population Health (NDPH), University of Oxford, Oxford, UK
- Clinical Trial Service Unit and Epidemiological Studies Unit (CTSU), NDPH, University of Oxford, Oxford, UK
| | - Richard Haynes
- Medical Research Council Population Health Research Unit at the University of Oxford, Nuffield Department of Population Health (NDPH), University of Oxford, Oxford, UK
- Clinical Trial Service Unit and Epidemiological Studies Unit (CTSU), NDPH, University of Oxford, Oxford, UK
| | - Martin J Landray
- Medical Research Council Population Health Research Unit at the University of Oxford, Nuffield Department of Population Health (NDPH), University of Oxford, Oxford, UK
- Clinical Trial Service Unit and Epidemiological Studies Unit (CTSU), NDPH, University of Oxford, Oxford, UK
- Big Data Institute, Li Ka Shing Centre for Health Information & Discovery, NDPH, University of Oxford, Oxford, UK
| | - Sarah Parish
- Medical Research Council Population Health Research Unit at the University of Oxford, Nuffield Department of Population Health (NDPH), University of Oxford, Oxford, UK
- Clinical Trial Service Unit and Epidemiological Studies Unit (CTSU), NDPH, University of Oxford, Oxford, UK
| | - Louise Bowman
- Medical Research Council Population Health Research Unit at the University of Oxford, Nuffield Department of Population Health (NDPH), University of Oxford, Oxford, UK
- Clinical Trial Service Unit and Epidemiological Studies Unit (CTSU), NDPH, University of Oxford, Oxford, UK
| | - Jane Armitage
- Medical Research Council Population Health Research Unit at the University of Oxford, Nuffield Department of Population Health (NDPH), University of Oxford, Oxford, UK
- Clinical Trial Service Unit and Epidemiological Studies Unit (CTSU), NDPH, University of Oxford, Oxford, UK
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Haynes R, Mafham M, Toh CH, Landray MJ. Delivering trials in the NHS: more than worth it. Clin Med (Lond) 2023; 23:525-526. [PMID: 37775179 PMCID: PMC10541267 DOI: 10.7861/clinmed.2023-0296] [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: 10/01/2023]
Abstract
Randomised trials are the best method to determine the efficacy and safety of health technologies. A recent report by Lord O'Shaughnessy highlighted many of the current challenges to delivering trials in the UK and proposed potential solutions. Among these, making trials the business of all NHS institutions and a valued part of all doctors' work, while leveraging the potential of the data that the NHS collects routinely, offers an opportunity to improve NHS efficiency, doctors' job satisfaction and population health simultaneously.
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Affiliation(s)
- Richard Haynes
- Nuffield Department of Population Health, University of Oxford, Oxford, UK, and chief scientist, Protas, Salford, UK
| | - Marion Mafham
- Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Cheng Hock Toh
- University of Liverpool, Liverpool, UK, and honorary consultant in haematology, Liverpool University Hospitals NHS Foundation Trust, Liverpool, UK
| | - Martin J Landray
- Nuffield Department of Population Health, University of Oxford, Oxford, UK, and chief executive officer, Protas, Salford, UK
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Herrington WG, Harper C, Staplin N, Haynes R, Emberson JR, Reith C, Hooi LS, Levin A, Wanner C, Baigent C, Landray MJ. Impact of outcome adjudication in kidney disease trials: observations from the Study of Heart and Renal Protection (SHARP). Kidney Int Rep 2023; 8:1489-1495. [PMID: 37538810 PMCID: PMC7614871 DOI: 10.1016/j.ekir.2023.05.008] [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] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2023] [Accepted: 05/08/2023] [Indexed: 08/05/2023] Open
Abstract
Introduction We aimed to assess opportunities for trial streamlining and the scientific impact of adjudication on kidney and cardiovascular outcomes in CKD. Methods We analysed the effects of adjudication of ~2100 maintenance kidney replacement therapy (KRT) and ~1300 major atherosclerotic events (MAEs) recorded in SHARP. We first compared outcome classification before versus after adjudication, and then re-ran randomised comparisons using pre-adjudicated follow-up data. Results For maintenance KRT, adjudication had little impact with only 1% of events being refuted (28/2115). Consequently, randomised comparisons using pre-adjudication reports found almost identical results (pre-adjudication: simvastatin/ezetimibe 1038 vs placebo 1077; risk ratio [RR] 0.95, 95%CI 0.88-1.04; post-adjudicated: 1057 vs 1084; RR=0.97, 95%CI 0.89-1.05). For MAEs, about one-quarter of patient reports were refuted (324/1275 [25%]), and reviewing 3538 other potential vascular events and death reports identified only 194 additional MAEs. Nevertheless, randomised analyses using SHARP's pre-adjudicated data alone found similar results to analyses based on adjudicated outcomes (pre-adjudication: 573 vs 702; RR=0.80, 95%CI 0.72-0.89; adjudicated: 526 vs 619; RR=0.83, 95%CI 0.74- 0.94), and also suggested refuted MAEs were likely to represent atherosclerotic disease (RR for refuted MAEs=0.80, 95%CI 0.65-1.00). Conclusions These analyses provide three key insights. First, they provide a rationale for nephrology trials not to adjudicate maintenance KRT. Secondly, when an event that mimics an atherosclerotic outcome is not expected to be influenced by the treatment under study (e.g. heart failure), the aim of adjudicating atherosclerotic outcomes should be to remove such events. Lastly, restrictive definitions for the remaining suspected atherosclerotic outcomes may reduce statistical power.
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Affiliation(s)
- William G. Herrington
- Medical Research Council Population Health Research Unit at the University of Oxford, Nuffield Department of Population Health (NDPH), University of Oxford, UK
- Clinical Trial Service Unit and Epidemiologic Studies Unit (CTSU), NDPH, University of Oxford, UK
- Oxford Kidney Unit, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Charlie Harper
- Medical Research Council Population Health Research Unit at the University of Oxford, Nuffield Department of Population Health (NDPH), University of Oxford, UK
- Clinical Trial Service Unit and Epidemiologic Studies Unit (CTSU), NDPH, University of Oxford, UK
| | - Natalie Staplin
- Medical Research Council Population Health Research Unit at the University of Oxford, Nuffield Department of Population Health (NDPH), University of Oxford, UK
- Clinical Trial Service Unit and Epidemiologic Studies Unit (CTSU), NDPH, University of Oxford, UK
| | - Richard Haynes
- Medical Research Council Population Health Research Unit at the University of Oxford, Nuffield Department of Population Health (NDPH), University of Oxford, UK
- Clinical Trial Service Unit and Epidemiologic Studies Unit (CTSU), NDPH, University of Oxford, UK
- Oxford Kidney Unit, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Jonathan R. Emberson
- Medical Research Council Population Health Research Unit at the University of Oxford, Nuffield Department of Population Health (NDPH), University of Oxford, UK
- Clinical Trial Service Unit and Epidemiologic Studies Unit (CTSU), NDPH, University of Oxford, UK
| | - Christina Reith
- Medical Research Council Population Health Research Unit at the University of Oxford, Nuffield Department of Population Health (NDPH), University of Oxford, UK
- Clinical Trial Service Unit and Epidemiologic Studies Unit (CTSU), NDPH, University of Oxford, UK
| | | | - Adeera Levin
- Division of Nephrology, University of British Columbia, Vancouver, Canada
| | - Christoph Wanner
- Division of Nephrology, University Clinic of Würzburg, Würzburg, Germany
| | - Colin Baigent
- Medical Research Council Population Health Research Unit at the University of Oxford, Nuffield Department of Population Health (NDPH), University of Oxford, UK
- Clinical Trial Service Unit and Epidemiologic Studies Unit (CTSU), NDPH, University of Oxford, UK
| | - Martin J. Landray
- Medical Research Council Population Health Research Unit at the University of Oxford, Nuffield Department of Population Health (NDPH), University of Oxford, UK
- Clinical Trial Service Unit and Epidemiologic Studies Unit (CTSU), NDPH, University of Oxford, UK
| | - SHARP Collaborative Group7
- Medical Research Council Population Health Research Unit at the University of Oxford, Nuffield Department of Population Health (NDPH), University of Oxford, UK
- Clinical Trial Service Unit and Epidemiologic Studies Unit (CTSU), NDPH, University of Oxford, UK
- Oxford Kidney Unit, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
- Hospital Sultanah Aminah, Johor Bahru, Malaysia
- Division of Nephrology, University of British Columbia, Vancouver, Canada
- Division of Nephrology, University Clinic of Würzburg, Würzburg, Germany
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Landray MJ, Haynes R, Reith C. Accelerating clinical trials: time to turn words into action. Lancet 2023:S0140-6736(23)01181-9. [PMID: 37307840 DOI: 10.1016/s0140-6736(23)01181-9] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2023] [Accepted: 06/06/2023] [Indexed: 06/14/2023]
Affiliation(s)
- Martin J Landray
- Nuffield Department of Population Health, University of Oxford, Oxford OX3 7LF, UK; Protas, London, UK.
| | - Richard Haynes
- Nuffield Department of Population Health, University of Oxford, Oxford OX3 7LF, UK; Protas, London, UK
| | - Christina Reith
- Nuffield Department of Population Health, University of Oxford, Oxford OX3 7LF, UK
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Chapman D, Judge PK, Sardell RJ, Staplin N, Arnold T, Zhu D, Ng S, Moffat S, Landray MJ, Baigent C, Hill M, Haynes R, Clark S, Herrington WG. Interference of urinary albumin-to-creatinine ratio measurement by glycosuria: clinical implications when using SGLT-2 inhibitors. Kidney Int 2023; 103:787-790. [PMID: 36736537 DOI: 10.1016/j.kint.2022.12.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2022] [Revised: 12/21/2022] [Accepted: 12/27/2022] [Indexed: 02/05/2023]
Affiliation(s)
- Daniel Chapman
- Clinical Trial Service Unit and Epidemiological Studies Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Parminder K Judge
- Clinical Trial Service Unit and Epidemiological Studies Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Rebecca J Sardell
- Clinical Trial Service Unit and Epidemiological Studies Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Natalie Staplin
- Clinical Trial Service Unit and Epidemiological Studies Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK; Medical Research Council-Population Health Research Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Thomas Arnold
- Clinical Trial Service Unit and Epidemiological Studies Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Doreen Zhu
- Clinical Trial Service Unit and Epidemiological Studies Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Sarah Ng
- Clinical Trial Service Unit and Epidemiological Studies Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Stewart Moffat
- Clinical Trial Service Unit and Epidemiological Studies Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Martin J Landray
- Clinical Trial Service Unit and Epidemiological Studies Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK; Medical Research Council-Population Health Research Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Colin Baigent
- Clinical Trial Service Unit and Epidemiological Studies Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK; Medical Research Council-Population Health Research Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Michael Hill
- Clinical Trial Service Unit and Epidemiological Studies Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK; Medical Research Council-Population Health Research Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Richard Haynes
- Clinical Trial Service Unit and Epidemiological Studies Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK; Medical Research Council-Population Health Research Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Sarah Clark
- Clinical Trial Service Unit and Epidemiological Studies Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - William G Herrington
- Clinical Trial Service Unit and Epidemiological Studies Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK; Medical Research Council-Population Health Research Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK.
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Johansen ND, Modin D, Nealon J, Samson S, Salamand C, Loiacono MM, Larsen CS, Jensen AMR, Landler NE, Claggett BL, Solomon SD, Landray MJ, Gislason GH, Køber L, Jensen JUS, Sivapalan P, Vestergaard LS, Valentiner-Branth P, Krause TG, Biering-Sørensen T. A Pragmatic Randomized Feasibility Trial of Influenza Vaccines. NEJM Evid 2023; 2:EVIDoa2200206. [PMID: 38320035 DOI: 10.1056/evidoa2200206] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/08/2024]
Abstract
Randomized Feasibility Trial of Influenza VaccinesThis pragmatic, open-label, active-controlled, randomized feasibility trial of QIV-HD versus QIV-SD was conducted in Danish citizens aged 65 to 79 years during the 2021-2022 influenza season. Randomization was integrated into routine vaccination practice. Only nationwide administrative health registries were used for data collection.
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Affiliation(s)
- Niklas Dyrby Johansen
- Department of Cardiology, Copenhagen University Hospital-Herlev and Gentofte, Copenhagen
- Center for Translational Cardiology and Pragmatic Randomized Trials, Department of Biomedical Sciences, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen
| | - Daniel Modin
- Department of Cardiology, Copenhagen University Hospital-Herlev and Gentofte, Copenhagen
- Center for Translational Cardiology and Pragmatic Randomized Trials, Department of Biomedical Sciences, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen
| | - Joshua Nealon
- School of Public Health, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Pokfulam, Hong Kong
| | | | | | | | - Carsten Schade Larsen
- Department of Clinical Medicine, Department of Infectious Diseases, Aarhus University Hospital, Aarhus, Denmark
| | - Anne Marie Reimer Jensen
- Department of Cardiology, Copenhagen University Hospital-Herlev and Gentofte, Copenhagen
- Center for Translational Cardiology and Pragmatic Randomized Trials, Department of Biomedical Sciences, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen
| | - Nino Emanuel Landler
- Department of Cardiology, Copenhagen University Hospital-Herlev and Gentofte, Copenhagen
- Center for Translational Cardiology and Pragmatic Randomized Trials, Department of Biomedical Sciences, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen
| | - Brian L Claggett
- Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston
| | - Scott D Solomon
- Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston
| | - Martin J Landray
- Clinical Trial Service Unit and Epidemiological Studies Unit, Nuffield Department of Public Health, University of Oxford, Oxford, United Kingdom
- Big Data Institute, University of Oxford, Oxford, United Kingdom
| | - Gunnar H Gislason
- Department of Cardiology, Copenhagen University Hospital-Herlev and Gentofte, Copenhagen
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen
- The Danish Heart Foundation, Copenhagen
- The National Institute of Public Health, University of Southern Denmark, Copenhagen
| | - Lars Køber
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen
- Department of Cardiology, Copenhagen University Hospital-Rigshospitalet, Copenhagen
| | - Jens Ulrik Stæhr Jensen
- Respiratory Medicine Section, Department of Medicine, Copenhagen University Hospital-Herlev and Gentofte, Copenhagen
| | - Pradeesh Sivapalan
- Respiratory Medicine Section, Department of Medicine, Copenhagen University Hospital-Herlev and Gentofte, Copenhagen
| | | | | | - Tyra Grove Krause
- Epidemiological Infectious Disease Preparedness, Statens Serum Institut, Copenhagen
| | - Tor Biering-Sørensen
- Department of Cardiology, Copenhagen University Hospital-Herlev and Gentofte, Copenhagen
- Center for Translational Cardiology and Pragmatic Randomized Trials, Department of Biomedical Sciences, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen
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Herrington WG, Staplin N, Wanner C, Green JB, Hauske SJ, Emberson JR, Preiss D, Judge P, Mayne KJ, Ng SYA, Sammons E, Zhu D, Hill M, Stevens W, Wallendszus K, Brenner S, Cheung AK, Liu ZH, Li J, Hooi LS, Liu W, Kadowaki T, Nangaku M, Levin A, Cherney D, Maggioni AP, Pontremoli R, Deo R, Goto S, Rossello X, Tuttle KR, Steubl D, Petrini M, Massey D, Eilbracht J, Brueckmann M, Landray MJ, Baigent C, Haynes R. Empagliflozin in Patients with Chronic Kidney Disease. N Engl J Med 2023; 388:117-127. [PMID: 36331190 PMCID: PMC7614055 DOI: 10.1056/nejmoa2204233] [Citation(s) in RCA: 507] [Impact Index Per Article: 507.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND The effects of empagliflozin in patients with chronic kidney disease who are at risk for disease progression are not well understood. The EMPA-KIDNEY trial was designed to assess the effects of treatment with empagliflozin in a broad range of such patients. METHODS We enrolled patients with chronic kidney disease who had an estimated glomerular filtration rate (eGFR) of at least 20 but less than 45 ml per minute per 1.73 m2 of body-surface area, or who had an eGFR of at least 45 but less than 90 ml per minute per 1.73 m2 with a urinary albumin-to-creatinine ratio (with albumin measured in milligrams and creatinine measured in grams) of at least 200. Patients were randomly assigned to receive empagliflozin (10 mg once daily) or matching placebo. The primary outcome was a composite of progression of kidney disease (defined as end-stage kidney disease, a sustained decrease in eGFR to <10 ml per minute per 1.73 m2, a sustained decrease in eGFR of ≥40% from baseline, or death from renal causes) or death from cardiovascular causes. RESULTS A total of 6609 patients underwent randomization. During a median of 2.0 years of follow-up, progression of kidney disease or death from cardiovascular causes occurred in 432 of 3304 patients (13.1%) in the empagliflozin group and in 558 of 3305 patients (16.9%) in the placebo group (hazard ratio, 0.72; 95% confidence interval [CI], 0.64 to 0.82; P<0.001). Results were consistent among patients with or without diabetes and across subgroups defined according to eGFR ranges. The rate of hospitalization from any cause was lower in the empagliflozin group than in the placebo group (hazard ratio, 0.86; 95% CI, 0.78 to 0.95; P = 0.003), but there were no significant between-group differences with respect to the composite outcome of hospitalization for heart failure or death from cardiovascular causes (which occurred in 4.0% in the empagliflozin group and 4.6% in the placebo group) or death from any cause (in 4.5% and 5.1%, respectively). The rates of serious adverse events were similar in the two groups. CONCLUSIONS Among a wide range of patients with chronic kidney disease who were at risk for disease progression, empagliflozin therapy led to a lower risk of progression of kidney disease or death from cardiovascular causes than placebo. (Funded by Boehringer Ingelheim and others; EMPA-KIDNEY ClinicalTrials.gov number, NCT03594110; EudraCT number, 2017-002971-24.).
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Affiliation(s)
- William G Herrington
- The affiliations of the members of the writing committee are as follows: the Clinical Trial Service Unit and Epidemiological Studies Unit, Nuffield Department of Population Health (W.G.H., N.S., J.R.E., D.P., P.J., K.J.M., S.Y.A.N., E.S., D.Z., M.H., W.S., K.W., M.J.L., C.B., R.H.), and the Medical Research Council Population Health Research Unit (W.G.H., N.S., J.R.E., D.P., M.H., M.J.L., C.B., R.H.), University of Oxford, Oxford; University Clinic Würzburg, Würzburg (C.W., S.B.), Boehringer Ingelheim International (S.J.H., D.S., J.E., M.B.) and Boehringer Ingelheim Pharmaceuticals (M.P.), Ingelheim am Rhein, Elderbrook Solutions, Bietigheim-Bissingen (D.M.), the Fifth Department of Medicine, University Medical Center Mannheim (S.J.H.) and the First Department of Medicine, Faculty of Medicine Mannheim (M.B.), University of Heidelberg, Mannheim, and the Department of Nephrology, Hospital Rechts der Isar, Technical University of Munich, Munich (D.S.) - all in Germany; Duke Clinical Research Institute, Durham, NC (J.B.G.); University of Utah, Salt Lake City (A.K.C.); National Clinical Research Center of Kidney Diseases, Jinling Hospital, Nanjing University School of Medicine, Nanjing (Z.-H.L.), and Fuwai Hospital, Chinese Academy of Medical Sciences, National Center for Cardiovascular Diseases, Beijing (J.L.) - both in China; Hospital Sultanah Aminah, Johor Bahru, Malaysia (L.S.H., W.L.); the University of Tokyo School of Medicine, Toranomon Hospital (T.K.), and the University of Tokyo School of Medicine (M.N.), Tokyo, Tokai University School of Medicine, Isehara (S.G.) - both in Japan; University of British Columbia, Vancouver (A.L.), and University of Toronto, Toronto (D.C.) - both in Canada; Università degli Studi and IRCCS Ospedale Policlinico San Martino di Genova, Genoa (R.P.), and Associazione Nazionale Medici Cardiologi Ospedalieri Research Center, Florence (A.P.M.) - both in Italy; University of Pennsylvania Perelman School of Medicine, Philadelphia (R.D.); Providence Health, Renton, and University of Washington, Seattle (K.R.T.) - both in Washington; and Hospital Universitari Son Espases, Health Research Institute of the Balearic Islands, University of the Balearic Islands, Palma de Mallorca, Spain (X.R.)
| | - Natalie Staplin
- The affiliations of the members of the writing committee are as follows: the Clinical Trial Service Unit and Epidemiological Studies Unit, Nuffield Department of Population Health (W.G.H., N.S., J.R.E., D.P., P.J., K.J.M., S.Y.A.N., E.S., D.Z., M.H., W.S., K.W., M.J.L., C.B., R.H.), and the Medical Research Council Population Health Research Unit (W.G.H., N.S., J.R.E., D.P., M.H., M.J.L., C.B., R.H.), University of Oxford, Oxford; University Clinic Würzburg, Würzburg (C.W., S.B.), Boehringer Ingelheim International (S.J.H., D.S., J.E., M.B.) and Boehringer Ingelheim Pharmaceuticals (M.P.), Ingelheim am Rhein, Elderbrook Solutions, Bietigheim-Bissingen (D.M.), the Fifth Department of Medicine, University Medical Center Mannheim (S.J.H.) and the First Department of Medicine, Faculty of Medicine Mannheim (M.B.), University of Heidelberg, Mannheim, and the Department of Nephrology, Hospital Rechts der Isar, Technical University of Munich, Munich (D.S.) - all in Germany; Duke Clinical Research Institute, Durham, NC (J.B.G.); University of Utah, Salt Lake City (A.K.C.); National Clinical Research Center of Kidney Diseases, Jinling Hospital, Nanjing University School of Medicine, Nanjing (Z.-H.L.), and Fuwai Hospital, Chinese Academy of Medical Sciences, National Center for Cardiovascular Diseases, Beijing (J.L.) - both in China; Hospital Sultanah Aminah, Johor Bahru, Malaysia (L.S.H., W.L.); the University of Tokyo School of Medicine, Toranomon Hospital (T.K.), and the University of Tokyo School of Medicine (M.N.), Tokyo, Tokai University School of Medicine, Isehara (S.G.) - both in Japan; University of British Columbia, Vancouver (A.L.), and University of Toronto, Toronto (D.C.) - both in Canada; Università degli Studi and IRCCS Ospedale Policlinico San Martino di Genova, Genoa (R.P.), and Associazione Nazionale Medici Cardiologi Ospedalieri Research Center, Florence (A.P.M.) - both in Italy; University of Pennsylvania Perelman School of Medicine, Philadelphia (R.D.); Providence Health, Renton, and University of Washington, Seattle (K.R.T.) - both in Washington; and Hospital Universitari Son Espases, Health Research Institute of the Balearic Islands, University of the Balearic Islands, Palma de Mallorca, Spain (X.R.)
| | - Christoph Wanner
- The affiliations of the members of the writing committee are as follows: the Clinical Trial Service Unit and Epidemiological Studies Unit, Nuffield Department of Population Health (W.G.H., N.S., J.R.E., D.P., P.J., K.J.M., S.Y.A.N., E.S., D.Z., M.H., W.S., K.W., M.J.L., C.B., R.H.), and the Medical Research Council Population Health Research Unit (W.G.H., N.S., J.R.E., D.P., M.H., M.J.L., C.B., R.H.), University of Oxford, Oxford; University Clinic Würzburg, Würzburg (C.W., S.B.), Boehringer Ingelheim International (S.J.H., D.S., J.E., M.B.) and Boehringer Ingelheim Pharmaceuticals (M.P.), Ingelheim am Rhein, Elderbrook Solutions, Bietigheim-Bissingen (D.M.), the Fifth Department of Medicine, University Medical Center Mannheim (S.J.H.) and the First Department of Medicine, Faculty of Medicine Mannheim (M.B.), University of Heidelberg, Mannheim, and the Department of Nephrology, Hospital Rechts der Isar, Technical University of Munich, Munich (D.S.) - all in Germany; Duke Clinical Research Institute, Durham, NC (J.B.G.); University of Utah, Salt Lake City (A.K.C.); National Clinical Research Center of Kidney Diseases, Jinling Hospital, Nanjing University School of Medicine, Nanjing (Z.-H.L.), and Fuwai Hospital, Chinese Academy of Medical Sciences, National Center for Cardiovascular Diseases, Beijing (J.L.) - both in China; Hospital Sultanah Aminah, Johor Bahru, Malaysia (L.S.H., W.L.); the University of Tokyo School of Medicine, Toranomon Hospital (T.K.), and the University of Tokyo School of Medicine (M.N.), Tokyo, Tokai University School of Medicine, Isehara (S.G.) - both in Japan; University of British Columbia, Vancouver (A.L.), and University of Toronto, Toronto (D.C.) - both in Canada; Università degli Studi and IRCCS Ospedale Policlinico San Martino di Genova, Genoa (R.P.), and Associazione Nazionale Medici Cardiologi Ospedalieri Research Center, Florence (A.P.M.) - both in Italy; University of Pennsylvania Perelman School of Medicine, Philadelphia (R.D.); Providence Health, Renton, and University of Washington, Seattle (K.R.T.) - both in Washington; and Hospital Universitari Son Espases, Health Research Institute of the Balearic Islands, University of the Balearic Islands, Palma de Mallorca, Spain (X.R.)
| | - Jennifer B Green
- The affiliations of the members of the writing committee are as follows: the Clinical Trial Service Unit and Epidemiological Studies Unit, Nuffield Department of Population Health (W.G.H., N.S., J.R.E., D.P., P.J., K.J.M., S.Y.A.N., E.S., D.Z., M.H., W.S., K.W., M.J.L., C.B., R.H.), and the Medical Research Council Population Health Research Unit (W.G.H., N.S., J.R.E., D.P., M.H., M.J.L., C.B., R.H.), University of Oxford, Oxford; University Clinic Würzburg, Würzburg (C.W., S.B.), Boehringer Ingelheim International (S.J.H., D.S., J.E., M.B.) and Boehringer Ingelheim Pharmaceuticals (M.P.), Ingelheim am Rhein, Elderbrook Solutions, Bietigheim-Bissingen (D.M.), the Fifth Department of Medicine, University Medical Center Mannheim (S.J.H.) and the First Department of Medicine, Faculty of Medicine Mannheim (M.B.), University of Heidelberg, Mannheim, and the Department of Nephrology, Hospital Rechts der Isar, Technical University of Munich, Munich (D.S.) - all in Germany; Duke Clinical Research Institute, Durham, NC (J.B.G.); University of Utah, Salt Lake City (A.K.C.); National Clinical Research Center of Kidney Diseases, Jinling Hospital, Nanjing University School of Medicine, Nanjing (Z.-H.L.), and Fuwai Hospital, Chinese Academy of Medical Sciences, National Center for Cardiovascular Diseases, Beijing (J.L.) - both in China; Hospital Sultanah Aminah, Johor Bahru, Malaysia (L.S.H., W.L.); the University of Tokyo School of Medicine, Toranomon Hospital (T.K.), and the University of Tokyo School of Medicine (M.N.), Tokyo, Tokai University School of Medicine, Isehara (S.G.) - both in Japan; University of British Columbia, Vancouver (A.L.), and University of Toronto, Toronto (D.C.) - both in Canada; Università degli Studi and IRCCS Ospedale Policlinico San Martino di Genova, Genoa (R.P.), and Associazione Nazionale Medici Cardiologi Ospedalieri Research Center, Florence (A.P.M.) - both in Italy; University of Pennsylvania Perelman School of Medicine, Philadelphia (R.D.); Providence Health, Renton, and University of Washington, Seattle (K.R.T.) - both in Washington; and Hospital Universitari Son Espases, Health Research Institute of the Balearic Islands, University of the Balearic Islands, Palma de Mallorca, Spain (X.R.)
| | - Sibylle J Hauske
- The affiliations of the members of the writing committee are as follows: the Clinical Trial Service Unit and Epidemiological Studies Unit, Nuffield Department of Population Health (W.G.H., N.S., J.R.E., D.P., P.J., K.J.M., S.Y.A.N., E.S., D.Z., M.H., W.S., K.W., M.J.L., C.B., R.H.), and the Medical Research Council Population Health Research Unit (W.G.H., N.S., J.R.E., D.P., M.H., M.J.L., C.B., R.H.), University of Oxford, Oxford; University Clinic Würzburg, Würzburg (C.W., S.B.), Boehringer Ingelheim International (S.J.H., D.S., J.E., M.B.) and Boehringer Ingelheim Pharmaceuticals (M.P.), Ingelheim am Rhein, Elderbrook Solutions, Bietigheim-Bissingen (D.M.), the Fifth Department of Medicine, University Medical Center Mannheim (S.J.H.) and the First Department of Medicine, Faculty of Medicine Mannheim (M.B.), University of Heidelberg, Mannheim, and the Department of Nephrology, Hospital Rechts der Isar, Technical University of Munich, Munich (D.S.) - all in Germany; Duke Clinical Research Institute, Durham, NC (J.B.G.); University of Utah, Salt Lake City (A.K.C.); National Clinical Research Center of Kidney Diseases, Jinling Hospital, Nanjing University School of Medicine, Nanjing (Z.-H.L.), and Fuwai Hospital, Chinese Academy of Medical Sciences, National Center for Cardiovascular Diseases, Beijing (J.L.) - both in China; Hospital Sultanah Aminah, Johor Bahru, Malaysia (L.S.H., W.L.); the University of Tokyo School of Medicine, Toranomon Hospital (T.K.), and the University of Tokyo School of Medicine (M.N.), Tokyo, Tokai University School of Medicine, Isehara (S.G.) - both in Japan; University of British Columbia, Vancouver (A.L.), and University of Toronto, Toronto (D.C.) - both in Canada; Università degli Studi and IRCCS Ospedale Policlinico San Martino di Genova, Genoa (R.P.), and Associazione Nazionale Medici Cardiologi Ospedalieri Research Center, Florence (A.P.M.) - both in Italy; University of Pennsylvania Perelman School of Medicine, Philadelphia (R.D.); Providence Health, Renton, and University of Washington, Seattle (K.R.T.) - both in Washington; and Hospital Universitari Son Espases, Health Research Institute of the Balearic Islands, University of the Balearic Islands, Palma de Mallorca, Spain (X.R.)
| | - Jonathan R Emberson
- The affiliations of the members of the writing committee are as follows: the Clinical Trial Service Unit and Epidemiological Studies Unit, Nuffield Department of Population Health (W.G.H., N.S., J.R.E., D.P., P.J., K.J.M., S.Y.A.N., E.S., D.Z., M.H., W.S., K.W., M.J.L., C.B., R.H.), and the Medical Research Council Population Health Research Unit (W.G.H., N.S., J.R.E., D.P., M.H., M.J.L., C.B., R.H.), University of Oxford, Oxford; University Clinic Würzburg, Würzburg (C.W., S.B.), Boehringer Ingelheim International (S.J.H., D.S., J.E., M.B.) and Boehringer Ingelheim Pharmaceuticals (M.P.), Ingelheim am Rhein, Elderbrook Solutions, Bietigheim-Bissingen (D.M.), the Fifth Department of Medicine, University Medical Center Mannheim (S.J.H.) and the First Department of Medicine, Faculty of Medicine Mannheim (M.B.), University of Heidelberg, Mannheim, and the Department of Nephrology, Hospital Rechts der Isar, Technical University of Munich, Munich (D.S.) - all in Germany; Duke Clinical Research Institute, Durham, NC (J.B.G.); University of Utah, Salt Lake City (A.K.C.); National Clinical Research Center of Kidney Diseases, Jinling Hospital, Nanjing University School of Medicine, Nanjing (Z.-H.L.), and Fuwai Hospital, Chinese Academy of Medical Sciences, National Center for Cardiovascular Diseases, Beijing (J.L.) - both in China; Hospital Sultanah Aminah, Johor Bahru, Malaysia (L.S.H., W.L.); the University of Tokyo School of Medicine, Toranomon Hospital (T.K.), and the University of Tokyo School of Medicine (M.N.), Tokyo, Tokai University School of Medicine, Isehara (S.G.) - both in Japan; University of British Columbia, Vancouver (A.L.), and University of Toronto, Toronto (D.C.) - both in Canada; Università degli Studi and IRCCS Ospedale Policlinico San Martino di Genova, Genoa (R.P.), and Associazione Nazionale Medici Cardiologi Ospedalieri Research Center, Florence (A.P.M.) - both in Italy; University of Pennsylvania Perelman School of Medicine, Philadelphia (R.D.); Providence Health, Renton, and University of Washington, Seattle (K.R.T.) - both in Washington; and Hospital Universitari Son Espases, Health Research Institute of the Balearic Islands, University of the Balearic Islands, Palma de Mallorca, Spain (X.R.)
| | - David Preiss
- The affiliations of the members of the writing committee are as follows: the Clinical Trial Service Unit and Epidemiological Studies Unit, Nuffield Department of Population Health (W.G.H., N.S., J.R.E., D.P., P.J., K.J.M., S.Y.A.N., E.S., D.Z., M.H., W.S., K.W., M.J.L., C.B., R.H.), and the Medical Research Council Population Health Research Unit (W.G.H., N.S., J.R.E., D.P., M.H., M.J.L., C.B., R.H.), University of Oxford, Oxford; University Clinic Würzburg, Würzburg (C.W., S.B.), Boehringer Ingelheim International (S.J.H., D.S., J.E., M.B.) and Boehringer Ingelheim Pharmaceuticals (M.P.), Ingelheim am Rhein, Elderbrook Solutions, Bietigheim-Bissingen (D.M.), the Fifth Department of Medicine, University Medical Center Mannheim (S.J.H.) and the First Department of Medicine, Faculty of Medicine Mannheim (M.B.), University of Heidelberg, Mannheim, and the Department of Nephrology, Hospital Rechts der Isar, Technical University of Munich, Munich (D.S.) - all in Germany; Duke Clinical Research Institute, Durham, NC (J.B.G.); University of Utah, Salt Lake City (A.K.C.); National Clinical Research Center of Kidney Diseases, Jinling Hospital, Nanjing University School of Medicine, Nanjing (Z.-H.L.), and Fuwai Hospital, Chinese Academy of Medical Sciences, National Center for Cardiovascular Diseases, Beijing (J.L.) - both in China; Hospital Sultanah Aminah, Johor Bahru, Malaysia (L.S.H., W.L.); the University of Tokyo School of Medicine, Toranomon Hospital (T.K.), and the University of Tokyo School of Medicine (M.N.), Tokyo, Tokai University School of Medicine, Isehara (S.G.) - both in Japan; University of British Columbia, Vancouver (A.L.), and University of Toronto, Toronto (D.C.) - both in Canada; Università degli Studi and IRCCS Ospedale Policlinico San Martino di Genova, Genoa (R.P.), and Associazione Nazionale Medici Cardiologi Ospedalieri Research Center, Florence (A.P.M.) - both in Italy; University of Pennsylvania Perelman School of Medicine, Philadelphia (R.D.); Providence Health, Renton, and University of Washington, Seattle (K.R.T.) - both in Washington; and Hospital Universitari Son Espases, Health Research Institute of the Balearic Islands, University of the Balearic Islands, Palma de Mallorca, Spain (X.R.)
| | - Parminder Judge
- The affiliations of the members of the writing committee are as follows: the Clinical Trial Service Unit and Epidemiological Studies Unit, Nuffield Department of Population Health (W.G.H., N.S., J.R.E., D.P., P.J., K.J.M., S.Y.A.N., E.S., D.Z., M.H., W.S., K.W., M.J.L., C.B., R.H.), and the Medical Research Council Population Health Research Unit (W.G.H., N.S., J.R.E., D.P., M.H., M.J.L., C.B., R.H.), University of Oxford, Oxford; University Clinic Würzburg, Würzburg (C.W., S.B.), Boehringer Ingelheim International (S.J.H., D.S., J.E., M.B.) and Boehringer Ingelheim Pharmaceuticals (M.P.), Ingelheim am Rhein, Elderbrook Solutions, Bietigheim-Bissingen (D.M.), the Fifth Department of Medicine, University Medical Center Mannheim (S.J.H.) and the First Department of Medicine, Faculty of Medicine Mannheim (M.B.), University of Heidelberg, Mannheim, and the Department of Nephrology, Hospital Rechts der Isar, Technical University of Munich, Munich (D.S.) - all in Germany; Duke Clinical Research Institute, Durham, NC (J.B.G.); University of Utah, Salt Lake City (A.K.C.); National Clinical Research Center of Kidney Diseases, Jinling Hospital, Nanjing University School of Medicine, Nanjing (Z.-H.L.), and Fuwai Hospital, Chinese Academy of Medical Sciences, National Center for Cardiovascular Diseases, Beijing (J.L.) - both in China; Hospital Sultanah Aminah, Johor Bahru, Malaysia (L.S.H., W.L.); the University of Tokyo School of Medicine, Toranomon Hospital (T.K.), and the University of Tokyo School of Medicine (M.N.), Tokyo, Tokai University School of Medicine, Isehara (S.G.) - both in Japan; University of British Columbia, Vancouver (A.L.), and University of Toronto, Toronto (D.C.) - both in Canada; Università degli Studi and IRCCS Ospedale Policlinico San Martino di Genova, Genoa (R.P.), and Associazione Nazionale Medici Cardiologi Ospedalieri Research Center, Florence (A.P.M.) - both in Italy; University of Pennsylvania Perelman School of Medicine, Philadelphia (R.D.); Providence Health, Renton, and University of Washington, Seattle (K.R.T.) - both in Washington; and Hospital Universitari Son Espases, Health Research Institute of the Balearic Islands, University of the Balearic Islands, Palma de Mallorca, Spain (X.R.)
| | - Kaitlin J Mayne
- The affiliations of the members of the writing committee are as follows: the Clinical Trial Service Unit and Epidemiological Studies Unit, Nuffield Department of Population Health (W.G.H., N.S., J.R.E., D.P., P.J., K.J.M., S.Y.A.N., E.S., D.Z., M.H., W.S., K.W., M.J.L., C.B., R.H.), and the Medical Research Council Population Health Research Unit (W.G.H., N.S., J.R.E., D.P., M.H., M.J.L., C.B., R.H.), University of Oxford, Oxford; University Clinic Würzburg, Würzburg (C.W., S.B.), Boehringer Ingelheim International (S.J.H., D.S., J.E., M.B.) and Boehringer Ingelheim Pharmaceuticals (M.P.), Ingelheim am Rhein, Elderbrook Solutions, Bietigheim-Bissingen (D.M.), the Fifth Department of Medicine, University Medical Center Mannheim (S.J.H.) and the First Department of Medicine, Faculty of Medicine Mannheim (M.B.), University of Heidelberg, Mannheim, and the Department of Nephrology, Hospital Rechts der Isar, Technical University of Munich, Munich (D.S.) - all in Germany; Duke Clinical Research Institute, Durham, NC (J.B.G.); University of Utah, Salt Lake City (A.K.C.); National Clinical Research Center of Kidney Diseases, Jinling Hospital, Nanjing University School of Medicine, Nanjing (Z.-H.L.), and Fuwai Hospital, Chinese Academy of Medical Sciences, National Center for Cardiovascular Diseases, Beijing (J.L.) - both in China; Hospital Sultanah Aminah, Johor Bahru, Malaysia (L.S.H., W.L.); the University of Tokyo School of Medicine, Toranomon Hospital (T.K.), and the University of Tokyo School of Medicine (M.N.), Tokyo, Tokai University School of Medicine, Isehara (S.G.) - both in Japan; University of British Columbia, Vancouver (A.L.), and University of Toronto, Toronto (D.C.) - both in Canada; Università degli Studi and IRCCS Ospedale Policlinico San Martino di Genova, Genoa (R.P.), and Associazione Nazionale Medici Cardiologi Ospedalieri Research Center, Florence (A.P.M.) - both in Italy; University of Pennsylvania Perelman School of Medicine, Philadelphia (R.D.); Providence Health, Renton, and University of Washington, Seattle (K.R.T.) - both in Washington; and Hospital Universitari Son Espases, Health Research Institute of the Balearic Islands, University of the Balearic Islands, Palma de Mallorca, Spain (X.R.)
| | - Sarah Y A Ng
- The affiliations of the members of the writing committee are as follows: the Clinical Trial Service Unit and Epidemiological Studies Unit, Nuffield Department of Population Health (W.G.H., N.S., J.R.E., D.P., P.J., K.J.M., S.Y.A.N., E.S., D.Z., M.H., W.S., K.W., M.J.L., C.B., R.H.), and the Medical Research Council Population Health Research Unit (W.G.H., N.S., J.R.E., D.P., M.H., M.J.L., C.B., R.H.), University of Oxford, Oxford; University Clinic Würzburg, Würzburg (C.W., S.B.), Boehringer Ingelheim International (S.J.H., D.S., J.E., M.B.) and Boehringer Ingelheim Pharmaceuticals (M.P.), Ingelheim am Rhein, Elderbrook Solutions, Bietigheim-Bissingen (D.M.), the Fifth Department of Medicine, University Medical Center Mannheim (S.J.H.) and the First Department of Medicine, Faculty of Medicine Mannheim (M.B.), University of Heidelberg, Mannheim, and the Department of Nephrology, Hospital Rechts der Isar, Technical University of Munich, Munich (D.S.) - all in Germany; Duke Clinical Research Institute, Durham, NC (J.B.G.); University of Utah, Salt Lake City (A.K.C.); National Clinical Research Center of Kidney Diseases, Jinling Hospital, Nanjing University School of Medicine, Nanjing (Z.-H.L.), and Fuwai Hospital, Chinese Academy of Medical Sciences, National Center for Cardiovascular Diseases, Beijing (J.L.) - both in China; Hospital Sultanah Aminah, Johor Bahru, Malaysia (L.S.H., W.L.); the University of Tokyo School of Medicine, Toranomon Hospital (T.K.), and the University of Tokyo School of Medicine (M.N.), Tokyo, Tokai University School of Medicine, Isehara (S.G.) - both in Japan; University of British Columbia, Vancouver (A.L.), and University of Toronto, Toronto (D.C.) - both in Canada; Università degli Studi and IRCCS Ospedale Policlinico San Martino di Genova, Genoa (R.P.), and Associazione Nazionale Medici Cardiologi Ospedalieri Research Center, Florence (A.P.M.) - both in Italy; University of Pennsylvania Perelman School of Medicine, Philadelphia (R.D.); Providence Health, Renton, and University of Washington, Seattle (K.R.T.) - both in Washington; and Hospital Universitari Son Espases, Health Research Institute of the Balearic Islands, University of the Balearic Islands, Palma de Mallorca, Spain (X.R.)
| | - Emily Sammons
- The affiliations of the members of the writing committee are as follows: the Clinical Trial Service Unit and Epidemiological Studies Unit, Nuffield Department of Population Health (W.G.H., N.S., J.R.E., D.P., P.J., K.J.M., S.Y.A.N., E.S., D.Z., M.H., W.S., K.W., M.J.L., C.B., R.H.), and the Medical Research Council Population Health Research Unit (W.G.H., N.S., J.R.E., D.P., M.H., M.J.L., C.B., R.H.), University of Oxford, Oxford; University Clinic Würzburg, Würzburg (C.W., S.B.), Boehringer Ingelheim International (S.J.H., D.S., J.E., M.B.) and Boehringer Ingelheim Pharmaceuticals (M.P.), Ingelheim am Rhein, Elderbrook Solutions, Bietigheim-Bissingen (D.M.), the Fifth Department of Medicine, University Medical Center Mannheim (S.J.H.) and the First Department of Medicine, Faculty of Medicine Mannheim (M.B.), University of Heidelberg, Mannheim, and the Department of Nephrology, Hospital Rechts der Isar, Technical University of Munich, Munich (D.S.) - all in Germany; Duke Clinical Research Institute, Durham, NC (J.B.G.); University of Utah, Salt Lake City (A.K.C.); National Clinical Research Center of Kidney Diseases, Jinling Hospital, Nanjing University School of Medicine, Nanjing (Z.-H.L.), and Fuwai Hospital, Chinese Academy of Medical Sciences, National Center for Cardiovascular Diseases, Beijing (J.L.) - both in China; Hospital Sultanah Aminah, Johor Bahru, Malaysia (L.S.H., W.L.); the University of Tokyo School of Medicine, Toranomon Hospital (T.K.), and the University of Tokyo School of Medicine (M.N.), Tokyo, Tokai University School of Medicine, Isehara (S.G.) - both in Japan; University of British Columbia, Vancouver (A.L.), and University of Toronto, Toronto (D.C.) - both in Canada; Università degli Studi and IRCCS Ospedale Policlinico San Martino di Genova, Genoa (R.P.), and Associazione Nazionale Medici Cardiologi Ospedalieri Research Center, Florence (A.P.M.) - both in Italy; University of Pennsylvania Perelman School of Medicine, Philadelphia (R.D.); Providence Health, Renton, and University of Washington, Seattle (K.R.T.) - both in Washington; and Hospital Universitari Son Espases, Health Research Institute of the Balearic Islands, University of the Balearic Islands, Palma de Mallorca, Spain (X.R.)
| | - Doreen Zhu
- The affiliations of the members of the writing committee are as follows: the Clinical Trial Service Unit and Epidemiological Studies Unit, Nuffield Department of Population Health (W.G.H., N.S., J.R.E., D.P., P.J., K.J.M., S.Y.A.N., E.S., D.Z., M.H., W.S., K.W., M.J.L., C.B., R.H.), and the Medical Research Council Population Health Research Unit (W.G.H., N.S., J.R.E., D.P., M.H., M.J.L., C.B., R.H.), University of Oxford, Oxford; University Clinic Würzburg, Würzburg (C.W., S.B.), Boehringer Ingelheim International (S.J.H., D.S., J.E., M.B.) and Boehringer Ingelheim Pharmaceuticals (M.P.), Ingelheim am Rhein, Elderbrook Solutions, Bietigheim-Bissingen (D.M.), the Fifth Department of Medicine, University Medical Center Mannheim (S.J.H.) and the First Department of Medicine, Faculty of Medicine Mannheim (M.B.), University of Heidelberg, Mannheim, and the Department of Nephrology, Hospital Rechts der Isar, Technical University of Munich, Munich (D.S.) - all in Germany; Duke Clinical Research Institute, Durham, NC (J.B.G.); University of Utah, Salt Lake City (A.K.C.); National Clinical Research Center of Kidney Diseases, Jinling Hospital, Nanjing University School of Medicine, Nanjing (Z.-H.L.), and Fuwai Hospital, Chinese Academy of Medical Sciences, National Center for Cardiovascular Diseases, Beijing (J.L.) - both in China; Hospital Sultanah Aminah, Johor Bahru, Malaysia (L.S.H., W.L.); the University of Tokyo School of Medicine, Toranomon Hospital (T.K.), and the University of Tokyo School of Medicine (M.N.), Tokyo, Tokai University School of Medicine, Isehara (S.G.) - both in Japan; University of British Columbia, Vancouver (A.L.), and University of Toronto, Toronto (D.C.) - both in Canada; Università degli Studi and IRCCS Ospedale Policlinico San Martino di Genova, Genoa (R.P.), and Associazione Nazionale Medici Cardiologi Ospedalieri Research Center, Florence (A.P.M.) - both in Italy; University of Pennsylvania Perelman School of Medicine, Philadelphia (R.D.); Providence Health, Renton, and University of Washington, Seattle (K.R.T.) - both in Washington; and Hospital Universitari Son Espases, Health Research Institute of the Balearic Islands, University of the Balearic Islands, Palma de Mallorca, Spain (X.R.)
| | - Michael Hill
- The affiliations of the members of the writing committee are as follows: the Clinical Trial Service Unit and Epidemiological Studies Unit, Nuffield Department of Population Health (W.G.H., N.S., J.R.E., D.P., P.J., K.J.M., S.Y.A.N., E.S., D.Z., M.H., W.S., K.W., M.J.L., C.B., R.H.), and the Medical Research Council Population Health Research Unit (W.G.H., N.S., J.R.E., D.P., M.H., M.J.L., C.B., R.H.), University of Oxford, Oxford; University Clinic Würzburg, Würzburg (C.W., S.B.), Boehringer Ingelheim International (S.J.H., D.S., J.E., M.B.) and Boehringer Ingelheim Pharmaceuticals (M.P.), Ingelheim am Rhein, Elderbrook Solutions, Bietigheim-Bissingen (D.M.), the Fifth Department of Medicine, University Medical Center Mannheim (S.J.H.) and the First Department of Medicine, Faculty of Medicine Mannheim (M.B.), University of Heidelberg, Mannheim, and the Department of Nephrology, Hospital Rechts der Isar, Technical University of Munich, Munich (D.S.) - all in Germany; Duke Clinical Research Institute, Durham, NC (J.B.G.); University of Utah, Salt Lake City (A.K.C.); National Clinical Research Center of Kidney Diseases, Jinling Hospital, Nanjing University School of Medicine, Nanjing (Z.-H.L.), and Fuwai Hospital, Chinese Academy of Medical Sciences, National Center for Cardiovascular Diseases, Beijing (J.L.) - both in China; Hospital Sultanah Aminah, Johor Bahru, Malaysia (L.S.H., W.L.); the University of Tokyo School of Medicine, Toranomon Hospital (T.K.), and the University of Tokyo School of Medicine (M.N.), Tokyo, Tokai University School of Medicine, Isehara (S.G.) - both in Japan; University of British Columbia, Vancouver (A.L.), and University of Toronto, Toronto (D.C.) - both in Canada; Università degli Studi and IRCCS Ospedale Policlinico San Martino di Genova, Genoa (R.P.), and Associazione Nazionale Medici Cardiologi Ospedalieri Research Center, Florence (A.P.M.) - both in Italy; University of Pennsylvania Perelman School of Medicine, Philadelphia (R.D.); Providence Health, Renton, and University of Washington, Seattle (K.R.T.) - both in Washington; and Hospital Universitari Son Espases, Health Research Institute of the Balearic Islands, University of the Balearic Islands, Palma de Mallorca, Spain (X.R.)
| | - Will Stevens
- The affiliations of the members of the writing committee are as follows: the Clinical Trial Service Unit and Epidemiological Studies Unit, Nuffield Department of Population Health (W.G.H., N.S., J.R.E., D.P., P.J., K.J.M., S.Y.A.N., E.S., D.Z., M.H., W.S., K.W., M.J.L., C.B., R.H.), and the Medical Research Council Population Health Research Unit (W.G.H., N.S., J.R.E., D.P., M.H., M.J.L., C.B., R.H.), University of Oxford, Oxford; University Clinic Würzburg, Würzburg (C.W., S.B.), Boehringer Ingelheim International (S.J.H., D.S., J.E., M.B.) and Boehringer Ingelheim Pharmaceuticals (M.P.), Ingelheim am Rhein, Elderbrook Solutions, Bietigheim-Bissingen (D.M.), the Fifth Department of Medicine, University Medical Center Mannheim (S.J.H.) and the First Department of Medicine, Faculty of Medicine Mannheim (M.B.), University of Heidelberg, Mannheim, and the Department of Nephrology, Hospital Rechts der Isar, Technical University of Munich, Munich (D.S.) - all in Germany; Duke Clinical Research Institute, Durham, NC (J.B.G.); University of Utah, Salt Lake City (A.K.C.); National Clinical Research Center of Kidney Diseases, Jinling Hospital, Nanjing University School of Medicine, Nanjing (Z.-H.L.), and Fuwai Hospital, Chinese Academy of Medical Sciences, National Center for Cardiovascular Diseases, Beijing (J.L.) - both in China; Hospital Sultanah Aminah, Johor Bahru, Malaysia (L.S.H., W.L.); the University of Tokyo School of Medicine, Toranomon Hospital (T.K.), and the University of Tokyo School of Medicine (M.N.), Tokyo, Tokai University School of Medicine, Isehara (S.G.) - both in Japan; University of British Columbia, Vancouver (A.L.), and University of Toronto, Toronto (D.C.) - both in Canada; Università degli Studi and IRCCS Ospedale Policlinico San Martino di Genova, Genoa (R.P.), and Associazione Nazionale Medici Cardiologi Ospedalieri Research Center, Florence (A.P.M.) - both in Italy; University of Pennsylvania Perelman School of Medicine, Philadelphia (R.D.); Providence Health, Renton, and University of Washington, Seattle (K.R.T.) - both in Washington; and Hospital Universitari Son Espases, Health Research Institute of the Balearic Islands, University of the Balearic Islands, Palma de Mallorca, Spain (X.R.)
| | - Karl Wallendszus
- The affiliations of the members of the writing committee are as follows: the Clinical Trial Service Unit and Epidemiological Studies Unit, Nuffield Department of Population Health (W.G.H., N.S., J.R.E., D.P., P.J., K.J.M., S.Y.A.N., E.S., D.Z., M.H., W.S., K.W., M.J.L., C.B., R.H.), and the Medical Research Council Population Health Research Unit (W.G.H., N.S., J.R.E., D.P., M.H., M.J.L., C.B., R.H.), University of Oxford, Oxford; University Clinic Würzburg, Würzburg (C.W., S.B.), Boehringer Ingelheim International (S.J.H., D.S., J.E., M.B.) and Boehringer Ingelheim Pharmaceuticals (M.P.), Ingelheim am Rhein, Elderbrook Solutions, Bietigheim-Bissingen (D.M.), the Fifth Department of Medicine, University Medical Center Mannheim (S.J.H.) and the First Department of Medicine, Faculty of Medicine Mannheim (M.B.), University of Heidelberg, Mannheim, and the Department of Nephrology, Hospital Rechts der Isar, Technical University of Munich, Munich (D.S.) - all in Germany; Duke Clinical Research Institute, Durham, NC (J.B.G.); University of Utah, Salt Lake City (A.K.C.); National Clinical Research Center of Kidney Diseases, Jinling Hospital, Nanjing University School of Medicine, Nanjing (Z.-H.L.), and Fuwai Hospital, Chinese Academy of Medical Sciences, National Center for Cardiovascular Diseases, Beijing (J.L.) - both in China; Hospital Sultanah Aminah, Johor Bahru, Malaysia (L.S.H., W.L.); the University of Tokyo School of Medicine, Toranomon Hospital (T.K.), and the University of Tokyo School of Medicine (M.N.), Tokyo, Tokai University School of Medicine, Isehara (S.G.) - both in Japan; University of British Columbia, Vancouver (A.L.), and University of Toronto, Toronto (D.C.) - both in Canada; Università degli Studi and IRCCS Ospedale Policlinico San Martino di Genova, Genoa (R.P.), and Associazione Nazionale Medici Cardiologi Ospedalieri Research Center, Florence (A.P.M.) - both in Italy; University of Pennsylvania Perelman School of Medicine, Philadelphia (R.D.); Providence Health, Renton, and University of Washington, Seattle (K.R.T.) - both in Washington; and Hospital Universitari Son Espases, Health Research Institute of the Balearic Islands, University of the Balearic Islands, Palma de Mallorca, Spain (X.R.)
| | - Susanne Brenner
- The affiliations of the members of the writing committee are as follows: the Clinical Trial Service Unit and Epidemiological Studies Unit, Nuffield Department of Population Health (W.G.H., N.S., J.R.E., D.P., P.J., K.J.M., S.Y.A.N., E.S., D.Z., M.H., W.S., K.W., M.J.L., C.B., R.H.), and the Medical Research Council Population Health Research Unit (W.G.H., N.S., J.R.E., D.P., M.H., M.J.L., C.B., R.H.), University of Oxford, Oxford; University Clinic Würzburg, Würzburg (C.W., S.B.), Boehringer Ingelheim International (S.J.H., D.S., J.E., M.B.) and Boehringer Ingelheim Pharmaceuticals (M.P.), Ingelheim am Rhein, Elderbrook Solutions, Bietigheim-Bissingen (D.M.), the Fifth Department of Medicine, University Medical Center Mannheim (S.J.H.) and the First Department of Medicine, Faculty of Medicine Mannheim (M.B.), University of Heidelberg, Mannheim, and the Department of Nephrology, Hospital Rechts der Isar, Technical University of Munich, Munich (D.S.) - all in Germany; Duke Clinical Research Institute, Durham, NC (J.B.G.); University of Utah, Salt Lake City (A.K.C.); National Clinical Research Center of Kidney Diseases, Jinling Hospital, Nanjing University School of Medicine, Nanjing (Z.-H.L.), and Fuwai Hospital, Chinese Academy of Medical Sciences, National Center for Cardiovascular Diseases, Beijing (J.L.) - both in China; Hospital Sultanah Aminah, Johor Bahru, Malaysia (L.S.H., W.L.); the University of Tokyo School of Medicine, Toranomon Hospital (T.K.), and the University of Tokyo School of Medicine (M.N.), Tokyo, Tokai University School of Medicine, Isehara (S.G.) - both in Japan; University of British Columbia, Vancouver (A.L.), and University of Toronto, Toronto (D.C.) - both in Canada; Università degli Studi and IRCCS Ospedale Policlinico San Martino di Genova, Genoa (R.P.), and Associazione Nazionale Medici Cardiologi Ospedalieri Research Center, Florence (A.P.M.) - both in Italy; University of Pennsylvania Perelman School of Medicine, Philadelphia (R.D.); Providence Health, Renton, and University of Washington, Seattle (K.R.T.) - both in Washington; and Hospital Universitari Son Espases, Health Research Institute of the Balearic Islands, University of the Balearic Islands, Palma de Mallorca, Spain (X.R.)
| | - Alfred K Cheung
- The affiliations of the members of the writing committee are as follows: the Clinical Trial Service Unit and Epidemiological Studies Unit, Nuffield Department of Population Health (W.G.H., N.S., J.R.E., D.P., P.J., K.J.M., S.Y.A.N., E.S., D.Z., M.H., W.S., K.W., M.J.L., C.B., R.H.), and the Medical Research Council Population Health Research Unit (W.G.H., N.S., J.R.E., D.P., M.H., M.J.L., C.B., R.H.), University of Oxford, Oxford; University Clinic Würzburg, Würzburg (C.W., S.B.), Boehringer Ingelheim International (S.J.H., D.S., J.E., M.B.) and Boehringer Ingelheim Pharmaceuticals (M.P.), Ingelheim am Rhein, Elderbrook Solutions, Bietigheim-Bissingen (D.M.), the Fifth Department of Medicine, University Medical Center Mannheim (S.J.H.) and the First Department of Medicine, Faculty of Medicine Mannheim (M.B.), University of Heidelberg, Mannheim, and the Department of Nephrology, Hospital Rechts der Isar, Technical University of Munich, Munich (D.S.) - all in Germany; Duke Clinical Research Institute, Durham, NC (J.B.G.); University of Utah, Salt Lake City (A.K.C.); National Clinical Research Center of Kidney Diseases, Jinling Hospital, Nanjing University School of Medicine, Nanjing (Z.-H.L.), and Fuwai Hospital, Chinese Academy of Medical Sciences, National Center for Cardiovascular Diseases, Beijing (J.L.) - both in China; Hospital Sultanah Aminah, Johor Bahru, Malaysia (L.S.H., W.L.); the University of Tokyo School of Medicine, Toranomon Hospital (T.K.), and the University of Tokyo School of Medicine (M.N.), Tokyo, Tokai University School of Medicine, Isehara (S.G.) - both in Japan; University of British Columbia, Vancouver (A.L.), and University of Toronto, Toronto (D.C.) - both in Canada; Università degli Studi and IRCCS Ospedale Policlinico San Martino di Genova, Genoa (R.P.), and Associazione Nazionale Medici Cardiologi Ospedalieri Research Center, Florence (A.P.M.) - both in Italy; University of Pennsylvania Perelman School of Medicine, Philadelphia (R.D.); Providence Health, Renton, and University of Washington, Seattle (K.R.T.) - both in Washington; and Hospital Universitari Son Espases, Health Research Institute of the Balearic Islands, University of the Balearic Islands, Palma de Mallorca, Spain (X.R.)
| | - Zhi-Hong Liu
- The affiliations of the members of the writing committee are as follows: the Clinical Trial Service Unit and Epidemiological Studies Unit, Nuffield Department of Population Health (W.G.H., N.S., J.R.E., D.P., P.J., K.J.M., S.Y.A.N., E.S., D.Z., M.H., W.S., K.W., M.J.L., C.B., R.H.), and the Medical Research Council Population Health Research Unit (W.G.H., N.S., J.R.E., D.P., M.H., M.J.L., C.B., R.H.), University of Oxford, Oxford; University Clinic Würzburg, Würzburg (C.W., S.B.), Boehringer Ingelheim International (S.J.H., D.S., J.E., M.B.) and Boehringer Ingelheim Pharmaceuticals (M.P.), Ingelheim am Rhein, Elderbrook Solutions, Bietigheim-Bissingen (D.M.), the Fifth Department of Medicine, University Medical Center Mannheim (S.J.H.) and the First Department of Medicine, Faculty of Medicine Mannheim (M.B.), University of Heidelberg, Mannheim, and the Department of Nephrology, Hospital Rechts der Isar, Technical University of Munich, Munich (D.S.) - all in Germany; Duke Clinical Research Institute, Durham, NC (J.B.G.); University of Utah, Salt Lake City (A.K.C.); National Clinical Research Center of Kidney Diseases, Jinling Hospital, Nanjing University School of Medicine, Nanjing (Z.-H.L.), and Fuwai Hospital, Chinese Academy of Medical Sciences, National Center for Cardiovascular Diseases, Beijing (J.L.) - both in China; Hospital Sultanah Aminah, Johor Bahru, Malaysia (L.S.H., W.L.); the University of Tokyo School of Medicine, Toranomon Hospital (T.K.), and the University of Tokyo School of Medicine (M.N.), Tokyo, Tokai University School of Medicine, Isehara (S.G.) - both in Japan; University of British Columbia, Vancouver (A.L.), and University of Toronto, Toronto (D.C.) - both in Canada; Università degli Studi and IRCCS Ospedale Policlinico San Martino di Genova, Genoa (R.P.), and Associazione Nazionale Medici Cardiologi Ospedalieri Research Center, Florence (A.P.M.) - both in Italy; University of Pennsylvania Perelman School of Medicine, Philadelphia (R.D.); Providence Health, Renton, and University of Washington, Seattle (K.R.T.) - both in Washington; and Hospital Universitari Son Espases, Health Research Institute of the Balearic Islands, University of the Balearic Islands, Palma de Mallorca, Spain (X.R.)
| | - Jing Li
- The affiliations of the members of the writing committee are as follows: the Clinical Trial Service Unit and Epidemiological Studies Unit, Nuffield Department of Population Health (W.G.H., N.S., J.R.E., D.P., P.J., K.J.M., S.Y.A.N., E.S., D.Z., M.H., W.S., K.W., M.J.L., C.B., R.H.), and the Medical Research Council Population Health Research Unit (W.G.H., N.S., J.R.E., D.P., M.H., M.J.L., C.B., R.H.), University of Oxford, Oxford; University Clinic Würzburg, Würzburg (C.W., S.B.), Boehringer Ingelheim International (S.J.H., D.S., J.E., M.B.) and Boehringer Ingelheim Pharmaceuticals (M.P.), Ingelheim am Rhein, Elderbrook Solutions, Bietigheim-Bissingen (D.M.), the Fifth Department of Medicine, University Medical Center Mannheim (S.J.H.) and the First Department of Medicine, Faculty of Medicine Mannheim (M.B.), University of Heidelberg, Mannheim, and the Department of Nephrology, Hospital Rechts der Isar, Technical University of Munich, Munich (D.S.) - all in Germany; Duke Clinical Research Institute, Durham, NC (J.B.G.); University of Utah, Salt Lake City (A.K.C.); National Clinical Research Center of Kidney Diseases, Jinling Hospital, Nanjing University School of Medicine, Nanjing (Z.-H.L.), and Fuwai Hospital, Chinese Academy of Medical Sciences, National Center for Cardiovascular Diseases, Beijing (J.L.) - both in China; Hospital Sultanah Aminah, Johor Bahru, Malaysia (L.S.H., W.L.); the University of Tokyo School of Medicine, Toranomon Hospital (T.K.), and the University of Tokyo School of Medicine (M.N.), Tokyo, Tokai University School of Medicine, Isehara (S.G.) - both in Japan; University of British Columbia, Vancouver (A.L.), and University of Toronto, Toronto (D.C.) - both in Canada; Università degli Studi and IRCCS Ospedale Policlinico San Martino di Genova, Genoa (R.P.), and Associazione Nazionale Medici Cardiologi Ospedalieri Research Center, Florence (A.P.M.) - both in Italy; University of Pennsylvania Perelman School of Medicine, Philadelphia (R.D.); Providence Health, Renton, and University of Washington, Seattle (K.R.T.) - both in Washington; and Hospital Universitari Son Espases, Health Research Institute of the Balearic Islands, University of the Balearic Islands, Palma de Mallorca, Spain (X.R.)
| | - Lai Seong Hooi
- The affiliations of the members of the writing committee are as follows: the Clinical Trial Service Unit and Epidemiological Studies Unit, Nuffield Department of Population Health (W.G.H., N.S., J.R.E., D.P., P.J., K.J.M., S.Y.A.N., E.S., D.Z., M.H., W.S., K.W., M.J.L., C.B., R.H.), and the Medical Research Council Population Health Research Unit (W.G.H., N.S., J.R.E., D.P., M.H., M.J.L., C.B., R.H.), University of Oxford, Oxford; University Clinic Würzburg, Würzburg (C.W., S.B.), Boehringer Ingelheim International (S.J.H., D.S., J.E., M.B.) and Boehringer Ingelheim Pharmaceuticals (M.P.), Ingelheim am Rhein, Elderbrook Solutions, Bietigheim-Bissingen (D.M.), the Fifth Department of Medicine, University Medical Center Mannheim (S.J.H.) and the First Department of Medicine, Faculty of Medicine Mannheim (M.B.), University of Heidelberg, Mannheim, and the Department of Nephrology, Hospital Rechts der Isar, Technical University of Munich, Munich (D.S.) - all in Germany; Duke Clinical Research Institute, Durham, NC (J.B.G.); University of Utah, Salt Lake City (A.K.C.); National Clinical Research Center of Kidney Diseases, Jinling Hospital, Nanjing University School of Medicine, Nanjing (Z.-H.L.), and Fuwai Hospital, Chinese Academy of Medical Sciences, National Center for Cardiovascular Diseases, Beijing (J.L.) - both in China; Hospital Sultanah Aminah, Johor Bahru, Malaysia (L.S.H., W.L.); the University of Tokyo School of Medicine, Toranomon Hospital (T.K.), and the University of Tokyo School of Medicine (M.N.), Tokyo, Tokai University School of Medicine, Isehara (S.G.) - both in Japan; University of British Columbia, Vancouver (A.L.), and University of Toronto, Toronto (D.C.) - both in Canada; Università degli Studi and IRCCS Ospedale Policlinico San Martino di Genova, Genoa (R.P.), and Associazione Nazionale Medici Cardiologi Ospedalieri Research Center, Florence (A.P.M.) - both in Italy; University of Pennsylvania Perelman School of Medicine, Philadelphia (R.D.); Providence Health, Renton, and University of Washington, Seattle (K.R.T.) - both in Washington; and Hospital Universitari Son Espases, Health Research Institute of the Balearic Islands, University of the Balearic Islands, Palma de Mallorca, Spain (X.R.)
| | - Wen Liu
- The affiliations of the members of the writing committee are as follows: the Clinical Trial Service Unit and Epidemiological Studies Unit, Nuffield Department of Population Health (W.G.H., N.S., J.R.E., D.P., P.J., K.J.M., S.Y.A.N., E.S., D.Z., M.H., W.S., K.W., M.J.L., C.B., R.H.), and the Medical Research Council Population Health Research Unit (W.G.H., N.S., J.R.E., D.P., M.H., M.J.L., C.B., R.H.), University of Oxford, Oxford; University Clinic Würzburg, Würzburg (C.W., S.B.), Boehringer Ingelheim International (S.J.H., D.S., J.E., M.B.) and Boehringer Ingelheim Pharmaceuticals (M.P.), Ingelheim am Rhein, Elderbrook Solutions, Bietigheim-Bissingen (D.M.), the Fifth Department of Medicine, University Medical Center Mannheim (S.J.H.) and the First Department of Medicine, Faculty of Medicine Mannheim (M.B.), University of Heidelberg, Mannheim, and the Department of Nephrology, Hospital Rechts der Isar, Technical University of Munich, Munich (D.S.) - all in Germany; Duke Clinical Research Institute, Durham, NC (J.B.G.); University of Utah, Salt Lake City (A.K.C.); National Clinical Research Center of Kidney Diseases, Jinling Hospital, Nanjing University School of Medicine, Nanjing (Z.-H.L.), and Fuwai Hospital, Chinese Academy of Medical Sciences, National Center for Cardiovascular Diseases, Beijing (J.L.) - both in China; Hospital Sultanah Aminah, Johor Bahru, Malaysia (L.S.H., W.L.); the University of Tokyo School of Medicine, Toranomon Hospital (T.K.), and the University of Tokyo School of Medicine (M.N.), Tokyo, Tokai University School of Medicine, Isehara (S.G.) - both in Japan; University of British Columbia, Vancouver (A.L.), and University of Toronto, Toronto (D.C.) - both in Canada; Università degli Studi and IRCCS Ospedale Policlinico San Martino di Genova, Genoa (R.P.), and Associazione Nazionale Medici Cardiologi Ospedalieri Research Center, Florence (A.P.M.) - both in Italy; University of Pennsylvania Perelman School of Medicine, Philadelphia (R.D.); Providence Health, Renton, and University of Washington, Seattle (K.R.T.) - both in Washington; and Hospital Universitari Son Espases, Health Research Institute of the Balearic Islands, University of the Balearic Islands, Palma de Mallorca, Spain (X.R.)
| | - Takashi Kadowaki
- The affiliations of the members of the writing committee are as follows: the Clinical Trial Service Unit and Epidemiological Studies Unit, Nuffield Department of Population Health (W.G.H., N.S., J.R.E., D.P., P.J., K.J.M., S.Y.A.N., E.S., D.Z., M.H., W.S., K.W., M.J.L., C.B., R.H.), and the Medical Research Council Population Health Research Unit (W.G.H., N.S., J.R.E., D.P., M.H., M.J.L., C.B., R.H.), University of Oxford, Oxford; University Clinic Würzburg, Würzburg (C.W., S.B.), Boehringer Ingelheim International (S.J.H., D.S., J.E., M.B.) and Boehringer Ingelheim Pharmaceuticals (M.P.), Ingelheim am Rhein, Elderbrook Solutions, Bietigheim-Bissingen (D.M.), the Fifth Department of Medicine, University Medical Center Mannheim (S.J.H.) and the First Department of Medicine, Faculty of Medicine Mannheim (M.B.), University of Heidelberg, Mannheim, and the Department of Nephrology, Hospital Rechts der Isar, Technical University of Munich, Munich (D.S.) - all in Germany; Duke Clinical Research Institute, Durham, NC (J.B.G.); University of Utah, Salt Lake City (A.K.C.); National Clinical Research Center of Kidney Diseases, Jinling Hospital, Nanjing University School of Medicine, Nanjing (Z.-H.L.), and Fuwai Hospital, Chinese Academy of Medical Sciences, National Center for Cardiovascular Diseases, Beijing (J.L.) - both in China; Hospital Sultanah Aminah, Johor Bahru, Malaysia (L.S.H., W.L.); the University of Tokyo School of Medicine, Toranomon Hospital (T.K.), and the University of Tokyo School of Medicine (M.N.), Tokyo, Tokai University School of Medicine, Isehara (S.G.) - both in Japan; University of British Columbia, Vancouver (A.L.), and University of Toronto, Toronto (D.C.) - both in Canada; Università degli Studi and IRCCS Ospedale Policlinico San Martino di Genova, Genoa (R.P.), and Associazione Nazionale Medici Cardiologi Ospedalieri Research Center, Florence (A.P.M.) - both in Italy; University of Pennsylvania Perelman School of Medicine, Philadelphia (R.D.); Providence Health, Renton, and University of Washington, Seattle (K.R.T.) - both in Washington; and Hospital Universitari Son Espases, Health Research Institute of the Balearic Islands, University of the Balearic Islands, Palma de Mallorca, Spain (X.R.)
| | - Masaomi Nangaku
- The affiliations of the members of the writing committee are as follows: the Clinical Trial Service Unit and Epidemiological Studies Unit, Nuffield Department of Population Health (W.G.H., N.S., J.R.E., D.P., P.J., K.J.M., S.Y.A.N., E.S., D.Z., M.H., W.S., K.W., M.J.L., C.B., R.H.), and the Medical Research Council Population Health Research Unit (W.G.H., N.S., J.R.E., D.P., M.H., M.J.L., C.B., R.H.), University of Oxford, Oxford; University Clinic Würzburg, Würzburg (C.W., S.B.), Boehringer Ingelheim International (S.J.H., D.S., J.E., M.B.) and Boehringer Ingelheim Pharmaceuticals (M.P.), Ingelheim am Rhein, Elderbrook Solutions, Bietigheim-Bissingen (D.M.), the Fifth Department of Medicine, University Medical Center Mannheim (S.J.H.) and the First Department of Medicine, Faculty of Medicine Mannheim (M.B.), University of Heidelberg, Mannheim, and the Department of Nephrology, Hospital Rechts der Isar, Technical University of Munich, Munich (D.S.) - all in Germany; Duke Clinical Research Institute, Durham, NC (J.B.G.); University of Utah, Salt Lake City (A.K.C.); National Clinical Research Center of Kidney Diseases, Jinling Hospital, Nanjing University School of Medicine, Nanjing (Z.-H.L.), and Fuwai Hospital, Chinese Academy of Medical Sciences, National Center for Cardiovascular Diseases, Beijing (J.L.) - both in China; Hospital Sultanah Aminah, Johor Bahru, Malaysia (L.S.H., W.L.); the University of Tokyo School of Medicine, Toranomon Hospital (T.K.), and the University of Tokyo School of Medicine (M.N.), Tokyo, Tokai University School of Medicine, Isehara (S.G.) - both in Japan; University of British Columbia, Vancouver (A.L.), and University of Toronto, Toronto (D.C.) - both in Canada; Università degli Studi and IRCCS Ospedale Policlinico San Martino di Genova, Genoa (R.P.), and Associazione Nazionale Medici Cardiologi Ospedalieri Research Center, Florence (A.P.M.) - both in Italy; University of Pennsylvania Perelman School of Medicine, Philadelphia (R.D.); Providence Health, Renton, and University of Washington, Seattle (K.R.T.) - both in Washington; and Hospital Universitari Son Espases, Health Research Institute of the Balearic Islands, University of the Balearic Islands, Palma de Mallorca, Spain (X.R.)
| | - Adeera Levin
- The affiliations of the members of the writing committee are as follows: the Clinical Trial Service Unit and Epidemiological Studies Unit, Nuffield Department of Population Health (W.G.H., N.S., J.R.E., D.P., P.J., K.J.M., S.Y.A.N., E.S., D.Z., M.H., W.S., K.W., M.J.L., C.B., R.H.), and the Medical Research Council Population Health Research Unit (W.G.H., N.S., J.R.E., D.P., M.H., M.J.L., C.B., R.H.), University of Oxford, Oxford; University Clinic Würzburg, Würzburg (C.W., S.B.), Boehringer Ingelheim International (S.J.H., D.S., J.E., M.B.) and Boehringer Ingelheim Pharmaceuticals (M.P.), Ingelheim am Rhein, Elderbrook Solutions, Bietigheim-Bissingen (D.M.), the Fifth Department of Medicine, University Medical Center Mannheim (S.J.H.) and the First Department of Medicine, Faculty of Medicine Mannheim (M.B.), University of Heidelberg, Mannheim, and the Department of Nephrology, Hospital Rechts der Isar, Technical University of Munich, Munich (D.S.) - all in Germany; Duke Clinical Research Institute, Durham, NC (J.B.G.); University of Utah, Salt Lake City (A.K.C.); National Clinical Research Center of Kidney Diseases, Jinling Hospital, Nanjing University School of Medicine, Nanjing (Z.-H.L.), and Fuwai Hospital, Chinese Academy of Medical Sciences, National Center for Cardiovascular Diseases, Beijing (J.L.) - both in China; Hospital Sultanah Aminah, Johor Bahru, Malaysia (L.S.H., W.L.); the University of Tokyo School of Medicine, Toranomon Hospital (T.K.), and the University of Tokyo School of Medicine (M.N.), Tokyo, Tokai University School of Medicine, Isehara (S.G.) - both in Japan; University of British Columbia, Vancouver (A.L.), and University of Toronto, Toronto (D.C.) - both in Canada; Università degli Studi and IRCCS Ospedale Policlinico San Martino di Genova, Genoa (R.P.), and Associazione Nazionale Medici Cardiologi Ospedalieri Research Center, Florence (A.P.M.) - both in Italy; University of Pennsylvania Perelman School of Medicine, Philadelphia (R.D.); Providence Health, Renton, and University of Washington, Seattle (K.R.T.) - both in Washington; and Hospital Universitari Son Espases, Health Research Institute of the Balearic Islands, University of the Balearic Islands, Palma de Mallorca, Spain (X.R.)
| | - David Cherney
- The affiliations of the members of the writing committee are as follows: the Clinical Trial Service Unit and Epidemiological Studies Unit, Nuffield Department of Population Health (W.G.H., N.S., J.R.E., D.P., P.J., K.J.M., S.Y.A.N., E.S., D.Z., M.H., W.S., K.W., M.J.L., C.B., R.H.), and the Medical Research Council Population Health Research Unit (W.G.H., N.S., J.R.E., D.P., M.H., M.J.L., C.B., R.H.), University of Oxford, Oxford; University Clinic Würzburg, Würzburg (C.W., S.B.), Boehringer Ingelheim International (S.J.H., D.S., J.E., M.B.) and Boehringer Ingelheim Pharmaceuticals (M.P.), Ingelheim am Rhein, Elderbrook Solutions, Bietigheim-Bissingen (D.M.), the Fifth Department of Medicine, University Medical Center Mannheim (S.J.H.) and the First Department of Medicine, Faculty of Medicine Mannheim (M.B.), University of Heidelberg, Mannheim, and the Department of Nephrology, Hospital Rechts der Isar, Technical University of Munich, Munich (D.S.) - all in Germany; Duke Clinical Research Institute, Durham, NC (J.B.G.); University of Utah, Salt Lake City (A.K.C.); National Clinical Research Center of Kidney Diseases, Jinling Hospital, Nanjing University School of Medicine, Nanjing (Z.-H.L.), and Fuwai Hospital, Chinese Academy of Medical Sciences, National Center for Cardiovascular Diseases, Beijing (J.L.) - both in China; Hospital Sultanah Aminah, Johor Bahru, Malaysia (L.S.H., W.L.); the University of Tokyo School of Medicine, Toranomon Hospital (T.K.), and the University of Tokyo School of Medicine (M.N.), Tokyo, Tokai University School of Medicine, Isehara (S.G.) - both in Japan; University of British Columbia, Vancouver (A.L.), and University of Toronto, Toronto (D.C.) - both in Canada; Università degli Studi and IRCCS Ospedale Policlinico San Martino di Genova, Genoa (R.P.), and Associazione Nazionale Medici Cardiologi Ospedalieri Research Center, Florence (A.P.M.) - both in Italy; University of Pennsylvania Perelman School of Medicine, Philadelphia (R.D.); Providence Health, Renton, and University of Washington, Seattle (K.R.T.) - both in Washington; and Hospital Universitari Son Espases, Health Research Institute of the Balearic Islands, University of the Balearic Islands, Palma de Mallorca, Spain (X.R.)
| | - Aldo P Maggioni
- The affiliations of the members of the writing committee are as follows: the Clinical Trial Service Unit and Epidemiological Studies Unit, Nuffield Department of Population Health (W.G.H., N.S., J.R.E., D.P., P.J., K.J.M., S.Y.A.N., E.S., D.Z., M.H., W.S., K.W., M.J.L., C.B., R.H.), and the Medical Research Council Population Health Research Unit (W.G.H., N.S., J.R.E., D.P., M.H., M.J.L., C.B., R.H.), University of Oxford, Oxford; University Clinic Würzburg, Würzburg (C.W., S.B.), Boehringer Ingelheim International (S.J.H., D.S., J.E., M.B.) and Boehringer Ingelheim Pharmaceuticals (M.P.), Ingelheim am Rhein, Elderbrook Solutions, Bietigheim-Bissingen (D.M.), the Fifth Department of Medicine, University Medical Center Mannheim (S.J.H.) and the First Department of Medicine, Faculty of Medicine Mannheim (M.B.), University of Heidelberg, Mannheim, and the Department of Nephrology, Hospital Rechts der Isar, Technical University of Munich, Munich (D.S.) - all in Germany; Duke Clinical Research Institute, Durham, NC (J.B.G.); University of Utah, Salt Lake City (A.K.C.); National Clinical Research Center of Kidney Diseases, Jinling Hospital, Nanjing University School of Medicine, Nanjing (Z.-H.L.), and Fuwai Hospital, Chinese Academy of Medical Sciences, National Center for Cardiovascular Diseases, Beijing (J.L.) - both in China; Hospital Sultanah Aminah, Johor Bahru, Malaysia (L.S.H., W.L.); the University of Tokyo School of Medicine, Toranomon Hospital (T.K.), and the University of Tokyo School of Medicine (M.N.), Tokyo, Tokai University School of Medicine, Isehara (S.G.) - both in Japan; University of British Columbia, Vancouver (A.L.), and University of Toronto, Toronto (D.C.) - both in Canada; Università degli Studi and IRCCS Ospedale Policlinico San Martino di Genova, Genoa (R.P.), and Associazione Nazionale Medici Cardiologi Ospedalieri Research Center, Florence (A.P.M.) - both in Italy; University of Pennsylvania Perelman School of Medicine, Philadelphia (R.D.); Providence Health, Renton, and University of Washington, Seattle (K.R.T.) - both in Washington; and Hospital Universitari Son Espases, Health Research Institute of the Balearic Islands, University of the Balearic Islands, Palma de Mallorca, Spain (X.R.)
| | - Roberto Pontremoli
- The affiliations of the members of the writing committee are as follows: the Clinical Trial Service Unit and Epidemiological Studies Unit, Nuffield Department of Population Health (W.G.H., N.S., J.R.E., D.P., P.J., K.J.M., S.Y.A.N., E.S., D.Z., M.H., W.S., K.W., M.J.L., C.B., R.H.), and the Medical Research Council Population Health Research Unit (W.G.H., N.S., J.R.E., D.P., M.H., M.J.L., C.B., R.H.), University of Oxford, Oxford; University Clinic Würzburg, Würzburg (C.W., S.B.), Boehringer Ingelheim International (S.J.H., D.S., J.E., M.B.) and Boehringer Ingelheim Pharmaceuticals (M.P.), Ingelheim am Rhein, Elderbrook Solutions, Bietigheim-Bissingen (D.M.), the Fifth Department of Medicine, University Medical Center Mannheim (S.J.H.) and the First Department of Medicine, Faculty of Medicine Mannheim (M.B.), University of Heidelberg, Mannheim, and the Department of Nephrology, Hospital Rechts der Isar, Technical University of Munich, Munich (D.S.) - all in Germany; Duke Clinical Research Institute, Durham, NC (J.B.G.); University of Utah, Salt Lake City (A.K.C.); National Clinical Research Center of Kidney Diseases, Jinling Hospital, Nanjing University School of Medicine, Nanjing (Z.-H.L.), and Fuwai Hospital, Chinese Academy of Medical Sciences, National Center for Cardiovascular Diseases, Beijing (J.L.) - both in China; Hospital Sultanah Aminah, Johor Bahru, Malaysia (L.S.H., W.L.); the University of Tokyo School of Medicine, Toranomon Hospital (T.K.), and the University of Tokyo School of Medicine (M.N.), Tokyo, Tokai University School of Medicine, Isehara (S.G.) - both in Japan; University of British Columbia, Vancouver (A.L.), and University of Toronto, Toronto (D.C.) - both in Canada; Università degli Studi and IRCCS Ospedale Policlinico San Martino di Genova, Genoa (R.P.), and Associazione Nazionale Medici Cardiologi Ospedalieri Research Center, Florence (A.P.M.) - both in Italy; University of Pennsylvania Perelman School of Medicine, Philadelphia (R.D.); Providence Health, Renton, and University of Washington, Seattle (K.R.T.) - both in Washington; and Hospital Universitari Son Espases, Health Research Institute of the Balearic Islands, University of the Balearic Islands, Palma de Mallorca, Spain (X.R.)
| | - Rajat Deo
- The affiliations of the members of the writing committee are as follows: the Clinical Trial Service Unit and Epidemiological Studies Unit, Nuffield Department of Population Health (W.G.H., N.S., J.R.E., D.P., P.J., K.J.M., S.Y.A.N., E.S., D.Z., M.H., W.S., K.W., M.J.L., C.B., R.H.), and the Medical Research Council Population Health Research Unit (W.G.H., N.S., J.R.E., D.P., M.H., M.J.L., C.B., R.H.), University of Oxford, Oxford; University Clinic Würzburg, Würzburg (C.W., S.B.), Boehringer Ingelheim International (S.J.H., D.S., J.E., M.B.) and Boehringer Ingelheim Pharmaceuticals (M.P.), Ingelheim am Rhein, Elderbrook Solutions, Bietigheim-Bissingen (D.M.), the Fifth Department of Medicine, University Medical Center Mannheim (S.J.H.) and the First Department of Medicine, Faculty of Medicine Mannheim (M.B.), University of Heidelberg, Mannheim, and the Department of Nephrology, Hospital Rechts der Isar, Technical University of Munich, Munich (D.S.) - all in Germany; Duke Clinical Research Institute, Durham, NC (J.B.G.); University of Utah, Salt Lake City (A.K.C.); National Clinical Research Center of Kidney Diseases, Jinling Hospital, Nanjing University School of Medicine, Nanjing (Z.-H.L.), and Fuwai Hospital, Chinese Academy of Medical Sciences, National Center for Cardiovascular Diseases, Beijing (J.L.) - both in China; Hospital Sultanah Aminah, Johor Bahru, Malaysia (L.S.H., W.L.); the University of Tokyo School of Medicine, Toranomon Hospital (T.K.), and the University of Tokyo School of Medicine (M.N.), Tokyo, Tokai University School of Medicine, Isehara (S.G.) - both in Japan; University of British Columbia, Vancouver (A.L.), and University of Toronto, Toronto (D.C.) - both in Canada; Università degli Studi and IRCCS Ospedale Policlinico San Martino di Genova, Genoa (R.P.), and Associazione Nazionale Medici Cardiologi Ospedalieri Research Center, Florence (A.P.M.) - both in Italy; University of Pennsylvania Perelman School of Medicine, Philadelphia (R.D.); Providence Health, Renton, and University of Washington, Seattle (K.R.T.) - both in Washington; and Hospital Universitari Son Espases, Health Research Institute of the Balearic Islands, University of the Balearic Islands, Palma de Mallorca, Spain (X.R.)
| | - Shinya Goto
- The affiliations of the members of the writing committee are as follows: the Clinical Trial Service Unit and Epidemiological Studies Unit, Nuffield Department of Population Health (W.G.H., N.S., J.R.E., D.P., P.J., K.J.M., S.Y.A.N., E.S., D.Z., M.H., W.S., K.W., M.J.L., C.B., R.H.), and the Medical Research Council Population Health Research Unit (W.G.H., N.S., J.R.E., D.P., M.H., M.J.L., C.B., R.H.), University of Oxford, Oxford; University Clinic Würzburg, Würzburg (C.W., S.B.), Boehringer Ingelheim International (S.J.H., D.S., J.E., M.B.) and Boehringer Ingelheim Pharmaceuticals (M.P.), Ingelheim am Rhein, Elderbrook Solutions, Bietigheim-Bissingen (D.M.), the Fifth Department of Medicine, University Medical Center Mannheim (S.J.H.) and the First Department of Medicine, Faculty of Medicine Mannheim (M.B.), University of Heidelberg, Mannheim, and the Department of Nephrology, Hospital Rechts der Isar, Technical University of Munich, Munich (D.S.) - all in Germany; Duke Clinical Research Institute, Durham, NC (J.B.G.); University of Utah, Salt Lake City (A.K.C.); National Clinical Research Center of Kidney Diseases, Jinling Hospital, Nanjing University School of Medicine, Nanjing (Z.-H.L.), and Fuwai Hospital, Chinese Academy of Medical Sciences, National Center for Cardiovascular Diseases, Beijing (J.L.) - both in China; Hospital Sultanah Aminah, Johor Bahru, Malaysia (L.S.H., W.L.); the University of Tokyo School of Medicine, Toranomon Hospital (T.K.), and the University of Tokyo School of Medicine (M.N.), Tokyo, Tokai University School of Medicine, Isehara (S.G.) - both in Japan; University of British Columbia, Vancouver (A.L.), and University of Toronto, Toronto (D.C.) - both in Canada; Università degli Studi and IRCCS Ospedale Policlinico San Martino di Genova, Genoa (R.P.), and Associazione Nazionale Medici Cardiologi Ospedalieri Research Center, Florence (A.P.M.) - both in Italy; University of Pennsylvania Perelman School of Medicine, Philadelphia (R.D.); Providence Health, Renton, and University of Washington, Seattle (K.R.T.) - both in Washington; and Hospital Universitari Son Espases, Health Research Institute of the Balearic Islands, University of the Balearic Islands, Palma de Mallorca, Spain (X.R.)
| | - Xavier Rossello
- The affiliations of the members of the writing committee are as follows: the Clinical Trial Service Unit and Epidemiological Studies Unit, Nuffield Department of Population Health (W.G.H., N.S., J.R.E., D.P., P.J., K.J.M., S.Y.A.N., E.S., D.Z., M.H., W.S., K.W., M.J.L., C.B., R.H.), and the Medical Research Council Population Health Research Unit (W.G.H., N.S., J.R.E., D.P., M.H., M.J.L., C.B., R.H.), University of Oxford, Oxford; University Clinic Würzburg, Würzburg (C.W., S.B.), Boehringer Ingelheim International (S.J.H., D.S., J.E., M.B.) and Boehringer Ingelheim Pharmaceuticals (M.P.), Ingelheim am Rhein, Elderbrook Solutions, Bietigheim-Bissingen (D.M.), the Fifth Department of Medicine, University Medical Center Mannheim (S.J.H.) and the First Department of Medicine, Faculty of Medicine Mannheim (M.B.), University of Heidelberg, Mannheim, and the Department of Nephrology, Hospital Rechts der Isar, Technical University of Munich, Munich (D.S.) - all in Germany; Duke Clinical Research Institute, Durham, NC (J.B.G.); University of Utah, Salt Lake City (A.K.C.); National Clinical Research Center of Kidney Diseases, Jinling Hospital, Nanjing University School of Medicine, Nanjing (Z.-H.L.), and Fuwai Hospital, Chinese Academy of Medical Sciences, National Center for Cardiovascular Diseases, Beijing (J.L.) - both in China; Hospital Sultanah Aminah, Johor Bahru, Malaysia (L.S.H., W.L.); the University of Tokyo School of Medicine, Toranomon Hospital (T.K.), and the University of Tokyo School of Medicine (M.N.), Tokyo, Tokai University School of Medicine, Isehara (S.G.) - both in Japan; University of British Columbia, Vancouver (A.L.), and University of Toronto, Toronto (D.C.) - both in Canada; Università degli Studi and IRCCS Ospedale Policlinico San Martino di Genova, Genoa (R.P.), and Associazione Nazionale Medici Cardiologi Ospedalieri Research Center, Florence (A.P.M.) - both in Italy; University of Pennsylvania Perelman School of Medicine, Philadelphia (R.D.); Providence Health, Renton, and University of Washington, Seattle (K.R.T.) - both in Washington; and Hospital Universitari Son Espases, Health Research Institute of the Balearic Islands, University of the Balearic Islands, Palma de Mallorca, Spain (X.R.)
| | - Katherine R Tuttle
- The affiliations of the members of the writing committee are as follows: the Clinical Trial Service Unit and Epidemiological Studies Unit, Nuffield Department of Population Health (W.G.H., N.S., J.R.E., D.P., P.J., K.J.M., S.Y.A.N., E.S., D.Z., M.H., W.S., K.W., M.J.L., C.B., R.H.), and the Medical Research Council Population Health Research Unit (W.G.H., N.S., J.R.E., D.P., M.H., M.J.L., C.B., R.H.), University of Oxford, Oxford; University Clinic Würzburg, Würzburg (C.W., S.B.), Boehringer Ingelheim International (S.J.H., D.S., J.E., M.B.) and Boehringer Ingelheim Pharmaceuticals (M.P.), Ingelheim am Rhein, Elderbrook Solutions, Bietigheim-Bissingen (D.M.), the Fifth Department of Medicine, University Medical Center Mannheim (S.J.H.) and the First Department of Medicine, Faculty of Medicine Mannheim (M.B.), University of Heidelberg, Mannheim, and the Department of Nephrology, Hospital Rechts der Isar, Technical University of Munich, Munich (D.S.) - all in Germany; Duke Clinical Research Institute, Durham, NC (J.B.G.); University of Utah, Salt Lake City (A.K.C.); National Clinical Research Center of Kidney Diseases, Jinling Hospital, Nanjing University School of Medicine, Nanjing (Z.-H.L.), and Fuwai Hospital, Chinese Academy of Medical Sciences, National Center for Cardiovascular Diseases, Beijing (J.L.) - both in China; Hospital Sultanah Aminah, Johor Bahru, Malaysia (L.S.H., W.L.); the University of Tokyo School of Medicine, Toranomon Hospital (T.K.), and the University of Tokyo School of Medicine (M.N.), Tokyo, Tokai University School of Medicine, Isehara (S.G.) - both in Japan; University of British Columbia, Vancouver (A.L.), and University of Toronto, Toronto (D.C.) - both in Canada; Università degli Studi and IRCCS Ospedale Policlinico San Martino di Genova, Genoa (R.P.), and Associazione Nazionale Medici Cardiologi Ospedalieri Research Center, Florence (A.P.M.) - both in Italy; University of Pennsylvania Perelman School of Medicine, Philadelphia (R.D.); Providence Health, Renton, and University of Washington, Seattle (K.R.T.) - both in Washington; and Hospital Universitari Son Espases, Health Research Institute of the Balearic Islands, University of the Balearic Islands, Palma de Mallorca, Spain (X.R.)
| | - Dominik Steubl
- The affiliations of the members of the writing committee are as follows: the Clinical Trial Service Unit and Epidemiological Studies Unit, Nuffield Department of Population Health (W.G.H., N.S., J.R.E., D.P., P.J., K.J.M., S.Y.A.N., E.S., D.Z., M.H., W.S., K.W., M.J.L., C.B., R.H.), and the Medical Research Council Population Health Research Unit (W.G.H., N.S., J.R.E., D.P., M.H., M.J.L., C.B., R.H.), University of Oxford, Oxford; University Clinic Würzburg, Würzburg (C.W., S.B.), Boehringer Ingelheim International (S.J.H., D.S., J.E., M.B.) and Boehringer Ingelheim Pharmaceuticals (M.P.), Ingelheim am Rhein, Elderbrook Solutions, Bietigheim-Bissingen (D.M.), the Fifth Department of Medicine, University Medical Center Mannheim (S.J.H.) and the First Department of Medicine, Faculty of Medicine Mannheim (M.B.), University of Heidelberg, Mannheim, and the Department of Nephrology, Hospital Rechts der Isar, Technical University of Munich, Munich (D.S.) - all in Germany; Duke Clinical Research Institute, Durham, NC (J.B.G.); University of Utah, Salt Lake City (A.K.C.); National Clinical Research Center of Kidney Diseases, Jinling Hospital, Nanjing University School of Medicine, Nanjing (Z.-H.L.), and Fuwai Hospital, Chinese Academy of Medical Sciences, National Center for Cardiovascular Diseases, Beijing (J.L.) - both in China; Hospital Sultanah Aminah, Johor Bahru, Malaysia (L.S.H., W.L.); the University of Tokyo School of Medicine, Toranomon Hospital (T.K.), and the University of Tokyo School of Medicine (M.N.), Tokyo, Tokai University School of Medicine, Isehara (S.G.) - both in Japan; University of British Columbia, Vancouver (A.L.), and University of Toronto, Toronto (D.C.) - both in Canada; Università degli Studi and IRCCS Ospedale Policlinico San Martino di Genova, Genoa (R.P.), and Associazione Nazionale Medici Cardiologi Ospedalieri Research Center, Florence (A.P.M.) - both in Italy; University of Pennsylvania Perelman School of Medicine, Philadelphia (R.D.); Providence Health, Renton, and University of Washington, Seattle (K.R.T.) - both in Washington; and Hospital Universitari Son Espases, Health Research Institute of the Balearic Islands, University of the Balearic Islands, Palma de Mallorca, Spain (X.R.)
| | - Michaela Petrini
- The affiliations of the members of the writing committee are as follows: the Clinical Trial Service Unit and Epidemiological Studies Unit, Nuffield Department of Population Health (W.G.H., N.S., J.R.E., D.P., P.J., K.J.M., S.Y.A.N., E.S., D.Z., M.H., W.S., K.W., M.J.L., C.B., R.H.), and the Medical Research Council Population Health Research Unit (W.G.H., N.S., J.R.E., D.P., M.H., M.J.L., C.B., R.H.), University of Oxford, Oxford; University Clinic Würzburg, Würzburg (C.W., S.B.), Boehringer Ingelheim International (S.J.H., D.S., J.E., M.B.) and Boehringer Ingelheim Pharmaceuticals (M.P.), Ingelheim am Rhein, Elderbrook Solutions, Bietigheim-Bissingen (D.M.), the Fifth Department of Medicine, University Medical Center Mannheim (S.J.H.) and the First Department of Medicine, Faculty of Medicine Mannheim (M.B.), University of Heidelberg, Mannheim, and the Department of Nephrology, Hospital Rechts der Isar, Technical University of Munich, Munich (D.S.) - all in Germany; Duke Clinical Research Institute, Durham, NC (J.B.G.); University of Utah, Salt Lake City (A.K.C.); National Clinical Research Center of Kidney Diseases, Jinling Hospital, Nanjing University School of Medicine, Nanjing (Z.-H.L.), and Fuwai Hospital, Chinese Academy of Medical Sciences, National Center for Cardiovascular Diseases, Beijing (J.L.) - both in China; Hospital Sultanah Aminah, Johor Bahru, Malaysia (L.S.H., W.L.); the University of Tokyo School of Medicine, Toranomon Hospital (T.K.), and the University of Tokyo School of Medicine (M.N.), Tokyo, Tokai University School of Medicine, Isehara (S.G.) - both in Japan; University of British Columbia, Vancouver (A.L.), and University of Toronto, Toronto (D.C.) - both in Canada; Università degli Studi and IRCCS Ospedale Policlinico San Martino di Genova, Genoa (R.P.), and Associazione Nazionale Medici Cardiologi Ospedalieri Research Center, Florence (A.P.M.) - both in Italy; University of Pennsylvania Perelman School of Medicine, Philadelphia (R.D.); Providence Health, Renton, and University of Washington, Seattle (K.R.T.) - both in Washington; and Hospital Universitari Son Espases, Health Research Institute of the Balearic Islands, University of the Balearic Islands, Palma de Mallorca, Spain (X.R.)
| | - Dan Massey
- The affiliations of the members of the writing committee are as follows: the Clinical Trial Service Unit and Epidemiological Studies Unit, Nuffield Department of Population Health (W.G.H., N.S., J.R.E., D.P., P.J., K.J.M., S.Y.A.N., E.S., D.Z., M.H., W.S., K.W., M.J.L., C.B., R.H.), and the Medical Research Council Population Health Research Unit (W.G.H., N.S., J.R.E., D.P., M.H., M.J.L., C.B., R.H.), University of Oxford, Oxford; University Clinic Würzburg, Würzburg (C.W., S.B.), Boehringer Ingelheim International (S.J.H., D.S., J.E., M.B.) and Boehringer Ingelheim Pharmaceuticals (M.P.), Ingelheim am Rhein, Elderbrook Solutions, Bietigheim-Bissingen (D.M.), the Fifth Department of Medicine, University Medical Center Mannheim (S.J.H.) and the First Department of Medicine, Faculty of Medicine Mannheim (M.B.), University of Heidelberg, Mannheim, and the Department of Nephrology, Hospital Rechts der Isar, Technical University of Munich, Munich (D.S.) - all in Germany; Duke Clinical Research Institute, Durham, NC (J.B.G.); University of Utah, Salt Lake City (A.K.C.); National Clinical Research Center of Kidney Diseases, Jinling Hospital, Nanjing University School of Medicine, Nanjing (Z.-H.L.), and Fuwai Hospital, Chinese Academy of Medical Sciences, National Center for Cardiovascular Diseases, Beijing (J.L.) - both in China; Hospital Sultanah Aminah, Johor Bahru, Malaysia (L.S.H., W.L.); the University of Tokyo School of Medicine, Toranomon Hospital (T.K.), and the University of Tokyo School of Medicine (M.N.), Tokyo, Tokai University School of Medicine, Isehara (S.G.) - both in Japan; University of British Columbia, Vancouver (A.L.), and University of Toronto, Toronto (D.C.) - both in Canada; Università degli Studi and IRCCS Ospedale Policlinico San Martino di Genova, Genoa (R.P.), and Associazione Nazionale Medici Cardiologi Ospedalieri Research Center, Florence (A.P.M.) - both in Italy; University of Pennsylvania Perelman School of Medicine, Philadelphia (R.D.); Providence Health, Renton, and University of Washington, Seattle (K.R.T.) - both in Washington; and Hospital Universitari Son Espases, Health Research Institute of the Balearic Islands, University of the Balearic Islands, Palma de Mallorca, Spain (X.R.)
| | - Jens Eilbracht
- The affiliations of the members of the writing committee are as follows: the Clinical Trial Service Unit and Epidemiological Studies Unit, Nuffield Department of Population Health (W.G.H., N.S., J.R.E., D.P., P.J., K.J.M., S.Y.A.N., E.S., D.Z., M.H., W.S., K.W., M.J.L., C.B., R.H.), and the Medical Research Council Population Health Research Unit (W.G.H., N.S., J.R.E., D.P., M.H., M.J.L., C.B., R.H.), University of Oxford, Oxford; University Clinic Würzburg, Würzburg (C.W., S.B.), Boehringer Ingelheim International (S.J.H., D.S., J.E., M.B.) and Boehringer Ingelheim Pharmaceuticals (M.P.), Ingelheim am Rhein, Elderbrook Solutions, Bietigheim-Bissingen (D.M.), the Fifth Department of Medicine, University Medical Center Mannheim (S.J.H.) and the First Department of Medicine, Faculty of Medicine Mannheim (M.B.), University of Heidelberg, Mannheim, and the Department of Nephrology, Hospital Rechts der Isar, Technical University of Munich, Munich (D.S.) - all in Germany; Duke Clinical Research Institute, Durham, NC (J.B.G.); University of Utah, Salt Lake City (A.K.C.); National Clinical Research Center of Kidney Diseases, Jinling Hospital, Nanjing University School of Medicine, Nanjing (Z.-H.L.), and Fuwai Hospital, Chinese Academy of Medical Sciences, National Center for Cardiovascular Diseases, Beijing (J.L.) - both in China; Hospital Sultanah Aminah, Johor Bahru, Malaysia (L.S.H., W.L.); the University of Tokyo School of Medicine, Toranomon Hospital (T.K.), and the University of Tokyo School of Medicine (M.N.), Tokyo, Tokai University School of Medicine, Isehara (S.G.) - both in Japan; University of British Columbia, Vancouver (A.L.), and University of Toronto, Toronto (D.C.) - both in Canada; Università degli Studi and IRCCS Ospedale Policlinico San Martino di Genova, Genoa (R.P.), and Associazione Nazionale Medici Cardiologi Ospedalieri Research Center, Florence (A.P.M.) - both in Italy; University of Pennsylvania Perelman School of Medicine, Philadelphia (R.D.); Providence Health, Renton, and University of Washington, Seattle (K.R.T.) - both in Washington; and Hospital Universitari Son Espases, Health Research Institute of the Balearic Islands, University of the Balearic Islands, Palma de Mallorca, Spain (X.R.)
| | - Martina Brueckmann
- The affiliations of the members of the writing committee are as follows: the Clinical Trial Service Unit and Epidemiological Studies Unit, Nuffield Department of Population Health (W.G.H., N.S., J.R.E., D.P., P.J., K.J.M., S.Y.A.N., E.S., D.Z., M.H., W.S., K.W., M.J.L., C.B., R.H.), and the Medical Research Council Population Health Research Unit (W.G.H., N.S., J.R.E., D.P., M.H., M.J.L., C.B., R.H.), University of Oxford, Oxford; University Clinic Würzburg, Würzburg (C.W., S.B.), Boehringer Ingelheim International (S.J.H., D.S., J.E., M.B.) and Boehringer Ingelheim Pharmaceuticals (M.P.), Ingelheim am Rhein, Elderbrook Solutions, Bietigheim-Bissingen (D.M.), the Fifth Department of Medicine, University Medical Center Mannheim (S.J.H.) and the First Department of Medicine, Faculty of Medicine Mannheim (M.B.), University of Heidelberg, Mannheim, and the Department of Nephrology, Hospital Rechts der Isar, Technical University of Munich, Munich (D.S.) - all in Germany; Duke Clinical Research Institute, Durham, NC (J.B.G.); University of Utah, Salt Lake City (A.K.C.); National Clinical Research Center of Kidney Diseases, Jinling Hospital, Nanjing University School of Medicine, Nanjing (Z.-H.L.), and Fuwai Hospital, Chinese Academy of Medical Sciences, National Center for Cardiovascular Diseases, Beijing (J.L.) - both in China; Hospital Sultanah Aminah, Johor Bahru, Malaysia (L.S.H., W.L.); the University of Tokyo School of Medicine, Toranomon Hospital (T.K.), and the University of Tokyo School of Medicine (M.N.), Tokyo, Tokai University School of Medicine, Isehara (S.G.) - both in Japan; University of British Columbia, Vancouver (A.L.), and University of Toronto, Toronto (D.C.) - both in Canada; Università degli Studi and IRCCS Ospedale Policlinico San Martino di Genova, Genoa (R.P.), and Associazione Nazionale Medici Cardiologi Ospedalieri Research Center, Florence (A.P.M.) - both in Italy; University of Pennsylvania Perelman School of Medicine, Philadelphia (R.D.); Providence Health, Renton, and University of Washington, Seattle (K.R.T.) - both in Washington; and Hospital Universitari Son Espases, Health Research Institute of the Balearic Islands, University of the Balearic Islands, Palma de Mallorca, Spain (X.R.)
| | - Martin J Landray
- The affiliations of the members of the writing committee are as follows: the Clinical Trial Service Unit and Epidemiological Studies Unit, Nuffield Department of Population Health (W.G.H., N.S., J.R.E., D.P., P.J., K.J.M., S.Y.A.N., E.S., D.Z., M.H., W.S., K.W., M.J.L., C.B., R.H.), and the Medical Research Council Population Health Research Unit (W.G.H., N.S., J.R.E., D.P., M.H., M.J.L., C.B., R.H.), University of Oxford, Oxford; University Clinic Würzburg, Würzburg (C.W., S.B.), Boehringer Ingelheim International (S.J.H., D.S., J.E., M.B.) and Boehringer Ingelheim Pharmaceuticals (M.P.), Ingelheim am Rhein, Elderbrook Solutions, Bietigheim-Bissingen (D.M.), the Fifth Department of Medicine, University Medical Center Mannheim (S.J.H.) and the First Department of Medicine, Faculty of Medicine Mannheim (M.B.), University of Heidelberg, Mannheim, and the Department of Nephrology, Hospital Rechts der Isar, Technical University of Munich, Munich (D.S.) - all in Germany; Duke Clinical Research Institute, Durham, NC (J.B.G.); University of Utah, Salt Lake City (A.K.C.); National Clinical Research Center of Kidney Diseases, Jinling Hospital, Nanjing University School of Medicine, Nanjing (Z.-H.L.), and Fuwai Hospital, Chinese Academy of Medical Sciences, National Center for Cardiovascular Diseases, Beijing (J.L.) - both in China; Hospital Sultanah Aminah, Johor Bahru, Malaysia (L.S.H., W.L.); the University of Tokyo School of Medicine, Toranomon Hospital (T.K.), and the University of Tokyo School of Medicine (M.N.), Tokyo, Tokai University School of Medicine, Isehara (S.G.) - both in Japan; University of British Columbia, Vancouver (A.L.), and University of Toronto, Toronto (D.C.) - both in Canada; Università degli Studi and IRCCS Ospedale Policlinico San Martino di Genova, Genoa (R.P.), and Associazione Nazionale Medici Cardiologi Ospedalieri Research Center, Florence (A.P.M.) - both in Italy; University of Pennsylvania Perelman School of Medicine, Philadelphia (R.D.); Providence Health, Renton, and University of Washington, Seattle (K.R.T.) - both in Washington; and Hospital Universitari Son Espases, Health Research Institute of the Balearic Islands, University of the Balearic Islands, Palma de Mallorca, Spain (X.R.)
| | - Colin Baigent
- The affiliations of the members of the writing committee are as follows: the Clinical Trial Service Unit and Epidemiological Studies Unit, Nuffield Department of Population Health (W.G.H., N.S., J.R.E., D.P., P.J., K.J.M., S.Y.A.N., E.S., D.Z., M.H., W.S., K.W., M.J.L., C.B., R.H.), and the Medical Research Council Population Health Research Unit (W.G.H., N.S., J.R.E., D.P., M.H., M.J.L., C.B., R.H.), University of Oxford, Oxford; University Clinic Würzburg, Würzburg (C.W., S.B.), Boehringer Ingelheim International (S.J.H., D.S., J.E., M.B.) and Boehringer Ingelheim Pharmaceuticals (M.P.), Ingelheim am Rhein, Elderbrook Solutions, Bietigheim-Bissingen (D.M.), the Fifth Department of Medicine, University Medical Center Mannheim (S.J.H.) and the First Department of Medicine, Faculty of Medicine Mannheim (M.B.), University of Heidelberg, Mannheim, and the Department of Nephrology, Hospital Rechts der Isar, Technical University of Munich, Munich (D.S.) - all in Germany; Duke Clinical Research Institute, Durham, NC (J.B.G.); University of Utah, Salt Lake City (A.K.C.); National Clinical Research Center of Kidney Diseases, Jinling Hospital, Nanjing University School of Medicine, Nanjing (Z.-H.L.), and Fuwai Hospital, Chinese Academy of Medical Sciences, National Center for Cardiovascular Diseases, Beijing (J.L.) - both in China; Hospital Sultanah Aminah, Johor Bahru, Malaysia (L.S.H., W.L.); the University of Tokyo School of Medicine, Toranomon Hospital (T.K.), and the University of Tokyo School of Medicine (M.N.), Tokyo, Tokai University School of Medicine, Isehara (S.G.) - both in Japan; University of British Columbia, Vancouver (A.L.), and University of Toronto, Toronto (D.C.) - both in Canada; Università degli Studi and IRCCS Ospedale Policlinico San Martino di Genova, Genoa (R.P.), and Associazione Nazionale Medici Cardiologi Ospedalieri Research Center, Florence (A.P.M.) - both in Italy; University of Pennsylvania Perelman School of Medicine, Philadelphia (R.D.); Providence Health, Renton, and University of Washington, Seattle (K.R.T.) - both in Washington; and Hospital Universitari Son Espases, Health Research Institute of the Balearic Islands, University of the Balearic Islands, Palma de Mallorca, Spain (X.R.)
| | - Richard Haynes
- The affiliations of the members of the writing committee are as follows: the Clinical Trial Service Unit and Epidemiological Studies Unit, Nuffield Department of Population Health (W.G.H., N.S., J.R.E., D.P., P.J., K.J.M., S.Y.A.N., E.S., D.Z., M.H., W.S., K.W., M.J.L., C.B., R.H.), and the Medical Research Council Population Health Research Unit (W.G.H., N.S., J.R.E., D.P., M.H., M.J.L., C.B., R.H.), University of Oxford, Oxford; University Clinic Würzburg, Würzburg (C.W., S.B.), Boehringer Ingelheim International (S.J.H., D.S., J.E., M.B.) and Boehringer Ingelheim Pharmaceuticals (M.P.), Ingelheim am Rhein, Elderbrook Solutions, Bietigheim-Bissingen (D.M.), the Fifth Department of Medicine, University Medical Center Mannheim (S.J.H.) and the First Department of Medicine, Faculty of Medicine Mannheim (M.B.), University of Heidelberg, Mannheim, and the Department of Nephrology, Hospital Rechts der Isar, Technical University of Munich, Munich (D.S.) - all in Germany; Duke Clinical Research Institute, Durham, NC (J.B.G.); University of Utah, Salt Lake City (A.K.C.); National Clinical Research Center of Kidney Diseases, Jinling Hospital, Nanjing University School of Medicine, Nanjing (Z.-H.L.), and Fuwai Hospital, Chinese Academy of Medical Sciences, National Center for Cardiovascular Diseases, Beijing (J.L.) - both in China; Hospital Sultanah Aminah, Johor Bahru, Malaysia (L.S.H., W.L.); the University of Tokyo School of Medicine, Toranomon Hospital (T.K.), and the University of Tokyo School of Medicine (M.N.), Tokyo, Tokai University School of Medicine, Isehara (S.G.) - both in Japan; University of British Columbia, Vancouver (A.L.), and University of Toronto, Toronto (D.C.) - both in Canada; Università degli Studi and IRCCS Ospedale Policlinico San Martino di Genova, Genoa (R.P.), and Associazione Nazionale Medici Cardiologi Ospedalieri Research Center, Florence (A.P.M.) - both in Italy; University of Pennsylvania Perelman School of Medicine, Philadelphia (R.D.); Providence Health, Renton, and University of Washington, Seattle (K.R.T.) - both in Washington; and Hospital Universitari Son Espases, Health Research Institute of the Balearic Islands, University of the Balearic Islands, Palma de Mallorca, Spain (X.R.)
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Staplin N, Herrington WG, Murgia F, Ibrahim M, Bull KR, Judge PK, Ng SYA, Turner M, Zhu D, Emberson J, Landray MJ, Baigent C, Haynes R, Hopewell JC. Determining the Relationship Between Blood Pressure, Kidney Function, and Chronic Kidney Disease: Insights From Genetic Epidemiology. Hypertension 2022; 79:2671-2681. [PMID: 36082669 PMCID: PMC9640248 DOI: 10.1161/hypertensionaha.122.19354] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
BACKGROUND It is well established that decreased kidney function can increase blood pressure (BP), but it is unproven whether moderately elevated BP causes chronic kidney disease (CKD) or glomerular hyperfiltration. METHODS 311 119 White British UK Biobank participants were included in logistic regression analyses to estimate the odds of CKD (defined as long-term kidney replacement therapy, estimated glomerular filtration rate [eGFR]< 60mL/min/1.73m2, or urinary albumin:creatinine ratio ≥3 mg/mmol) associated with higher genetically predicted BP using genetic risk scores comprising 219 systolic and 223 diastolic BP loci. Analyses estimating associations with clinical categories of eGFR and urinary albumin:creatinine ratio were also conducted, with an eGFR ≥120 mL (min·1.73m2) considered evidence of glomerular hyperfiltration. RESULTS 21 623 participants had CKD: 7781 with reduced eGFR and 15 500 with albuminuria. 1828 participants had an eGFR ≥120 mL/min/1.73m2. Each genetically predicted 10 mmHg higher systolic BP and 5 mmHg higher diastolic BP were associated with a 37% (95% CI, 1.29-1.45) and 19% (1.14-1.25) higher odds of CKD, respectively. Associations were evident for both the reduced eGFR and albuminuria components of the CKD outcome. The odds of hyperfiltration (versus an eGFR ≥60 and <90 mL/min/1.73m2 were 49% higher (95% CI, 1.21-1.84) for each genetically predicted 10 mmHg higher systolic BP. Associations with CKD and hyperfiltration were similar irrespective of preexisting diabetes, vascular disease, or different levels of adiposity. CONCLUSIONS In this general population, genetic epidemiological evidence supports a causal role of life-long differences in BP for decreased kidney function, glomerular hyperfiltration, and albuminuria. Physiological autoregulation may not afford complete renal protection against the moderate BP elevations.
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Affiliation(s)
- Natalie Staplin
- Medical Research Council Population Health Research Unit at the University of Oxford, Nuffield Department of Population Health (NDPH), United Kingdom (N.S., W.G.H., S.Y.A.N., M.T., D.Z., J.E., M.J.L., C.B., R.H., J.C.H.).,Clinical Trial Service Unit and Epidemiological Studies Unit, NDPH (N.S., W.G.H., F.M., M.I., P.J., S.Y.A.N., M.T., D.Z., J.E., M.J.L., C.B., R.H., J.C.H.), University of Oxford, Oxford, United Kingdom.,Big Data Institute, Li Ka Shing Centre for Health Information and Discovery (N.S., F.M., M.I., J.E., M.J.L., J.C.H.), University of Oxford, Oxford, United Kingdom
| | - William G Herrington
- Medical Research Council Population Health Research Unit at the University of Oxford, Nuffield Department of Population Health (NDPH), United Kingdom (N.S., W.G.H., S.Y.A.N., M.T., D.Z., J.E., M.J.L., C.B., R.H., J.C.H.).,Clinical Trial Service Unit and Epidemiological Studies Unit, NDPH (N.S., W.G.H., F.M., M.I., P.J., S.Y.A.N., M.T., D.Z., J.E., M.J.L., C.B., R.H., J.C.H.), University of Oxford, Oxford, United Kingdom.,Health Data Research UK (W.G.H., M.J.L.), University of Oxford, Oxford, United Kingdom.,Oxford Kidney Unit, Churchill Hospital, Oxford, United Kingdom (W.G.H., K.R.B., P.K.J., M.T., D.Z., R.H.)
| | - Federico Murgia
- Clinical Trial Service Unit and Epidemiological Studies Unit, NDPH (N.S., W.G.H., F.M., M.I., P.J., S.Y.A.N., M.T., D.Z., J.E., M.J.L., C.B., R.H., J.C.H.), University of Oxford, Oxford, United Kingdom.,Big Data Institute, Li Ka Shing Centre for Health Information and Discovery (N.S., F.M., M.I., J.E., M.J.L., J.C.H.), University of Oxford, Oxford, United Kingdom
| | - Maysson Ibrahim
- Clinical Trial Service Unit and Epidemiological Studies Unit, NDPH (N.S., W.G.H., F.M., M.I., P.J., S.Y.A.N., M.T., D.Z., J.E., M.J.L., C.B., R.H., J.C.H.), University of Oxford, Oxford, United Kingdom.,Big Data Institute, Li Ka Shing Centre for Health Information and Discovery (N.S., F.M., M.I., J.E., M.J.L., J.C.H.), University of Oxford, Oxford, United Kingdom
| | - Katherine R Bull
- Nuffield Department of Medicine (K.R.B.), University of Oxford, Oxford, United Kingdom.,Oxford Kidney Unit, Churchill Hospital, Oxford, United Kingdom (W.G.H., K.R.B., P.K.J., M.T., D.Z., R.H.)
| | - Parminder K Judge
- Clinical Trial Service Unit and Epidemiological Studies Unit, NDPH (N.S., W.G.H., F.M., M.I., P.J., S.Y.A.N., M.T., D.Z., J.E., M.J.L., C.B., R.H., J.C.H.), University of Oxford, Oxford, United Kingdom.,Oxford Kidney Unit, Churchill Hospital, Oxford, United Kingdom (W.G.H., K.R.B., P.K.J., M.T., D.Z., R.H.)
| | - Sarah Y A Ng
- Medical Research Council Population Health Research Unit at the University of Oxford, Nuffield Department of Population Health (NDPH), United Kingdom (N.S., W.G.H., S.Y.A.N., M.T., D.Z., J.E., M.J.L., C.B., R.H., J.C.H.).,Clinical Trial Service Unit and Epidemiological Studies Unit, NDPH (N.S., W.G.H., F.M., M.I., P.J., S.Y.A.N., M.T., D.Z., J.E., M.J.L., C.B., R.H., J.C.H.), University of Oxford, Oxford, United Kingdom
| | - Michael Turner
- Medical Research Council Population Health Research Unit at the University of Oxford, Nuffield Department of Population Health (NDPH), United Kingdom (N.S., W.G.H., S.Y.A.N., M.T., D.Z., J.E., M.J.L., C.B., R.H., J.C.H.).,Clinical Trial Service Unit and Epidemiological Studies Unit, NDPH (N.S., W.G.H., F.M., M.I., P.J., S.Y.A.N., M.T., D.Z., J.E., M.J.L., C.B., R.H., J.C.H.), University of Oxford, Oxford, United Kingdom.,Oxford Kidney Unit, Churchill Hospital, Oxford, United Kingdom (W.G.H., K.R.B., P.K.J., M.T., D.Z., R.H.)
| | - Doreen Zhu
- Medical Research Council Population Health Research Unit at the University of Oxford, Nuffield Department of Population Health (NDPH), United Kingdom (N.S., W.G.H., S.Y.A.N., M.T., D.Z., J.E., M.J.L., C.B., R.H., J.C.H.).,Clinical Trial Service Unit and Epidemiological Studies Unit, NDPH (N.S., W.G.H., F.M., M.I., P.J., S.Y.A.N., M.T., D.Z., J.E., M.J.L., C.B., R.H., J.C.H.), University of Oxford, Oxford, United Kingdom.,Oxford Kidney Unit, Churchill Hospital, Oxford, United Kingdom (W.G.H., K.R.B., P.K.J., M.T., D.Z., R.H.)
| | - Jonathan Emberson
- Medical Research Council Population Health Research Unit at the University of Oxford, Nuffield Department of Population Health (NDPH), United Kingdom (N.S., W.G.H., S.Y.A.N., M.T., D.Z., J.E., M.J.L., C.B., R.H., J.C.H.).,Clinical Trial Service Unit and Epidemiological Studies Unit, NDPH (N.S., W.G.H., F.M., M.I., P.J., S.Y.A.N., M.T., D.Z., J.E., M.J.L., C.B., R.H., J.C.H.), University of Oxford, Oxford, United Kingdom.,Big Data Institute, Li Ka Shing Centre for Health Information and Discovery (N.S., F.M., M.I., J.E., M.J.L., J.C.H.), University of Oxford, Oxford, United Kingdom
| | - Martin J Landray
- Medical Research Council Population Health Research Unit at the University of Oxford, Nuffield Department of Population Health (NDPH), United Kingdom (N.S., W.G.H., S.Y.A.N., M.T., D.Z., J.E., M.J.L., C.B., R.H., J.C.H.).,Clinical Trial Service Unit and Epidemiological Studies Unit, NDPH (N.S., W.G.H., F.M., M.I., P.J., S.Y.A.N., M.T., D.Z., J.E., M.J.L., C.B., R.H., J.C.H.), University of Oxford, Oxford, United Kingdom.,Big Data Institute, Li Ka Shing Centre for Health Information and Discovery (N.S., F.M., M.I., J.E., M.J.L., J.C.H.), University of Oxford, Oxford, United Kingdom.,Health Data Research UK (W.G.H., M.J.L.), University of Oxford, Oxford, United Kingdom.,National Institute for Health Research Oxford Biomedical Research Centre (M.J.L.), University of Oxford, Oxford, United Kingdom
| | - Colin Baigent
- Medical Research Council Population Health Research Unit at the University of Oxford, Nuffield Department of Population Health (NDPH), United Kingdom (N.S., W.G.H., S.Y.A.N., M.T., D.Z., J.E., M.J.L., C.B., R.H., J.C.H.).,Clinical Trial Service Unit and Epidemiological Studies Unit, NDPH (N.S., W.G.H., F.M., M.I., P.J., S.Y.A.N., M.T., D.Z., J.E., M.J.L., C.B., R.H., J.C.H.), University of Oxford, Oxford, United Kingdom
| | - Richard Haynes
- Medical Research Council Population Health Research Unit at the University of Oxford, Nuffield Department of Population Health (NDPH), United Kingdom (N.S., W.G.H., S.Y.A.N., M.T., D.Z., J.E., M.J.L., C.B., R.H., J.C.H.).,Clinical Trial Service Unit and Epidemiological Studies Unit, NDPH (N.S., W.G.H., F.M., M.I., P.J., S.Y.A.N., M.T., D.Z., J.E., M.J.L., C.B., R.H., J.C.H.), University of Oxford, Oxford, United Kingdom.,Oxford Kidney Unit, Churchill Hospital, Oxford, United Kingdom (W.G.H., K.R.B., P.K.J., M.T., D.Z., R.H.)
| | - Jemma C Hopewell
- Medical Research Council Population Health Research Unit at the University of Oxford, Nuffield Department of Population Health (NDPH), United Kingdom (N.S., W.G.H., S.Y.A.N., M.T., D.Z., J.E., M.J.L., C.B., R.H., J.C.H.).,Clinical Trial Service Unit and Epidemiological Studies Unit, NDPH (N.S., W.G.H., F.M., M.I., P.J., S.Y.A.N., M.T., D.Z., J.E., M.J.L., C.B., R.H., J.C.H.), University of Oxford, Oxford, United Kingdom.,Big Data Institute, Li Ka Shing Centre for Health Information and Discovery (N.S., F.M., M.I., J.E., M.J.L., J.C.H.), University of Oxford, Oxford, United Kingdom
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Baigent C, Emberson J, Haynes R, Herrington WG, Judge P, Landray MJ, Mayne KJ, Ng SY, Preiss D, Roddick AJ, Staplin N, Zhu D, Anker SD, Bhatt DL, Brueckmann M, Butler J, Cherney DZ, Green JB, Hauske SJ, Haynes R, Heerspink HJ, Herrington WG, Inzucchi SE, Jardine MJ, Liu CC, Mahaffey KW, McCausland FR, McGuire DK, McMurray JJ, Neal B, Neuen BL, Packer M, Perkovic V, Sabatine MS, Solomon SD, Vaduganathan M, Wanner C, Wheeler DC, Wiviott SD, Zannad F. Impact of diabetes on the effects of sodium glucose co-transporter-2 inhibitors on kidney outcomes: collaborative meta-analysis of large placebo-controlled trials. Lancet 2022; 400:1788-1801. [PMID: 36351458 PMCID: PMC7613836 DOI: 10.1016/s0140-6736(22)02074-8] [Citation(s) in RCA: 200] [Impact Index Per Article: 100.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2022] [Revised: 10/13/2022] [Accepted: 10/14/2022] [Indexed: 11/08/2022]
Abstract
BACKGROUND Large trials have shown that sodium glucose co-transporter-2 (SGLT2) inhibitors reduce the risk of adverse kidney and cardiovascular outcomes in patients with heart failure or chronic kidney disease, or with type 2 diabetes and high risk of atherosclerotic cardiovascular disease. None of the trials recruiting patients with and without diabetes were designed to assess outcomes separately in patients without diabetes. METHODS We did a systematic review and meta-analysis of SGLT2 inhibitor trials. We searched the MEDLINE and Embase databases for trials published from database inception to Sept 5, 2022. SGLT2 inhibitor trials that were double-blind, placebo-controlled, performed in adults (age ≥18 years), large (≥500 participants per group), and at least 6 months in duration were included. Summary-level data used for analysis were extracted from published reports or provided by trial investigators, and inverse-variance-weighted meta-analyses were conducted to estimate treatment effects. The main efficacy outcomes were kidney disease progression (standardised to a definition of a sustained ≥50% decrease in estimated glomerular filtration rate [eGFR] from randomisation, a sustained low eGFR, end-stage kidney disease, or death from kidney failure), acute kidney injury, and a composite of cardiovascular death or hospitalisation for heart failure. Other outcomes were death from cardiovascular and non-cardiovascular disease considered separately, and the main safety outcomes were ketoacidosis and lower limb amputation. This study is registered with PROSPERO, CRD42022351618. FINDINGS We identified 13 trials involving 90 413 participants. After exclusion of four participants with uncertain diabetes status, we analysed 90 409 participants (74 804 [82·7%] participants with diabetes [>99% with type 2 diabetes] and 15 605 [17·3%] without diabetes; trial-level mean baseline eGFR range 37-85 mL/min per 1·73 m2). Compared with placebo, allocation to an SGLT2 inhibitor reduced the risk of kidney disease progression by 37% (relative risk [RR] 0·63, 95% CI 0·58-0·69) with similar RRs in patients with and without diabetes. In the four chronic kidney disease trials, RRs were similar irrespective of primary kidney diagnosis. SGLT2 inhibitors reduced the risk of acute kidney injury by 23% (0·77, 0·70-0·84) and the risk of cardiovascular death or hospitalisation for heart failure by 23% (0·77, 0·74-0·81), again with similar effects in those with and without diabetes. SGLT2 inhibitors also reduced the risk of cardiovascular death (0·86, 0·81-0·92) but did not significantly reduce the risk of non-cardiovascular death (0·94, 0·88-1·02). For these mortality outcomes, RRs were similar in patients with and without diabetes. For all outcomes, results were broadly similar irrespective of trial mean baseline eGFR. Based on estimates of absolute effects, the absolute benefits of SGLT2 inhibition outweighed any serious hazards of ketoacidosis or amputation. INTERPRETATION In addition to the established cardiovascular benefits of SGLT2 inhibitors, the randomised data support their use for modifying risk of kidney disease progression and acute kidney injury, not only in patients with type 2 diabetes at high cardiovascular risk, but also in patients with chronic kidney disease or heart failure irrespective of diabetes status, primary kidney disease, or kidney function. FUNDING UK Medical Research Council and Kidney Research UK.
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Murray ML, Love SB, Carpenter JR, Hartley S, Landray MJ, Mafham M, Parmar MKB, Pinches H, Sydes MR. Data provenance and integrity of health-care systems data for clinical trials. Lancet Digit Health 2022; 4:e567-e568. [PMID: 35868811 PMCID: PMC9296098 DOI: 10.1016/s2589-7500(22)00122-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2022] [Revised: 05/16/2022] [Accepted: 06/14/2022] [Indexed: 12/30/2022]
Affiliation(s)
- Macey L Murray
- Institute of Clinical Trials and Methodology, University College London, London WC1V 6LJ, UK; Health Data Research UK, London, UK; NHS DigiTrials Programme, NHS Digital, Leeds, UK.
| | - Sharon B Love
- Institute of Clinical Trials and Methodology, University College London, London WC1V 6LJ, UK; Health Data Research UK, London, UK
| | - James R Carpenter
- Institute of Clinical Trials and Methodology, University College London, London WC1V 6LJ, UK; Health Data Research UK, London, UK; Medical Statistics, London School of Hygiene and Tropical Medicine, University of London, London, UK
| | | | - Martin J Landray
- Health Data Research UK, London, UK; NHS DigiTrials Programme, NHS Digital, Leeds, UK; Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Marion Mafham
- Health Data Research UK, London, UK; NHS DigiTrials Programme, NHS Digital, Leeds, UK; Clinical Trial Service Unit and Epidemiological Studies Unit, University of Oxford, Oxford, UK
| | - Mahesh K B Parmar
- Institute of Clinical Trials and Methodology, University College London, London WC1V 6LJ, UK; Health Data Research UK, London, UK
| | | | - Matthew R Sydes
- Institute of Clinical Trials and Methodology, University College London, London WC1V 6LJ, UK; Health Data Research UK, London, UK; British Heart Foundation Data Science Centre, Health Data Research UK, London, UK
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17
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Harper C, Mafham M, Herrington W, Staplin N, Stevens W, Wallendszus K, Haynes R, Landray MJ, Parish S, Bowman L, Armitage J. Comparison of the Accuracy and Completeness of Records of Serious Vascular Events in Routinely Collected Data vs Clinical Trial-Adjudicated Direct Follow-up Data in the UK: Secondary Analysis of the ASCEND Randomized Clinical Trial. JAMA Netw Open 2021; 4:e2139748. [PMID: 34962561 PMCID: PMC8715347 DOI: 10.1001/jamanetworkopen.2021.39748] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [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] [Received: 06/03/2021] [Accepted: 10/26/2021] [Indexed: 12/15/2022] Open
Abstract
Importance Routinely collected data could substantially decrease the cost of conducting trials. Objective To assess the accuracy and completeness of UK routine data for ascertaining serious vascular events (SVEs) compared with adjudicated follow-up data. Design, Setting, and Participants This was a secondary analysis of a randomized clinical trial. From June 24, 2005, to July 28, 2011, the ASCEND (A Study of Cardiovascular Events in Diabetes) primary prevention trial used mail-based methods to randomize people with diabetes without evidence of atherosclerotic vascular disease using a 2 × 2 factorial design to aspirin and/or ω-fatty acids vs matching placebo in the UK. Direct participant mail-based follow-up was the main source of outcome data, with more than 90% of the primary outcome events undergoing adjudication. Follow-up was completed on July 31, 2017. In parallel, more than 99% of participants were linked to routinely collected hospital admission and death registry data (ie, routine data), enabling post hoc randomized comparisons of different sources of outcome data (conducted from September 1, 2018, to October 1, 2021). Interventions Random allocation to 100 mg of aspirin once daily vs matching placebo and separately to 1 g of ω-3 fatty acids once daily vs placebo. Main Outcomes and Measures The primary outcome consisted of SVEs (a composite of nonfatal myocardial infarction, ischemic stroke, transient ischemic attack [TIA], or vascular death, excluding hemorrhagic stroke). Results A total of 15 480 participants were randomized (mean [SD] age, 63 [9] years; 9684 [62.6%] men) and followed up for a mean (SD) of 7.4 (1.8) years. For SVEs, agreement between adjudicated direct follow-up and routine data sources was strong (1401 vs 1127 events; κ = 0.78 [95% CI, 0.76-0.80]; sensitivity, 72.0% [95% CI, 69.7%-74.4%]; specificity, 99.2% [95% CI, 99.0%-99.3%]), and sensitivity improved for SVEs excluding transient ischemic attack (1129 vs 1026 events; sensitivity, 80.6% [95% CI, 78.3%-82.9%]). Rate ratios for the aspirin-randomized comparison for adjudicated direct follow-up vs follow-up solely through routine data alone were 0.88 (95% CI, 0.79-0.97) vs 0.91 (95% CI, 0.81-1.02) for the primary outcome and 0.92 (95% CI, 0.82-1.03) vs 0.91 (95% CI, 0.80-1.02) for SVEs excluding TIA. Results were similar for the ω-3 fatty acid comparison, and adjudication did not seem to markedly change rate ratios. Conclusions and Relevance Post hoc analyses of the ASCEND trial suggest that routinely collected hospital admission and death registry data in the UK could be used as the sole method of follow-up for myocardial infarction, ischemic stroke resulting in hospitalization, vascular death, and arterial revascularization in primary prevention cardiovascular trials, without the need for verification by clinical adjudication.
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Affiliation(s)
- Charlie Harper
- Medical Research Council Population Health Research Unit at the University of Oxford, Nuffield Department of Population Health (NDPH), University of Oxford, Oxford, United Kingdom
- Clinical Trial Service Unit and Epidemiological Studies Unit, NDPH, University of Oxford, Oxford, United Kingdom
| | - Marion Mafham
- Clinical Trial Service Unit and Epidemiological Studies Unit, NDPH, University of Oxford, Oxford, United Kingdom
| | - William Herrington
- Medical Research Council Population Health Research Unit at the University of Oxford, Nuffield Department of Population Health (NDPH), University of Oxford, Oxford, United Kingdom
- Clinical Trial Service Unit and Epidemiological Studies Unit, NDPH, University of Oxford, Oxford, United Kingdom
| | - Natalie Staplin
- Medical Research Council Population Health Research Unit at the University of Oxford, Nuffield Department of Population Health (NDPH), University of Oxford, Oxford, United Kingdom
- Clinical Trial Service Unit and Epidemiological Studies Unit, NDPH, University of Oxford, Oxford, United Kingdom
| | - William Stevens
- Medical Research Council Population Health Research Unit at the University of Oxford, Nuffield Department of Population Health (NDPH), University of Oxford, Oxford, United Kingdom
- Clinical Trial Service Unit and Epidemiological Studies Unit, NDPH, University of Oxford, Oxford, United Kingdom
| | - Karl Wallendszus
- Medical Research Council Population Health Research Unit at the University of Oxford, Nuffield Department of Population Health (NDPH), University of Oxford, Oxford, United Kingdom
- Clinical Trial Service Unit and Epidemiological Studies Unit, NDPH, University of Oxford, Oxford, United Kingdom
| | - Richard Haynes
- Medical Research Council Population Health Research Unit at the University of Oxford, Nuffield Department of Population Health (NDPH), University of Oxford, Oxford, United Kingdom
- Clinical Trial Service Unit and Epidemiological Studies Unit, NDPH, University of Oxford, Oxford, United Kingdom
| | - Martin J. Landray
- Medical Research Council Population Health Research Unit at the University of Oxford, Nuffield Department of Population Health (NDPH), University of Oxford, Oxford, United Kingdom
- Clinical Trial Service Unit and Epidemiological Studies Unit, NDPH, University of Oxford, Oxford, United Kingdom
- Big Data Institute, Li Ka Shing Centre for Health Information and Discovery, NDPH, University of Oxford, Oxford, United Kingdom
| | - Sarah Parish
- Medical Research Council Population Health Research Unit at the University of Oxford, Nuffield Department of Population Health (NDPH), University of Oxford, Oxford, United Kingdom
- Clinical Trial Service Unit and Epidemiological Studies Unit, NDPH, University of Oxford, Oxford, United Kingdom
| | - Louise Bowman
- Medical Research Council Population Health Research Unit at the University of Oxford, Nuffield Department of Population Health (NDPH), University of Oxford, Oxford, United Kingdom
- Clinical Trial Service Unit and Epidemiological Studies Unit, NDPH, University of Oxford, Oxford, United Kingdom
| | - Jane Armitage
- Medical Research Council Population Health Research Unit at the University of Oxford, Nuffield Department of Population Health (NDPH), University of Oxford, Oxford, United Kingdom
- Clinical Trial Service Unit and Epidemiological Studies Unit, NDPH, University of Oxford, Oxford, United Kingdom
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18
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Shankar-Hari M, Vale CL, Godolphin PJ, Fisher D, Higgins JPT, Spiga F, Savovic J, Tierney J, Baron G, Benbenishty JS, Berry LR, Broman N, Cavalcanti AB, Colman R, De Buyser SL, Derde LPG, Domingo P, Omar SF, Fernandez-Cruz A, Feuth T, Garcia F, Garcia-Vicuna R, Gonzalez-Alvaro I, Gordon AC, Haynes R, Hermine O, Horby PW, Horick NK, Kumar K, Lambrecht BN, Landray MJ, Leal L, Lederer DJ, Lorenzi E, Mariette X, Merchante N, Misnan NA, Mohan SV, Nivens MC, Oksi J, Perez-Molina JA, Pizov R, Porcher R, Postma S, Rajasuriar R, Ramanan AV, Ravaud P, Reid PD, Rutgers A, Sancho-Lopez A, Seto TB, Sivapalasingam S, Soin AS, Staplin N, Stone JH, Strohbehn GW, Sunden-Cullberg J, Torre-Cisneros J, Tsai LW, van Hoogstraten H, van Meerten T, Veiga VC, Westerweel PE, Murthy S, Diaz JV, Marshall JC, Sterne JAC. Association Between Administration of IL-6 Antagonists and Mortality Among Patients Hospitalized for COVID-19: A Meta-analysis. JAMA 2021; 326:499-518. [PMID: 34228774 PMCID: PMC8261689 DOI: 10.1001/jama.2021.11330] [Citation(s) in RCA: 397] [Impact Index Per Article: 132.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2021] [Accepted: 06/24/2021] [Indexed: 12/23/2022]
Abstract
Importance Clinical trials assessing the efficacy of IL-6 antagonists in patients hospitalized for COVID-19 have variously reported benefit, no effect, and harm. Objective To estimate the association between administration of IL-6 antagonists compared with usual care or placebo and 28-day all-cause mortality and other outcomes. Data Sources Trials were identified through systematic searches of electronic databases between October 2020 and January 2021. Searches were not restricted by trial status or language. Additional trials were identified through contact with experts. Study Selection Eligible trials randomly assigned patients hospitalized for COVID-19 to a group in whom IL-6 antagonists were administered and to a group in whom neither IL-6 antagonists nor any other immunomodulators except corticosteroids were administered. Among 72 potentially eligible trials, 27 (37.5%) met study selection criteria. Data Extraction and Synthesis In this prospective meta-analysis, risk of bias was assessed using the Cochrane Risk of Bias Assessment Tool. Inconsistency among trial results was assessed using the I2 statistic. The primary analysis was an inverse variance-weighted fixed-effects meta-analysis of odds ratios (ORs) for 28-day all-cause mortality. Main Outcomes and Measures The primary outcome measure was all-cause mortality at 28 days after randomization. There were 9 secondary outcomes including progression to invasive mechanical ventilation or death and risk of secondary infection by 28 days. Results A total of 10 930 patients (median age, 61 years [range of medians, 52-68 years]; 3560 [33%] were women) participating in 27 trials were included. By 28 days, there were 1407 deaths among 6449 patients randomized to IL-6 antagonists and 1158 deaths among 4481 patients randomized to usual care or placebo (summary OR, 0.86 [95% CI, 0.79-0.95]; P = .003 based on a fixed-effects meta-analysis). This corresponds to an absolute mortality risk of 22% for IL-6 antagonists compared with an assumed mortality risk of 25% for usual care or placebo. The corresponding summary ORs were 0.83 (95% CI, 0.74-0.92; P < .001) for tocilizumab and 1.08 (95% CI, 0.86-1.36; P = .52) for sarilumab. The summary ORs for the association with mortality compared with usual care or placebo in those receiving corticosteroids were 0.77 (95% CI, 0.68-0.87) for tocilizumab and 0.92 (95% CI, 0.61-1.38) for sarilumab. The ORs for the association with progression to invasive mechanical ventilation or death, compared with usual care or placebo, were 0.77 (95% CI, 0.70-0.85) for all IL-6 antagonists, 0.74 (95% CI, 0.66-0.82) for tocilizumab, and 1.00 (95% CI, 0.74-1.34) for sarilumab. Secondary infections by 28 days occurred in 21.9% of patients treated with IL-6 antagonists vs 17.6% of patients treated with usual care or placebo (OR accounting for trial sample sizes, 0.99; 95% CI, 0.85-1.16). Conclusions and Relevance In this prospective meta-analysis of clinical trials of patients hospitalized for COVID-19, administration of IL-6 antagonists, compared with usual care or placebo, was associated with lower 28-day all-cause mortality. Trial Registration PROSPERO Identifier: CRD42021230155.
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Affiliation(s)
- Manu Shankar-Hari
- Guy's and St Thomas' NHS Foundation Trust, ICU Support Offices, St Thomas' Hospital, London, England
- School of Immunology and Microbial Sciences, Kings College London, London, England
| | - Claire L Vale
- University College London, MRC Clinical Trials Unit at UCL, London, England
| | - Peter J Godolphin
- University College London, MRC Clinical Trials Unit at UCL, London, England
| | - David Fisher
- University College London, MRC Clinical Trials Unit at UCL, London, England
| | - Julian P T Higgins
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, England
- NIHR Bristol Biomedical Research Centre, Bristol, England
- National Institute for Health Research Applied Research Collaboration West at University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, England
| | | | - Jelena Savovic
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, England
- National Institute for Health Research Applied Research Collaboration West at University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, England
| | - Jayne Tierney
- University College London, MRC Clinical Trials Unit at UCL, London, England
| | - Gabriel Baron
- Assistance Publique-Hôpitaux de Paris, Centre for Clinical Epidemiology, Hôpital Hôtel-Dieu, Paris, France
- INSERM UMRS-1153, Centre de Recherche Epidémiologie et Statistique Université de Paris, METHODS Team, Paris, France
| | - Julie S Benbenishty
- Department of Nursing, Hadassah Hebrew University Medical Center, Jerusalem, Israel
| | | | - Niklas Broman
- Turku University Hospital, Department of Infectious Diseases, Turku, Finland
| | | | - Roos Colman
- Department of Public Health and Primary Care, Ghent University, Ghent, Belgium
| | | | - Lennie P G Derde
- Department of Intensive Care Medicine, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Pere Domingo
- Department of Infectious Diseases, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
| | | | - Ana Fernandez-Cruz
- Infectious Diseases Unit, Internal Medicine Department, Hospital Universitario Puerta de Hierro-Majadahonda, Madrid, Spain
| | - Thijs Feuth
- Department of Pulmonary Diseases, Turku University Hospital, Turku, Finland
| | - Felipe Garcia
- Infectious Diseases Department, Hospital Clinic Barcelona-IDIBAPS, Barcelona, Spain
| | | | | | - Anthony C Gordon
- Division of Anaesthetics, Pain Medicine and Intensive Care, Imperial College London, London, England
| | - Richard Haynes
- Nuffield Department of Population Health, University of Oxford, Oxford, England
- MRC Population Health Research Unit, University of Oxford, Oxford, England
| | - Olivier Hermine
- Department of Hematology, Necker Hospital, Paris, France
- Imagine Institute, University of Paris, INSERM U1153, Paris, France
| | - Peter W Horby
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, England
- International Severe Acute Respiratory and Emerging Infections Consortium, University of Oxford, Oxford, England
- Pandemic Sciences Centre, University of Oxford, Oxford, England
| | - Nora K Horick
- Department of Medicine, Massachusetts General Hospital, Boston
| | - Kuldeep Kumar
- Medanta-The Medicity, Institute of Liver Transplantation and Regenerative Medicine, Gurugram, India
- Research Department, Medanta Institute of Education and Research, Gurugram, India
| | - Bart N Lambrecht
- VIB Center for Inflammation Research, Ghent University, Ghent, Belgium
- Department of Internal Medicine and Pediatrics, Ghent University, Ghent, Belgium
| | - Martin J Landray
- Nuffield Department of Population Health, University of Oxford, Oxford, England
- MRC Population Health Research Unit, University of Oxford, Oxford, England
| | - Lorna Leal
- Infectious Diseases Department, Hospital Clinic Barcelona-IDIBAPS, Barcelona, Spain
| | | | | | - Xavier Mariette
- Centre for Immunology of Viral Infections and Autoimmune Diseases, Université Paris-Saclay, INSERM UMR1184, Le Kremlin-Bicêtre, Paris, France
- Department of Rheumatology, Assistance Publique-Hôpitaux de Paris, Le Le Kremlin-Bicêtre, Paris, France
| | - Nicolas Merchante
- Unit of Infectious Diseases and Microbiology, Valme University Hospital, Institute of Biomedicine of Sevilla, Seville, Spain
| | | | | | | | - Jarmo Oksi
- Turku University Hospital, Department of Infectious Diseases, Turku, Finland
| | - Jose A Perez-Molina
- Hospital Universitario Ramón y Cajal IRYCIS, Infectious Diseases Department, Madrid, Spain
| | - Reuven Pizov
- Department of Anesthesilogy Critical Care and Pain Medicine, Hadassah Hebrew University Hospital, Jerusalem, Israel
| | - Raphael Porcher
- Assistance Publique-Hôpitaux de Paris, Centre for Clinical Epidemiology, Hôpital Hôtel-Dieu, Paris, France
- INSERM UMRS-1153, Centre de Recherche Epidémiologie et Statistique Université de Paris, METHODS Team, Paris, France
- University de Paris, CRESS UMR1153, INSERM, INRA, Paris, France
| | - Simone Postma
- Department of Rheumatology and Clinical Immunology, University Hospital Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - Reena Rajasuriar
- Department of Medicine, University of Malaya, Kuala Lumpur, Malaysia
- Peter Doherty Institute for Infection and Immunity, University of Melbourne, Melbourne, Australia
| | - Athimalaipet V Ramanan
- Department of Paediatric Rheumatology, University Hospitals Bristol, NHS Foundation Trust, Bristol, England
| | - Philippe Ravaud
- Assistance Publique-Hôpitaux de Paris, Centre for Clinical Epidemiology, Hôpital Hôtel-Dieu, Paris, France
- INSERM UMRS-1153, Centre de Recherche Epidémiologie et Statistique Université de Paris, METHODS Team, Paris, France
- University de Paris, CRESS UMR1153, INSERM, INRA, Paris, France
| | - Pankti D Reid
- Department of Medicine (Rheumatology), University of Chicago Medical Center, Chicago, Illinois
| | - Abraham Rutgers
- Department of Rheumatology and Clinical Immunology, University Hospital Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - Aranzazu Sancho-Lopez
- Department of Clinical Pharmacology, Hospital Universitario Puerta de Hierro Majadahonda, Madrid, Spain
| | - Todd B Seto
- Center for Outcomes Research and Evaluation, Queen's Medical Center, Honolulu, Hawaii
| | | | - Arvinder Singh Soin
- Medanta-The Medicity, Institute of Liver Transplantation and Regenerative Medicine, Gurugram, India
| | - Natalie Staplin
- Nuffield Department of Population Health, University of Oxford, Oxford, England
- MRC Population Health Research Unit, University of Oxford, Oxford, England
| | - John H Stone
- Division of Rheumatology, Allergy, and Immunology, Massachusetts General Hospital, Boston
- Department of Medicine (Rheumatology), Massachusetts General Hospital, Boston
| | - Garth W Strohbehn
- VA Ann Arbor, Center for Clinical Management and Research, Ann Arbor, Michigan
| | - Jonas Sunden-Cullberg
- Department of Infectious Diseases, Karolinska Institute at Karolinska University Hospital Huddinge, Stockholm, Sweden
| | - Julian Torre-Cisneros
- Maimonides Institute for Biomedical Research of Cordoba/Reina Sofia University Hospital/University of Córdoba, Córdoba, Spain
| | | | | | - Tom van Meerten
- Department of Hematology, University Medical Center Groningen, Groningen, the Netherlands
| | | | - Peter E Westerweel
- Department of Internal Medicine, Albert Schweitzer Hospital, Dordrecht, the Netherlands
| | - Srinivas Murthy
- Department of Pediatrics, University of British Columbia, Vancouver, Canada
| | - Janet V Diaz
- Clinical Unit, Health Emergencies Programme, World Health Organization, Geneva, Switzerland
| | - John C Marshall
- Li Ka Shing Knowledge Institute, St Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Jonathan A C Sterne
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, England
- NIHR Bristol Biomedical Research Centre, Bristol, England
- Health Data Research UK South-West, Bristol, England
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19
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Hopewell JC, Offer A, Haynes R, Bowman L, Li J, Chen F, Bulbulia R, Lathrop M, Baigent C, Landray MJ, Collins R, Armitage J, Parish S. Independent risk factors for simvastatin-related myopathy and relevance to different types of muscle symptom. Eur Heart J 2021; 41:3336-3342. [PMID: 32702748 PMCID: PMC7544537 DOI: 10.1093/eurheartj/ehaa574] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2019] [Revised: 07/12/2019] [Accepted: 07/02/2020] [Indexed: 01/14/2023] Open
Abstract
Aims Statins are widely used to prevent cardiovascular events, but little is known about the impact of different risk factors for statin-related myopathy or their relevance to reports of other types of muscle symptom. Methods and results An observational analysis was undertaken of 171 clinically adjudicated cases of myopathy (defined as unexplained muscle pain or weakness with creatine kinase >10× upper limit of normal) and, separately, of 15 208 cases of other muscle symptoms among 58 390 individuals with vascular disease treated with simvastatin for a mean of 3.4 years. Cox proportional hazards models were used to identify independent predictors of myopathy. The rate of myopathy was low: 9 per 10 000 person-years of simvastatin therapy. Independent risk factors for myopathy included: simvastatin dose, ethnicity, sex, age, body mass index, medically treated diabetes, concomitant use of niacin-laropiprant, verapamil, beta-blockers, diltiazem and diuretics. In combination, these risk factors predicted more than a 30-fold risk difference between the top and bottom thirds of a myopathy risk score (hazard ratio : 34.35, 95% CI: 12.73–92.69, P across thirds = 9·1 × 10−48). However, despite the strong association with myopathy, this score was not associated with the other reported muscle symptoms (P across thirds = 0.93). Likewise, although SLCO1B1 genotype was associated with myopathy, it was not associated with other muscle symptoms. Conclusions The absolute risk of simvastatin-related myopathy is low, but individuals at higher risk can be identified to help guide patient management. The lack of association of the myopathy risk score with other muscle symptoms reinforces randomized placebo-controlled evidence that statins do not cause the vast majority of reported muscle symptoms. ![]()
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Affiliation(s)
- Jemma C Hopewell
- Clinical Trial Service Unit and Epidemiological Studies Unit, Nuffield Department of Population Health, Big Data Institute, University of Oxford, Old Road Campus, Oxford OX3 7LF, UK
| | - Alison Offer
- Clinical Trial Service Unit and Epidemiological Studies Unit, Nuffield Department of Population Health, Big Data Institute, University of Oxford, Old Road Campus, Oxford OX3 7LF, UK
| | - Richard Haynes
- Clinical Trial Service Unit and Epidemiological Studies Unit, Nuffield Department of Population Health, Big Data Institute, University of Oxford, Old Road Campus, Oxford OX3 7LF, UK.,MRC Population Health Research Unit, Nuffield Department of Population Health, University of Oxford, Richard Doll Building, Old Road Campus, Oxford OX3 7LF, UK
| | - Louise Bowman
- Clinical Trial Service Unit and Epidemiological Studies Unit, Nuffield Department of Population Health, Big Data Institute, University of Oxford, Old Road Campus, Oxford OX3 7LF, UK
| | - Jing Li
- National Clinical Research Center of Cardiovascular Diseases, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Fang Chen
- Clinical Trial Service Unit and Epidemiological Studies Unit, Nuffield Department of Population Health, Big Data Institute, University of Oxford, Old Road Campus, Oxford OX3 7LF, UK
| | - Richard Bulbulia
- Clinical Trial Service Unit and Epidemiological Studies Unit, Nuffield Department of Population Health, Big Data Institute, University of Oxford, Old Road Campus, Oxford OX3 7LF, UK
| | - Mark Lathrop
- McGill University and Génome Québec Innovation Centre, 740 Dr Penfield Ave, Montréal, Québec H3A 0G1, Canada
| | - Colin Baigent
- Clinical Trial Service Unit and Epidemiological Studies Unit, Nuffield Department of Population Health, Big Data Institute, University of Oxford, Old Road Campus, Oxford OX3 7LF, UK.,MRC Population Health Research Unit, Nuffield Department of Population Health, University of Oxford, Richard Doll Building, Old Road Campus, Oxford OX3 7LF, UK
| | - Martin J Landray
- Clinical Trial Service Unit and Epidemiological Studies Unit, Nuffield Department of Population Health, Big Data Institute, University of Oxford, Old Road Campus, Oxford OX3 7LF, UK
| | - Rory Collins
- Clinical Trial Service Unit and Epidemiological Studies Unit, Nuffield Department of Population Health, Big Data Institute, University of Oxford, Old Road Campus, Oxford OX3 7LF, UK
| | - Jane Armitage
- Clinical Trial Service Unit and Epidemiological Studies Unit, Nuffield Department of Population Health, Big Data Institute, University of Oxford, Old Road Campus, Oxford OX3 7LF, UK.,MRC Population Health Research Unit, Nuffield Department of Population Health, University of Oxford, Richard Doll Building, Old Road Campus, Oxford OX3 7LF, UK
| | - Sarah Parish
- Clinical Trial Service Unit and Epidemiological Studies Unit, Nuffield Department of Population Health, Big Data Institute, University of Oxford, Old Road Campus, Oxford OX3 7LF, UK.,MRC Population Health Research Unit, Nuffield Department of Population Health, University of Oxford, Richard Doll Building, Old Road Campus, Oxford OX3 7LF, UK
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20
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Horby P, Lim WS, Emberson JR, Mafham M, Bell JL, Linsell L, Staplin N, Brightling C, Ustianowski A, Elmahi E, Prudon B, Green C, Felton T, Chadwick D, Rege K, Fegan C, Chappell LC, Faust SN, Jaki T, Jeffery K, Montgomery A, Rowan K, Juszczak E, Baillie JK, Haynes R, Landray MJ. Dexamethasone in Hospitalized Patients with Covid-19. N Engl J Med 2021. [PMID: 32678530 DOI: 10.1101/2020.06.22.20137273] [Citation(s) in RCA: 252] [Impact Index Per Article: 84.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/19/2023]
Abstract
BACKGROUND Coronavirus disease 2019 (Covid-19) is associated with diffuse lung damage. Glucocorticoids may modulate inflammation-mediated lung injury and thereby reduce progression to respiratory failure and death. METHODS In this controlled, open-label trial comparing a range of possible treatments in patients who were hospitalized with Covid-19, we randomly assigned patients to receive oral or intravenous dexamethasone (at a dose of 6 mg once daily) for up to 10 days or to receive usual care alone. The primary outcome was 28-day mortality. Here, we report the final results of this assessment. RESULTS A total of 2104 patients were assigned to receive dexamethasone and 4321 to receive usual care. Overall, 482 patients (22.9%) in the dexamethasone group and 1110 patients (25.7%) in the usual care group died within 28 days after randomization (age-adjusted rate ratio, 0.83; 95% confidence interval [CI], 0.75 to 0.93; P<0.001). The proportional and absolute between-group differences in mortality varied considerably according to the level of respiratory support that the patients were receiving at the time of randomization. In the dexamethasone group, the incidence of death was lower than that in the usual care group among patients receiving invasive mechanical ventilation (29.3% vs. 41.4%; rate ratio, 0.64; 95% CI, 0.51 to 0.81) and among those receiving oxygen without invasive mechanical ventilation (23.3% vs. 26.2%; rate ratio, 0.82; 95% CI, 0.72 to 0.94) but not among those who were receiving no respiratory support at randomization (17.8% vs. 14.0%; rate ratio, 1.19; 95% CI, 0.92 to 1.55). CONCLUSIONS In patients hospitalized with Covid-19, the use of dexamethasone resulted in lower 28-day mortality among those who were receiving either invasive mechanical ventilation or oxygen alone at randomization but not among those receiving no respiratory support. (Funded by the Medical Research Council and National Institute for Health Research and others; RECOVERY ClinicalTrials.gov number, NCT04381936; ISRCTN number, 50189673.).
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Affiliation(s)
- Peter Horby
- From the Nuffield Department of Medicine (P.H.), Nuffield Department of Population Health (J.R.E., M.M., J.L.B., L.L., N.S., E.J., R.H., M.J.L.), and MRC Population Health Research Unit (J.R.E., N.S., R.H., M.J.L.), University of Oxford, the Oxford University Hospitals NHS Foundation Trust (K.J.), and National Institute for Health Research (NIHR) Oxford Biomedical Research Centre (M.J.L.), Oxford, the Respiratory Medicine Department, Nottingham University Hospitals NHS Trust (W.S.L.), and the School of Medicine, University of Nottingham (A.M.), Nottingham, the Institute for Lung Health, Leicester NIHR Biomedical Research Centre, University of Leicester, Leicester (C.B.), the Regional Infectious Diseases Unit, North Manchester General Hospital and University of Manchester (A.U.), and the University of Manchester and Manchester University NHS Foundation Trust (T.F.), Manchester, the Research and Development Department, Northampton General Hospital, Northampton (E.E.), the Department of Respiratory Medicine, North Tees and Hartlepool NHS Foundation Trust, Stockton-on-Tees (B.P.), University Hospitals Birmingham NHS Foundation Trust and Institute of Microbiology and Infection, University of Birmingham, Birmingham (C.G.), the Centre for Clinical Infection, James Cook University Hospital, Middlesbrough (D.C.), the North West Anglia NHS Foundation Trust, Peterborough (K. Rege), the Department of Research and Development, Cardiff and Vale University Health Board, Cardiff (C.F.), the School of Life Course Sciences, King's College London (L.C.C.), and the Intensive Care National Audit and Research Centre (K. Rowan), London, the NIHR Southampton Clinical Research Facility and Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust and University of Southampton, Southampton (S.N.F.), the Department of Mathematics and Statistics, Lancaster University, Lancaster (T.J.), the MRC Biostatistics Unit, University of Cambridge, Cambridge (T.J.), and Roslin Institute, University of Edinburgh, Edinburgh (J.K.B.) - all in the United Kingdom
| | - Wei Shen Lim
- From the Nuffield Department of Medicine (P.H.), Nuffield Department of Population Health (J.R.E., M.M., J.L.B., L.L., N.S., E.J., R.H., M.J.L.), and MRC Population Health Research Unit (J.R.E., N.S., R.H., M.J.L.), University of Oxford, the Oxford University Hospitals NHS Foundation Trust (K.J.), and National Institute for Health Research (NIHR) Oxford Biomedical Research Centre (M.J.L.), Oxford, the Respiratory Medicine Department, Nottingham University Hospitals NHS Trust (W.S.L.), and the School of Medicine, University of Nottingham (A.M.), Nottingham, the Institute for Lung Health, Leicester NIHR Biomedical Research Centre, University of Leicester, Leicester (C.B.), the Regional Infectious Diseases Unit, North Manchester General Hospital and University of Manchester (A.U.), and the University of Manchester and Manchester University NHS Foundation Trust (T.F.), Manchester, the Research and Development Department, Northampton General Hospital, Northampton (E.E.), the Department of Respiratory Medicine, North Tees and Hartlepool NHS Foundation Trust, Stockton-on-Tees (B.P.), University Hospitals Birmingham NHS Foundation Trust and Institute of Microbiology and Infection, University of Birmingham, Birmingham (C.G.), the Centre for Clinical Infection, James Cook University Hospital, Middlesbrough (D.C.), the North West Anglia NHS Foundation Trust, Peterborough (K. Rege), the Department of Research and Development, Cardiff and Vale University Health Board, Cardiff (C.F.), the School of Life Course Sciences, King's College London (L.C.C.), and the Intensive Care National Audit and Research Centre (K. Rowan), London, the NIHR Southampton Clinical Research Facility and Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust and University of Southampton, Southampton (S.N.F.), the Department of Mathematics and Statistics, Lancaster University, Lancaster (T.J.), the MRC Biostatistics Unit, University of Cambridge, Cambridge (T.J.), and Roslin Institute, University of Edinburgh, Edinburgh (J.K.B.) - all in the United Kingdom
| | - Jonathan R Emberson
- From the Nuffield Department of Medicine (P.H.), Nuffield Department of Population Health (J.R.E., M.M., J.L.B., L.L., N.S., E.J., R.H., M.J.L.), and MRC Population Health Research Unit (J.R.E., N.S., R.H., M.J.L.), University of Oxford, the Oxford University Hospitals NHS Foundation Trust (K.J.), and National Institute for Health Research (NIHR) Oxford Biomedical Research Centre (M.J.L.), Oxford, the Respiratory Medicine Department, Nottingham University Hospitals NHS Trust (W.S.L.), and the School of Medicine, University of Nottingham (A.M.), Nottingham, the Institute for Lung Health, Leicester NIHR Biomedical Research Centre, University of Leicester, Leicester (C.B.), the Regional Infectious Diseases Unit, North Manchester General Hospital and University of Manchester (A.U.), and the University of Manchester and Manchester University NHS Foundation Trust (T.F.), Manchester, the Research and Development Department, Northampton General Hospital, Northampton (E.E.), the Department of Respiratory Medicine, North Tees and Hartlepool NHS Foundation Trust, Stockton-on-Tees (B.P.), University Hospitals Birmingham NHS Foundation Trust and Institute of Microbiology and Infection, University of Birmingham, Birmingham (C.G.), the Centre for Clinical Infection, James Cook University Hospital, Middlesbrough (D.C.), the North West Anglia NHS Foundation Trust, Peterborough (K. Rege), the Department of Research and Development, Cardiff and Vale University Health Board, Cardiff (C.F.), the School of Life Course Sciences, King's College London (L.C.C.), and the Intensive Care National Audit and Research Centre (K. Rowan), London, the NIHR Southampton Clinical Research Facility and Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust and University of Southampton, Southampton (S.N.F.), the Department of Mathematics and Statistics, Lancaster University, Lancaster (T.J.), the MRC Biostatistics Unit, University of Cambridge, Cambridge (T.J.), and Roslin Institute, University of Edinburgh, Edinburgh (J.K.B.) - all in the United Kingdom
| | - Marion Mafham
- From the Nuffield Department of Medicine (P.H.), Nuffield Department of Population Health (J.R.E., M.M., J.L.B., L.L., N.S., E.J., R.H., M.J.L.), and MRC Population Health Research Unit (J.R.E., N.S., R.H., M.J.L.), University of Oxford, the Oxford University Hospitals NHS Foundation Trust (K.J.), and National Institute for Health Research (NIHR) Oxford Biomedical Research Centre (M.J.L.), Oxford, the Respiratory Medicine Department, Nottingham University Hospitals NHS Trust (W.S.L.), and the School of Medicine, University of Nottingham (A.M.), Nottingham, the Institute for Lung Health, Leicester NIHR Biomedical Research Centre, University of Leicester, Leicester (C.B.), the Regional Infectious Diseases Unit, North Manchester General Hospital and University of Manchester (A.U.), and the University of Manchester and Manchester University NHS Foundation Trust (T.F.), Manchester, the Research and Development Department, Northampton General Hospital, Northampton (E.E.), the Department of Respiratory Medicine, North Tees and Hartlepool NHS Foundation Trust, Stockton-on-Tees (B.P.), University Hospitals Birmingham NHS Foundation Trust and Institute of Microbiology and Infection, University of Birmingham, Birmingham (C.G.), the Centre for Clinical Infection, James Cook University Hospital, Middlesbrough (D.C.), the North West Anglia NHS Foundation Trust, Peterborough (K. Rege), the Department of Research and Development, Cardiff and Vale University Health Board, Cardiff (C.F.), the School of Life Course Sciences, King's College London (L.C.C.), and the Intensive Care National Audit and Research Centre (K. Rowan), London, the NIHR Southampton Clinical Research Facility and Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust and University of Southampton, Southampton (S.N.F.), the Department of Mathematics and Statistics, Lancaster University, Lancaster (T.J.), the MRC Biostatistics Unit, University of Cambridge, Cambridge (T.J.), and Roslin Institute, University of Edinburgh, Edinburgh (J.K.B.) - all in the United Kingdom
| | - Jennifer L Bell
- From the Nuffield Department of Medicine (P.H.), Nuffield Department of Population Health (J.R.E., M.M., J.L.B., L.L., N.S., E.J., R.H., M.J.L.), and MRC Population Health Research Unit (J.R.E., N.S., R.H., M.J.L.), University of Oxford, the Oxford University Hospitals NHS Foundation Trust (K.J.), and National Institute for Health Research (NIHR) Oxford Biomedical Research Centre (M.J.L.), Oxford, the Respiratory Medicine Department, Nottingham University Hospitals NHS Trust (W.S.L.), and the School of Medicine, University of Nottingham (A.M.), Nottingham, the Institute for Lung Health, Leicester NIHR Biomedical Research Centre, University of Leicester, Leicester (C.B.), the Regional Infectious Diseases Unit, North Manchester General Hospital and University of Manchester (A.U.), and the University of Manchester and Manchester University NHS Foundation Trust (T.F.), Manchester, the Research and Development Department, Northampton General Hospital, Northampton (E.E.), the Department of Respiratory Medicine, North Tees and Hartlepool NHS Foundation Trust, Stockton-on-Tees (B.P.), University Hospitals Birmingham NHS Foundation Trust and Institute of Microbiology and Infection, University of Birmingham, Birmingham (C.G.), the Centre for Clinical Infection, James Cook University Hospital, Middlesbrough (D.C.), the North West Anglia NHS Foundation Trust, Peterborough (K. Rege), the Department of Research and Development, Cardiff and Vale University Health Board, Cardiff (C.F.), the School of Life Course Sciences, King's College London (L.C.C.), and the Intensive Care National Audit and Research Centre (K. Rowan), London, the NIHR Southampton Clinical Research Facility and Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust and University of Southampton, Southampton (S.N.F.), the Department of Mathematics and Statistics, Lancaster University, Lancaster (T.J.), the MRC Biostatistics Unit, University of Cambridge, Cambridge (T.J.), and Roslin Institute, University of Edinburgh, Edinburgh (J.K.B.) - all in the United Kingdom
| | - Louise Linsell
- From the Nuffield Department of Medicine (P.H.), Nuffield Department of Population Health (J.R.E., M.M., J.L.B., L.L., N.S., E.J., R.H., M.J.L.), and MRC Population Health Research Unit (J.R.E., N.S., R.H., M.J.L.), University of Oxford, the Oxford University Hospitals NHS Foundation Trust (K.J.), and National Institute for Health Research (NIHR) Oxford Biomedical Research Centre (M.J.L.), Oxford, the Respiratory Medicine Department, Nottingham University Hospitals NHS Trust (W.S.L.), and the School of Medicine, University of Nottingham (A.M.), Nottingham, the Institute for Lung Health, Leicester NIHR Biomedical Research Centre, University of Leicester, Leicester (C.B.), the Regional Infectious Diseases Unit, North Manchester General Hospital and University of Manchester (A.U.), and the University of Manchester and Manchester University NHS Foundation Trust (T.F.), Manchester, the Research and Development Department, Northampton General Hospital, Northampton (E.E.), the Department of Respiratory Medicine, North Tees and Hartlepool NHS Foundation Trust, Stockton-on-Tees (B.P.), University Hospitals Birmingham NHS Foundation Trust and Institute of Microbiology and Infection, University of Birmingham, Birmingham (C.G.), the Centre for Clinical Infection, James Cook University Hospital, Middlesbrough (D.C.), the North West Anglia NHS Foundation Trust, Peterborough (K. Rege), the Department of Research and Development, Cardiff and Vale University Health Board, Cardiff (C.F.), the School of Life Course Sciences, King's College London (L.C.C.), and the Intensive Care National Audit and Research Centre (K. Rowan), London, the NIHR Southampton Clinical Research Facility and Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust and University of Southampton, Southampton (S.N.F.), the Department of Mathematics and Statistics, Lancaster University, Lancaster (T.J.), the MRC Biostatistics Unit, University of Cambridge, Cambridge (T.J.), and Roslin Institute, University of Edinburgh, Edinburgh (J.K.B.) - all in the United Kingdom
| | - Natalie Staplin
- From the Nuffield Department of Medicine (P.H.), Nuffield Department of Population Health (J.R.E., M.M., J.L.B., L.L., N.S., E.J., R.H., M.J.L.), and MRC Population Health Research Unit (J.R.E., N.S., R.H., M.J.L.), University of Oxford, the Oxford University Hospitals NHS Foundation Trust (K.J.), and National Institute for Health Research (NIHR) Oxford Biomedical Research Centre (M.J.L.), Oxford, the Respiratory Medicine Department, Nottingham University Hospitals NHS Trust (W.S.L.), and the School of Medicine, University of Nottingham (A.M.), Nottingham, the Institute for Lung Health, Leicester NIHR Biomedical Research Centre, University of Leicester, Leicester (C.B.), the Regional Infectious Diseases Unit, North Manchester General Hospital and University of Manchester (A.U.), and the University of Manchester and Manchester University NHS Foundation Trust (T.F.), Manchester, the Research and Development Department, Northampton General Hospital, Northampton (E.E.), the Department of Respiratory Medicine, North Tees and Hartlepool NHS Foundation Trust, Stockton-on-Tees (B.P.), University Hospitals Birmingham NHS Foundation Trust and Institute of Microbiology and Infection, University of Birmingham, Birmingham (C.G.), the Centre for Clinical Infection, James Cook University Hospital, Middlesbrough (D.C.), the North West Anglia NHS Foundation Trust, Peterborough (K. Rege), the Department of Research and Development, Cardiff and Vale University Health Board, Cardiff (C.F.), the School of Life Course Sciences, King's College London (L.C.C.), and the Intensive Care National Audit and Research Centre (K. Rowan), London, the NIHR Southampton Clinical Research Facility and Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust and University of Southampton, Southampton (S.N.F.), the Department of Mathematics and Statistics, Lancaster University, Lancaster (T.J.), the MRC Biostatistics Unit, University of Cambridge, Cambridge (T.J.), and Roslin Institute, University of Edinburgh, Edinburgh (J.K.B.) - all in the United Kingdom
| | - Christopher Brightling
- From the Nuffield Department of Medicine (P.H.), Nuffield Department of Population Health (J.R.E., M.M., J.L.B., L.L., N.S., E.J., R.H., M.J.L.), and MRC Population Health Research Unit (J.R.E., N.S., R.H., M.J.L.), University of Oxford, the Oxford University Hospitals NHS Foundation Trust (K.J.), and National Institute for Health Research (NIHR) Oxford Biomedical Research Centre (M.J.L.), Oxford, the Respiratory Medicine Department, Nottingham University Hospitals NHS Trust (W.S.L.), and the School of Medicine, University of Nottingham (A.M.), Nottingham, the Institute for Lung Health, Leicester NIHR Biomedical Research Centre, University of Leicester, Leicester (C.B.), the Regional Infectious Diseases Unit, North Manchester General Hospital and University of Manchester (A.U.), and the University of Manchester and Manchester University NHS Foundation Trust (T.F.), Manchester, the Research and Development Department, Northampton General Hospital, Northampton (E.E.), the Department of Respiratory Medicine, North Tees and Hartlepool NHS Foundation Trust, Stockton-on-Tees (B.P.), University Hospitals Birmingham NHS Foundation Trust and Institute of Microbiology and Infection, University of Birmingham, Birmingham (C.G.), the Centre for Clinical Infection, James Cook University Hospital, Middlesbrough (D.C.), the North West Anglia NHS Foundation Trust, Peterborough (K. Rege), the Department of Research and Development, Cardiff and Vale University Health Board, Cardiff (C.F.), the School of Life Course Sciences, King's College London (L.C.C.), and the Intensive Care National Audit and Research Centre (K. Rowan), London, the NIHR Southampton Clinical Research Facility and Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust and University of Southampton, Southampton (S.N.F.), the Department of Mathematics and Statistics, Lancaster University, Lancaster (T.J.), the MRC Biostatistics Unit, University of Cambridge, Cambridge (T.J.), and Roslin Institute, University of Edinburgh, Edinburgh (J.K.B.) - all in the United Kingdom
| | - Andrew Ustianowski
- From the Nuffield Department of Medicine (P.H.), Nuffield Department of Population Health (J.R.E., M.M., J.L.B., L.L., N.S., E.J., R.H., M.J.L.), and MRC Population Health Research Unit (J.R.E., N.S., R.H., M.J.L.), University of Oxford, the Oxford University Hospitals NHS Foundation Trust (K.J.), and National Institute for Health Research (NIHR) Oxford Biomedical Research Centre (M.J.L.), Oxford, the Respiratory Medicine Department, Nottingham University Hospitals NHS Trust (W.S.L.), and the School of Medicine, University of Nottingham (A.M.), Nottingham, the Institute for Lung Health, Leicester NIHR Biomedical Research Centre, University of Leicester, Leicester (C.B.), the Regional Infectious Diseases Unit, North Manchester General Hospital and University of Manchester (A.U.), and the University of Manchester and Manchester University NHS Foundation Trust (T.F.), Manchester, the Research and Development Department, Northampton General Hospital, Northampton (E.E.), the Department of Respiratory Medicine, North Tees and Hartlepool NHS Foundation Trust, Stockton-on-Tees (B.P.), University Hospitals Birmingham NHS Foundation Trust and Institute of Microbiology and Infection, University of Birmingham, Birmingham (C.G.), the Centre for Clinical Infection, James Cook University Hospital, Middlesbrough (D.C.), the North West Anglia NHS Foundation Trust, Peterborough (K. Rege), the Department of Research and Development, Cardiff and Vale University Health Board, Cardiff (C.F.), the School of Life Course Sciences, King's College London (L.C.C.), and the Intensive Care National Audit and Research Centre (K. Rowan), London, the NIHR Southampton Clinical Research Facility and Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust and University of Southampton, Southampton (S.N.F.), the Department of Mathematics and Statistics, Lancaster University, Lancaster (T.J.), the MRC Biostatistics Unit, University of Cambridge, Cambridge (T.J.), and Roslin Institute, University of Edinburgh, Edinburgh (J.K.B.) - all in the United Kingdom
| | - Einas Elmahi
- From the Nuffield Department of Medicine (P.H.), Nuffield Department of Population Health (J.R.E., M.M., J.L.B., L.L., N.S., E.J., R.H., M.J.L.), and MRC Population Health Research Unit (J.R.E., N.S., R.H., M.J.L.), University of Oxford, the Oxford University Hospitals NHS Foundation Trust (K.J.), and National Institute for Health Research (NIHR) Oxford Biomedical Research Centre (M.J.L.), Oxford, the Respiratory Medicine Department, Nottingham University Hospitals NHS Trust (W.S.L.), and the School of Medicine, University of Nottingham (A.M.), Nottingham, the Institute for Lung Health, Leicester NIHR Biomedical Research Centre, University of Leicester, Leicester (C.B.), the Regional Infectious Diseases Unit, North Manchester General Hospital and University of Manchester (A.U.), and the University of Manchester and Manchester University NHS Foundation Trust (T.F.), Manchester, the Research and Development Department, Northampton General Hospital, Northampton (E.E.), the Department of Respiratory Medicine, North Tees and Hartlepool NHS Foundation Trust, Stockton-on-Tees (B.P.), University Hospitals Birmingham NHS Foundation Trust and Institute of Microbiology and Infection, University of Birmingham, Birmingham (C.G.), the Centre for Clinical Infection, James Cook University Hospital, Middlesbrough (D.C.), the North West Anglia NHS Foundation Trust, Peterborough (K. Rege), the Department of Research and Development, Cardiff and Vale University Health Board, Cardiff (C.F.), the School of Life Course Sciences, King's College London (L.C.C.), and the Intensive Care National Audit and Research Centre (K. Rowan), London, the NIHR Southampton Clinical Research Facility and Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust and University of Southampton, Southampton (S.N.F.), the Department of Mathematics and Statistics, Lancaster University, Lancaster (T.J.), the MRC Biostatistics Unit, University of Cambridge, Cambridge (T.J.), and Roslin Institute, University of Edinburgh, Edinburgh (J.K.B.) - all in the United Kingdom
| | - Benjamin Prudon
- From the Nuffield Department of Medicine (P.H.), Nuffield Department of Population Health (J.R.E., M.M., J.L.B., L.L., N.S., E.J., R.H., M.J.L.), and MRC Population Health Research Unit (J.R.E., N.S., R.H., M.J.L.), University of Oxford, the Oxford University Hospitals NHS Foundation Trust (K.J.), and National Institute for Health Research (NIHR) Oxford Biomedical Research Centre (M.J.L.), Oxford, the Respiratory Medicine Department, Nottingham University Hospitals NHS Trust (W.S.L.), and the School of Medicine, University of Nottingham (A.M.), Nottingham, the Institute for Lung Health, Leicester NIHR Biomedical Research Centre, University of Leicester, Leicester (C.B.), the Regional Infectious Diseases Unit, North Manchester General Hospital and University of Manchester (A.U.), and the University of Manchester and Manchester University NHS Foundation Trust (T.F.), Manchester, the Research and Development Department, Northampton General Hospital, Northampton (E.E.), the Department of Respiratory Medicine, North Tees and Hartlepool NHS Foundation Trust, Stockton-on-Tees (B.P.), University Hospitals Birmingham NHS Foundation Trust and Institute of Microbiology and Infection, University of Birmingham, Birmingham (C.G.), the Centre for Clinical Infection, James Cook University Hospital, Middlesbrough (D.C.), the North West Anglia NHS Foundation Trust, Peterborough (K. Rege), the Department of Research and Development, Cardiff and Vale University Health Board, Cardiff (C.F.), the School of Life Course Sciences, King's College London (L.C.C.), and the Intensive Care National Audit and Research Centre (K. Rowan), London, the NIHR Southampton Clinical Research Facility and Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust and University of Southampton, Southampton (S.N.F.), the Department of Mathematics and Statistics, Lancaster University, Lancaster (T.J.), the MRC Biostatistics Unit, University of Cambridge, Cambridge (T.J.), and Roslin Institute, University of Edinburgh, Edinburgh (J.K.B.) - all in the United Kingdom
| | - Christopher Green
- From the Nuffield Department of Medicine (P.H.), Nuffield Department of Population Health (J.R.E., M.M., J.L.B., L.L., N.S., E.J., R.H., M.J.L.), and MRC Population Health Research Unit (J.R.E., N.S., R.H., M.J.L.), University of Oxford, the Oxford University Hospitals NHS Foundation Trust (K.J.), and National Institute for Health Research (NIHR) Oxford Biomedical Research Centre (M.J.L.), Oxford, the Respiratory Medicine Department, Nottingham University Hospitals NHS Trust (W.S.L.), and the School of Medicine, University of Nottingham (A.M.), Nottingham, the Institute for Lung Health, Leicester NIHR Biomedical Research Centre, University of Leicester, Leicester (C.B.), the Regional Infectious Diseases Unit, North Manchester General Hospital and University of Manchester (A.U.), and the University of Manchester and Manchester University NHS Foundation Trust (T.F.), Manchester, the Research and Development Department, Northampton General Hospital, Northampton (E.E.), the Department of Respiratory Medicine, North Tees and Hartlepool NHS Foundation Trust, Stockton-on-Tees (B.P.), University Hospitals Birmingham NHS Foundation Trust and Institute of Microbiology and Infection, University of Birmingham, Birmingham (C.G.), the Centre for Clinical Infection, James Cook University Hospital, Middlesbrough (D.C.), the North West Anglia NHS Foundation Trust, Peterborough (K. Rege), the Department of Research and Development, Cardiff and Vale University Health Board, Cardiff (C.F.), the School of Life Course Sciences, King's College London (L.C.C.), and the Intensive Care National Audit and Research Centre (K. Rowan), London, the NIHR Southampton Clinical Research Facility and Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust and University of Southampton, Southampton (S.N.F.), the Department of Mathematics and Statistics, Lancaster University, Lancaster (T.J.), the MRC Biostatistics Unit, University of Cambridge, Cambridge (T.J.), and Roslin Institute, University of Edinburgh, Edinburgh (J.K.B.) - all in the United Kingdom
| | - Timothy Felton
- From the Nuffield Department of Medicine (P.H.), Nuffield Department of Population Health (J.R.E., M.M., J.L.B., L.L., N.S., E.J., R.H., M.J.L.), and MRC Population Health Research Unit (J.R.E., N.S., R.H., M.J.L.), University of Oxford, the Oxford University Hospitals NHS Foundation Trust (K.J.), and National Institute for Health Research (NIHR) Oxford Biomedical Research Centre (M.J.L.), Oxford, the Respiratory Medicine Department, Nottingham University Hospitals NHS Trust (W.S.L.), and the School of Medicine, University of Nottingham (A.M.), Nottingham, the Institute for Lung Health, Leicester NIHR Biomedical Research Centre, University of Leicester, Leicester (C.B.), the Regional Infectious Diseases Unit, North Manchester General Hospital and University of Manchester (A.U.), and the University of Manchester and Manchester University NHS Foundation Trust (T.F.), Manchester, the Research and Development Department, Northampton General Hospital, Northampton (E.E.), the Department of Respiratory Medicine, North Tees and Hartlepool NHS Foundation Trust, Stockton-on-Tees (B.P.), University Hospitals Birmingham NHS Foundation Trust and Institute of Microbiology and Infection, University of Birmingham, Birmingham (C.G.), the Centre for Clinical Infection, James Cook University Hospital, Middlesbrough (D.C.), the North West Anglia NHS Foundation Trust, Peterborough (K. Rege), the Department of Research and Development, Cardiff and Vale University Health Board, Cardiff (C.F.), the School of Life Course Sciences, King's College London (L.C.C.), and the Intensive Care National Audit and Research Centre (K. Rowan), London, the NIHR Southampton Clinical Research Facility and Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust and University of Southampton, Southampton (S.N.F.), the Department of Mathematics and Statistics, Lancaster University, Lancaster (T.J.), the MRC Biostatistics Unit, University of Cambridge, Cambridge (T.J.), and Roslin Institute, University of Edinburgh, Edinburgh (J.K.B.) - all in the United Kingdom
| | - David Chadwick
- From the Nuffield Department of Medicine (P.H.), Nuffield Department of Population Health (J.R.E., M.M., J.L.B., L.L., N.S., E.J., R.H., M.J.L.), and MRC Population Health Research Unit (J.R.E., N.S., R.H., M.J.L.), University of Oxford, the Oxford University Hospitals NHS Foundation Trust (K.J.), and National Institute for Health Research (NIHR) Oxford Biomedical Research Centre (M.J.L.), Oxford, the Respiratory Medicine Department, Nottingham University Hospitals NHS Trust (W.S.L.), and the School of Medicine, University of Nottingham (A.M.), Nottingham, the Institute for Lung Health, Leicester NIHR Biomedical Research Centre, University of Leicester, Leicester (C.B.), the Regional Infectious Diseases Unit, North Manchester General Hospital and University of Manchester (A.U.), and the University of Manchester and Manchester University NHS Foundation Trust (T.F.), Manchester, the Research and Development Department, Northampton General Hospital, Northampton (E.E.), the Department of Respiratory Medicine, North Tees and Hartlepool NHS Foundation Trust, Stockton-on-Tees (B.P.), University Hospitals Birmingham NHS Foundation Trust and Institute of Microbiology and Infection, University of Birmingham, Birmingham (C.G.), the Centre for Clinical Infection, James Cook University Hospital, Middlesbrough (D.C.), the North West Anglia NHS Foundation Trust, Peterborough (K. Rege), the Department of Research and Development, Cardiff and Vale University Health Board, Cardiff (C.F.), the School of Life Course Sciences, King's College London (L.C.C.), and the Intensive Care National Audit and Research Centre (K. Rowan), London, the NIHR Southampton Clinical Research Facility and Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust and University of Southampton, Southampton (S.N.F.), the Department of Mathematics and Statistics, Lancaster University, Lancaster (T.J.), the MRC Biostatistics Unit, University of Cambridge, Cambridge (T.J.), and Roslin Institute, University of Edinburgh, Edinburgh (J.K.B.) - all in the United Kingdom
| | - Kanchan Rege
- From the Nuffield Department of Medicine (P.H.), Nuffield Department of Population Health (J.R.E., M.M., J.L.B., L.L., N.S., E.J., R.H., M.J.L.), and MRC Population Health Research Unit (J.R.E., N.S., R.H., M.J.L.), University of Oxford, the Oxford University Hospitals NHS Foundation Trust (K.J.), and National Institute for Health Research (NIHR) Oxford Biomedical Research Centre (M.J.L.), Oxford, the Respiratory Medicine Department, Nottingham University Hospitals NHS Trust (W.S.L.), and the School of Medicine, University of Nottingham (A.M.), Nottingham, the Institute for Lung Health, Leicester NIHR Biomedical Research Centre, University of Leicester, Leicester (C.B.), the Regional Infectious Diseases Unit, North Manchester General Hospital and University of Manchester (A.U.), and the University of Manchester and Manchester University NHS Foundation Trust (T.F.), Manchester, the Research and Development Department, Northampton General Hospital, Northampton (E.E.), the Department of Respiratory Medicine, North Tees and Hartlepool NHS Foundation Trust, Stockton-on-Tees (B.P.), University Hospitals Birmingham NHS Foundation Trust and Institute of Microbiology and Infection, University of Birmingham, Birmingham (C.G.), the Centre for Clinical Infection, James Cook University Hospital, Middlesbrough (D.C.), the North West Anglia NHS Foundation Trust, Peterborough (K. Rege), the Department of Research and Development, Cardiff and Vale University Health Board, Cardiff (C.F.), the School of Life Course Sciences, King's College London (L.C.C.), and the Intensive Care National Audit and Research Centre (K. Rowan), London, the NIHR Southampton Clinical Research Facility and Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust and University of Southampton, Southampton (S.N.F.), the Department of Mathematics and Statistics, Lancaster University, Lancaster (T.J.), the MRC Biostatistics Unit, University of Cambridge, Cambridge (T.J.), and Roslin Institute, University of Edinburgh, Edinburgh (J.K.B.) - all in the United Kingdom
| | - Christopher Fegan
- From the Nuffield Department of Medicine (P.H.), Nuffield Department of Population Health (J.R.E., M.M., J.L.B., L.L., N.S., E.J., R.H., M.J.L.), and MRC Population Health Research Unit (J.R.E., N.S., R.H., M.J.L.), University of Oxford, the Oxford University Hospitals NHS Foundation Trust (K.J.), and National Institute for Health Research (NIHR) Oxford Biomedical Research Centre (M.J.L.), Oxford, the Respiratory Medicine Department, Nottingham University Hospitals NHS Trust (W.S.L.), and the School of Medicine, University of Nottingham (A.M.), Nottingham, the Institute for Lung Health, Leicester NIHR Biomedical Research Centre, University of Leicester, Leicester (C.B.), the Regional Infectious Diseases Unit, North Manchester General Hospital and University of Manchester (A.U.), and the University of Manchester and Manchester University NHS Foundation Trust (T.F.), Manchester, the Research and Development Department, Northampton General Hospital, Northampton (E.E.), the Department of Respiratory Medicine, North Tees and Hartlepool NHS Foundation Trust, Stockton-on-Tees (B.P.), University Hospitals Birmingham NHS Foundation Trust and Institute of Microbiology and Infection, University of Birmingham, Birmingham (C.G.), the Centre for Clinical Infection, James Cook University Hospital, Middlesbrough (D.C.), the North West Anglia NHS Foundation Trust, Peterborough (K. Rege), the Department of Research and Development, Cardiff and Vale University Health Board, Cardiff (C.F.), the School of Life Course Sciences, King's College London (L.C.C.), and the Intensive Care National Audit and Research Centre (K. Rowan), London, the NIHR Southampton Clinical Research Facility and Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust and University of Southampton, Southampton (S.N.F.), the Department of Mathematics and Statistics, Lancaster University, Lancaster (T.J.), the MRC Biostatistics Unit, University of Cambridge, Cambridge (T.J.), and Roslin Institute, University of Edinburgh, Edinburgh (J.K.B.) - all in the United Kingdom
| | - Lucy C Chappell
- From the Nuffield Department of Medicine (P.H.), Nuffield Department of Population Health (J.R.E., M.M., J.L.B., L.L., N.S., E.J., R.H., M.J.L.), and MRC Population Health Research Unit (J.R.E., N.S., R.H., M.J.L.), University of Oxford, the Oxford University Hospitals NHS Foundation Trust (K.J.), and National Institute for Health Research (NIHR) Oxford Biomedical Research Centre (M.J.L.), Oxford, the Respiratory Medicine Department, Nottingham University Hospitals NHS Trust (W.S.L.), and the School of Medicine, University of Nottingham (A.M.), Nottingham, the Institute for Lung Health, Leicester NIHR Biomedical Research Centre, University of Leicester, Leicester (C.B.), the Regional Infectious Diseases Unit, North Manchester General Hospital and University of Manchester (A.U.), and the University of Manchester and Manchester University NHS Foundation Trust (T.F.), Manchester, the Research and Development Department, Northampton General Hospital, Northampton (E.E.), the Department of Respiratory Medicine, North Tees and Hartlepool NHS Foundation Trust, Stockton-on-Tees (B.P.), University Hospitals Birmingham NHS Foundation Trust and Institute of Microbiology and Infection, University of Birmingham, Birmingham (C.G.), the Centre for Clinical Infection, James Cook University Hospital, Middlesbrough (D.C.), the North West Anglia NHS Foundation Trust, Peterborough (K. Rege), the Department of Research and Development, Cardiff and Vale University Health Board, Cardiff (C.F.), the School of Life Course Sciences, King's College London (L.C.C.), and the Intensive Care National Audit and Research Centre (K. Rowan), London, the NIHR Southampton Clinical Research Facility and Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust and University of Southampton, Southampton (S.N.F.), the Department of Mathematics and Statistics, Lancaster University, Lancaster (T.J.), the MRC Biostatistics Unit, University of Cambridge, Cambridge (T.J.), and Roslin Institute, University of Edinburgh, Edinburgh (J.K.B.) - all in the United Kingdom
| | - Saul N Faust
- From the Nuffield Department of Medicine (P.H.), Nuffield Department of Population Health (J.R.E., M.M., J.L.B., L.L., N.S., E.J., R.H., M.J.L.), and MRC Population Health Research Unit (J.R.E., N.S., R.H., M.J.L.), University of Oxford, the Oxford University Hospitals NHS Foundation Trust (K.J.), and National Institute for Health Research (NIHR) Oxford Biomedical Research Centre (M.J.L.), Oxford, the Respiratory Medicine Department, Nottingham University Hospitals NHS Trust (W.S.L.), and the School of Medicine, University of Nottingham (A.M.), Nottingham, the Institute for Lung Health, Leicester NIHR Biomedical Research Centre, University of Leicester, Leicester (C.B.), the Regional Infectious Diseases Unit, North Manchester General Hospital and University of Manchester (A.U.), and the University of Manchester and Manchester University NHS Foundation Trust (T.F.), Manchester, the Research and Development Department, Northampton General Hospital, Northampton (E.E.), the Department of Respiratory Medicine, North Tees and Hartlepool NHS Foundation Trust, Stockton-on-Tees (B.P.), University Hospitals Birmingham NHS Foundation Trust and Institute of Microbiology and Infection, University of Birmingham, Birmingham (C.G.), the Centre for Clinical Infection, James Cook University Hospital, Middlesbrough (D.C.), the North West Anglia NHS Foundation Trust, Peterborough (K. Rege), the Department of Research and Development, Cardiff and Vale University Health Board, Cardiff (C.F.), the School of Life Course Sciences, King's College London (L.C.C.), and the Intensive Care National Audit and Research Centre (K. Rowan), London, the NIHR Southampton Clinical Research Facility and Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust and University of Southampton, Southampton (S.N.F.), the Department of Mathematics and Statistics, Lancaster University, Lancaster (T.J.), the MRC Biostatistics Unit, University of Cambridge, Cambridge (T.J.), and Roslin Institute, University of Edinburgh, Edinburgh (J.K.B.) - all in the United Kingdom
| | - Thomas Jaki
- From the Nuffield Department of Medicine (P.H.), Nuffield Department of Population Health (J.R.E., M.M., J.L.B., L.L., N.S., E.J., R.H., M.J.L.), and MRC Population Health Research Unit (J.R.E., N.S., R.H., M.J.L.), University of Oxford, the Oxford University Hospitals NHS Foundation Trust (K.J.), and National Institute for Health Research (NIHR) Oxford Biomedical Research Centre (M.J.L.), Oxford, the Respiratory Medicine Department, Nottingham University Hospitals NHS Trust (W.S.L.), and the School of Medicine, University of Nottingham (A.M.), Nottingham, the Institute for Lung Health, Leicester NIHR Biomedical Research Centre, University of Leicester, Leicester (C.B.), the Regional Infectious Diseases Unit, North Manchester General Hospital and University of Manchester (A.U.), and the University of Manchester and Manchester University NHS Foundation Trust (T.F.), Manchester, the Research and Development Department, Northampton General Hospital, Northampton (E.E.), the Department of Respiratory Medicine, North Tees and Hartlepool NHS Foundation Trust, Stockton-on-Tees (B.P.), University Hospitals Birmingham NHS Foundation Trust and Institute of Microbiology and Infection, University of Birmingham, Birmingham (C.G.), the Centre for Clinical Infection, James Cook University Hospital, Middlesbrough (D.C.), the North West Anglia NHS Foundation Trust, Peterborough (K. Rege), the Department of Research and Development, Cardiff and Vale University Health Board, Cardiff (C.F.), the School of Life Course Sciences, King's College London (L.C.C.), and the Intensive Care National Audit and Research Centre (K. Rowan), London, the NIHR Southampton Clinical Research Facility and Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust and University of Southampton, Southampton (S.N.F.), the Department of Mathematics and Statistics, Lancaster University, Lancaster (T.J.), the MRC Biostatistics Unit, University of Cambridge, Cambridge (T.J.), and Roslin Institute, University of Edinburgh, Edinburgh (J.K.B.) - all in the United Kingdom
| | - Katie Jeffery
- From the Nuffield Department of Medicine (P.H.), Nuffield Department of Population Health (J.R.E., M.M., J.L.B., L.L., N.S., E.J., R.H., M.J.L.), and MRC Population Health Research Unit (J.R.E., N.S., R.H., M.J.L.), University of Oxford, the Oxford University Hospitals NHS Foundation Trust (K.J.), and National Institute for Health Research (NIHR) Oxford Biomedical Research Centre (M.J.L.), Oxford, the Respiratory Medicine Department, Nottingham University Hospitals NHS Trust (W.S.L.), and the School of Medicine, University of Nottingham (A.M.), Nottingham, the Institute for Lung Health, Leicester NIHR Biomedical Research Centre, University of Leicester, Leicester (C.B.), the Regional Infectious Diseases Unit, North Manchester General Hospital and University of Manchester (A.U.), and the University of Manchester and Manchester University NHS Foundation Trust (T.F.), Manchester, the Research and Development Department, Northampton General Hospital, Northampton (E.E.), the Department of Respiratory Medicine, North Tees and Hartlepool NHS Foundation Trust, Stockton-on-Tees (B.P.), University Hospitals Birmingham NHS Foundation Trust and Institute of Microbiology and Infection, University of Birmingham, Birmingham (C.G.), the Centre for Clinical Infection, James Cook University Hospital, Middlesbrough (D.C.), the North West Anglia NHS Foundation Trust, Peterborough (K. Rege), the Department of Research and Development, Cardiff and Vale University Health Board, Cardiff (C.F.), the School of Life Course Sciences, King's College London (L.C.C.), and the Intensive Care National Audit and Research Centre (K. Rowan), London, the NIHR Southampton Clinical Research Facility and Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust and University of Southampton, Southampton (S.N.F.), the Department of Mathematics and Statistics, Lancaster University, Lancaster (T.J.), the MRC Biostatistics Unit, University of Cambridge, Cambridge (T.J.), and Roslin Institute, University of Edinburgh, Edinburgh (J.K.B.) - all in the United Kingdom
| | - Alan Montgomery
- From the Nuffield Department of Medicine (P.H.), Nuffield Department of Population Health (J.R.E., M.M., J.L.B., L.L., N.S., E.J., R.H., M.J.L.), and MRC Population Health Research Unit (J.R.E., N.S., R.H., M.J.L.), University of Oxford, the Oxford University Hospitals NHS Foundation Trust (K.J.), and National Institute for Health Research (NIHR) Oxford Biomedical Research Centre (M.J.L.), Oxford, the Respiratory Medicine Department, Nottingham University Hospitals NHS Trust (W.S.L.), and the School of Medicine, University of Nottingham (A.M.), Nottingham, the Institute for Lung Health, Leicester NIHR Biomedical Research Centre, University of Leicester, Leicester (C.B.), the Regional Infectious Diseases Unit, North Manchester General Hospital and University of Manchester (A.U.), and the University of Manchester and Manchester University NHS Foundation Trust (T.F.), Manchester, the Research and Development Department, Northampton General Hospital, Northampton (E.E.), the Department of Respiratory Medicine, North Tees and Hartlepool NHS Foundation Trust, Stockton-on-Tees (B.P.), University Hospitals Birmingham NHS Foundation Trust and Institute of Microbiology and Infection, University of Birmingham, Birmingham (C.G.), the Centre for Clinical Infection, James Cook University Hospital, Middlesbrough (D.C.), the North West Anglia NHS Foundation Trust, Peterborough (K. Rege), the Department of Research and Development, Cardiff and Vale University Health Board, Cardiff (C.F.), the School of Life Course Sciences, King's College London (L.C.C.), and the Intensive Care National Audit and Research Centre (K. Rowan), London, the NIHR Southampton Clinical Research Facility and Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust and University of Southampton, Southampton (S.N.F.), the Department of Mathematics and Statistics, Lancaster University, Lancaster (T.J.), the MRC Biostatistics Unit, University of Cambridge, Cambridge (T.J.), and Roslin Institute, University of Edinburgh, Edinburgh (J.K.B.) - all in the United Kingdom
| | - Kathryn Rowan
- From the Nuffield Department of Medicine (P.H.), Nuffield Department of Population Health (J.R.E., M.M., J.L.B., L.L., N.S., E.J., R.H., M.J.L.), and MRC Population Health Research Unit (J.R.E., N.S., R.H., M.J.L.), University of Oxford, the Oxford University Hospitals NHS Foundation Trust (K.J.), and National Institute for Health Research (NIHR) Oxford Biomedical Research Centre (M.J.L.), Oxford, the Respiratory Medicine Department, Nottingham University Hospitals NHS Trust (W.S.L.), and the School of Medicine, University of Nottingham (A.M.), Nottingham, the Institute for Lung Health, Leicester NIHR Biomedical Research Centre, University of Leicester, Leicester (C.B.), the Regional Infectious Diseases Unit, North Manchester General Hospital and University of Manchester (A.U.), and the University of Manchester and Manchester University NHS Foundation Trust (T.F.), Manchester, the Research and Development Department, Northampton General Hospital, Northampton (E.E.), the Department of Respiratory Medicine, North Tees and Hartlepool NHS Foundation Trust, Stockton-on-Tees (B.P.), University Hospitals Birmingham NHS Foundation Trust and Institute of Microbiology and Infection, University of Birmingham, Birmingham (C.G.), the Centre for Clinical Infection, James Cook University Hospital, Middlesbrough (D.C.), the North West Anglia NHS Foundation Trust, Peterborough (K. Rege), the Department of Research and Development, Cardiff and Vale University Health Board, Cardiff (C.F.), the School of Life Course Sciences, King's College London (L.C.C.), and the Intensive Care National Audit and Research Centre (K. Rowan), London, the NIHR Southampton Clinical Research Facility and Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust and University of Southampton, Southampton (S.N.F.), the Department of Mathematics and Statistics, Lancaster University, Lancaster (T.J.), the MRC Biostatistics Unit, University of Cambridge, Cambridge (T.J.), and Roslin Institute, University of Edinburgh, Edinburgh (J.K.B.) - all in the United Kingdom
| | - Edmund Juszczak
- From the Nuffield Department of Medicine (P.H.), Nuffield Department of Population Health (J.R.E., M.M., J.L.B., L.L., N.S., E.J., R.H., M.J.L.), and MRC Population Health Research Unit (J.R.E., N.S., R.H., M.J.L.), University of Oxford, the Oxford University Hospitals NHS Foundation Trust (K.J.), and National Institute for Health Research (NIHR) Oxford Biomedical Research Centre (M.J.L.), Oxford, the Respiratory Medicine Department, Nottingham University Hospitals NHS Trust (W.S.L.), and the School of Medicine, University of Nottingham (A.M.), Nottingham, the Institute for Lung Health, Leicester NIHR Biomedical Research Centre, University of Leicester, Leicester (C.B.), the Regional Infectious Diseases Unit, North Manchester General Hospital and University of Manchester (A.U.), and the University of Manchester and Manchester University NHS Foundation Trust (T.F.), Manchester, the Research and Development Department, Northampton General Hospital, Northampton (E.E.), the Department of Respiratory Medicine, North Tees and Hartlepool NHS Foundation Trust, Stockton-on-Tees (B.P.), University Hospitals Birmingham NHS Foundation Trust and Institute of Microbiology and Infection, University of Birmingham, Birmingham (C.G.), the Centre for Clinical Infection, James Cook University Hospital, Middlesbrough (D.C.), the North West Anglia NHS Foundation Trust, Peterborough (K. Rege), the Department of Research and Development, Cardiff and Vale University Health Board, Cardiff (C.F.), the School of Life Course Sciences, King's College London (L.C.C.), and the Intensive Care National Audit and Research Centre (K. Rowan), London, the NIHR Southampton Clinical Research Facility and Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust and University of Southampton, Southampton (S.N.F.), the Department of Mathematics and Statistics, Lancaster University, Lancaster (T.J.), the MRC Biostatistics Unit, University of Cambridge, Cambridge (T.J.), and Roslin Institute, University of Edinburgh, Edinburgh (J.K.B.) - all in the United Kingdom
| | - J Kenneth Baillie
- From the Nuffield Department of Medicine (P.H.), Nuffield Department of Population Health (J.R.E., M.M., J.L.B., L.L., N.S., E.J., R.H., M.J.L.), and MRC Population Health Research Unit (J.R.E., N.S., R.H., M.J.L.), University of Oxford, the Oxford University Hospitals NHS Foundation Trust (K.J.), and National Institute for Health Research (NIHR) Oxford Biomedical Research Centre (M.J.L.), Oxford, the Respiratory Medicine Department, Nottingham University Hospitals NHS Trust (W.S.L.), and the School of Medicine, University of Nottingham (A.M.), Nottingham, the Institute for Lung Health, Leicester NIHR Biomedical Research Centre, University of Leicester, Leicester (C.B.), the Regional Infectious Diseases Unit, North Manchester General Hospital and University of Manchester (A.U.), and the University of Manchester and Manchester University NHS Foundation Trust (T.F.), Manchester, the Research and Development Department, Northampton General Hospital, Northampton (E.E.), the Department of Respiratory Medicine, North Tees and Hartlepool NHS Foundation Trust, Stockton-on-Tees (B.P.), University Hospitals Birmingham NHS Foundation Trust and Institute of Microbiology and Infection, University of Birmingham, Birmingham (C.G.), the Centre for Clinical Infection, James Cook University Hospital, Middlesbrough (D.C.), the North West Anglia NHS Foundation Trust, Peterborough (K. Rege), the Department of Research and Development, Cardiff and Vale University Health Board, Cardiff (C.F.), the School of Life Course Sciences, King's College London (L.C.C.), and the Intensive Care National Audit and Research Centre (K. Rowan), London, the NIHR Southampton Clinical Research Facility and Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust and University of Southampton, Southampton (S.N.F.), the Department of Mathematics and Statistics, Lancaster University, Lancaster (T.J.), the MRC Biostatistics Unit, University of Cambridge, Cambridge (T.J.), and Roslin Institute, University of Edinburgh, Edinburgh (J.K.B.) - all in the United Kingdom
| | - Richard Haynes
- From the Nuffield Department of Medicine (P.H.), Nuffield Department of Population Health (J.R.E., M.M., J.L.B., L.L., N.S., E.J., R.H., M.J.L.), and MRC Population Health Research Unit (J.R.E., N.S., R.H., M.J.L.), University of Oxford, the Oxford University Hospitals NHS Foundation Trust (K.J.), and National Institute for Health Research (NIHR) Oxford Biomedical Research Centre (M.J.L.), Oxford, the Respiratory Medicine Department, Nottingham University Hospitals NHS Trust (W.S.L.), and the School of Medicine, University of Nottingham (A.M.), Nottingham, the Institute for Lung Health, Leicester NIHR Biomedical Research Centre, University of Leicester, Leicester (C.B.), the Regional Infectious Diseases Unit, North Manchester General Hospital and University of Manchester (A.U.), and the University of Manchester and Manchester University NHS Foundation Trust (T.F.), Manchester, the Research and Development Department, Northampton General Hospital, Northampton (E.E.), the Department of Respiratory Medicine, North Tees and Hartlepool NHS Foundation Trust, Stockton-on-Tees (B.P.), University Hospitals Birmingham NHS Foundation Trust and Institute of Microbiology and Infection, University of Birmingham, Birmingham (C.G.), the Centre for Clinical Infection, James Cook University Hospital, Middlesbrough (D.C.), the North West Anglia NHS Foundation Trust, Peterborough (K. Rege), the Department of Research and Development, Cardiff and Vale University Health Board, Cardiff (C.F.), the School of Life Course Sciences, King's College London (L.C.C.), and the Intensive Care National Audit and Research Centre (K. Rowan), London, the NIHR Southampton Clinical Research Facility and Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust and University of Southampton, Southampton (S.N.F.), the Department of Mathematics and Statistics, Lancaster University, Lancaster (T.J.), the MRC Biostatistics Unit, University of Cambridge, Cambridge (T.J.), and Roslin Institute, University of Edinburgh, Edinburgh (J.K.B.) - all in the United Kingdom
| | - Martin J Landray
- From the Nuffield Department of Medicine (P.H.), Nuffield Department of Population Health (J.R.E., M.M., J.L.B., L.L., N.S., E.J., R.H., M.J.L.), and MRC Population Health Research Unit (J.R.E., N.S., R.H., M.J.L.), University of Oxford, the Oxford University Hospitals NHS Foundation Trust (K.J.), and National Institute for Health Research (NIHR) Oxford Biomedical Research Centre (M.J.L.), Oxford, the Respiratory Medicine Department, Nottingham University Hospitals NHS Trust (W.S.L.), and the School of Medicine, University of Nottingham (A.M.), Nottingham, the Institute for Lung Health, Leicester NIHR Biomedical Research Centre, University of Leicester, Leicester (C.B.), the Regional Infectious Diseases Unit, North Manchester General Hospital and University of Manchester (A.U.), and the University of Manchester and Manchester University NHS Foundation Trust (T.F.), Manchester, the Research and Development Department, Northampton General Hospital, Northampton (E.E.), the Department of Respiratory Medicine, North Tees and Hartlepool NHS Foundation Trust, Stockton-on-Tees (B.P.), University Hospitals Birmingham NHS Foundation Trust and Institute of Microbiology and Infection, University of Birmingham, Birmingham (C.G.), the Centre for Clinical Infection, James Cook University Hospital, Middlesbrough (D.C.), the North West Anglia NHS Foundation Trust, Peterborough (K. Rege), the Department of Research and Development, Cardiff and Vale University Health Board, Cardiff (C.F.), the School of Life Course Sciences, King's College London (L.C.C.), and the Intensive Care National Audit and Research Centre (K. Rowan), London, the NIHR Southampton Clinical Research Facility and Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust and University of Southampton, Southampton (S.N.F.), the Department of Mathematics and Statistics, Lancaster University, Lancaster (T.J.), the MRC Biostatistics Unit, University of Cambridge, Cambridge (T.J.), and Roslin Institute, University of Edinburgh, Edinburgh (J.K.B.) - all in the United Kingdom
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Horby P, Lim WS, Emberson JR, Mafham M, Bell JL, Linsell L, Staplin N, Brightling C, Ustianowski A, Elmahi E, Prudon B, Green C, Felton T, Chadwick D, Rege K, Fegan C, Chappell LC, Faust SN, Jaki T, Jeffery K, Montgomery A, Rowan K, Juszczak E, Baillie JK, Haynes R, Landray MJ. Dexamethasone in Hospitalized Patients with Covid-19. N Engl J Med 2021; 384:693-704. [PMID: 32678530 PMCID: PMC7383595 DOI: 10.1056/nejmoa2021436] [Citation(s) in RCA: 6629] [Impact Index Per Article: 2209.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND Coronavirus disease 2019 (Covid-19) is associated with diffuse lung damage. Glucocorticoids may modulate inflammation-mediated lung injury and thereby reduce progression to respiratory failure and death. METHODS In this controlled, open-label trial comparing a range of possible treatments in patients who were hospitalized with Covid-19, we randomly assigned patients to receive oral or intravenous dexamethasone (at a dose of 6 mg once daily) for up to 10 days or to receive usual care alone. The primary outcome was 28-day mortality. Here, we report the final results of this assessment. RESULTS A total of 2104 patients were assigned to receive dexamethasone and 4321 to receive usual care. Overall, 482 patients (22.9%) in the dexamethasone group and 1110 patients (25.7%) in the usual care group died within 28 days after randomization (age-adjusted rate ratio, 0.83; 95% confidence interval [CI], 0.75 to 0.93; P<0.001). The proportional and absolute between-group differences in mortality varied considerably according to the level of respiratory support that the patients were receiving at the time of randomization. In the dexamethasone group, the incidence of death was lower than that in the usual care group among patients receiving invasive mechanical ventilation (29.3% vs. 41.4%; rate ratio, 0.64; 95% CI, 0.51 to 0.81) and among those receiving oxygen without invasive mechanical ventilation (23.3% vs. 26.2%; rate ratio, 0.82; 95% CI, 0.72 to 0.94) but not among those who were receiving no respiratory support at randomization (17.8% vs. 14.0%; rate ratio, 1.19; 95% CI, 0.92 to 1.55). CONCLUSIONS In patients hospitalized with Covid-19, the use of dexamethasone resulted in lower 28-day mortality among those who were receiving either invasive mechanical ventilation or oxygen alone at randomization but not among those receiving no respiratory support. (Funded by the Medical Research Council and National Institute for Health Research and others; RECOVERY ClinicalTrials.gov number, NCT04381936; ISRCTN number, 50189673.).
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Affiliation(s)
- Peter Horby
- From the Nuffield Department of Medicine (P.H.), Nuffield Department of Population Health (J.R.E., M.M., J.L.B., L.L., N.S., E.J., R.H., M.J.L.), and MRC Population Health Research Unit (J.R.E., N.S., R.H., M.J.L.), University of Oxford, the Oxford University Hospitals NHS Foundation Trust (K.J.), and National Institute for Health Research (NIHR) Oxford Biomedical Research Centre (M.J.L.), Oxford, the Respiratory Medicine Department, Nottingham University Hospitals NHS Trust (W.S.L.), and the School of Medicine, University of Nottingham (A.M.), Nottingham, the Institute for Lung Health, Leicester NIHR Biomedical Research Centre, University of Leicester, Leicester (C.B.), the Regional Infectious Diseases Unit, North Manchester General Hospital and University of Manchester (A.U.), and the University of Manchester and Manchester University NHS Foundation Trust (T.F.), Manchester, the Research and Development Department, Northampton General Hospital, Northampton (E.E.), the Department of Respiratory Medicine, North Tees and Hartlepool NHS Foundation Trust, Stockton-on-Tees (B.P.), University Hospitals Birmingham NHS Foundation Trust and Institute of Microbiology and Infection, University of Birmingham, Birmingham (C.G.), the Centre for Clinical Infection, James Cook University Hospital, Middlesbrough (D.C.), the North West Anglia NHS Foundation Trust, Peterborough (K. Rege), the Department of Research and Development, Cardiff and Vale University Health Board, Cardiff (C.F.), the School of Life Course Sciences, King's College London (L.C.C.), and the Intensive Care National Audit and Research Centre (K. Rowan), London, the NIHR Southampton Clinical Research Facility and Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust and University of Southampton, Southampton (S.N.F.), the Department of Mathematics and Statistics, Lancaster University, Lancaster (T.J.), the MRC Biostatistics Unit, University of Cambridge, Cambridge (T.J.), and Roslin Institute, University of Edinburgh, Edinburgh (J.K.B.) - all in the United Kingdom
| | - Wei Shen Lim
- From the Nuffield Department of Medicine (P.H.), Nuffield Department of Population Health (J.R.E., M.M., J.L.B., L.L., N.S., E.J., R.H., M.J.L.), and MRC Population Health Research Unit (J.R.E., N.S., R.H., M.J.L.), University of Oxford, the Oxford University Hospitals NHS Foundation Trust (K.J.), and National Institute for Health Research (NIHR) Oxford Biomedical Research Centre (M.J.L.), Oxford, the Respiratory Medicine Department, Nottingham University Hospitals NHS Trust (W.S.L.), and the School of Medicine, University of Nottingham (A.M.), Nottingham, the Institute for Lung Health, Leicester NIHR Biomedical Research Centre, University of Leicester, Leicester (C.B.), the Regional Infectious Diseases Unit, North Manchester General Hospital and University of Manchester (A.U.), and the University of Manchester and Manchester University NHS Foundation Trust (T.F.), Manchester, the Research and Development Department, Northampton General Hospital, Northampton (E.E.), the Department of Respiratory Medicine, North Tees and Hartlepool NHS Foundation Trust, Stockton-on-Tees (B.P.), University Hospitals Birmingham NHS Foundation Trust and Institute of Microbiology and Infection, University of Birmingham, Birmingham (C.G.), the Centre for Clinical Infection, James Cook University Hospital, Middlesbrough (D.C.), the North West Anglia NHS Foundation Trust, Peterborough (K. Rege), the Department of Research and Development, Cardiff and Vale University Health Board, Cardiff (C.F.), the School of Life Course Sciences, King's College London (L.C.C.), and the Intensive Care National Audit and Research Centre (K. Rowan), London, the NIHR Southampton Clinical Research Facility and Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust and University of Southampton, Southampton (S.N.F.), the Department of Mathematics and Statistics, Lancaster University, Lancaster (T.J.), the MRC Biostatistics Unit, University of Cambridge, Cambridge (T.J.), and Roslin Institute, University of Edinburgh, Edinburgh (J.K.B.) - all in the United Kingdom
| | - Jonathan R Emberson
- From the Nuffield Department of Medicine (P.H.), Nuffield Department of Population Health (J.R.E., M.M., J.L.B., L.L., N.S., E.J., R.H., M.J.L.), and MRC Population Health Research Unit (J.R.E., N.S., R.H., M.J.L.), University of Oxford, the Oxford University Hospitals NHS Foundation Trust (K.J.), and National Institute for Health Research (NIHR) Oxford Biomedical Research Centre (M.J.L.), Oxford, the Respiratory Medicine Department, Nottingham University Hospitals NHS Trust (W.S.L.), and the School of Medicine, University of Nottingham (A.M.), Nottingham, the Institute for Lung Health, Leicester NIHR Biomedical Research Centre, University of Leicester, Leicester (C.B.), the Regional Infectious Diseases Unit, North Manchester General Hospital and University of Manchester (A.U.), and the University of Manchester and Manchester University NHS Foundation Trust (T.F.), Manchester, the Research and Development Department, Northampton General Hospital, Northampton (E.E.), the Department of Respiratory Medicine, North Tees and Hartlepool NHS Foundation Trust, Stockton-on-Tees (B.P.), University Hospitals Birmingham NHS Foundation Trust and Institute of Microbiology and Infection, University of Birmingham, Birmingham (C.G.), the Centre for Clinical Infection, James Cook University Hospital, Middlesbrough (D.C.), the North West Anglia NHS Foundation Trust, Peterborough (K. Rege), the Department of Research and Development, Cardiff and Vale University Health Board, Cardiff (C.F.), the School of Life Course Sciences, King's College London (L.C.C.), and the Intensive Care National Audit and Research Centre (K. Rowan), London, the NIHR Southampton Clinical Research Facility and Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust and University of Southampton, Southampton (S.N.F.), the Department of Mathematics and Statistics, Lancaster University, Lancaster (T.J.), the MRC Biostatistics Unit, University of Cambridge, Cambridge (T.J.), and Roslin Institute, University of Edinburgh, Edinburgh (J.K.B.) - all in the United Kingdom
| | - Marion Mafham
- From the Nuffield Department of Medicine (P.H.), Nuffield Department of Population Health (J.R.E., M.M., J.L.B., L.L., N.S., E.J., R.H., M.J.L.), and MRC Population Health Research Unit (J.R.E., N.S., R.H., M.J.L.), University of Oxford, the Oxford University Hospitals NHS Foundation Trust (K.J.), and National Institute for Health Research (NIHR) Oxford Biomedical Research Centre (M.J.L.), Oxford, the Respiratory Medicine Department, Nottingham University Hospitals NHS Trust (W.S.L.), and the School of Medicine, University of Nottingham (A.M.), Nottingham, the Institute for Lung Health, Leicester NIHR Biomedical Research Centre, University of Leicester, Leicester (C.B.), the Regional Infectious Diseases Unit, North Manchester General Hospital and University of Manchester (A.U.), and the University of Manchester and Manchester University NHS Foundation Trust (T.F.), Manchester, the Research and Development Department, Northampton General Hospital, Northampton (E.E.), the Department of Respiratory Medicine, North Tees and Hartlepool NHS Foundation Trust, Stockton-on-Tees (B.P.), University Hospitals Birmingham NHS Foundation Trust and Institute of Microbiology and Infection, University of Birmingham, Birmingham (C.G.), the Centre for Clinical Infection, James Cook University Hospital, Middlesbrough (D.C.), the North West Anglia NHS Foundation Trust, Peterborough (K. Rege), the Department of Research and Development, Cardiff and Vale University Health Board, Cardiff (C.F.), the School of Life Course Sciences, King's College London (L.C.C.), and the Intensive Care National Audit and Research Centre (K. Rowan), London, the NIHR Southampton Clinical Research Facility and Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust and University of Southampton, Southampton (S.N.F.), the Department of Mathematics and Statistics, Lancaster University, Lancaster (T.J.), the MRC Biostatistics Unit, University of Cambridge, Cambridge (T.J.), and Roslin Institute, University of Edinburgh, Edinburgh (J.K.B.) - all in the United Kingdom
| | - Jennifer L Bell
- From the Nuffield Department of Medicine (P.H.), Nuffield Department of Population Health (J.R.E., M.M., J.L.B., L.L., N.S., E.J., R.H., M.J.L.), and MRC Population Health Research Unit (J.R.E., N.S., R.H., M.J.L.), University of Oxford, the Oxford University Hospitals NHS Foundation Trust (K.J.), and National Institute for Health Research (NIHR) Oxford Biomedical Research Centre (M.J.L.), Oxford, the Respiratory Medicine Department, Nottingham University Hospitals NHS Trust (W.S.L.), and the School of Medicine, University of Nottingham (A.M.), Nottingham, the Institute for Lung Health, Leicester NIHR Biomedical Research Centre, University of Leicester, Leicester (C.B.), the Regional Infectious Diseases Unit, North Manchester General Hospital and University of Manchester (A.U.), and the University of Manchester and Manchester University NHS Foundation Trust (T.F.), Manchester, the Research and Development Department, Northampton General Hospital, Northampton (E.E.), the Department of Respiratory Medicine, North Tees and Hartlepool NHS Foundation Trust, Stockton-on-Tees (B.P.), University Hospitals Birmingham NHS Foundation Trust and Institute of Microbiology and Infection, University of Birmingham, Birmingham (C.G.), the Centre for Clinical Infection, James Cook University Hospital, Middlesbrough (D.C.), the North West Anglia NHS Foundation Trust, Peterborough (K. Rege), the Department of Research and Development, Cardiff and Vale University Health Board, Cardiff (C.F.), the School of Life Course Sciences, King's College London (L.C.C.), and the Intensive Care National Audit and Research Centre (K. Rowan), London, the NIHR Southampton Clinical Research Facility and Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust and University of Southampton, Southampton (S.N.F.), the Department of Mathematics and Statistics, Lancaster University, Lancaster (T.J.), the MRC Biostatistics Unit, University of Cambridge, Cambridge (T.J.), and Roslin Institute, University of Edinburgh, Edinburgh (J.K.B.) - all in the United Kingdom
| | - Louise Linsell
- From the Nuffield Department of Medicine (P.H.), Nuffield Department of Population Health (J.R.E., M.M., J.L.B., L.L., N.S., E.J., R.H., M.J.L.), and MRC Population Health Research Unit (J.R.E., N.S., R.H., M.J.L.), University of Oxford, the Oxford University Hospitals NHS Foundation Trust (K.J.), and National Institute for Health Research (NIHR) Oxford Biomedical Research Centre (M.J.L.), Oxford, the Respiratory Medicine Department, Nottingham University Hospitals NHS Trust (W.S.L.), and the School of Medicine, University of Nottingham (A.M.), Nottingham, the Institute for Lung Health, Leicester NIHR Biomedical Research Centre, University of Leicester, Leicester (C.B.), the Regional Infectious Diseases Unit, North Manchester General Hospital and University of Manchester (A.U.), and the University of Manchester and Manchester University NHS Foundation Trust (T.F.), Manchester, the Research and Development Department, Northampton General Hospital, Northampton (E.E.), the Department of Respiratory Medicine, North Tees and Hartlepool NHS Foundation Trust, Stockton-on-Tees (B.P.), University Hospitals Birmingham NHS Foundation Trust and Institute of Microbiology and Infection, University of Birmingham, Birmingham (C.G.), the Centre for Clinical Infection, James Cook University Hospital, Middlesbrough (D.C.), the North West Anglia NHS Foundation Trust, Peterborough (K. Rege), the Department of Research and Development, Cardiff and Vale University Health Board, Cardiff (C.F.), the School of Life Course Sciences, King's College London (L.C.C.), and the Intensive Care National Audit and Research Centre (K. Rowan), London, the NIHR Southampton Clinical Research Facility and Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust and University of Southampton, Southampton (S.N.F.), the Department of Mathematics and Statistics, Lancaster University, Lancaster (T.J.), the MRC Biostatistics Unit, University of Cambridge, Cambridge (T.J.), and Roslin Institute, University of Edinburgh, Edinburgh (J.K.B.) - all in the United Kingdom
| | - Natalie Staplin
- From the Nuffield Department of Medicine (P.H.), Nuffield Department of Population Health (J.R.E., M.M., J.L.B., L.L., N.S., E.J., R.H., M.J.L.), and MRC Population Health Research Unit (J.R.E., N.S., R.H., M.J.L.), University of Oxford, the Oxford University Hospitals NHS Foundation Trust (K.J.), and National Institute for Health Research (NIHR) Oxford Biomedical Research Centre (M.J.L.), Oxford, the Respiratory Medicine Department, Nottingham University Hospitals NHS Trust (W.S.L.), and the School of Medicine, University of Nottingham (A.M.), Nottingham, the Institute for Lung Health, Leicester NIHR Biomedical Research Centre, University of Leicester, Leicester (C.B.), the Regional Infectious Diseases Unit, North Manchester General Hospital and University of Manchester (A.U.), and the University of Manchester and Manchester University NHS Foundation Trust (T.F.), Manchester, the Research and Development Department, Northampton General Hospital, Northampton (E.E.), the Department of Respiratory Medicine, North Tees and Hartlepool NHS Foundation Trust, Stockton-on-Tees (B.P.), University Hospitals Birmingham NHS Foundation Trust and Institute of Microbiology and Infection, University of Birmingham, Birmingham (C.G.), the Centre for Clinical Infection, James Cook University Hospital, Middlesbrough (D.C.), the North West Anglia NHS Foundation Trust, Peterborough (K. Rege), the Department of Research and Development, Cardiff and Vale University Health Board, Cardiff (C.F.), the School of Life Course Sciences, King's College London (L.C.C.), and the Intensive Care National Audit and Research Centre (K. Rowan), London, the NIHR Southampton Clinical Research Facility and Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust and University of Southampton, Southampton (S.N.F.), the Department of Mathematics and Statistics, Lancaster University, Lancaster (T.J.), the MRC Biostatistics Unit, University of Cambridge, Cambridge (T.J.), and Roslin Institute, University of Edinburgh, Edinburgh (J.K.B.) - all in the United Kingdom
| | - Christopher Brightling
- From the Nuffield Department of Medicine (P.H.), Nuffield Department of Population Health (J.R.E., M.M., J.L.B., L.L., N.S., E.J., R.H., M.J.L.), and MRC Population Health Research Unit (J.R.E., N.S., R.H., M.J.L.), University of Oxford, the Oxford University Hospitals NHS Foundation Trust (K.J.), and National Institute for Health Research (NIHR) Oxford Biomedical Research Centre (M.J.L.), Oxford, the Respiratory Medicine Department, Nottingham University Hospitals NHS Trust (W.S.L.), and the School of Medicine, University of Nottingham (A.M.), Nottingham, the Institute for Lung Health, Leicester NIHR Biomedical Research Centre, University of Leicester, Leicester (C.B.), the Regional Infectious Diseases Unit, North Manchester General Hospital and University of Manchester (A.U.), and the University of Manchester and Manchester University NHS Foundation Trust (T.F.), Manchester, the Research and Development Department, Northampton General Hospital, Northampton (E.E.), the Department of Respiratory Medicine, North Tees and Hartlepool NHS Foundation Trust, Stockton-on-Tees (B.P.), University Hospitals Birmingham NHS Foundation Trust and Institute of Microbiology and Infection, University of Birmingham, Birmingham (C.G.), the Centre for Clinical Infection, James Cook University Hospital, Middlesbrough (D.C.), the North West Anglia NHS Foundation Trust, Peterborough (K. Rege), the Department of Research and Development, Cardiff and Vale University Health Board, Cardiff (C.F.), the School of Life Course Sciences, King's College London (L.C.C.), and the Intensive Care National Audit and Research Centre (K. Rowan), London, the NIHR Southampton Clinical Research Facility and Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust and University of Southampton, Southampton (S.N.F.), the Department of Mathematics and Statistics, Lancaster University, Lancaster (T.J.), the MRC Biostatistics Unit, University of Cambridge, Cambridge (T.J.), and Roslin Institute, University of Edinburgh, Edinburgh (J.K.B.) - all in the United Kingdom
| | - Andrew Ustianowski
- From the Nuffield Department of Medicine (P.H.), Nuffield Department of Population Health (J.R.E., M.M., J.L.B., L.L., N.S., E.J., R.H., M.J.L.), and MRC Population Health Research Unit (J.R.E., N.S., R.H., M.J.L.), University of Oxford, the Oxford University Hospitals NHS Foundation Trust (K.J.), and National Institute for Health Research (NIHR) Oxford Biomedical Research Centre (M.J.L.), Oxford, the Respiratory Medicine Department, Nottingham University Hospitals NHS Trust (W.S.L.), and the School of Medicine, University of Nottingham (A.M.), Nottingham, the Institute for Lung Health, Leicester NIHR Biomedical Research Centre, University of Leicester, Leicester (C.B.), the Regional Infectious Diseases Unit, North Manchester General Hospital and University of Manchester (A.U.), and the University of Manchester and Manchester University NHS Foundation Trust (T.F.), Manchester, the Research and Development Department, Northampton General Hospital, Northampton (E.E.), the Department of Respiratory Medicine, North Tees and Hartlepool NHS Foundation Trust, Stockton-on-Tees (B.P.), University Hospitals Birmingham NHS Foundation Trust and Institute of Microbiology and Infection, University of Birmingham, Birmingham (C.G.), the Centre for Clinical Infection, James Cook University Hospital, Middlesbrough (D.C.), the North West Anglia NHS Foundation Trust, Peterborough (K. Rege), the Department of Research and Development, Cardiff and Vale University Health Board, Cardiff (C.F.), the School of Life Course Sciences, King's College London (L.C.C.), and the Intensive Care National Audit and Research Centre (K. Rowan), London, the NIHR Southampton Clinical Research Facility and Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust and University of Southampton, Southampton (S.N.F.), the Department of Mathematics and Statistics, Lancaster University, Lancaster (T.J.), the MRC Biostatistics Unit, University of Cambridge, Cambridge (T.J.), and Roslin Institute, University of Edinburgh, Edinburgh (J.K.B.) - all in the United Kingdom
| | - Einas Elmahi
- From the Nuffield Department of Medicine (P.H.), Nuffield Department of Population Health (J.R.E., M.M., J.L.B., L.L., N.S., E.J., R.H., M.J.L.), and MRC Population Health Research Unit (J.R.E., N.S., R.H., M.J.L.), University of Oxford, the Oxford University Hospitals NHS Foundation Trust (K.J.), and National Institute for Health Research (NIHR) Oxford Biomedical Research Centre (M.J.L.), Oxford, the Respiratory Medicine Department, Nottingham University Hospitals NHS Trust (W.S.L.), and the School of Medicine, University of Nottingham (A.M.), Nottingham, the Institute for Lung Health, Leicester NIHR Biomedical Research Centre, University of Leicester, Leicester (C.B.), the Regional Infectious Diseases Unit, North Manchester General Hospital and University of Manchester (A.U.), and the University of Manchester and Manchester University NHS Foundation Trust (T.F.), Manchester, the Research and Development Department, Northampton General Hospital, Northampton (E.E.), the Department of Respiratory Medicine, North Tees and Hartlepool NHS Foundation Trust, Stockton-on-Tees (B.P.), University Hospitals Birmingham NHS Foundation Trust and Institute of Microbiology and Infection, University of Birmingham, Birmingham (C.G.), the Centre for Clinical Infection, James Cook University Hospital, Middlesbrough (D.C.), the North West Anglia NHS Foundation Trust, Peterborough (K. Rege), the Department of Research and Development, Cardiff and Vale University Health Board, Cardiff (C.F.), the School of Life Course Sciences, King's College London (L.C.C.), and the Intensive Care National Audit and Research Centre (K. Rowan), London, the NIHR Southampton Clinical Research Facility and Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust and University of Southampton, Southampton (S.N.F.), the Department of Mathematics and Statistics, Lancaster University, Lancaster (T.J.), the MRC Biostatistics Unit, University of Cambridge, Cambridge (T.J.), and Roslin Institute, University of Edinburgh, Edinburgh (J.K.B.) - all in the United Kingdom
| | - Benjamin Prudon
- From the Nuffield Department of Medicine (P.H.), Nuffield Department of Population Health (J.R.E., M.M., J.L.B., L.L., N.S., E.J., R.H., M.J.L.), and MRC Population Health Research Unit (J.R.E., N.S., R.H., M.J.L.), University of Oxford, the Oxford University Hospitals NHS Foundation Trust (K.J.), and National Institute for Health Research (NIHR) Oxford Biomedical Research Centre (M.J.L.), Oxford, the Respiratory Medicine Department, Nottingham University Hospitals NHS Trust (W.S.L.), and the School of Medicine, University of Nottingham (A.M.), Nottingham, the Institute for Lung Health, Leicester NIHR Biomedical Research Centre, University of Leicester, Leicester (C.B.), the Regional Infectious Diseases Unit, North Manchester General Hospital and University of Manchester (A.U.), and the University of Manchester and Manchester University NHS Foundation Trust (T.F.), Manchester, the Research and Development Department, Northampton General Hospital, Northampton (E.E.), the Department of Respiratory Medicine, North Tees and Hartlepool NHS Foundation Trust, Stockton-on-Tees (B.P.), University Hospitals Birmingham NHS Foundation Trust and Institute of Microbiology and Infection, University of Birmingham, Birmingham (C.G.), the Centre for Clinical Infection, James Cook University Hospital, Middlesbrough (D.C.), the North West Anglia NHS Foundation Trust, Peterborough (K. Rege), the Department of Research and Development, Cardiff and Vale University Health Board, Cardiff (C.F.), the School of Life Course Sciences, King's College London (L.C.C.), and the Intensive Care National Audit and Research Centre (K. Rowan), London, the NIHR Southampton Clinical Research Facility and Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust and University of Southampton, Southampton (S.N.F.), the Department of Mathematics and Statistics, Lancaster University, Lancaster (T.J.), the MRC Biostatistics Unit, University of Cambridge, Cambridge (T.J.), and Roslin Institute, University of Edinburgh, Edinburgh (J.K.B.) - all in the United Kingdom
| | - Christopher Green
- From the Nuffield Department of Medicine (P.H.), Nuffield Department of Population Health (J.R.E., M.M., J.L.B., L.L., N.S., E.J., R.H., M.J.L.), and MRC Population Health Research Unit (J.R.E., N.S., R.H., M.J.L.), University of Oxford, the Oxford University Hospitals NHS Foundation Trust (K.J.), and National Institute for Health Research (NIHR) Oxford Biomedical Research Centre (M.J.L.), Oxford, the Respiratory Medicine Department, Nottingham University Hospitals NHS Trust (W.S.L.), and the School of Medicine, University of Nottingham (A.M.), Nottingham, the Institute for Lung Health, Leicester NIHR Biomedical Research Centre, University of Leicester, Leicester (C.B.), the Regional Infectious Diseases Unit, North Manchester General Hospital and University of Manchester (A.U.), and the University of Manchester and Manchester University NHS Foundation Trust (T.F.), Manchester, the Research and Development Department, Northampton General Hospital, Northampton (E.E.), the Department of Respiratory Medicine, North Tees and Hartlepool NHS Foundation Trust, Stockton-on-Tees (B.P.), University Hospitals Birmingham NHS Foundation Trust and Institute of Microbiology and Infection, University of Birmingham, Birmingham (C.G.), the Centre for Clinical Infection, James Cook University Hospital, Middlesbrough (D.C.), the North West Anglia NHS Foundation Trust, Peterborough (K. Rege), the Department of Research and Development, Cardiff and Vale University Health Board, Cardiff (C.F.), the School of Life Course Sciences, King's College London (L.C.C.), and the Intensive Care National Audit and Research Centre (K. Rowan), London, the NIHR Southampton Clinical Research Facility and Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust and University of Southampton, Southampton (S.N.F.), the Department of Mathematics and Statistics, Lancaster University, Lancaster (T.J.), the MRC Biostatistics Unit, University of Cambridge, Cambridge (T.J.), and Roslin Institute, University of Edinburgh, Edinburgh (J.K.B.) - all in the United Kingdom
| | - Timothy Felton
- From the Nuffield Department of Medicine (P.H.), Nuffield Department of Population Health (J.R.E., M.M., J.L.B., L.L., N.S., E.J., R.H., M.J.L.), and MRC Population Health Research Unit (J.R.E., N.S., R.H., M.J.L.), University of Oxford, the Oxford University Hospitals NHS Foundation Trust (K.J.), and National Institute for Health Research (NIHR) Oxford Biomedical Research Centre (M.J.L.), Oxford, the Respiratory Medicine Department, Nottingham University Hospitals NHS Trust (W.S.L.), and the School of Medicine, University of Nottingham (A.M.), Nottingham, the Institute for Lung Health, Leicester NIHR Biomedical Research Centre, University of Leicester, Leicester (C.B.), the Regional Infectious Diseases Unit, North Manchester General Hospital and University of Manchester (A.U.), and the University of Manchester and Manchester University NHS Foundation Trust (T.F.), Manchester, the Research and Development Department, Northampton General Hospital, Northampton (E.E.), the Department of Respiratory Medicine, North Tees and Hartlepool NHS Foundation Trust, Stockton-on-Tees (B.P.), University Hospitals Birmingham NHS Foundation Trust and Institute of Microbiology and Infection, University of Birmingham, Birmingham (C.G.), the Centre for Clinical Infection, James Cook University Hospital, Middlesbrough (D.C.), the North West Anglia NHS Foundation Trust, Peterborough (K. Rege), the Department of Research and Development, Cardiff and Vale University Health Board, Cardiff (C.F.), the School of Life Course Sciences, King's College London (L.C.C.), and the Intensive Care National Audit and Research Centre (K. Rowan), London, the NIHR Southampton Clinical Research Facility and Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust and University of Southampton, Southampton (S.N.F.), the Department of Mathematics and Statistics, Lancaster University, Lancaster (T.J.), the MRC Biostatistics Unit, University of Cambridge, Cambridge (T.J.), and Roslin Institute, University of Edinburgh, Edinburgh (J.K.B.) - all in the United Kingdom
| | - David Chadwick
- From the Nuffield Department of Medicine (P.H.), Nuffield Department of Population Health (J.R.E., M.M., J.L.B., L.L., N.S., E.J., R.H., M.J.L.), and MRC Population Health Research Unit (J.R.E., N.S., R.H., M.J.L.), University of Oxford, the Oxford University Hospitals NHS Foundation Trust (K.J.), and National Institute for Health Research (NIHR) Oxford Biomedical Research Centre (M.J.L.), Oxford, the Respiratory Medicine Department, Nottingham University Hospitals NHS Trust (W.S.L.), and the School of Medicine, University of Nottingham (A.M.), Nottingham, the Institute for Lung Health, Leicester NIHR Biomedical Research Centre, University of Leicester, Leicester (C.B.), the Regional Infectious Diseases Unit, North Manchester General Hospital and University of Manchester (A.U.), and the University of Manchester and Manchester University NHS Foundation Trust (T.F.), Manchester, the Research and Development Department, Northampton General Hospital, Northampton (E.E.), the Department of Respiratory Medicine, North Tees and Hartlepool NHS Foundation Trust, Stockton-on-Tees (B.P.), University Hospitals Birmingham NHS Foundation Trust and Institute of Microbiology and Infection, University of Birmingham, Birmingham (C.G.), the Centre for Clinical Infection, James Cook University Hospital, Middlesbrough (D.C.), the North West Anglia NHS Foundation Trust, Peterborough (K. Rege), the Department of Research and Development, Cardiff and Vale University Health Board, Cardiff (C.F.), the School of Life Course Sciences, King's College London (L.C.C.), and the Intensive Care National Audit and Research Centre (K. Rowan), London, the NIHR Southampton Clinical Research Facility and Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust and University of Southampton, Southampton (S.N.F.), the Department of Mathematics and Statistics, Lancaster University, Lancaster (T.J.), the MRC Biostatistics Unit, University of Cambridge, Cambridge (T.J.), and Roslin Institute, University of Edinburgh, Edinburgh (J.K.B.) - all in the United Kingdom
| | - Kanchan Rege
- From the Nuffield Department of Medicine (P.H.), Nuffield Department of Population Health (J.R.E., M.M., J.L.B., L.L., N.S., E.J., R.H., M.J.L.), and MRC Population Health Research Unit (J.R.E., N.S., R.H., M.J.L.), University of Oxford, the Oxford University Hospitals NHS Foundation Trust (K.J.), and National Institute for Health Research (NIHR) Oxford Biomedical Research Centre (M.J.L.), Oxford, the Respiratory Medicine Department, Nottingham University Hospitals NHS Trust (W.S.L.), and the School of Medicine, University of Nottingham (A.M.), Nottingham, the Institute for Lung Health, Leicester NIHR Biomedical Research Centre, University of Leicester, Leicester (C.B.), the Regional Infectious Diseases Unit, North Manchester General Hospital and University of Manchester (A.U.), and the University of Manchester and Manchester University NHS Foundation Trust (T.F.), Manchester, the Research and Development Department, Northampton General Hospital, Northampton (E.E.), the Department of Respiratory Medicine, North Tees and Hartlepool NHS Foundation Trust, Stockton-on-Tees (B.P.), University Hospitals Birmingham NHS Foundation Trust and Institute of Microbiology and Infection, University of Birmingham, Birmingham (C.G.), the Centre for Clinical Infection, James Cook University Hospital, Middlesbrough (D.C.), the North West Anglia NHS Foundation Trust, Peterborough (K. Rege), the Department of Research and Development, Cardiff and Vale University Health Board, Cardiff (C.F.), the School of Life Course Sciences, King's College London (L.C.C.), and the Intensive Care National Audit and Research Centre (K. Rowan), London, the NIHR Southampton Clinical Research Facility and Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust and University of Southampton, Southampton (S.N.F.), the Department of Mathematics and Statistics, Lancaster University, Lancaster (T.J.), the MRC Biostatistics Unit, University of Cambridge, Cambridge (T.J.), and Roslin Institute, University of Edinburgh, Edinburgh (J.K.B.) - all in the United Kingdom
| | - Christopher Fegan
- From the Nuffield Department of Medicine (P.H.), Nuffield Department of Population Health (J.R.E., M.M., J.L.B., L.L., N.S., E.J., R.H., M.J.L.), and MRC Population Health Research Unit (J.R.E., N.S., R.H., M.J.L.), University of Oxford, the Oxford University Hospitals NHS Foundation Trust (K.J.), and National Institute for Health Research (NIHR) Oxford Biomedical Research Centre (M.J.L.), Oxford, the Respiratory Medicine Department, Nottingham University Hospitals NHS Trust (W.S.L.), and the School of Medicine, University of Nottingham (A.M.), Nottingham, the Institute for Lung Health, Leicester NIHR Biomedical Research Centre, University of Leicester, Leicester (C.B.), the Regional Infectious Diseases Unit, North Manchester General Hospital and University of Manchester (A.U.), and the University of Manchester and Manchester University NHS Foundation Trust (T.F.), Manchester, the Research and Development Department, Northampton General Hospital, Northampton (E.E.), the Department of Respiratory Medicine, North Tees and Hartlepool NHS Foundation Trust, Stockton-on-Tees (B.P.), University Hospitals Birmingham NHS Foundation Trust and Institute of Microbiology and Infection, University of Birmingham, Birmingham (C.G.), the Centre for Clinical Infection, James Cook University Hospital, Middlesbrough (D.C.), the North West Anglia NHS Foundation Trust, Peterborough (K. Rege), the Department of Research and Development, Cardiff and Vale University Health Board, Cardiff (C.F.), the School of Life Course Sciences, King's College London (L.C.C.), and the Intensive Care National Audit and Research Centre (K. Rowan), London, the NIHR Southampton Clinical Research Facility and Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust and University of Southampton, Southampton (S.N.F.), the Department of Mathematics and Statistics, Lancaster University, Lancaster (T.J.), the MRC Biostatistics Unit, University of Cambridge, Cambridge (T.J.), and Roslin Institute, University of Edinburgh, Edinburgh (J.K.B.) - all in the United Kingdom
| | - Lucy C Chappell
- From the Nuffield Department of Medicine (P.H.), Nuffield Department of Population Health (J.R.E., M.M., J.L.B., L.L., N.S., E.J., R.H., M.J.L.), and MRC Population Health Research Unit (J.R.E., N.S., R.H., M.J.L.), University of Oxford, the Oxford University Hospitals NHS Foundation Trust (K.J.), and National Institute for Health Research (NIHR) Oxford Biomedical Research Centre (M.J.L.), Oxford, the Respiratory Medicine Department, Nottingham University Hospitals NHS Trust (W.S.L.), and the School of Medicine, University of Nottingham (A.M.), Nottingham, the Institute for Lung Health, Leicester NIHR Biomedical Research Centre, University of Leicester, Leicester (C.B.), the Regional Infectious Diseases Unit, North Manchester General Hospital and University of Manchester (A.U.), and the University of Manchester and Manchester University NHS Foundation Trust (T.F.), Manchester, the Research and Development Department, Northampton General Hospital, Northampton (E.E.), the Department of Respiratory Medicine, North Tees and Hartlepool NHS Foundation Trust, Stockton-on-Tees (B.P.), University Hospitals Birmingham NHS Foundation Trust and Institute of Microbiology and Infection, University of Birmingham, Birmingham (C.G.), the Centre for Clinical Infection, James Cook University Hospital, Middlesbrough (D.C.), the North West Anglia NHS Foundation Trust, Peterborough (K. Rege), the Department of Research and Development, Cardiff and Vale University Health Board, Cardiff (C.F.), the School of Life Course Sciences, King's College London (L.C.C.), and the Intensive Care National Audit and Research Centre (K. Rowan), London, the NIHR Southampton Clinical Research Facility and Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust and University of Southampton, Southampton (S.N.F.), the Department of Mathematics and Statistics, Lancaster University, Lancaster (T.J.), the MRC Biostatistics Unit, University of Cambridge, Cambridge (T.J.), and Roslin Institute, University of Edinburgh, Edinburgh (J.K.B.) - all in the United Kingdom
| | - Saul N Faust
- From the Nuffield Department of Medicine (P.H.), Nuffield Department of Population Health (J.R.E., M.M., J.L.B., L.L., N.S., E.J., R.H., M.J.L.), and MRC Population Health Research Unit (J.R.E., N.S., R.H., M.J.L.), University of Oxford, the Oxford University Hospitals NHS Foundation Trust (K.J.), and National Institute for Health Research (NIHR) Oxford Biomedical Research Centre (M.J.L.), Oxford, the Respiratory Medicine Department, Nottingham University Hospitals NHS Trust (W.S.L.), and the School of Medicine, University of Nottingham (A.M.), Nottingham, the Institute for Lung Health, Leicester NIHR Biomedical Research Centre, University of Leicester, Leicester (C.B.), the Regional Infectious Diseases Unit, North Manchester General Hospital and University of Manchester (A.U.), and the University of Manchester and Manchester University NHS Foundation Trust (T.F.), Manchester, the Research and Development Department, Northampton General Hospital, Northampton (E.E.), the Department of Respiratory Medicine, North Tees and Hartlepool NHS Foundation Trust, Stockton-on-Tees (B.P.), University Hospitals Birmingham NHS Foundation Trust and Institute of Microbiology and Infection, University of Birmingham, Birmingham (C.G.), the Centre for Clinical Infection, James Cook University Hospital, Middlesbrough (D.C.), the North West Anglia NHS Foundation Trust, Peterborough (K. Rege), the Department of Research and Development, Cardiff and Vale University Health Board, Cardiff (C.F.), the School of Life Course Sciences, King's College London (L.C.C.), and the Intensive Care National Audit and Research Centre (K. Rowan), London, the NIHR Southampton Clinical Research Facility and Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust and University of Southampton, Southampton (S.N.F.), the Department of Mathematics and Statistics, Lancaster University, Lancaster (T.J.), the MRC Biostatistics Unit, University of Cambridge, Cambridge (T.J.), and Roslin Institute, University of Edinburgh, Edinburgh (J.K.B.) - all in the United Kingdom
| | - Thomas Jaki
- From the Nuffield Department of Medicine (P.H.), Nuffield Department of Population Health (J.R.E., M.M., J.L.B., L.L., N.S., E.J., R.H., M.J.L.), and MRC Population Health Research Unit (J.R.E., N.S., R.H., M.J.L.), University of Oxford, the Oxford University Hospitals NHS Foundation Trust (K.J.), and National Institute for Health Research (NIHR) Oxford Biomedical Research Centre (M.J.L.), Oxford, the Respiratory Medicine Department, Nottingham University Hospitals NHS Trust (W.S.L.), and the School of Medicine, University of Nottingham (A.M.), Nottingham, the Institute for Lung Health, Leicester NIHR Biomedical Research Centre, University of Leicester, Leicester (C.B.), the Regional Infectious Diseases Unit, North Manchester General Hospital and University of Manchester (A.U.), and the University of Manchester and Manchester University NHS Foundation Trust (T.F.), Manchester, the Research and Development Department, Northampton General Hospital, Northampton (E.E.), the Department of Respiratory Medicine, North Tees and Hartlepool NHS Foundation Trust, Stockton-on-Tees (B.P.), University Hospitals Birmingham NHS Foundation Trust and Institute of Microbiology and Infection, University of Birmingham, Birmingham (C.G.), the Centre for Clinical Infection, James Cook University Hospital, Middlesbrough (D.C.), the North West Anglia NHS Foundation Trust, Peterborough (K. Rege), the Department of Research and Development, Cardiff and Vale University Health Board, Cardiff (C.F.), the School of Life Course Sciences, King's College London (L.C.C.), and the Intensive Care National Audit and Research Centre (K. Rowan), London, the NIHR Southampton Clinical Research Facility and Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust and University of Southampton, Southampton (S.N.F.), the Department of Mathematics and Statistics, Lancaster University, Lancaster (T.J.), the MRC Biostatistics Unit, University of Cambridge, Cambridge (T.J.), and Roslin Institute, University of Edinburgh, Edinburgh (J.K.B.) - all in the United Kingdom
| | - Katie Jeffery
- From the Nuffield Department of Medicine (P.H.), Nuffield Department of Population Health (J.R.E., M.M., J.L.B., L.L., N.S., E.J., R.H., M.J.L.), and MRC Population Health Research Unit (J.R.E., N.S., R.H., M.J.L.), University of Oxford, the Oxford University Hospitals NHS Foundation Trust (K.J.), and National Institute for Health Research (NIHR) Oxford Biomedical Research Centre (M.J.L.), Oxford, the Respiratory Medicine Department, Nottingham University Hospitals NHS Trust (W.S.L.), and the School of Medicine, University of Nottingham (A.M.), Nottingham, the Institute for Lung Health, Leicester NIHR Biomedical Research Centre, University of Leicester, Leicester (C.B.), the Regional Infectious Diseases Unit, North Manchester General Hospital and University of Manchester (A.U.), and the University of Manchester and Manchester University NHS Foundation Trust (T.F.), Manchester, the Research and Development Department, Northampton General Hospital, Northampton (E.E.), the Department of Respiratory Medicine, North Tees and Hartlepool NHS Foundation Trust, Stockton-on-Tees (B.P.), University Hospitals Birmingham NHS Foundation Trust and Institute of Microbiology and Infection, University of Birmingham, Birmingham (C.G.), the Centre for Clinical Infection, James Cook University Hospital, Middlesbrough (D.C.), the North West Anglia NHS Foundation Trust, Peterborough (K. Rege), the Department of Research and Development, Cardiff and Vale University Health Board, Cardiff (C.F.), the School of Life Course Sciences, King's College London (L.C.C.), and the Intensive Care National Audit and Research Centre (K. Rowan), London, the NIHR Southampton Clinical Research Facility and Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust and University of Southampton, Southampton (S.N.F.), the Department of Mathematics and Statistics, Lancaster University, Lancaster (T.J.), the MRC Biostatistics Unit, University of Cambridge, Cambridge (T.J.), and Roslin Institute, University of Edinburgh, Edinburgh (J.K.B.) - all in the United Kingdom
| | - Alan Montgomery
- From the Nuffield Department of Medicine (P.H.), Nuffield Department of Population Health (J.R.E., M.M., J.L.B., L.L., N.S., E.J., R.H., M.J.L.), and MRC Population Health Research Unit (J.R.E., N.S., R.H., M.J.L.), University of Oxford, the Oxford University Hospitals NHS Foundation Trust (K.J.), and National Institute for Health Research (NIHR) Oxford Biomedical Research Centre (M.J.L.), Oxford, the Respiratory Medicine Department, Nottingham University Hospitals NHS Trust (W.S.L.), and the School of Medicine, University of Nottingham (A.M.), Nottingham, the Institute for Lung Health, Leicester NIHR Biomedical Research Centre, University of Leicester, Leicester (C.B.), the Regional Infectious Diseases Unit, North Manchester General Hospital and University of Manchester (A.U.), and the University of Manchester and Manchester University NHS Foundation Trust (T.F.), Manchester, the Research and Development Department, Northampton General Hospital, Northampton (E.E.), the Department of Respiratory Medicine, North Tees and Hartlepool NHS Foundation Trust, Stockton-on-Tees (B.P.), University Hospitals Birmingham NHS Foundation Trust and Institute of Microbiology and Infection, University of Birmingham, Birmingham (C.G.), the Centre for Clinical Infection, James Cook University Hospital, Middlesbrough (D.C.), the North West Anglia NHS Foundation Trust, Peterborough (K. Rege), the Department of Research and Development, Cardiff and Vale University Health Board, Cardiff (C.F.), the School of Life Course Sciences, King's College London (L.C.C.), and the Intensive Care National Audit and Research Centre (K. Rowan), London, the NIHR Southampton Clinical Research Facility and Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust and University of Southampton, Southampton (S.N.F.), the Department of Mathematics and Statistics, Lancaster University, Lancaster (T.J.), the MRC Biostatistics Unit, University of Cambridge, Cambridge (T.J.), and Roslin Institute, University of Edinburgh, Edinburgh (J.K.B.) - all in the United Kingdom
| | - Kathryn Rowan
- From the Nuffield Department of Medicine (P.H.), Nuffield Department of Population Health (J.R.E., M.M., J.L.B., L.L., N.S., E.J., R.H., M.J.L.), and MRC Population Health Research Unit (J.R.E., N.S., R.H., M.J.L.), University of Oxford, the Oxford University Hospitals NHS Foundation Trust (K.J.), and National Institute for Health Research (NIHR) Oxford Biomedical Research Centre (M.J.L.), Oxford, the Respiratory Medicine Department, Nottingham University Hospitals NHS Trust (W.S.L.), and the School of Medicine, University of Nottingham (A.M.), Nottingham, the Institute for Lung Health, Leicester NIHR Biomedical Research Centre, University of Leicester, Leicester (C.B.), the Regional Infectious Diseases Unit, North Manchester General Hospital and University of Manchester (A.U.), and the University of Manchester and Manchester University NHS Foundation Trust (T.F.), Manchester, the Research and Development Department, Northampton General Hospital, Northampton (E.E.), the Department of Respiratory Medicine, North Tees and Hartlepool NHS Foundation Trust, Stockton-on-Tees (B.P.), University Hospitals Birmingham NHS Foundation Trust and Institute of Microbiology and Infection, University of Birmingham, Birmingham (C.G.), the Centre for Clinical Infection, James Cook University Hospital, Middlesbrough (D.C.), the North West Anglia NHS Foundation Trust, Peterborough (K. Rege), the Department of Research and Development, Cardiff and Vale University Health Board, Cardiff (C.F.), the School of Life Course Sciences, King's College London (L.C.C.), and the Intensive Care National Audit and Research Centre (K. Rowan), London, the NIHR Southampton Clinical Research Facility and Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust and University of Southampton, Southampton (S.N.F.), the Department of Mathematics and Statistics, Lancaster University, Lancaster (T.J.), the MRC Biostatistics Unit, University of Cambridge, Cambridge (T.J.), and Roslin Institute, University of Edinburgh, Edinburgh (J.K.B.) - all in the United Kingdom
| | - Edmund Juszczak
- From the Nuffield Department of Medicine (P.H.), Nuffield Department of Population Health (J.R.E., M.M., J.L.B., L.L., N.S., E.J., R.H., M.J.L.), and MRC Population Health Research Unit (J.R.E., N.S., R.H., M.J.L.), University of Oxford, the Oxford University Hospitals NHS Foundation Trust (K.J.), and National Institute for Health Research (NIHR) Oxford Biomedical Research Centre (M.J.L.), Oxford, the Respiratory Medicine Department, Nottingham University Hospitals NHS Trust (W.S.L.), and the School of Medicine, University of Nottingham (A.M.), Nottingham, the Institute for Lung Health, Leicester NIHR Biomedical Research Centre, University of Leicester, Leicester (C.B.), the Regional Infectious Diseases Unit, North Manchester General Hospital and University of Manchester (A.U.), and the University of Manchester and Manchester University NHS Foundation Trust (T.F.), Manchester, the Research and Development Department, Northampton General Hospital, Northampton (E.E.), the Department of Respiratory Medicine, North Tees and Hartlepool NHS Foundation Trust, Stockton-on-Tees (B.P.), University Hospitals Birmingham NHS Foundation Trust and Institute of Microbiology and Infection, University of Birmingham, Birmingham (C.G.), the Centre for Clinical Infection, James Cook University Hospital, Middlesbrough (D.C.), the North West Anglia NHS Foundation Trust, Peterborough (K. Rege), the Department of Research and Development, Cardiff and Vale University Health Board, Cardiff (C.F.), the School of Life Course Sciences, King's College London (L.C.C.), and the Intensive Care National Audit and Research Centre (K. Rowan), London, the NIHR Southampton Clinical Research Facility and Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust and University of Southampton, Southampton (S.N.F.), the Department of Mathematics and Statistics, Lancaster University, Lancaster (T.J.), the MRC Biostatistics Unit, University of Cambridge, Cambridge (T.J.), and Roslin Institute, University of Edinburgh, Edinburgh (J.K.B.) - all in the United Kingdom
| | - J Kenneth Baillie
- From the Nuffield Department of Medicine (P.H.), Nuffield Department of Population Health (J.R.E., M.M., J.L.B., L.L., N.S., E.J., R.H., M.J.L.), and MRC Population Health Research Unit (J.R.E., N.S., R.H., M.J.L.), University of Oxford, the Oxford University Hospitals NHS Foundation Trust (K.J.), and National Institute for Health Research (NIHR) Oxford Biomedical Research Centre (M.J.L.), Oxford, the Respiratory Medicine Department, Nottingham University Hospitals NHS Trust (W.S.L.), and the School of Medicine, University of Nottingham (A.M.), Nottingham, the Institute for Lung Health, Leicester NIHR Biomedical Research Centre, University of Leicester, Leicester (C.B.), the Regional Infectious Diseases Unit, North Manchester General Hospital and University of Manchester (A.U.), and the University of Manchester and Manchester University NHS Foundation Trust (T.F.), Manchester, the Research and Development Department, Northampton General Hospital, Northampton (E.E.), the Department of Respiratory Medicine, North Tees and Hartlepool NHS Foundation Trust, Stockton-on-Tees (B.P.), University Hospitals Birmingham NHS Foundation Trust and Institute of Microbiology and Infection, University of Birmingham, Birmingham (C.G.), the Centre for Clinical Infection, James Cook University Hospital, Middlesbrough (D.C.), the North West Anglia NHS Foundation Trust, Peterborough (K. Rege), the Department of Research and Development, Cardiff and Vale University Health Board, Cardiff (C.F.), the School of Life Course Sciences, King's College London (L.C.C.), and the Intensive Care National Audit and Research Centre (K. Rowan), London, the NIHR Southampton Clinical Research Facility and Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust and University of Southampton, Southampton (S.N.F.), the Department of Mathematics and Statistics, Lancaster University, Lancaster (T.J.), the MRC Biostatistics Unit, University of Cambridge, Cambridge (T.J.), and Roslin Institute, University of Edinburgh, Edinburgh (J.K.B.) - all in the United Kingdom
| | - Richard Haynes
- From the Nuffield Department of Medicine (P.H.), Nuffield Department of Population Health (J.R.E., M.M., J.L.B., L.L., N.S., E.J., R.H., M.J.L.), and MRC Population Health Research Unit (J.R.E., N.S., R.H., M.J.L.), University of Oxford, the Oxford University Hospitals NHS Foundation Trust (K.J.), and National Institute for Health Research (NIHR) Oxford Biomedical Research Centre (M.J.L.), Oxford, the Respiratory Medicine Department, Nottingham University Hospitals NHS Trust (W.S.L.), and the School of Medicine, University of Nottingham (A.M.), Nottingham, the Institute for Lung Health, Leicester NIHR Biomedical Research Centre, University of Leicester, Leicester (C.B.), the Regional Infectious Diseases Unit, North Manchester General Hospital and University of Manchester (A.U.), and the University of Manchester and Manchester University NHS Foundation Trust (T.F.), Manchester, the Research and Development Department, Northampton General Hospital, Northampton (E.E.), the Department of Respiratory Medicine, North Tees and Hartlepool NHS Foundation Trust, Stockton-on-Tees (B.P.), University Hospitals Birmingham NHS Foundation Trust and Institute of Microbiology and Infection, University of Birmingham, Birmingham (C.G.), the Centre for Clinical Infection, James Cook University Hospital, Middlesbrough (D.C.), the North West Anglia NHS Foundation Trust, Peterborough (K. Rege), the Department of Research and Development, Cardiff and Vale University Health Board, Cardiff (C.F.), the School of Life Course Sciences, King's College London (L.C.C.), and the Intensive Care National Audit and Research Centre (K. Rowan), London, the NIHR Southampton Clinical Research Facility and Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust and University of Southampton, Southampton (S.N.F.), the Department of Mathematics and Statistics, Lancaster University, Lancaster (T.J.), the MRC Biostatistics Unit, University of Cambridge, Cambridge (T.J.), and Roslin Institute, University of Edinburgh, Edinburgh (J.K.B.) - all in the United Kingdom
| | - Martin J Landray
- From the Nuffield Department of Medicine (P.H.), Nuffield Department of Population Health (J.R.E., M.M., J.L.B., L.L., N.S., E.J., R.H., M.J.L.), and MRC Population Health Research Unit (J.R.E., N.S., R.H., M.J.L.), University of Oxford, the Oxford University Hospitals NHS Foundation Trust (K.J.), and National Institute for Health Research (NIHR) Oxford Biomedical Research Centre (M.J.L.), Oxford, the Respiratory Medicine Department, Nottingham University Hospitals NHS Trust (W.S.L.), and the School of Medicine, University of Nottingham (A.M.), Nottingham, the Institute for Lung Health, Leicester NIHR Biomedical Research Centre, University of Leicester, Leicester (C.B.), the Regional Infectious Diseases Unit, North Manchester General Hospital and University of Manchester (A.U.), and the University of Manchester and Manchester University NHS Foundation Trust (T.F.), Manchester, the Research and Development Department, Northampton General Hospital, Northampton (E.E.), the Department of Respiratory Medicine, North Tees and Hartlepool NHS Foundation Trust, Stockton-on-Tees (B.P.), University Hospitals Birmingham NHS Foundation Trust and Institute of Microbiology and Infection, University of Birmingham, Birmingham (C.G.), the Centre for Clinical Infection, James Cook University Hospital, Middlesbrough (D.C.), the North West Anglia NHS Foundation Trust, Peterborough (K. Rege), the Department of Research and Development, Cardiff and Vale University Health Board, Cardiff (C.F.), the School of Life Course Sciences, King's College London (L.C.C.), and the Intensive Care National Audit and Research Centre (K. Rowan), London, the NIHR Southampton Clinical Research Facility and Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust and University of Southampton, Southampton (S.N.F.), the Department of Mathematics and Statistics, Lancaster University, Lancaster (T.J.), the MRC Biostatistics Unit, University of Cambridge, Cambridge (T.J.), and Roslin Institute, University of Edinburgh, Edinburgh (J.K.B.) - all in the United Kingdom
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Zhu P, Herrington WG, Haynes R, Emberson J, Landray MJ, Sudlow CL, Woodward M, Baigent C, Lewington S, Staplin N. Conventional and Genetic Evidence on the Association between Adiposity and CKD. J Am Soc Nephrol 2021; 32:127-137. [PMID: 33127858 PMCID: PMC7894659 DOI: 10.1681/asn.2020050679] [Citation(s) in RCA: 29] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2020] [Accepted: 09/10/2020] [Indexed: 01/13/2023] Open
Abstract
BACKGROUND The size of any causal contribution of central and general adiposity to CKD risk and the underlying mechanism of mediation are unknown. METHODS Data from 281,228 UK Biobank participants were used to estimate the relevance of waist-to-hip ratio and body mass index (BMI) to CKD prevalence. Conventional approaches used logistic regression. Genetic analyses used Mendelian randomization (MR) and data from 394 waist-to-hip ratio and 773 BMI-associated loci. Models assessed the role of known mediators (diabetes mellitus and BP) by adjusting for measured values (conventional analyses) or genetic associations of the selected loci (multivariable MR). RESULTS Evidence of CKD was found in 18,034 (6.4%) participants. Each 0.06 higher measured waist-to-hip ratio and each 5-kg/m2 increase in BMI were associated with 69% (odds ratio, 1.69; 95% CI, 1.64 to 1.74) and 58% (1.58; 1.55 to 1.62) higher odds of CKD, respectively. In analogous MR analyses, each 0.06-genetically-predicted higher waist-to-hip ratio was associated with a 29% (1.29; 1.20 to 1.38) increased odds of CKD, and each 5-kg/m2 genetically-predicted higher BMI was associated with a 49% (1.49; 1.39 to 1.59) increased odds. After adjusting for diabetes and measured BP, chi-squared values for associations for waist-to-hip ratio and BMI fell by 56%. In contrast, mediator adjustment using multivariable MR found 83% and 69% reductions in chi-squared values for genetically-predicted waist-to-hip ratio and BMI models, respectively. CONCLUSIONS Genetic analyses suggest that conventional associations between central and general adiposity with CKD are largely causal. However, conventional approaches underestimate mediating roles of diabetes, BP, and their correlates. Genetic approaches suggest these mediators explain most of adiposity-CKD-associated risk.
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Affiliation(s)
- Pengfei Zhu
- Medical Research Council Population Health Research Unit at the University of Oxford, Nuffield Department of Population Health, Oxford, United Kingdom,Clinical Trial Service Unit and Epidemiological Studies Unit, Nuffield Department of Population Health, University of Oxford, Oxford, United Kingdom
| | - William G. Herrington
- Medical Research Council Population Health Research Unit at the University of Oxford, Nuffield Department of Population Health, Oxford, United Kingdom,Clinical Trial Service Unit and Epidemiological Studies Unit, Nuffield Department of Population Health, University of Oxford, Oxford, United Kingdom,Oxford Kidney Unit, Churchill Hospital, Oxford, United Kingdom
| | - Richard Haynes
- Medical Research Council Population Health Research Unit at the University of Oxford, Nuffield Department of Population Health, Oxford, United Kingdom,Clinical Trial Service Unit and Epidemiological Studies Unit, Nuffield Department of Population Health, University of Oxford, Oxford, United Kingdom,Oxford Kidney Unit, Churchill Hospital, Oxford, United Kingdom
| | - Jonathan Emberson
- Medical Research Council Population Health Research Unit at the University of Oxford, Nuffield Department of Population Health, Oxford, United Kingdom,Clinical Trial Service Unit and Epidemiological Studies Unit, Nuffield Department of Population Health, University of Oxford, Oxford, United Kingdom,Big Data Institute, Li Ka Shing Centre for Health Information and Discovery, University of Oxford, Oxford, United Kingdom
| | - Martin J. Landray
- Medical Research Council Population Health Research Unit at the University of Oxford, Nuffield Department of Population Health, Oxford, United Kingdom,Clinical Trial Service Unit and Epidemiological Studies Unit, Nuffield Department of Population Health, University of Oxford, Oxford, United Kingdom,Big Data Institute, Li Ka Shing Centre for Health Information and Discovery, University of Oxford, Oxford, United Kingdom,Health Data Research UK, University of Oxford, Oxford, United Kingdom,National Institute for Health Research Oxford Biomedical Research Centre, University of Oxford, Oxford, United Kingdom
| | - Cathie L.M. Sudlow
- Usher Institute of Population Health Sciences and Informatics, University of Edinburgh, Edinburgh, United Kingdom
| | - Mark Woodward
- The George Institute for Global Health, Faculty of Medicine, University of New South Wales, Sydney, Australia,The George Institute for Global Health, Nuffield Department of Women’s and Reproductive Health, University of Oxford, Oxford, United Kingdom,Welch Center for Prevention, Epidemiology and Clinical Research, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland
| | - Colin Baigent
- Medical Research Council Population Health Research Unit at the University of Oxford, Nuffield Department of Population Health, Oxford, United Kingdom,Clinical Trial Service Unit and Epidemiological Studies Unit, Nuffield Department of Population Health, University of Oxford, Oxford, United Kingdom
| | - Sarah Lewington
- Clinical Trial Service Unit and Epidemiological Studies Unit, Nuffield Department of Population Health, University of Oxford, Oxford, United Kingdom
| | - Natalie Staplin
- Medical Research Council Population Health Research Unit at the University of Oxford, Nuffield Department of Population Health, Oxford, United Kingdom,Clinical Trial Service Unit and Epidemiological Studies Unit, Nuffield Department of Population Health, University of Oxford, Oxford, United Kingdom,Big Data Institute, Li Ka Shing Centre for Health Information and Discovery, University of Oxford, Oxford, United Kingdom
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Horby P, Mafham M, Linsell L, Bell JL, Staplin N, Emberson JR, Wiselka M, Ustianowski A, Elmahi E, Prudon B, Whitehouse T, Felton T, Williams J, Faccenda J, Underwood J, Baillie JK, Chappell LC, Faust SN, Jaki T, Jeffery K, Lim WS, Montgomery A, Rowan K, Tarning J, Watson JA, White NJ, Juszczak E, Haynes R, Landray MJ. Effect of Hydroxychloroquine in Hospitalized Patients with Covid-19. N Engl J Med 2020; 383:2030-2040. [PMID: 33031652 PMCID: PMC7556338 DOI: 10.1056/nejmoa2022926] [Citation(s) in RCA: 799] [Impact Index Per Article: 199.8] [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] [Indexed: 01/28/2023]
Abstract
BACKGROUND Hydroxychloroquine and chloroquine have been proposed as treatments for coronavirus disease 2019 (Covid-19) on the basis of in vitro activity and data from uncontrolled studies and small, randomized trials. METHODS In this randomized, controlled, open-label platform trial comparing a range of possible treatments with usual care in patients hospitalized with Covid-19, we randomly assigned 1561 patients to receive hydroxychloroquine and 3155 to receive usual care. The primary outcome was 28-day mortality. RESULTS The enrollment of patients in the hydroxychloroquine group was closed on June 5, 2020, after an interim analysis determined that there was a lack of efficacy. Death within 28 days occurred in 421 patients (27.0%) in the hydroxychloroquine group and in 790 (25.0%) in the usual-care group (rate ratio, 1.09; 95% confidence interval [CI], 0.97 to 1.23; P = 0.15). Consistent results were seen in all prespecified subgroups of patients. The results suggest that patients in the hydroxychloroquine group were less likely to be discharged from the hospital alive within 28 days than those in the usual-care group (59.6% vs. 62.9%; rate ratio, 0.90; 95% CI, 0.83 to 0.98). Among the patients who were not undergoing mechanical ventilation at baseline, those in the hydroxychloroquine group had a higher frequency of invasive mechanical ventilation or death (30.7% vs. 26.9%; risk ratio, 1.14; 95% CI, 1.03 to 1.27). There was a small numerical excess of cardiac deaths (0.4 percentage points) but no difference in the incidence of new major cardiac arrhythmia among the patients who received hydroxychloroquine. CONCLUSIONS Among patients hospitalized with Covid-19, those who received hydroxychloroquine did not have a lower incidence of death at 28 days than those who received usual care. (Funded by UK Research and Innovation and National Institute for Health Research and others; RECOVERY ISRCTN number, ISRCTN50189673; ClinicalTrials.gov number, NCT04381936.).
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Affiliation(s)
- Peter Horby
- The affiliations of the members of the writing committee are as follows: the Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine (P.H., J.T., J.A.W., N.J.W.), Nuffield Department of Population Health (M.M., L.L., J.L.B., N.S., J.R.E., E.J., R.H., M.J.L.), the Medical Research Council (MRC) Population Health Research Unit (N.S., J.R.E., R.H., M.J.L.), University of Oxford, the Oxford University Hospitals NHS Foundation Trust (K.J., M.J.L.), and the National Institute for Health Research (NIHR) Oxford Biomedical Research Centre (M.J.L.), Oxford, University Hospitals of Leicester NHS Trust and University of Leicester, Leicester (M.W.), the Regional Infectious Diseases Unit, North Manchester General Hospital (A.U.), University of Manchester (A.U., T.F.), and Manchester University NHS Foundation Trust (T.F.), Manchester, the Research and Development Department, Northampton General Hospital, Northampton (E.E.), the Department of Respiratory Medicine, North Tees and Hartlepool NHS Foundation Trust, Stockton-on-Tees (B.P.), University Hospitals Birmingham NHS Foundation Trust and Institute of Microbiology and Infection, University of Birmingham, Birmingham (T.W.), James Cook University Hospital, Middlesbrough (J.W.), North West Anglia NHS Foundation Trust, Peterborough (J.F.), the Department of Infectious Diseases, Cardiff and Vale University Health Board, and the Division of Infection and Immunity, Cardiff University, Cardiff (J.U.), Roslin Institute, University of Edinburgh, Edinburgh (J.K.B.), the School of Life Course Sciences, King's College London (L.C.C.), and the Intensive Care National Audit and Research Centre (K.R.), London, the NIHR Southampton Clinical Research Facility and Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust and University of Southampton, Southampton (S.N.F.), the Department of Mathematics and Statistics, Lancaster University, Lancaster (T.J.), the MRC Biostatistics Unit, University of Cambridge, Cambridge (T.J.), and the Respiratory Medicine Department, Nottingham University Hospitals NHS Trust (W.S.L.), and the School of Medicine, University of Nottingham (A.M., E.J.), Nottingham - all in the United Kingdom; and the Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand (J.T., J.A.W., N.J.W.)
| | - Marion Mafham
- The affiliations of the members of the writing committee are as follows: the Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine (P.H., J.T., J.A.W., N.J.W.), Nuffield Department of Population Health (M.M., L.L., J.L.B., N.S., J.R.E., E.J., R.H., M.J.L.), the Medical Research Council (MRC) Population Health Research Unit (N.S., J.R.E., R.H., M.J.L.), University of Oxford, the Oxford University Hospitals NHS Foundation Trust (K.J., M.J.L.), and the National Institute for Health Research (NIHR) Oxford Biomedical Research Centre (M.J.L.), Oxford, University Hospitals of Leicester NHS Trust and University of Leicester, Leicester (M.W.), the Regional Infectious Diseases Unit, North Manchester General Hospital (A.U.), University of Manchester (A.U., T.F.), and Manchester University NHS Foundation Trust (T.F.), Manchester, the Research and Development Department, Northampton General Hospital, Northampton (E.E.), the Department of Respiratory Medicine, North Tees and Hartlepool NHS Foundation Trust, Stockton-on-Tees (B.P.), University Hospitals Birmingham NHS Foundation Trust and Institute of Microbiology and Infection, University of Birmingham, Birmingham (T.W.), James Cook University Hospital, Middlesbrough (J.W.), North West Anglia NHS Foundation Trust, Peterborough (J.F.), the Department of Infectious Diseases, Cardiff and Vale University Health Board, and the Division of Infection and Immunity, Cardiff University, Cardiff (J.U.), Roslin Institute, University of Edinburgh, Edinburgh (J.K.B.), the School of Life Course Sciences, King's College London (L.C.C.), and the Intensive Care National Audit and Research Centre (K.R.), London, the NIHR Southampton Clinical Research Facility and Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust and University of Southampton, Southampton (S.N.F.), the Department of Mathematics and Statistics, Lancaster University, Lancaster (T.J.), the MRC Biostatistics Unit, University of Cambridge, Cambridge (T.J.), and the Respiratory Medicine Department, Nottingham University Hospitals NHS Trust (W.S.L.), and the School of Medicine, University of Nottingham (A.M., E.J.), Nottingham - all in the United Kingdom; and the Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand (J.T., J.A.W., N.J.W.)
| | - Louise Linsell
- The affiliations of the members of the writing committee are as follows: the Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine (P.H., J.T., J.A.W., N.J.W.), Nuffield Department of Population Health (M.M., L.L., J.L.B., N.S., J.R.E., E.J., R.H., M.J.L.), the Medical Research Council (MRC) Population Health Research Unit (N.S., J.R.E., R.H., M.J.L.), University of Oxford, the Oxford University Hospitals NHS Foundation Trust (K.J., M.J.L.), and the National Institute for Health Research (NIHR) Oxford Biomedical Research Centre (M.J.L.), Oxford, University Hospitals of Leicester NHS Trust and University of Leicester, Leicester (M.W.), the Regional Infectious Diseases Unit, North Manchester General Hospital (A.U.), University of Manchester (A.U., T.F.), and Manchester University NHS Foundation Trust (T.F.), Manchester, the Research and Development Department, Northampton General Hospital, Northampton (E.E.), the Department of Respiratory Medicine, North Tees and Hartlepool NHS Foundation Trust, Stockton-on-Tees (B.P.), University Hospitals Birmingham NHS Foundation Trust and Institute of Microbiology and Infection, University of Birmingham, Birmingham (T.W.), James Cook University Hospital, Middlesbrough (J.W.), North West Anglia NHS Foundation Trust, Peterborough (J.F.), the Department of Infectious Diseases, Cardiff and Vale University Health Board, and the Division of Infection and Immunity, Cardiff University, Cardiff (J.U.), Roslin Institute, University of Edinburgh, Edinburgh (J.K.B.), the School of Life Course Sciences, King's College London (L.C.C.), and the Intensive Care National Audit and Research Centre (K.R.), London, the NIHR Southampton Clinical Research Facility and Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust and University of Southampton, Southampton (S.N.F.), the Department of Mathematics and Statistics, Lancaster University, Lancaster (T.J.), the MRC Biostatistics Unit, University of Cambridge, Cambridge (T.J.), and the Respiratory Medicine Department, Nottingham University Hospitals NHS Trust (W.S.L.), and the School of Medicine, University of Nottingham (A.M., E.J.), Nottingham - all in the United Kingdom; and the Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand (J.T., J.A.W., N.J.W.)
| | - Jennifer L Bell
- The affiliations of the members of the writing committee are as follows: the Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine (P.H., J.T., J.A.W., N.J.W.), Nuffield Department of Population Health (M.M., L.L., J.L.B., N.S., J.R.E., E.J., R.H., M.J.L.), the Medical Research Council (MRC) Population Health Research Unit (N.S., J.R.E., R.H., M.J.L.), University of Oxford, the Oxford University Hospitals NHS Foundation Trust (K.J., M.J.L.), and the National Institute for Health Research (NIHR) Oxford Biomedical Research Centre (M.J.L.), Oxford, University Hospitals of Leicester NHS Trust and University of Leicester, Leicester (M.W.), the Regional Infectious Diseases Unit, North Manchester General Hospital (A.U.), University of Manchester (A.U., T.F.), and Manchester University NHS Foundation Trust (T.F.), Manchester, the Research and Development Department, Northampton General Hospital, Northampton (E.E.), the Department of Respiratory Medicine, North Tees and Hartlepool NHS Foundation Trust, Stockton-on-Tees (B.P.), University Hospitals Birmingham NHS Foundation Trust and Institute of Microbiology and Infection, University of Birmingham, Birmingham (T.W.), James Cook University Hospital, Middlesbrough (J.W.), North West Anglia NHS Foundation Trust, Peterborough (J.F.), the Department of Infectious Diseases, Cardiff and Vale University Health Board, and the Division of Infection and Immunity, Cardiff University, Cardiff (J.U.), Roslin Institute, University of Edinburgh, Edinburgh (J.K.B.), the School of Life Course Sciences, King's College London (L.C.C.), and the Intensive Care National Audit and Research Centre (K.R.), London, the NIHR Southampton Clinical Research Facility and Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust and University of Southampton, Southampton (S.N.F.), the Department of Mathematics and Statistics, Lancaster University, Lancaster (T.J.), the MRC Biostatistics Unit, University of Cambridge, Cambridge (T.J.), and the Respiratory Medicine Department, Nottingham University Hospitals NHS Trust (W.S.L.), and the School of Medicine, University of Nottingham (A.M., E.J.), Nottingham - all in the United Kingdom; and the Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand (J.T., J.A.W., N.J.W.)
| | - Natalie Staplin
- The affiliations of the members of the writing committee are as follows: the Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine (P.H., J.T., J.A.W., N.J.W.), Nuffield Department of Population Health (M.M., L.L., J.L.B., N.S., J.R.E., E.J., R.H., M.J.L.), the Medical Research Council (MRC) Population Health Research Unit (N.S., J.R.E., R.H., M.J.L.), University of Oxford, the Oxford University Hospitals NHS Foundation Trust (K.J., M.J.L.), and the National Institute for Health Research (NIHR) Oxford Biomedical Research Centre (M.J.L.), Oxford, University Hospitals of Leicester NHS Trust and University of Leicester, Leicester (M.W.), the Regional Infectious Diseases Unit, North Manchester General Hospital (A.U.), University of Manchester (A.U., T.F.), and Manchester University NHS Foundation Trust (T.F.), Manchester, the Research and Development Department, Northampton General Hospital, Northampton (E.E.), the Department of Respiratory Medicine, North Tees and Hartlepool NHS Foundation Trust, Stockton-on-Tees (B.P.), University Hospitals Birmingham NHS Foundation Trust and Institute of Microbiology and Infection, University of Birmingham, Birmingham (T.W.), James Cook University Hospital, Middlesbrough (J.W.), North West Anglia NHS Foundation Trust, Peterborough (J.F.), the Department of Infectious Diseases, Cardiff and Vale University Health Board, and the Division of Infection and Immunity, Cardiff University, Cardiff (J.U.), Roslin Institute, University of Edinburgh, Edinburgh (J.K.B.), the School of Life Course Sciences, King's College London (L.C.C.), and the Intensive Care National Audit and Research Centre (K.R.), London, the NIHR Southampton Clinical Research Facility and Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust and University of Southampton, Southampton (S.N.F.), the Department of Mathematics and Statistics, Lancaster University, Lancaster (T.J.), the MRC Biostatistics Unit, University of Cambridge, Cambridge (T.J.), and the Respiratory Medicine Department, Nottingham University Hospitals NHS Trust (W.S.L.), and the School of Medicine, University of Nottingham (A.M., E.J.), Nottingham - all in the United Kingdom; and the Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand (J.T., J.A.W., N.J.W.)
| | - Jonathan R Emberson
- The affiliations of the members of the writing committee are as follows: the Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine (P.H., J.T., J.A.W., N.J.W.), Nuffield Department of Population Health (M.M., L.L., J.L.B., N.S., J.R.E., E.J., R.H., M.J.L.), the Medical Research Council (MRC) Population Health Research Unit (N.S., J.R.E., R.H., M.J.L.), University of Oxford, the Oxford University Hospitals NHS Foundation Trust (K.J., M.J.L.), and the National Institute for Health Research (NIHR) Oxford Biomedical Research Centre (M.J.L.), Oxford, University Hospitals of Leicester NHS Trust and University of Leicester, Leicester (M.W.), the Regional Infectious Diseases Unit, North Manchester General Hospital (A.U.), University of Manchester (A.U., T.F.), and Manchester University NHS Foundation Trust (T.F.), Manchester, the Research and Development Department, Northampton General Hospital, Northampton (E.E.), the Department of Respiratory Medicine, North Tees and Hartlepool NHS Foundation Trust, Stockton-on-Tees (B.P.), University Hospitals Birmingham NHS Foundation Trust and Institute of Microbiology and Infection, University of Birmingham, Birmingham (T.W.), James Cook University Hospital, Middlesbrough (J.W.), North West Anglia NHS Foundation Trust, Peterborough (J.F.), the Department of Infectious Diseases, Cardiff and Vale University Health Board, and the Division of Infection and Immunity, Cardiff University, Cardiff (J.U.), Roslin Institute, University of Edinburgh, Edinburgh (J.K.B.), the School of Life Course Sciences, King's College London (L.C.C.), and the Intensive Care National Audit and Research Centre (K.R.), London, the NIHR Southampton Clinical Research Facility and Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust and University of Southampton, Southampton (S.N.F.), the Department of Mathematics and Statistics, Lancaster University, Lancaster (T.J.), the MRC Biostatistics Unit, University of Cambridge, Cambridge (T.J.), and the Respiratory Medicine Department, Nottingham University Hospitals NHS Trust (W.S.L.), and the School of Medicine, University of Nottingham (A.M., E.J.), Nottingham - all in the United Kingdom; and the Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand (J.T., J.A.W., N.J.W.)
| | - Martin Wiselka
- The affiliations of the members of the writing committee are as follows: the Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine (P.H., J.T., J.A.W., N.J.W.), Nuffield Department of Population Health (M.M., L.L., J.L.B., N.S., J.R.E., E.J., R.H., M.J.L.), the Medical Research Council (MRC) Population Health Research Unit (N.S., J.R.E., R.H., M.J.L.), University of Oxford, the Oxford University Hospitals NHS Foundation Trust (K.J., M.J.L.), and the National Institute for Health Research (NIHR) Oxford Biomedical Research Centre (M.J.L.), Oxford, University Hospitals of Leicester NHS Trust and University of Leicester, Leicester (M.W.), the Regional Infectious Diseases Unit, North Manchester General Hospital (A.U.), University of Manchester (A.U., T.F.), and Manchester University NHS Foundation Trust (T.F.), Manchester, the Research and Development Department, Northampton General Hospital, Northampton (E.E.), the Department of Respiratory Medicine, North Tees and Hartlepool NHS Foundation Trust, Stockton-on-Tees (B.P.), University Hospitals Birmingham NHS Foundation Trust and Institute of Microbiology and Infection, University of Birmingham, Birmingham (T.W.), James Cook University Hospital, Middlesbrough (J.W.), North West Anglia NHS Foundation Trust, Peterborough (J.F.), the Department of Infectious Diseases, Cardiff and Vale University Health Board, and the Division of Infection and Immunity, Cardiff University, Cardiff (J.U.), Roslin Institute, University of Edinburgh, Edinburgh (J.K.B.), the School of Life Course Sciences, King's College London (L.C.C.), and the Intensive Care National Audit and Research Centre (K.R.), London, the NIHR Southampton Clinical Research Facility and Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust and University of Southampton, Southampton (S.N.F.), the Department of Mathematics and Statistics, Lancaster University, Lancaster (T.J.), the MRC Biostatistics Unit, University of Cambridge, Cambridge (T.J.), and the Respiratory Medicine Department, Nottingham University Hospitals NHS Trust (W.S.L.), and the School of Medicine, University of Nottingham (A.M., E.J.), Nottingham - all in the United Kingdom; and the Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand (J.T., J.A.W., N.J.W.)
| | - Andrew Ustianowski
- The affiliations of the members of the writing committee are as follows: the Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine (P.H., J.T., J.A.W., N.J.W.), Nuffield Department of Population Health (M.M., L.L., J.L.B., N.S., J.R.E., E.J., R.H., M.J.L.), the Medical Research Council (MRC) Population Health Research Unit (N.S., J.R.E., R.H., M.J.L.), University of Oxford, the Oxford University Hospitals NHS Foundation Trust (K.J., M.J.L.), and the National Institute for Health Research (NIHR) Oxford Biomedical Research Centre (M.J.L.), Oxford, University Hospitals of Leicester NHS Trust and University of Leicester, Leicester (M.W.), the Regional Infectious Diseases Unit, North Manchester General Hospital (A.U.), University of Manchester (A.U., T.F.), and Manchester University NHS Foundation Trust (T.F.), Manchester, the Research and Development Department, Northampton General Hospital, Northampton (E.E.), the Department of Respiratory Medicine, North Tees and Hartlepool NHS Foundation Trust, Stockton-on-Tees (B.P.), University Hospitals Birmingham NHS Foundation Trust and Institute of Microbiology and Infection, University of Birmingham, Birmingham (T.W.), James Cook University Hospital, Middlesbrough (J.W.), North West Anglia NHS Foundation Trust, Peterborough (J.F.), the Department of Infectious Diseases, Cardiff and Vale University Health Board, and the Division of Infection and Immunity, Cardiff University, Cardiff (J.U.), Roslin Institute, University of Edinburgh, Edinburgh (J.K.B.), the School of Life Course Sciences, King's College London (L.C.C.), and the Intensive Care National Audit and Research Centre (K.R.), London, the NIHR Southampton Clinical Research Facility and Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust and University of Southampton, Southampton (S.N.F.), the Department of Mathematics and Statistics, Lancaster University, Lancaster (T.J.), the MRC Biostatistics Unit, University of Cambridge, Cambridge (T.J.), and the Respiratory Medicine Department, Nottingham University Hospitals NHS Trust (W.S.L.), and the School of Medicine, University of Nottingham (A.M., E.J.), Nottingham - all in the United Kingdom; and the Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand (J.T., J.A.W., N.J.W.)
| | - Einas Elmahi
- The affiliations of the members of the writing committee are as follows: the Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine (P.H., J.T., J.A.W., N.J.W.), Nuffield Department of Population Health (M.M., L.L., J.L.B., N.S., J.R.E., E.J., R.H., M.J.L.), the Medical Research Council (MRC) Population Health Research Unit (N.S., J.R.E., R.H., M.J.L.), University of Oxford, the Oxford University Hospitals NHS Foundation Trust (K.J., M.J.L.), and the National Institute for Health Research (NIHR) Oxford Biomedical Research Centre (M.J.L.), Oxford, University Hospitals of Leicester NHS Trust and University of Leicester, Leicester (M.W.), the Regional Infectious Diseases Unit, North Manchester General Hospital (A.U.), University of Manchester (A.U., T.F.), and Manchester University NHS Foundation Trust (T.F.), Manchester, the Research and Development Department, Northampton General Hospital, Northampton (E.E.), the Department of Respiratory Medicine, North Tees and Hartlepool NHS Foundation Trust, Stockton-on-Tees (B.P.), University Hospitals Birmingham NHS Foundation Trust and Institute of Microbiology and Infection, University of Birmingham, Birmingham (T.W.), James Cook University Hospital, Middlesbrough (J.W.), North West Anglia NHS Foundation Trust, Peterborough (J.F.), the Department of Infectious Diseases, Cardiff and Vale University Health Board, and the Division of Infection and Immunity, Cardiff University, Cardiff (J.U.), Roslin Institute, University of Edinburgh, Edinburgh (J.K.B.), the School of Life Course Sciences, King's College London (L.C.C.), and the Intensive Care National Audit and Research Centre (K.R.), London, the NIHR Southampton Clinical Research Facility and Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust and University of Southampton, Southampton (S.N.F.), the Department of Mathematics and Statistics, Lancaster University, Lancaster (T.J.), the MRC Biostatistics Unit, University of Cambridge, Cambridge (T.J.), and the Respiratory Medicine Department, Nottingham University Hospitals NHS Trust (W.S.L.), and the School of Medicine, University of Nottingham (A.M., E.J.), Nottingham - all in the United Kingdom; and the Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand (J.T., J.A.W., N.J.W.)
| | - Benjamin Prudon
- The affiliations of the members of the writing committee are as follows: the Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine (P.H., J.T., J.A.W., N.J.W.), Nuffield Department of Population Health (M.M., L.L., J.L.B., N.S., J.R.E., E.J., R.H., M.J.L.), the Medical Research Council (MRC) Population Health Research Unit (N.S., J.R.E., R.H., M.J.L.), University of Oxford, the Oxford University Hospitals NHS Foundation Trust (K.J., M.J.L.), and the National Institute for Health Research (NIHR) Oxford Biomedical Research Centre (M.J.L.), Oxford, University Hospitals of Leicester NHS Trust and University of Leicester, Leicester (M.W.), the Regional Infectious Diseases Unit, North Manchester General Hospital (A.U.), University of Manchester (A.U., T.F.), and Manchester University NHS Foundation Trust (T.F.), Manchester, the Research and Development Department, Northampton General Hospital, Northampton (E.E.), the Department of Respiratory Medicine, North Tees and Hartlepool NHS Foundation Trust, Stockton-on-Tees (B.P.), University Hospitals Birmingham NHS Foundation Trust and Institute of Microbiology and Infection, University of Birmingham, Birmingham (T.W.), James Cook University Hospital, Middlesbrough (J.W.), North West Anglia NHS Foundation Trust, Peterborough (J.F.), the Department of Infectious Diseases, Cardiff and Vale University Health Board, and the Division of Infection and Immunity, Cardiff University, Cardiff (J.U.), Roslin Institute, University of Edinburgh, Edinburgh (J.K.B.), the School of Life Course Sciences, King's College London (L.C.C.), and the Intensive Care National Audit and Research Centre (K.R.), London, the NIHR Southampton Clinical Research Facility and Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust and University of Southampton, Southampton (S.N.F.), the Department of Mathematics and Statistics, Lancaster University, Lancaster (T.J.), the MRC Biostatistics Unit, University of Cambridge, Cambridge (T.J.), and the Respiratory Medicine Department, Nottingham University Hospitals NHS Trust (W.S.L.), and the School of Medicine, University of Nottingham (A.M., E.J.), Nottingham - all in the United Kingdom; and the Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand (J.T., J.A.W., N.J.W.)
| | - Tony Whitehouse
- The affiliations of the members of the writing committee are as follows: the Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine (P.H., J.T., J.A.W., N.J.W.), Nuffield Department of Population Health (M.M., L.L., J.L.B., N.S., J.R.E., E.J., R.H., M.J.L.), the Medical Research Council (MRC) Population Health Research Unit (N.S., J.R.E., R.H., M.J.L.), University of Oxford, the Oxford University Hospitals NHS Foundation Trust (K.J., M.J.L.), and the National Institute for Health Research (NIHR) Oxford Biomedical Research Centre (M.J.L.), Oxford, University Hospitals of Leicester NHS Trust and University of Leicester, Leicester (M.W.), the Regional Infectious Diseases Unit, North Manchester General Hospital (A.U.), University of Manchester (A.U., T.F.), and Manchester University NHS Foundation Trust (T.F.), Manchester, the Research and Development Department, Northampton General Hospital, Northampton (E.E.), the Department of Respiratory Medicine, North Tees and Hartlepool NHS Foundation Trust, Stockton-on-Tees (B.P.), University Hospitals Birmingham NHS Foundation Trust and Institute of Microbiology and Infection, University of Birmingham, Birmingham (T.W.), James Cook University Hospital, Middlesbrough (J.W.), North West Anglia NHS Foundation Trust, Peterborough (J.F.), the Department of Infectious Diseases, Cardiff and Vale University Health Board, and the Division of Infection and Immunity, Cardiff University, Cardiff (J.U.), Roslin Institute, University of Edinburgh, Edinburgh (J.K.B.), the School of Life Course Sciences, King's College London (L.C.C.), and the Intensive Care National Audit and Research Centre (K.R.), London, the NIHR Southampton Clinical Research Facility and Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust and University of Southampton, Southampton (S.N.F.), the Department of Mathematics and Statistics, Lancaster University, Lancaster (T.J.), the MRC Biostatistics Unit, University of Cambridge, Cambridge (T.J.), and the Respiratory Medicine Department, Nottingham University Hospitals NHS Trust (W.S.L.), and the School of Medicine, University of Nottingham (A.M., E.J.), Nottingham - all in the United Kingdom; and the Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand (J.T., J.A.W., N.J.W.)
| | - Timothy Felton
- The affiliations of the members of the writing committee are as follows: the Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine (P.H., J.T., J.A.W., N.J.W.), Nuffield Department of Population Health (M.M., L.L., J.L.B., N.S., J.R.E., E.J., R.H., M.J.L.), the Medical Research Council (MRC) Population Health Research Unit (N.S., J.R.E., R.H., M.J.L.), University of Oxford, the Oxford University Hospitals NHS Foundation Trust (K.J., M.J.L.), and the National Institute for Health Research (NIHR) Oxford Biomedical Research Centre (M.J.L.), Oxford, University Hospitals of Leicester NHS Trust and University of Leicester, Leicester (M.W.), the Regional Infectious Diseases Unit, North Manchester General Hospital (A.U.), University of Manchester (A.U., T.F.), and Manchester University NHS Foundation Trust (T.F.), Manchester, the Research and Development Department, Northampton General Hospital, Northampton (E.E.), the Department of Respiratory Medicine, North Tees and Hartlepool NHS Foundation Trust, Stockton-on-Tees (B.P.), University Hospitals Birmingham NHS Foundation Trust and Institute of Microbiology and Infection, University of Birmingham, Birmingham (T.W.), James Cook University Hospital, Middlesbrough (J.W.), North West Anglia NHS Foundation Trust, Peterborough (J.F.), the Department of Infectious Diseases, Cardiff and Vale University Health Board, and the Division of Infection and Immunity, Cardiff University, Cardiff (J.U.), Roslin Institute, University of Edinburgh, Edinburgh (J.K.B.), the School of Life Course Sciences, King's College London (L.C.C.), and the Intensive Care National Audit and Research Centre (K.R.), London, the NIHR Southampton Clinical Research Facility and Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust and University of Southampton, Southampton (S.N.F.), the Department of Mathematics and Statistics, Lancaster University, Lancaster (T.J.), the MRC Biostatistics Unit, University of Cambridge, Cambridge (T.J.), and the Respiratory Medicine Department, Nottingham University Hospitals NHS Trust (W.S.L.), and the School of Medicine, University of Nottingham (A.M., E.J.), Nottingham - all in the United Kingdom; and the Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand (J.T., J.A.W., N.J.W.)
| | - John Williams
- The affiliations of the members of the writing committee are as follows: the Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine (P.H., J.T., J.A.W., N.J.W.), Nuffield Department of Population Health (M.M., L.L., J.L.B., N.S., J.R.E., E.J., R.H., M.J.L.), the Medical Research Council (MRC) Population Health Research Unit (N.S., J.R.E., R.H., M.J.L.), University of Oxford, the Oxford University Hospitals NHS Foundation Trust (K.J., M.J.L.), and the National Institute for Health Research (NIHR) Oxford Biomedical Research Centre (M.J.L.), Oxford, University Hospitals of Leicester NHS Trust and University of Leicester, Leicester (M.W.), the Regional Infectious Diseases Unit, North Manchester General Hospital (A.U.), University of Manchester (A.U., T.F.), and Manchester University NHS Foundation Trust (T.F.), Manchester, the Research and Development Department, Northampton General Hospital, Northampton (E.E.), the Department of Respiratory Medicine, North Tees and Hartlepool NHS Foundation Trust, Stockton-on-Tees (B.P.), University Hospitals Birmingham NHS Foundation Trust and Institute of Microbiology and Infection, University of Birmingham, Birmingham (T.W.), James Cook University Hospital, Middlesbrough (J.W.), North West Anglia NHS Foundation Trust, Peterborough (J.F.), the Department of Infectious Diseases, Cardiff and Vale University Health Board, and the Division of Infection and Immunity, Cardiff University, Cardiff (J.U.), Roslin Institute, University of Edinburgh, Edinburgh (J.K.B.), the School of Life Course Sciences, King's College London (L.C.C.), and the Intensive Care National Audit and Research Centre (K.R.), London, the NIHR Southampton Clinical Research Facility and Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust and University of Southampton, Southampton (S.N.F.), the Department of Mathematics and Statistics, Lancaster University, Lancaster (T.J.), the MRC Biostatistics Unit, University of Cambridge, Cambridge (T.J.), and the Respiratory Medicine Department, Nottingham University Hospitals NHS Trust (W.S.L.), and the School of Medicine, University of Nottingham (A.M., E.J.), Nottingham - all in the United Kingdom; and the Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand (J.T., J.A.W., N.J.W.)
| | - Jakki Faccenda
- The affiliations of the members of the writing committee are as follows: the Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine (P.H., J.T., J.A.W., N.J.W.), Nuffield Department of Population Health (M.M., L.L., J.L.B., N.S., J.R.E., E.J., R.H., M.J.L.), the Medical Research Council (MRC) Population Health Research Unit (N.S., J.R.E., R.H., M.J.L.), University of Oxford, the Oxford University Hospitals NHS Foundation Trust (K.J., M.J.L.), and the National Institute for Health Research (NIHR) Oxford Biomedical Research Centre (M.J.L.), Oxford, University Hospitals of Leicester NHS Trust and University of Leicester, Leicester (M.W.), the Regional Infectious Diseases Unit, North Manchester General Hospital (A.U.), University of Manchester (A.U., T.F.), and Manchester University NHS Foundation Trust (T.F.), Manchester, the Research and Development Department, Northampton General Hospital, Northampton (E.E.), the Department of Respiratory Medicine, North Tees and Hartlepool NHS Foundation Trust, Stockton-on-Tees (B.P.), University Hospitals Birmingham NHS Foundation Trust and Institute of Microbiology and Infection, University of Birmingham, Birmingham (T.W.), James Cook University Hospital, Middlesbrough (J.W.), North West Anglia NHS Foundation Trust, Peterborough (J.F.), the Department of Infectious Diseases, Cardiff and Vale University Health Board, and the Division of Infection and Immunity, Cardiff University, Cardiff (J.U.), Roslin Institute, University of Edinburgh, Edinburgh (J.K.B.), the School of Life Course Sciences, King's College London (L.C.C.), and the Intensive Care National Audit and Research Centre (K.R.), London, the NIHR Southampton Clinical Research Facility and Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust and University of Southampton, Southampton (S.N.F.), the Department of Mathematics and Statistics, Lancaster University, Lancaster (T.J.), the MRC Biostatistics Unit, University of Cambridge, Cambridge (T.J.), and the Respiratory Medicine Department, Nottingham University Hospitals NHS Trust (W.S.L.), and the School of Medicine, University of Nottingham (A.M., E.J.), Nottingham - all in the United Kingdom; and the Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand (J.T., J.A.W., N.J.W.)
| | - Jonathan Underwood
- The affiliations of the members of the writing committee are as follows: the Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine (P.H., J.T., J.A.W., N.J.W.), Nuffield Department of Population Health (M.M., L.L., J.L.B., N.S., J.R.E., E.J., R.H., M.J.L.), the Medical Research Council (MRC) Population Health Research Unit (N.S., J.R.E., R.H., M.J.L.), University of Oxford, the Oxford University Hospitals NHS Foundation Trust (K.J., M.J.L.), and the National Institute for Health Research (NIHR) Oxford Biomedical Research Centre (M.J.L.), Oxford, University Hospitals of Leicester NHS Trust and University of Leicester, Leicester (M.W.), the Regional Infectious Diseases Unit, North Manchester General Hospital (A.U.), University of Manchester (A.U., T.F.), and Manchester University NHS Foundation Trust (T.F.), Manchester, the Research and Development Department, Northampton General Hospital, Northampton (E.E.), the Department of Respiratory Medicine, North Tees and Hartlepool NHS Foundation Trust, Stockton-on-Tees (B.P.), University Hospitals Birmingham NHS Foundation Trust and Institute of Microbiology and Infection, University of Birmingham, Birmingham (T.W.), James Cook University Hospital, Middlesbrough (J.W.), North West Anglia NHS Foundation Trust, Peterborough (J.F.), the Department of Infectious Diseases, Cardiff and Vale University Health Board, and the Division of Infection and Immunity, Cardiff University, Cardiff (J.U.), Roslin Institute, University of Edinburgh, Edinburgh (J.K.B.), the School of Life Course Sciences, King's College London (L.C.C.), and the Intensive Care National Audit and Research Centre (K.R.), London, the NIHR Southampton Clinical Research Facility and Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust and University of Southampton, Southampton (S.N.F.), the Department of Mathematics and Statistics, Lancaster University, Lancaster (T.J.), the MRC Biostatistics Unit, University of Cambridge, Cambridge (T.J.), and the Respiratory Medicine Department, Nottingham University Hospitals NHS Trust (W.S.L.), and the School of Medicine, University of Nottingham (A.M., E.J.), Nottingham - all in the United Kingdom; and the Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand (J.T., J.A.W., N.J.W.)
| | - J Kenneth Baillie
- The affiliations of the members of the writing committee are as follows: the Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine (P.H., J.T., J.A.W., N.J.W.), Nuffield Department of Population Health (M.M., L.L., J.L.B., N.S., J.R.E., E.J., R.H., M.J.L.), the Medical Research Council (MRC) Population Health Research Unit (N.S., J.R.E., R.H., M.J.L.), University of Oxford, the Oxford University Hospitals NHS Foundation Trust (K.J., M.J.L.), and the National Institute for Health Research (NIHR) Oxford Biomedical Research Centre (M.J.L.), Oxford, University Hospitals of Leicester NHS Trust and University of Leicester, Leicester (M.W.), the Regional Infectious Diseases Unit, North Manchester General Hospital (A.U.), University of Manchester (A.U., T.F.), and Manchester University NHS Foundation Trust (T.F.), Manchester, the Research and Development Department, Northampton General Hospital, Northampton (E.E.), the Department of Respiratory Medicine, North Tees and Hartlepool NHS Foundation Trust, Stockton-on-Tees (B.P.), University Hospitals Birmingham NHS Foundation Trust and Institute of Microbiology and Infection, University of Birmingham, Birmingham (T.W.), James Cook University Hospital, Middlesbrough (J.W.), North West Anglia NHS Foundation Trust, Peterborough (J.F.), the Department of Infectious Diseases, Cardiff and Vale University Health Board, and the Division of Infection and Immunity, Cardiff University, Cardiff (J.U.), Roslin Institute, University of Edinburgh, Edinburgh (J.K.B.), the School of Life Course Sciences, King's College London (L.C.C.), and the Intensive Care National Audit and Research Centre (K.R.), London, the NIHR Southampton Clinical Research Facility and Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust and University of Southampton, Southampton (S.N.F.), the Department of Mathematics and Statistics, Lancaster University, Lancaster (T.J.), the MRC Biostatistics Unit, University of Cambridge, Cambridge (T.J.), and the Respiratory Medicine Department, Nottingham University Hospitals NHS Trust (W.S.L.), and the School of Medicine, University of Nottingham (A.M., E.J.), Nottingham - all in the United Kingdom; and the Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand (J.T., J.A.W., N.J.W.)
| | - Lucy C Chappell
- The affiliations of the members of the writing committee are as follows: the Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine (P.H., J.T., J.A.W., N.J.W.), Nuffield Department of Population Health (M.M., L.L., J.L.B., N.S., J.R.E., E.J., R.H., M.J.L.), the Medical Research Council (MRC) Population Health Research Unit (N.S., J.R.E., R.H., M.J.L.), University of Oxford, the Oxford University Hospitals NHS Foundation Trust (K.J., M.J.L.), and the National Institute for Health Research (NIHR) Oxford Biomedical Research Centre (M.J.L.), Oxford, University Hospitals of Leicester NHS Trust and University of Leicester, Leicester (M.W.), the Regional Infectious Diseases Unit, North Manchester General Hospital (A.U.), University of Manchester (A.U., T.F.), and Manchester University NHS Foundation Trust (T.F.), Manchester, the Research and Development Department, Northampton General Hospital, Northampton (E.E.), the Department of Respiratory Medicine, North Tees and Hartlepool NHS Foundation Trust, Stockton-on-Tees (B.P.), University Hospitals Birmingham NHS Foundation Trust and Institute of Microbiology and Infection, University of Birmingham, Birmingham (T.W.), James Cook University Hospital, Middlesbrough (J.W.), North West Anglia NHS Foundation Trust, Peterborough (J.F.), the Department of Infectious Diseases, Cardiff and Vale University Health Board, and the Division of Infection and Immunity, Cardiff University, Cardiff (J.U.), Roslin Institute, University of Edinburgh, Edinburgh (J.K.B.), the School of Life Course Sciences, King's College London (L.C.C.), and the Intensive Care National Audit and Research Centre (K.R.), London, the NIHR Southampton Clinical Research Facility and Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust and University of Southampton, Southampton (S.N.F.), the Department of Mathematics and Statistics, Lancaster University, Lancaster (T.J.), the MRC Biostatistics Unit, University of Cambridge, Cambridge (T.J.), and the Respiratory Medicine Department, Nottingham University Hospitals NHS Trust (W.S.L.), and the School of Medicine, University of Nottingham (A.M., E.J.), Nottingham - all in the United Kingdom; and the Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand (J.T., J.A.W., N.J.W.)
| | - Saul N Faust
- The affiliations of the members of the writing committee are as follows: the Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine (P.H., J.T., J.A.W., N.J.W.), Nuffield Department of Population Health (M.M., L.L., J.L.B., N.S., J.R.E., E.J., R.H., M.J.L.), the Medical Research Council (MRC) Population Health Research Unit (N.S., J.R.E., R.H., M.J.L.), University of Oxford, the Oxford University Hospitals NHS Foundation Trust (K.J., M.J.L.), and the National Institute for Health Research (NIHR) Oxford Biomedical Research Centre (M.J.L.), Oxford, University Hospitals of Leicester NHS Trust and University of Leicester, Leicester (M.W.), the Regional Infectious Diseases Unit, North Manchester General Hospital (A.U.), University of Manchester (A.U., T.F.), and Manchester University NHS Foundation Trust (T.F.), Manchester, the Research and Development Department, Northampton General Hospital, Northampton (E.E.), the Department of Respiratory Medicine, North Tees and Hartlepool NHS Foundation Trust, Stockton-on-Tees (B.P.), University Hospitals Birmingham NHS Foundation Trust and Institute of Microbiology and Infection, University of Birmingham, Birmingham (T.W.), James Cook University Hospital, Middlesbrough (J.W.), North West Anglia NHS Foundation Trust, Peterborough (J.F.), the Department of Infectious Diseases, Cardiff and Vale University Health Board, and the Division of Infection and Immunity, Cardiff University, Cardiff (J.U.), Roslin Institute, University of Edinburgh, Edinburgh (J.K.B.), the School of Life Course Sciences, King's College London (L.C.C.), and the Intensive Care National Audit and Research Centre (K.R.), London, the NIHR Southampton Clinical Research Facility and Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust and University of Southampton, Southampton (S.N.F.), the Department of Mathematics and Statistics, Lancaster University, Lancaster (T.J.), the MRC Biostatistics Unit, University of Cambridge, Cambridge (T.J.), and the Respiratory Medicine Department, Nottingham University Hospitals NHS Trust (W.S.L.), and the School of Medicine, University of Nottingham (A.M., E.J.), Nottingham - all in the United Kingdom; and the Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand (J.T., J.A.W., N.J.W.)
| | - Thomas Jaki
- The affiliations of the members of the writing committee are as follows: the Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine (P.H., J.T., J.A.W., N.J.W.), Nuffield Department of Population Health (M.M., L.L., J.L.B., N.S., J.R.E., E.J., R.H., M.J.L.), the Medical Research Council (MRC) Population Health Research Unit (N.S., J.R.E., R.H., M.J.L.), University of Oxford, the Oxford University Hospitals NHS Foundation Trust (K.J., M.J.L.), and the National Institute for Health Research (NIHR) Oxford Biomedical Research Centre (M.J.L.), Oxford, University Hospitals of Leicester NHS Trust and University of Leicester, Leicester (M.W.), the Regional Infectious Diseases Unit, North Manchester General Hospital (A.U.), University of Manchester (A.U., T.F.), and Manchester University NHS Foundation Trust (T.F.), Manchester, the Research and Development Department, Northampton General Hospital, Northampton (E.E.), the Department of Respiratory Medicine, North Tees and Hartlepool NHS Foundation Trust, Stockton-on-Tees (B.P.), University Hospitals Birmingham NHS Foundation Trust and Institute of Microbiology and Infection, University of Birmingham, Birmingham (T.W.), James Cook University Hospital, Middlesbrough (J.W.), North West Anglia NHS Foundation Trust, Peterborough (J.F.), the Department of Infectious Diseases, Cardiff and Vale University Health Board, and the Division of Infection and Immunity, Cardiff University, Cardiff (J.U.), Roslin Institute, University of Edinburgh, Edinburgh (J.K.B.), the School of Life Course Sciences, King's College London (L.C.C.), and the Intensive Care National Audit and Research Centre (K.R.), London, the NIHR Southampton Clinical Research Facility and Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust and University of Southampton, Southampton (S.N.F.), the Department of Mathematics and Statistics, Lancaster University, Lancaster (T.J.), the MRC Biostatistics Unit, University of Cambridge, Cambridge (T.J.), and the Respiratory Medicine Department, Nottingham University Hospitals NHS Trust (W.S.L.), and the School of Medicine, University of Nottingham (A.M., E.J.), Nottingham - all in the United Kingdom; and the Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand (J.T., J.A.W., N.J.W.)
| | - Katie Jeffery
- The affiliations of the members of the writing committee are as follows: the Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine (P.H., J.T., J.A.W., N.J.W.), Nuffield Department of Population Health (M.M., L.L., J.L.B., N.S., J.R.E., E.J., R.H., M.J.L.), the Medical Research Council (MRC) Population Health Research Unit (N.S., J.R.E., R.H., M.J.L.), University of Oxford, the Oxford University Hospitals NHS Foundation Trust (K.J., M.J.L.), and the National Institute for Health Research (NIHR) Oxford Biomedical Research Centre (M.J.L.), Oxford, University Hospitals of Leicester NHS Trust and University of Leicester, Leicester (M.W.), the Regional Infectious Diseases Unit, North Manchester General Hospital (A.U.), University of Manchester (A.U., T.F.), and Manchester University NHS Foundation Trust (T.F.), Manchester, the Research and Development Department, Northampton General Hospital, Northampton (E.E.), the Department of Respiratory Medicine, North Tees and Hartlepool NHS Foundation Trust, Stockton-on-Tees (B.P.), University Hospitals Birmingham NHS Foundation Trust and Institute of Microbiology and Infection, University of Birmingham, Birmingham (T.W.), James Cook University Hospital, Middlesbrough (J.W.), North West Anglia NHS Foundation Trust, Peterborough (J.F.), the Department of Infectious Diseases, Cardiff and Vale University Health Board, and the Division of Infection and Immunity, Cardiff University, Cardiff (J.U.), Roslin Institute, University of Edinburgh, Edinburgh (J.K.B.), the School of Life Course Sciences, King's College London (L.C.C.), and the Intensive Care National Audit and Research Centre (K.R.), London, the NIHR Southampton Clinical Research Facility and Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust and University of Southampton, Southampton (S.N.F.), the Department of Mathematics and Statistics, Lancaster University, Lancaster (T.J.), the MRC Biostatistics Unit, University of Cambridge, Cambridge (T.J.), and the Respiratory Medicine Department, Nottingham University Hospitals NHS Trust (W.S.L.), and the School of Medicine, University of Nottingham (A.M., E.J.), Nottingham - all in the United Kingdom; and the Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand (J.T., J.A.W., N.J.W.)
| | - Wei Shen Lim
- The affiliations of the members of the writing committee are as follows: the Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine (P.H., J.T., J.A.W., N.J.W.), Nuffield Department of Population Health (M.M., L.L., J.L.B., N.S., J.R.E., E.J., R.H., M.J.L.), the Medical Research Council (MRC) Population Health Research Unit (N.S., J.R.E., R.H., M.J.L.), University of Oxford, the Oxford University Hospitals NHS Foundation Trust (K.J., M.J.L.), and the National Institute for Health Research (NIHR) Oxford Biomedical Research Centre (M.J.L.), Oxford, University Hospitals of Leicester NHS Trust and University of Leicester, Leicester (M.W.), the Regional Infectious Diseases Unit, North Manchester General Hospital (A.U.), University of Manchester (A.U., T.F.), and Manchester University NHS Foundation Trust (T.F.), Manchester, the Research and Development Department, Northampton General Hospital, Northampton (E.E.), the Department of Respiratory Medicine, North Tees and Hartlepool NHS Foundation Trust, Stockton-on-Tees (B.P.), University Hospitals Birmingham NHS Foundation Trust and Institute of Microbiology and Infection, University of Birmingham, Birmingham (T.W.), James Cook University Hospital, Middlesbrough (J.W.), North West Anglia NHS Foundation Trust, Peterborough (J.F.), the Department of Infectious Diseases, Cardiff and Vale University Health Board, and the Division of Infection and Immunity, Cardiff University, Cardiff (J.U.), Roslin Institute, University of Edinburgh, Edinburgh (J.K.B.), the School of Life Course Sciences, King's College London (L.C.C.), and the Intensive Care National Audit and Research Centre (K.R.), London, the NIHR Southampton Clinical Research Facility and Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust and University of Southampton, Southampton (S.N.F.), the Department of Mathematics and Statistics, Lancaster University, Lancaster (T.J.), the MRC Biostatistics Unit, University of Cambridge, Cambridge (T.J.), and the Respiratory Medicine Department, Nottingham University Hospitals NHS Trust (W.S.L.), and the School of Medicine, University of Nottingham (A.M., E.J.), Nottingham - all in the United Kingdom; and the Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand (J.T., J.A.W., N.J.W.)
| | - Alan Montgomery
- The affiliations of the members of the writing committee are as follows: the Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine (P.H., J.T., J.A.W., N.J.W.), Nuffield Department of Population Health (M.M., L.L., J.L.B., N.S., J.R.E., E.J., R.H., M.J.L.), the Medical Research Council (MRC) Population Health Research Unit (N.S., J.R.E., R.H., M.J.L.), University of Oxford, the Oxford University Hospitals NHS Foundation Trust (K.J., M.J.L.), and the National Institute for Health Research (NIHR) Oxford Biomedical Research Centre (M.J.L.), Oxford, University Hospitals of Leicester NHS Trust and University of Leicester, Leicester (M.W.), the Regional Infectious Diseases Unit, North Manchester General Hospital (A.U.), University of Manchester (A.U., T.F.), and Manchester University NHS Foundation Trust (T.F.), Manchester, the Research and Development Department, Northampton General Hospital, Northampton (E.E.), the Department of Respiratory Medicine, North Tees and Hartlepool NHS Foundation Trust, Stockton-on-Tees (B.P.), University Hospitals Birmingham NHS Foundation Trust and Institute of Microbiology and Infection, University of Birmingham, Birmingham (T.W.), James Cook University Hospital, Middlesbrough (J.W.), North West Anglia NHS Foundation Trust, Peterborough (J.F.), the Department of Infectious Diseases, Cardiff and Vale University Health Board, and the Division of Infection and Immunity, Cardiff University, Cardiff (J.U.), Roslin Institute, University of Edinburgh, Edinburgh (J.K.B.), the School of Life Course Sciences, King's College London (L.C.C.), and the Intensive Care National Audit and Research Centre (K.R.), London, the NIHR Southampton Clinical Research Facility and Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust and University of Southampton, Southampton (S.N.F.), the Department of Mathematics and Statistics, Lancaster University, Lancaster (T.J.), the MRC Biostatistics Unit, University of Cambridge, Cambridge (T.J.), and the Respiratory Medicine Department, Nottingham University Hospitals NHS Trust (W.S.L.), and the School of Medicine, University of Nottingham (A.M., E.J.), Nottingham - all in the United Kingdom; and the Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand (J.T., J.A.W., N.J.W.)
| | - Kathryn Rowan
- The affiliations of the members of the writing committee are as follows: the Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine (P.H., J.T., J.A.W., N.J.W.), Nuffield Department of Population Health (M.M., L.L., J.L.B., N.S., J.R.E., E.J., R.H., M.J.L.), the Medical Research Council (MRC) Population Health Research Unit (N.S., J.R.E., R.H., M.J.L.), University of Oxford, the Oxford University Hospitals NHS Foundation Trust (K.J., M.J.L.), and the National Institute for Health Research (NIHR) Oxford Biomedical Research Centre (M.J.L.), Oxford, University Hospitals of Leicester NHS Trust and University of Leicester, Leicester (M.W.), the Regional Infectious Diseases Unit, North Manchester General Hospital (A.U.), University of Manchester (A.U., T.F.), and Manchester University NHS Foundation Trust (T.F.), Manchester, the Research and Development Department, Northampton General Hospital, Northampton (E.E.), the Department of Respiratory Medicine, North Tees and Hartlepool NHS Foundation Trust, Stockton-on-Tees (B.P.), University Hospitals Birmingham NHS Foundation Trust and Institute of Microbiology and Infection, University of Birmingham, Birmingham (T.W.), James Cook University Hospital, Middlesbrough (J.W.), North West Anglia NHS Foundation Trust, Peterborough (J.F.), the Department of Infectious Diseases, Cardiff and Vale University Health Board, and the Division of Infection and Immunity, Cardiff University, Cardiff (J.U.), Roslin Institute, University of Edinburgh, Edinburgh (J.K.B.), the School of Life Course Sciences, King's College London (L.C.C.), and the Intensive Care National Audit and Research Centre (K.R.), London, the NIHR Southampton Clinical Research Facility and Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust and University of Southampton, Southampton (S.N.F.), the Department of Mathematics and Statistics, Lancaster University, Lancaster (T.J.), the MRC Biostatistics Unit, University of Cambridge, Cambridge (T.J.), and the Respiratory Medicine Department, Nottingham University Hospitals NHS Trust (W.S.L.), and the School of Medicine, University of Nottingham (A.M., E.J.), Nottingham - all in the United Kingdom; and the Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand (J.T., J.A.W., N.J.W.)
| | - Joel Tarning
- The affiliations of the members of the writing committee are as follows: the Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine (P.H., J.T., J.A.W., N.J.W.), Nuffield Department of Population Health (M.M., L.L., J.L.B., N.S., J.R.E., E.J., R.H., M.J.L.), the Medical Research Council (MRC) Population Health Research Unit (N.S., J.R.E., R.H., M.J.L.), University of Oxford, the Oxford University Hospitals NHS Foundation Trust (K.J., M.J.L.), and the National Institute for Health Research (NIHR) Oxford Biomedical Research Centre (M.J.L.), Oxford, University Hospitals of Leicester NHS Trust and University of Leicester, Leicester (M.W.), the Regional Infectious Diseases Unit, North Manchester General Hospital (A.U.), University of Manchester (A.U., T.F.), and Manchester University NHS Foundation Trust (T.F.), Manchester, the Research and Development Department, Northampton General Hospital, Northampton (E.E.), the Department of Respiratory Medicine, North Tees and Hartlepool NHS Foundation Trust, Stockton-on-Tees (B.P.), University Hospitals Birmingham NHS Foundation Trust and Institute of Microbiology and Infection, University of Birmingham, Birmingham (T.W.), James Cook University Hospital, Middlesbrough (J.W.), North West Anglia NHS Foundation Trust, Peterborough (J.F.), the Department of Infectious Diseases, Cardiff and Vale University Health Board, and the Division of Infection and Immunity, Cardiff University, Cardiff (J.U.), Roslin Institute, University of Edinburgh, Edinburgh (J.K.B.), the School of Life Course Sciences, King's College London (L.C.C.), and the Intensive Care National Audit and Research Centre (K.R.), London, the NIHR Southampton Clinical Research Facility and Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust and University of Southampton, Southampton (S.N.F.), the Department of Mathematics and Statistics, Lancaster University, Lancaster (T.J.), the MRC Biostatistics Unit, University of Cambridge, Cambridge (T.J.), and the Respiratory Medicine Department, Nottingham University Hospitals NHS Trust (W.S.L.), and the School of Medicine, University of Nottingham (A.M., E.J.), Nottingham - all in the United Kingdom; and the Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand (J.T., J.A.W., N.J.W.)
| | - James A Watson
- The affiliations of the members of the writing committee are as follows: the Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine (P.H., J.T., J.A.W., N.J.W.), Nuffield Department of Population Health (M.M., L.L., J.L.B., N.S., J.R.E., E.J., R.H., M.J.L.), the Medical Research Council (MRC) Population Health Research Unit (N.S., J.R.E., R.H., M.J.L.), University of Oxford, the Oxford University Hospitals NHS Foundation Trust (K.J., M.J.L.), and the National Institute for Health Research (NIHR) Oxford Biomedical Research Centre (M.J.L.), Oxford, University Hospitals of Leicester NHS Trust and University of Leicester, Leicester (M.W.), the Regional Infectious Diseases Unit, North Manchester General Hospital (A.U.), University of Manchester (A.U., T.F.), and Manchester University NHS Foundation Trust (T.F.), Manchester, the Research and Development Department, Northampton General Hospital, Northampton (E.E.), the Department of Respiratory Medicine, North Tees and Hartlepool NHS Foundation Trust, Stockton-on-Tees (B.P.), University Hospitals Birmingham NHS Foundation Trust and Institute of Microbiology and Infection, University of Birmingham, Birmingham (T.W.), James Cook University Hospital, Middlesbrough (J.W.), North West Anglia NHS Foundation Trust, Peterborough (J.F.), the Department of Infectious Diseases, Cardiff and Vale University Health Board, and the Division of Infection and Immunity, Cardiff University, Cardiff (J.U.), Roslin Institute, University of Edinburgh, Edinburgh (J.K.B.), the School of Life Course Sciences, King's College London (L.C.C.), and the Intensive Care National Audit and Research Centre (K.R.), London, the NIHR Southampton Clinical Research Facility and Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust and University of Southampton, Southampton (S.N.F.), the Department of Mathematics and Statistics, Lancaster University, Lancaster (T.J.), the MRC Biostatistics Unit, University of Cambridge, Cambridge (T.J.), and the Respiratory Medicine Department, Nottingham University Hospitals NHS Trust (W.S.L.), and the School of Medicine, University of Nottingham (A.M., E.J.), Nottingham - all in the United Kingdom; and the Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand (J.T., J.A.W., N.J.W.)
| | - Nicholas J White
- The affiliations of the members of the writing committee are as follows: the Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine (P.H., J.T., J.A.W., N.J.W.), Nuffield Department of Population Health (M.M., L.L., J.L.B., N.S., J.R.E., E.J., R.H., M.J.L.), the Medical Research Council (MRC) Population Health Research Unit (N.S., J.R.E., R.H., M.J.L.), University of Oxford, the Oxford University Hospitals NHS Foundation Trust (K.J., M.J.L.), and the National Institute for Health Research (NIHR) Oxford Biomedical Research Centre (M.J.L.), Oxford, University Hospitals of Leicester NHS Trust and University of Leicester, Leicester (M.W.), the Regional Infectious Diseases Unit, North Manchester General Hospital (A.U.), University of Manchester (A.U., T.F.), and Manchester University NHS Foundation Trust (T.F.), Manchester, the Research and Development Department, Northampton General Hospital, Northampton (E.E.), the Department of Respiratory Medicine, North Tees and Hartlepool NHS Foundation Trust, Stockton-on-Tees (B.P.), University Hospitals Birmingham NHS Foundation Trust and Institute of Microbiology and Infection, University of Birmingham, Birmingham (T.W.), James Cook University Hospital, Middlesbrough (J.W.), North West Anglia NHS Foundation Trust, Peterborough (J.F.), the Department of Infectious Diseases, Cardiff and Vale University Health Board, and the Division of Infection and Immunity, Cardiff University, Cardiff (J.U.), Roslin Institute, University of Edinburgh, Edinburgh (J.K.B.), the School of Life Course Sciences, King's College London (L.C.C.), and the Intensive Care National Audit and Research Centre (K.R.), London, the NIHR Southampton Clinical Research Facility and Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust and University of Southampton, Southampton (S.N.F.), the Department of Mathematics and Statistics, Lancaster University, Lancaster (T.J.), the MRC Biostatistics Unit, University of Cambridge, Cambridge (T.J.), and the Respiratory Medicine Department, Nottingham University Hospitals NHS Trust (W.S.L.), and the School of Medicine, University of Nottingham (A.M., E.J.), Nottingham - all in the United Kingdom; and the Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand (J.T., J.A.W., N.J.W.)
| | - Edmund Juszczak
- The affiliations of the members of the writing committee are as follows: the Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine (P.H., J.T., J.A.W., N.J.W.), Nuffield Department of Population Health (M.M., L.L., J.L.B., N.S., J.R.E., E.J., R.H., M.J.L.), the Medical Research Council (MRC) Population Health Research Unit (N.S., J.R.E., R.H., M.J.L.), University of Oxford, the Oxford University Hospitals NHS Foundation Trust (K.J., M.J.L.), and the National Institute for Health Research (NIHR) Oxford Biomedical Research Centre (M.J.L.), Oxford, University Hospitals of Leicester NHS Trust and University of Leicester, Leicester (M.W.), the Regional Infectious Diseases Unit, North Manchester General Hospital (A.U.), University of Manchester (A.U., T.F.), and Manchester University NHS Foundation Trust (T.F.), Manchester, the Research and Development Department, Northampton General Hospital, Northampton (E.E.), the Department of Respiratory Medicine, North Tees and Hartlepool NHS Foundation Trust, Stockton-on-Tees (B.P.), University Hospitals Birmingham NHS Foundation Trust and Institute of Microbiology and Infection, University of Birmingham, Birmingham (T.W.), James Cook University Hospital, Middlesbrough (J.W.), North West Anglia NHS Foundation Trust, Peterborough (J.F.), the Department of Infectious Diseases, Cardiff and Vale University Health Board, and the Division of Infection and Immunity, Cardiff University, Cardiff (J.U.), Roslin Institute, University of Edinburgh, Edinburgh (J.K.B.), the School of Life Course Sciences, King's College London (L.C.C.), and the Intensive Care National Audit and Research Centre (K.R.), London, the NIHR Southampton Clinical Research Facility and Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust and University of Southampton, Southampton (S.N.F.), the Department of Mathematics and Statistics, Lancaster University, Lancaster (T.J.), the MRC Biostatistics Unit, University of Cambridge, Cambridge (T.J.), and the Respiratory Medicine Department, Nottingham University Hospitals NHS Trust (W.S.L.), and the School of Medicine, University of Nottingham (A.M., E.J.), Nottingham - all in the United Kingdom; and the Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand (J.T., J.A.W., N.J.W.)
| | - Richard Haynes
- The affiliations of the members of the writing committee are as follows: the Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine (P.H., J.T., J.A.W., N.J.W.), Nuffield Department of Population Health (M.M., L.L., J.L.B., N.S., J.R.E., E.J., R.H., M.J.L.), the Medical Research Council (MRC) Population Health Research Unit (N.S., J.R.E., R.H., M.J.L.), University of Oxford, the Oxford University Hospitals NHS Foundation Trust (K.J., M.J.L.), and the National Institute for Health Research (NIHR) Oxford Biomedical Research Centre (M.J.L.), Oxford, University Hospitals of Leicester NHS Trust and University of Leicester, Leicester (M.W.), the Regional Infectious Diseases Unit, North Manchester General Hospital (A.U.), University of Manchester (A.U., T.F.), and Manchester University NHS Foundation Trust (T.F.), Manchester, the Research and Development Department, Northampton General Hospital, Northampton (E.E.), the Department of Respiratory Medicine, North Tees and Hartlepool NHS Foundation Trust, Stockton-on-Tees (B.P.), University Hospitals Birmingham NHS Foundation Trust and Institute of Microbiology and Infection, University of Birmingham, Birmingham (T.W.), James Cook University Hospital, Middlesbrough (J.W.), North West Anglia NHS Foundation Trust, Peterborough (J.F.), the Department of Infectious Diseases, Cardiff and Vale University Health Board, and the Division of Infection and Immunity, Cardiff University, Cardiff (J.U.), Roslin Institute, University of Edinburgh, Edinburgh (J.K.B.), the School of Life Course Sciences, King's College London (L.C.C.), and the Intensive Care National Audit and Research Centre (K.R.), London, the NIHR Southampton Clinical Research Facility and Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust and University of Southampton, Southampton (S.N.F.), the Department of Mathematics and Statistics, Lancaster University, Lancaster (T.J.), the MRC Biostatistics Unit, University of Cambridge, Cambridge (T.J.), and the Respiratory Medicine Department, Nottingham University Hospitals NHS Trust (W.S.L.), and the School of Medicine, University of Nottingham (A.M., E.J.), Nottingham - all in the United Kingdom; and the Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand (J.T., J.A.W., N.J.W.)
| | - Martin J Landray
- The affiliations of the members of the writing committee are as follows: the Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine (P.H., J.T., J.A.W., N.J.W.), Nuffield Department of Population Health (M.M., L.L., J.L.B., N.S., J.R.E., E.J., R.H., M.J.L.), the Medical Research Council (MRC) Population Health Research Unit (N.S., J.R.E., R.H., M.J.L.), University of Oxford, the Oxford University Hospitals NHS Foundation Trust (K.J., M.J.L.), and the National Institute for Health Research (NIHR) Oxford Biomedical Research Centre (M.J.L.), Oxford, University Hospitals of Leicester NHS Trust and University of Leicester, Leicester (M.W.), the Regional Infectious Diseases Unit, North Manchester General Hospital (A.U.), University of Manchester (A.U., T.F.), and Manchester University NHS Foundation Trust (T.F.), Manchester, the Research and Development Department, Northampton General Hospital, Northampton (E.E.), the Department of Respiratory Medicine, North Tees and Hartlepool NHS Foundation Trust, Stockton-on-Tees (B.P.), University Hospitals Birmingham NHS Foundation Trust and Institute of Microbiology and Infection, University of Birmingham, Birmingham (T.W.), James Cook University Hospital, Middlesbrough (J.W.), North West Anglia NHS Foundation Trust, Peterborough (J.F.), the Department of Infectious Diseases, Cardiff and Vale University Health Board, and the Division of Infection and Immunity, Cardiff University, Cardiff (J.U.), Roslin Institute, University of Edinburgh, Edinburgh (J.K.B.), the School of Life Course Sciences, King's College London (L.C.C.), and the Intensive Care National Audit and Research Centre (K.R.), London, the NIHR Southampton Clinical Research Facility and Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust and University of Southampton, Southampton (S.N.F.), the Department of Mathematics and Statistics, Lancaster University, Lancaster (T.J.), the MRC Biostatistics Unit, University of Cambridge, Cambridge (T.J.), and the Respiratory Medicine Department, Nottingham University Hospitals NHS Trust (W.S.L.), and the School of Medicine, University of Nottingham (A.M., E.J.), Nottingham - all in the United Kingdom; and the Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand (J.T., J.A.W., N.J.W.)
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24
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Horby PW, Mafham M, Bell JL, Linsell L, Staplin N, Emberson J, Palfreeman A, Raw J, Elmahi E, Prudon B, Green C, Carley S, Chadwick D, Davies M, Wise MP, Baillie JK, Chappell LC, Faust SN, Jaki T, Jefferey K, Lim WS, Montgomery A, Rowan K, Juszczak E, Haynes R, Landray MJ. Lopinavir-ritonavir in patients admitted to hospital with COVID-19 (RECOVERY): a randomised, controlled, open-label, platform trial. Lancet 2020; 396:1345-1352. [PMID: 33031764 PMCID: PMC7535623 DOI: 10.1016/s0140-6736(20)32013-4] [Citation(s) in RCA: 433] [Impact Index Per Article: 108.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2020] [Revised: 09/07/2020] [Accepted: 09/17/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND Lopinavir-ritonavir has been proposed as a treatment for COVID-19 on the basis of in vitro activity, preclinical studies, and observational studies. Here, we report the results of a randomised trial to assess whether lopinavir-ritonavir improves outcomes in patients admitted to hospital with COVID-19. METHODS In this randomised, controlled, open-label, platform trial, a range of possible treatments was compared with usual care in patients admitted to hospital with COVID-19. The trial is underway at 176 hospitals in the UK. Eligible and consenting patients were randomly allocated to either usual standard of care alone or usual standard of care plus lopinavir-ritonavir (400 mg and 100 mg, respectively) by mouth for 10 days or until discharge (or one of the other RECOVERY treatment groups: hydroxychloroquine, dexamethasone, or azithromycin) using web-based simple (unstratified) randomisation with allocation concealment. Randomisation to usual care was twice that of any of the active treatment groups (eg, 2:1 in favour of usual care if the patient was eligible for only one active group, 2:1:1 if the patient was eligible for two active groups). The primary outcome was 28-day all-cause mortality. Analyses were done on an intention-to-treat basis in all randomly assigned participants. The trial is registered with ISRCTN, 50189673, and ClinicalTrials.gov, NCT04381936. FINDINGS Between March 19, 2020, and June 29, 2020, 1616 patients were randomly allocated to receive lopinavir-ritonavir and 3424 patients to receive usual care. Overall, 374 (23%) patients allocated to lopinavir-ritonavir and 767 (22%) patients allocated to usual care died within 28 days (rate ratio 1·03, 95% CI 0·91-1·17; p=0·60). Results were consistent across all prespecified subgroups of patients. We observed no significant difference in time until discharge alive from hospital (median 11 days [IQR 5 to >28] in both groups) or the proportion of patients discharged from hospital alive within 28 days (rate ratio 0·98, 95% CI 0·91-1·05; p=0·53). Among patients not on invasive mechanical ventilation at baseline, there was no significant difference in the proportion who met the composite endpoint of invasive mechanical ventilation or death (risk ratio 1·09, 95% CI 0·99-1·20; p=0·092). INTERPRETATION In patients admitted to hospital with COVID-19, lopinavir-ritonavir was not associated with reductions in 28-day mortality, duration of hospital stay, or risk of progressing to invasive mechanical ventilation or death. These findings do not support the use of lopinavir-ritonavir for treatment of patients admitted to hospital with COVID-19. FUNDING Medical Research Council and National Institute for Health Research.
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25
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Sterne JAC, Murthy S, Diaz JV, Slutsky AS, Villar J, Angus DC, Annane D, Azevedo LCP, Berwanger O, Cavalcanti AB, Dequin PF, Du B, Emberson J, Fisher D, Giraudeau B, Gordon AC, Granholm A, Green C, Haynes R, Heming N, Higgins JPT, Horby P, Jüni P, Landray MJ, Le Gouge A, Leclerc M, Lim WS, Machado FR, McArthur C, Meziani F, Møller MH, Perner A, Petersen MW, Savovic J, Tomazini B, Veiga VC, Webb S, Marshall JC. Association Between Administration of Systemic Corticosteroids and Mortality Among Critically Ill Patients With COVID-19: A Meta-analysis. JAMA 2020; 324:1330-1341. [PMID: 32876694 PMCID: PMC7489434 DOI: 10.1001/jama.2020.17023] [Citation(s) in RCA: 1531] [Impact Index Per Article: 382.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2020] [Accepted: 08/21/2020] [Indexed: 01/28/2023]
Abstract
Importance Effective therapies for patients with coronavirus disease 2019 (COVID-19) are needed, and clinical trial data have demonstrated that low-dose dexamethasone reduced mortality in hospitalized patients with COVID-19 who required respiratory support. Objective To estimate the association between administration of corticosteroids compared with usual care or placebo and 28-day all-cause mortality. Design, Setting, and Participants Prospective meta-analysis that pooled data from 7 randomized clinical trials that evaluated the efficacy of corticosteroids in 1703 critically ill patients with COVID-19. The trials were conducted in 12 countries from February 26, 2020, to June 9, 2020, and the date of final follow-up was July 6, 2020. Pooled data were aggregated from the individual trials, overall, and in predefined subgroups. Risk of bias was assessed using the Cochrane Risk of Bias Assessment Tool. Inconsistency among trial results was assessed using the I2 statistic. The primary analysis was an inverse variance-weighted fixed-effect meta-analysis of overall mortality, with the association between the intervention and mortality quantified using odds ratios (ORs). Random-effects meta-analyses also were conducted (with the Paule-Mandel estimate of heterogeneity and the Hartung-Knapp adjustment) and an inverse variance-weighted fixed-effect analysis using risk ratios. Exposures Patients had been randomized to receive systemic dexamethasone, hydrocortisone, or methylprednisolone (678 patients) or to receive usual care or placebo (1025 patients). Main Outcomes and Measures The primary outcome measure was all-cause mortality at 28 days after randomization. A secondary outcome was investigator-defined serious adverse events. Results A total of 1703 patients (median age, 60 years [interquartile range, 52-68 years]; 488 [29%] women) were included in the analysis. Risk of bias was assessed as "low" for 6 of the 7 mortality results and as "some concerns" in 1 trial because of the randomization method. Five trials reported mortality at 28 days, 1 trial at 21 days, and 1 trial at 30 days. There were 222 deaths among the 678 patients randomized to corticosteroids and 425 deaths among the 1025 patients randomized to usual care or placebo (summary OR, 0.66 [95% CI, 0.53-0.82]; P < .001 based on a fixed-effect meta-analysis). There was little inconsistency between the trial results (I2 = 15.6%; P = .31 for heterogeneity) and the summary OR was 0.70 (95% CI, 0.48-1.01; P = .053) based on the random-effects meta-analysis. The fixed-effect summary OR for the association with mortality was 0.64 (95% CI, 0.50-0.82; P < .001) for dexamethasone compared with usual care or placebo (3 trials, 1282 patients, and 527 deaths), the OR was 0.69 (95% CI, 0.43-1.12; P = .13) for hydrocortisone (3 trials, 374 patients, and 94 deaths), and the OR was 0.91 (95% CI, 0.29-2.87; P = .87) for methylprednisolone (1 trial, 47 patients, and 26 deaths). Among the 6 trials that reported serious adverse events, 64 events occurred among 354 patients randomized to corticosteroids and 80 events occurred among 342 patients randomized to usual care or placebo. Conclusions and Relevance In this prospective meta-analysis of clinical trials of critically ill patients with COVID-19, administration of systemic corticosteroids, compared with usual care or placebo, was associated with lower 28-day all-cause mortality.
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Affiliation(s)
- Jonathan A C Sterne
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, England
- NIHR Bristol Biomedical Research Centre, Bristol, England
| | - Srinivas Murthy
- Department of Pediatrics, University of British Columbia, Vancouver, Canada
| | - Janet V Diaz
- Clinical Unit, Health Emergencies Programme, World Health Organization, Geneva, Switzerland
| | - Arthur S Slutsky
- Applied Health Research Centre, Li Ka Shing Knowledge Institute of St Michael's Hospital, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Jesús Villar
- Research Unit, Hospital Universitario Dr Negrín, Las Palmas de Gran Canaria, Spain
- CIBER de Enfermedades Respiratorias, Instituto de Salud Carlos III, Madrid, Spain
| | - Derek C Angus
- Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Djillali Annane
- Department of Intensive Care, Raymond Poincaré Hospital (APHP), School of Medicine Simone Veil, University Paris Saclay-UVSQ, Paris, France
| | - Luciano Cesar Pontes Azevedo
- Hospital Sírio-Libanês, São Paulo, Brazil
- Emergency Medicine Department, University of São Paulo School of Medicine, São Paulo, Brazil
| | - Otavio Berwanger
- Academic Research Organization, Hospital Israelita Albert Einstein, São Paulo, Brazil
| | | | - Pierre-Francois Dequin
- Médecine Intensive-Réanimation, INSERM CIC1415, CHRU de Tours, Tours, France
- CRICS-TriGGERSep Network, Centre d'Etude des Pathologies Respiratoires, Université de Tours, Tours, France
| | - Bin Du
- Peking Union Medical College Hospital, Beijing, China
| | - Jonathan Emberson
- Nuffield Department of Population Health, University of Oxford, Oxford, England
- MRC Population Health Research Unit, University of Oxford, Oxford, England
| | - David Fisher
- MRC Clinical Trials Unit at UCL, Institute of Clinical Trials and Methodology, Faculty of Population Health Sciences, University College London, London, England
| | | | - Anthony C Gordon
- Division of Anaesthetics, Pain Medicine and Intensive Care, Imperial College London, London, England
| | - Anders Granholm
- Department of Intensive Care, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Cameron Green
- Australian and New Zealand Intensive Care Research Centre, School of Epidemiology and Preventive Medicine, Monash University, Melbourne, Australia
| | - Richard Haynes
- Nuffield Department of Population Health, University of Oxford, Oxford, England
- MRC Population Health Research Unit, University of Oxford, Oxford, England
| | - Nicholas Heming
- Department of Intensive Care, Raymond Poincaré Hospital (APHP), School of Medicine Simone Veil, University Paris Saclay-UVSQ, Paris, France
| | - Julian P T Higgins
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, England
- NIHR Bristol Biomedical Research Centre, Bristol, England
- NIHR Applied Research Collaboration West, University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, England
| | - Peter Horby
- Nuffield Department of Medicine, University of Oxford, Oxford, England
| | - Peter Jüni
- Applied Health Research Centre, Li Ka Shing Knowledge Institute of St Michael's Hospital, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Martin J Landray
- Nuffield Department of Population Health, University of Oxford, Oxford, England
- MRC Population Health Research Unit, University of Oxford, Oxford, England
- NIHR Oxford Biomedical Research Centre, Oxford University Hospitals NHS Foundation Trust, Oxford, England
| | | | | | - Wei Shen Lim
- Respiratory Medicine Department, Nottingham University Hospitals NHS Trust, Nottingham, England
| | - Flávia R Machado
- Anesthesiology, Pain, and Intensive Care Department, Federal University of São Paulo, São Paulo, Brazil
| | - Colin McArthur
- Australian and New Zealand Intensive Care Research Centre, School of Epidemiology and Preventive Medicine, Monash University, Melbourne, Australia
- Department of Critical Care Medicine, Auckland City Hospital, Auckland, New Zealand
| | - Ferhat Meziani
- Hôpitaux Universitaires de Strasbourg, Service de Médecine Intensive Réanimation, Nouvel Hôpital Civil, Strasbourg, France
- INSERM UMR 1260, Regenerative Nanomedicine, FMTS, Strasbourg, France
| | - Morten Hylander Møller
- Department of Intensive Care, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Anders Perner
- Department of Intensive Care, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Marie Warrer Petersen
- Department of Intensive Care, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Jelena Savovic
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, England
- NIHR Applied Research Collaboration West, University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, England
| | - Bruno Tomazini
- Hospital Sírio-Libanês, São Paulo, Brazil
- Department of Surgery, School of Medicine, University of São Paulo, São Paulo, Brazil
| | - Viviane C Veiga
- BP-A Beneficência Portuguesa de São Paulo, São Paulo, Brazil
| | - Steve Webb
- Australian and New Zealand Intensive Care Research Centre, School of Epidemiology and Preventive Medicine, Monash University, Melbourne, Australia
- St John of God Healthcare, Subiaco, Australia
| | - John C Marshall
- Li Ka Shing Knowledge Institute, St Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
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26
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Nawab KA, Storey BC, Staplin N, Walmsley R, Haynes R, Sutherland S, Crosbie S, Pugh CW, Harper CHS, Landray MJ, Doherty A, Herrington WG. Accelerometer-measured physical activity and functional behaviours among people on dialysis. Clin Kidney J 2020; 14:950-958. [PMID: 33777379 PMCID: PMC7986362 DOI: 10.1093/ckj/sfaa045] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2019] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND The feasibility of wrist-worn accelerometers, and the patterns and determinants of physical activity, among people on dialysis are uncertain. METHODS People on maintenance dialysis were fitted with a wrist-worn AxivityAX3 accelerometer. Subsets also wore a 14-day electrocardiograph patch (Zio®PatchXT) and wearable cameras. Age-, sex- and season-matched UK Biobank control groups were derived for comparison. RESULTS Median (interquartile range) accelerometer wear time for the 101 recruits was 12.5 (10.4-13.5) days, of which 73 participants (mean age 66.5 years) had excellent wear on both dialysis and non-dialysis days. Mean (standard error) overall physical activity levels were 15.5 (0.7) milligravity units (mg), 14.8 (0.7) mg on dialysis days versus 16.2 (0.8) mg on non-dialysis days. This compared with 28.1 (0.5) mg for apparently healthy controls, 23.4 (0.4) mg for controls with prior cardiovascular disease (CVD) and/or diabetes mellitus and 22.9 (0.6) mg for heart failure controls. Each day, we estimated that those on dialysis spent an average of about 1 hour (h/day) walking, 0.6 h/day engaging in moderate-intensity activity, 0.7 h/day on light tasks, 13.2 h/day sedentary and 8.6 h/day asleep. Older age and self-reported leg weakness were associated with decreased levels of physical activity, but the presence of prior CVD, arrhythmias and listing for transplantation were not. CONCLUSIONS Wrist-worn accelerometers are an acceptable and reliable method to measure physical activity in people on dialysis and may also be used to estimate functional behaviours. Among people on dialysis, who are broadly half as active as general population controls, age and leg weakness appear to be more important determinants of low activity levels than CVD.
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Affiliation(s)
- Khizr A Nawab
- Oxford Kidney Unit, Oxford University Hospitals NHS Foundation Trust, Oxford, UK,Big Data Institute, Li Ka Shing Centre for Health Information and Discovery, University of Oxford, Oxford, UK
| | - Benjamin C Storey
- Oxford Kidney Unit, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Natalie Staplin
- Big Data Institute, Li Ka Shing Centre for Health Information and Discovery, University of Oxford, Oxford, UK,Medical Research Council Population Health Research Unit, Nuffield Department of Population Health (NDPH), University of Oxford, Oxford, UK,Clinical Trial Service Unit and Epidemiological Studies Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Rosemary Walmsley
- Big Data Institute, Li Ka Shing Centre for Health Information and Discovery, University of Oxford, Oxford, UK
| | - Richard Haynes
- Oxford Kidney Unit, Oxford University Hospitals NHS Foundation Trust, Oxford, UK,Medical Research Council Population Health Research Unit, Nuffield Department of Population Health (NDPH), University of Oxford, Oxford, UK,Clinical Trial Service Unit and Epidemiological Studies Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Sheera Sutherland
- Oxford Kidney Unit, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Sarah Crosbie
- Oxford Kidney Unit, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Christopher W Pugh
- Oxford Kidney Unit, Oxford University Hospitals NHS Foundation Trust, Oxford, UK,Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Charlie H S Harper
- Big Data Institute, Li Ka Shing Centre for Health Information and Discovery, University of Oxford, Oxford, UK,Medical Research Council Population Health Research Unit, Nuffield Department of Population Health (NDPH), University of Oxford, Oxford, UK
| | - Martin J Landray
- Big Data Institute, Li Ka Shing Centre for Health Information and Discovery, University of Oxford, Oxford, UK,Medical Research Council Population Health Research Unit, Nuffield Department of Population Health (NDPH), University of Oxford, Oxford, UK,Clinical Trial Service Unit and Epidemiological Studies Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK,National Institute of Health Research Oxford Biomedical Research Centre, Oxford University Hospitals NHS Foundation Trust, John Radcliffe Hospital, Oxford, UK
| | - Aiden Doherty
- Big Data Institute, Li Ka Shing Centre for Health Information and Discovery, University of Oxford, Oxford, UK,National Institute of Health Research Oxford Biomedical Research Centre, Oxford University Hospitals NHS Foundation Trust, John Radcliffe Hospital, Oxford, UK
| | - William G Herrington
- Oxford Kidney Unit, Oxford University Hospitals NHS Foundation Trust, Oxford, UK,Medical Research Council Population Health Research Unit, Nuffield Department of Population Health (NDPH), University of Oxford, Oxford, UK,Clinical Trial Service Unit and Epidemiological Studies Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK,Correspondence to: William G. Herrington; E-mail: ; Twitter handle: @willkidney; Aiden Doherty; E-mail:
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Mafham MM, Spata E, Goldacre R, Gair D, Curnow P, Bray M, Hollings S, Roebuck C, Gale CP, Mamas MA, Deanfield JE, de Belder MA, Luescher TF, Denwood T, Landray MJ, Emberson JR, Collins R, Morris EJA, Casadei B, Baigent C. COVID-19 pandemic and admission rates for and management of acute coronary syndromes in England. Lancet 2020; 396:381-389. [PMID: 32679111 PMCID: PMC7429983 DOI: 10.1016/s0140-6736(20)31356-8] [Citation(s) in RCA: 458] [Impact Index Per Article: 114.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2020] [Revised: 05/29/2020] [Accepted: 06/07/2020] [Indexed: 02/06/2023]
Abstract
BACKGROUND Several countries affected by the COVID-19 pandemic have reported a substantial drop in the number of patients attending the emergency department with acute coronary syndromes and a reduced number of cardiac procedures. We aimed to understand the scale, nature, and duration of changes to admissions for different types of acute coronary syndrome in England and to evaluate whether in-hospital management of patients has been affected as a result of the COVID-19 pandemic. METHODS We analysed data on hospital admissions in England for types of acute coronary syndrome from Jan 1, 2019, to May 24, 2020, that were recorded in the Secondary Uses Service Admitted Patient Care database. Admissions were classified as ST-elevation myocardial infarction (STEMI), non-STEMI (NSTEMI), myocardial infarction of unknown type, or other acute coronary syndromes (including unstable angina). We identified revascularisation procedures undertaken during these admissions (ie, coronary angiography without percutaneous coronary intervention [PCI], PCI, and coronary artery bypass graft surgery). We calculated the numbers of weekly admissions and procedures undertaken; percentage reductions in weekly admissions and across subgroups were also calculated, with 95% CIs. FINDINGS Hospital admissions for acute coronary syndrome declined from mid-February, 2020, falling from a 2019 baseline rate of 3017 admissions per week to 1813 per week by the end of March, 2020, a reduction of 40% (95% CI 37-43). This decline was partly reversed during April and May, 2020, such that by the last week of May, 2020, there were 2522 admissions, representing a 16% (95% CI 13-20) reduction from baseline. During the period of declining admissions, there were reductions in the numbers of admissions for all types of acute coronary syndrome, including both STEMI and NSTEMI, but relative and absolute reductions were larger for NSTEMI, with 1267 admissions per week in 2019 and 733 per week by the end of March, 2020, a percent reduction of 42% (95% CI 38-46). In parallel, reductions were recorded in the number of PCI procedures for patients with both STEMI (438 PCI procedures per week in 2019 vs 346 by the end of March, 2020; percent reduction 21%, 95% CI 12-29) and NSTEMI (383 PCI procedures per week in 2019 vs 240 by the end of March, 2020; percent reduction 37%, 29-45). The median length of stay among patients with acute coronary syndrome fell from 4 days (IQR 2-9) in 2019 to 3 days (1-5) by the end of March, 2020. INTERPRETATION Compared with the weekly average in 2019, there was a substantial reduction in the weekly numbers of patients with acute coronary syndrome who were admitted to hospital in England by the end of March, 2020, which had been partly reversed by the end of May, 2020. The reduced number of admissions during this period is likely to have resulted in increases in out-of-hospital deaths and long-term complications of myocardial infarction and missed opportunities to offer secondary prevention treatment for patients with coronary heart disease. The full extent of the effect of COVID-19 on the management of patients with acute coronary syndrome will continue to be assessed by updating these analyses. FUNDING UK Medical Research Council, British Heart Foundation, Public Health England, Health Data Research UK, and the National Institute for Health Research Oxford Biomedical Research Centre.
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Affiliation(s)
- Marion M Mafham
- Clinical Trial Service Unit and Epidemiological Studies Unit, Nuffield Department of Population Health, Oxford, UK
| | - Enti Spata
- Clinical Trial Service Unit and Epidemiological Studies Unit, Nuffield Department of Population Health, Oxford, UK; Medical Research Council Population Health Research Unit, Nuffield Department of Population Health, Oxford, UK
| | - Raphael Goldacre
- Big Data Institute, Nuffield Department of Population Health, Oxford, UK
| | | | | | | | | | | | - Chris P Gale
- Leeds Institute for Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, UK
| | - Mamas A Mamas
- Keele Cardiovascular Research Group, Institute for Prognosis Research, University of Keele, Keele, UK
| | - John E Deanfield
- Institute of Cardiovascular Sciences, University College London, London, UK
| | - Mark A de Belder
- National Institute for Cardiovascular Outcomes Research, Barts Health NHS Trust, London, UK
| | - Thomas F Luescher
- Imperial College, National Heart and Lung Institute, London, UK; Royal Brompton and Harefield Hospitals, London, UK
| | | | - Martin J Landray
- Clinical Trial Service Unit and Epidemiological Studies Unit, Nuffield Department of Population Health, Oxford, UK; Medical Research Council Population Health Research Unit, Nuffield Department of Population Health, Oxford, UK; Big Data Institute, Nuffield Department of Population Health, Oxford, UK
| | - Jonathan R Emberson
- Clinical Trial Service Unit and Epidemiological Studies Unit, Nuffield Department of Population Health, Oxford, UK; Medical Research Council Population Health Research Unit, Nuffield Department of Population Health, Oxford, UK
| | - Rory Collins
- Clinical Trial Service Unit and Epidemiological Studies Unit, Nuffield Department of Population Health, Oxford, UK
| | - Eva J A Morris
- Clinical Trial Service Unit and Epidemiological Studies Unit, Nuffield Department of Population Health, Oxford, UK; Big Data Institute, Nuffield Department of Population Health, Oxford, UK
| | - Barbara Casadei
- Division of Cardiovascular Medicine, Radcliffe Department of Medicine, John Radcliffe Hospital, Oxford, UK
| | - Colin Baigent
- Clinical Trial Service Unit and Epidemiological Studies Unit, Nuffield Department of Population Health, Oxford, UK; Medical Research Council Population Health Research Unit, Nuffield Department of Population Health, Oxford, UK.
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Haynes R, Chen F, Wincott E, Dayanandan R, Lay MJ, Parish S, Bowman L, Landray MJ, Armitage J. Investigating modifications to participant information materials to improve recruitment into a large randomized trial. Trials 2019; 20:681. [PMID: 31805983 PMCID: PMC6896768 DOI: 10.1186/s13063-019-3779-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2019] [Accepted: 10/09/2019] [Indexed: 11/24/2022] Open
Abstract
Background Large randomized trials are the best method to test the efficacy and safety of treatments expected to have moderate effects. We observed a significant decline in potential participants’ response to mailed invitations to participate in such trials over a 10-year period and investigated possible reasons behind this and potential modifications to the invitation process to mitigate it. Methods Participants who declined to participate in the HPS2-THRIVE trial were asked to give a reason. Formal focus groups were conducted to explore the reasons that potential participants might have for not participating. In addition, two embedded randomized comparisons around the timing of provision of the full participant information leaflet (PIL) and its style were conducted during recruitment into this large randomized trial. HPS2-THRIVE is registered at ClinicalTrials.gov (NCT00461630). Results The commonest reason given for declining invitations related to mobility and transportation (despite the offer of travel expenses). Both the focus groups and potential participants who declined their invitation indicated concern about side-effects of the treatment (as presented in the PIL) as a reason for declining the invitation. Neither delaying provision of the full PIL until the potential participant attended the trial clinic, nor modifying the style of the PIL improved the proportion of potential participants entering the trial: odds ratio (OR) 1.05 (95% confidence interval (CI) 0.94–1.17) and 1.10 (95% CI 0.94–1.28), respectively. However, modifying the style of the PIL did increase the proportion of participants attending screening appointments (OR 1.17, 95% CI 1.03–1.33). Conclusions Many reasons given for not participating in trials are not tractable to individual trials. However, modification of the PIL does show potential to modestly improve participation. If further trials could identify similar simple interventions that were beneficial, their net effects could substantially improve trial participation and facilitate recruitment into large trials.
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Affiliation(s)
| | - Richard Haynes
- MRC Population Health Research Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK.,Clinical Trial Service Unit & Epidemiological Studies Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Fang Chen
- Clinical Trial Service Unit & Epidemiological Studies Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Elizabeth Wincott
- Clinical Trial Service Unit & Epidemiological Studies Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Rejive Dayanandan
- Clinical Trial Service Unit & Epidemiological Studies Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Michael J Lay
- Clinical Trial Service Unit & Epidemiological Studies Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Sarah Parish
- MRC Population Health Research Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK.,Clinical Trial Service Unit & Epidemiological Studies Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Louise Bowman
- MRC Population Health Research Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK.,Clinical Trial Service Unit & Epidemiological Studies Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Martin J Landray
- MRC Population Health Research Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK.,Clinical Trial Service Unit & Epidemiological Studies Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Jane Armitage
- MRC Population Health Research Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK. .,Clinical Trial Service Unit & Epidemiological Studies Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK.
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Haynes R, Judge PK, Staplin N, Herrington WG, Storey BC, Bethel A, Bowman L, Brunskill N, Cockwell P, Hill M, Kalra PA, McMurray JJV, Taal M, Wheeler DC, Landray MJ, Baigent C. Effects of Sacubitril/Valsartan Versus Irbesartan in Patients With Chronic Kidney Disease. Circulation 2019; 138:1505-1514. [PMID: 30002098 DOI: 10.1161/circulationaha.118.034818] [Citation(s) in RCA: 102] [Impact Index Per Article: 20.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
BACKGROUND Sacubitril/valsartan reduces the risk of cardiovascular mortality among patients with heart failure with reduced ejection fraction, but its effects on kidney function and cardiac biomarkers in people with moderate to severe chronic kidney disease are unknown. METHODS The UK HARP-III trial (United Kingdom Heart and Renal Protection-III), a randomized double-blind trial, included 414 participants with an estimated glomerular filtration rate (GFR) 20 to 60 mL/min/1.73 m2 who were randomly assigned to sacubitril/valsartan 97/103 mg twice daily versus irbesartan 300 mg once daily. The primary outcome was measured GFR at 12 months using ANCOVA with adjustment for each individual's baseline measured GFR. All analyses were by intention to treat. RESULTS In total, 207 participants were assigned to sacubitril/valsartan and 207 to irbesartan. Baseline measured GFR was 34.0 (SE, 0.8) and 34.7 (SE, 0.8) mL/min/1.73 m2, respectively. At 12 months, there was no difference in measured GFR: 29.8 (SE 0.5) among those assigned sacubitril/valsartan versus 29.9 (SE, 0.5) mL/min/1.73 m2 among those assigned irbesartan; difference, -0.1 (0.7) mL/min/1.73 m2. Effects were similar in all prespecified subgroups. There was also no significant difference in estimated GFR at 3, 6, 9, or 12 months and no clear difference in urinary albumin:creatinine ratio between treatment arms (study average difference, -9%; 95% CI, -18 to 1). However, compared with irbesartan, allocation to sacubitril/valsartan reduced study average systolic and diastolic blood pressure by 5.4 (95% CI, 3.4-7.4) and 2.1 (95% CI, 1.0-3.3) mm Hg and levels of troponin I and N terminal of prohormone brain natriuretic peptide (tertiary end points) by 16% (95% CI, 8-23) and 18% (95% CI, 11-25), respectively. The incidence of serious adverse events (29.5% versus 28.5%; rate ratio, 1.07; 95% CI, 0.75-1.53), nonserious adverse reactions (36.7% versus 28.0%; rate ratio, 1.35; 95% CI, 0.96-1.90), and potassium ≥5.5 mmol/L (32% versus 24%, P=0.10) was not significantly different between randomized groups. CONCLUSIONS Over 12 months, sacubitril/valsartan has similar effects on kidney function and albuminuria to irbesartan, but it has the additional effect of lowering blood pressure and cardiac biomarkers in people with chronic kidney disease. CLINICAL TRIAL REGISTRATION URL: http://www.isrctn.com . Unique identifier: ISRCTN11958993.
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Affiliation(s)
- Richard Haynes
- Medical Research Council Population Health Research Unit (R.H., P.K.J., W.G.H., B.C.S., M.H., M.J.L., C.B.), University of Oxford, UK.,Clinical Trial Service Unit (R.H., P.K.J., N.S., W.G.H., B.C.S., L.B., M.H., M.J.L., C.B.), University of Oxford, UK
| | - Parminder K Judge
- Medical Research Council Population Health Research Unit (R.H., P.K.J., W.G.H., B.C.S., M.H., M.J.L., C.B.), University of Oxford, UK.,Clinical Trial Service Unit (R.H., P.K.J., N.S., W.G.H., B.C.S., L.B., M.H., M.J.L., C.B.), University of Oxford, UK
| | - Natalie Staplin
- Clinical Trial Service Unit (R.H., P.K.J., N.S., W.G.H., B.C.S., L.B., M.H., M.J.L., C.B.), University of Oxford, UK
| | - William G Herrington
- Medical Research Council Population Health Research Unit (R.H., P.K.J., W.G.H., B.C.S., M.H., M.J.L., C.B.), University of Oxford, UK.,Clinical Trial Service Unit (R.H., P.K.J., N.S., W.G.H., B.C.S., L.B., M.H., M.J.L., C.B.), University of Oxford, UK
| | - Benjamin C Storey
- Medical Research Council Population Health Research Unit (R.H., P.K.J., W.G.H., B.C.S., M.H., M.J.L., C.B.), University of Oxford, UK.,Clinical Trial Service Unit (R.H., P.K.J., N.S., W.G.H., B.C.S., L.B., M.H., M.J.L., C.B.), University of Oxford, UK
| | - Angelyn Bethel
- Nuffield Department of Population Health, and Diabetes Trials Unit, Radcliffe Department of Medicine (A.B.), University of Oxford, UK
| | - Louise Bowman
- Clinical Trial Service Unit (R.H., P.K.J., N.S., W.G.H., B.C.S., L.B., M.H., M.J.L., C.B.), University of Oxford, UK
| | - Nigel Brunskill
- Department of Infection, Immunity and Inflammation, University of Leicester, UK (N.B.)
| | - Paul Cockwell
- Department of Nephrology, University Hospitals Birmingham, UK (P.C.)
| | - Michael Hill
- Medical Research Council Population Health Research Unit (R.H., P.K.J., W.G.H., B.C.S., M.H., M.J.L., C.B.), University of Oxford, UK.,Clinical Trial Service Unit (R.H., P.K.J., N.S., W.G.H., B.C.S., L.B., M.H., M.J.L., C.B.), University of Oxford, UK
| | - Philip A Kalra
- Department of Nephrology, Salford Royal Hospital NHS Foundation Trust, UK (P.A.K.)
| | - John J V McMurray
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, UK (J.J.V.M.)
| | - Maarten Taal
- Faculty of Medicine and Health Sciences, University of Nottingham, UK (M.T.)
| | - David C Wheeler
- Centre for Nephrology, University College London, UK (D.C.W.)
| | - Martin J Landray
- Medical Research Council Population Health Research Unit (R.H., P.K.J., W.G.H., B.C.S., M.H., M.J.L., C.B.), University of Oxford, UK.,Clinical Trial Service Unit (R.H., P.K.J., N.S., W.G.H., B.C.S., L.B., M.H., M.J.L., C.B.), University of Oxford, UK
| | - Colin Baigent
- Medical Research Council Population Health Research Unit (R.H., P.K.J., W.G.H., B.C.S., M.H., M.J.L., C.B.), University of Oxford, UK.,Clinical Trial Service Unit (R.H., P.K.J., N.S., W.G.H., B.C.S., L.B., M.H., M.J.L., C.B.), University of Oxford, UK
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Hopewell JC, Ibrahim M, Hill M, Shaw PM, Braunwald E, Blaustein RO, Bowman L, Landray MJ, Sabatine MS, Collins R. Impact of ADCY9 Genotype on Response to Anacetrapib. Circulation 2019; 140:891-898. [PMID: 31331193 PMCID: PMC6749971 DOI: 10.1161/circulationaha.119.041546] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2019] [Accepted: 06/17/2019] [Indexed: 01/16/2023]
Abstract
BACKGROUND Exploratory analyses of previous randomized trials generated a hypothesis that the clinical response to cholesteryl ester transfer protein (CETP) inhibitor therapy differs by ADCY9 genotype, prompting the ongoing dal-GenE trial in individuals with a particular genetic profile. The randomized placebo-controlled REVEAL trial (Randomized Evaluation of the Effects of Anacetrapib through Lipid-Modification) demonstrated the clinical efficacy of the CETP inhibitor anacetrapib among patients with preexisting atherosclerotic vascular disease. In the present study, we examined the impact of ADCY9 genotype on response to anacetrapib in the REVEAL trial. METHODS Individuals with stable atherosclerotic vascular disease who were treated with intensive atorvastatin therapy received either anacetrapib 100 mg daily or matching placebo. Cox proportional hazards models, adjusted for the first 5 principal components of ancestry, were used to estimate the effects of allocation to anacetrapib on major vascular events (a composite of coronary death, myocardial infarction, coronary revascularization, or presumed ischemic stroke) and the interaction with ADCY9 rs1967309 genotype. RESULTS Among 19 210 genotyped individuals of European ancestry, 2504 (13.0%) had a first major vascular event during 4 years median follow-up: 1216 (12.6%) among anacetrapib-allocated participants and 1288 (13.4%) among placebo-allocated participants. Proportional reductions in the risk of major vascular events with anacetrapib did not differ significantly by ADCY9 genotype: hazard ratio (HR) = 0.92 (95% CI, 0.81-1.05) for GG; HR = 0.94 (95% CI, 0.84-1.06) for AG; and HR = 0.93 (95% CI, 0.76-1.13) for AA genotype carriers, respectively; genotypic P for interaction = 0.96. Furthermore, there were no associations between ADCY9 genotype and the proportional reductions in the separate components of major vascular events or meaningful differences in lipid response to anacetrapib. CONCLUSIONS The REVEAL trial is the single largest study to date evaluating the ADCY9 pharmacogenetic interaction. It provides no support for the hypothesis that ADCY9 genotype is materially relevant to the clinical effects of the CETP inhibitor anacetrapib. The ongoing dal-GenE study will provide direct evidence as to whether there is any specific pharmacogenetic interaction with dalcetrapib. CLINICAL TRIAL REGISTRATION URL: https://www. CLINICALTRIALS gov. Unique identifier: NCT01252953. URL: http://www.isrctn.com. Unique identifier: ISRCTN48678192. URL: https://www.clinicaltrialsregister.eu. Unique identifier: 2010-023467-18.
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Affiliation(s)
- Jemma C. Hopewell
- Clinical Trial Service Unit and Epidemiological Studies Unit (J.C.H., M.I., M.H., L.B., M.J.L., R.C.), Nuffield Department of Population Health, University of Oxford, United Kingdom
| | - Maysson Ibrahim
- Clinical Trial Service Unit and Epidemiological Studies Unit (J.C.H., M.I., M.H., L.B., M.J.L., R.C.), Nuffield Department of Population Health, University of Oxford, United Kingdom
| | - Michael Hill
- Clinical Trial Service Unit and Epidemiological Studies Unit (J.C.H., M.I., M.H., L.B., M.J.L., R.C.), Nuffield Department of Population Health, University of Oxford, United Kingdom
- Medical Research Council Population Health Research Unit (M.H., L.B.), Nuffield Department of Population Health, University of Oxford, United Kingdom
| | - Peter M. Shaw
- Department of Genetics and Pharmacogenomics (P.M.S.), Merck Research Laboratories, Merck & Co., Inc., Kenilworth, NJ
| | - Eugene Braunwald
- TIMI Study Group, Division of Cardiovascular Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, MA (E.B., M.S.S.)
| | - Robert O. Blaustein
- Cardiovascular Clinical Research (R.O.B.), Merck Research Laboratories, Merck & Co., Inc., Kenilworth, NJ
| | - Louise Bowman
- Clinical Trial Service Unit and Epidemiological Studies Unit (J.C.H., M.I., M.H., L.B., M.J.L., R.C.), Nuffield Department of Population Health, University of Oxford, United Kingdom
- Medical Research Council Population Health Research Unit (M.H., L.B.), Nuffield Department of Population Health, University of Oxford, United Kingdom
| | - Martin J. Landray
- Clinical Trial Service Unit and Epidemiological Studies Unit (J.C.H., M.I., M.H., L.B., M.J.L., R.C.), Nuffield Department of Population Health, University of Oxford, United Kingdom
| | - Marc S. Sabatine
- TIMI Study Group, Division of Cardiovascular Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, MA (E.B., M.S.S.)
| | - Rory Collins
- Clinical Trial Service Unit and Epidemiological Studies Unit (J.C.H., M.I., M.H., L.B., M.J.L., R.C.), Nuffield Department of Population Health, University of Oxford, United Kingdom
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Haynes R, Valdes-Marquez E, Hopewell JC, Chen F, Li J, Parish S, Landray MJ, Armitage J. Serious Adverse Effects of Extended-release Niacin/Laropiprant: Results From the Heart Protection Study 2-Treatment of HDL to Reduce the Incidence of Vascular Events (HPS2-THRIVE) Trial. Clin Ther 2019; 41:1767-1777. [PMID: 31447131 DOI: 10.1016/j.clinthera.2019.06.012] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2019] [Revised: 04/25/2019] [Accepted: 06/21/2019] [Indexed: 01/15/2023]
Abstract
PURPOSE The Heart Protection Study 2-Treatment of HDL to Reduce the Incidence of Vascular Events (HPS2-THRIVE) trial of patients at high risk of vascular disease found that adding extended-release niacin-laropiprant to intensive statin-based LDL-lowering therapy had no benefit on cardiovascular outcomes. However, the trial also identified previously unrecognized serious adverse effects (including new-onset diabetes, bleeding, and infection). Our objective was to explore the safety profile of niacin-laropiprant and examine whether any patients were at lower (or higher) risk of its adverse effects. METHODS HPS2-THRIVE was a randomized, double-blind trial of niacin-laropiprant (2000/40 mg/d) versus placebo among 25,673 patients at high risk of vascular disease. Information on all serious adverse events was collected during a median of 3.9 years of study treatment. Effects of niacin-laropiprant on new-onset diabetes, disturbances of diabetes control, bleeding, infection, and gastrointestinal upset were estimated by (1) time after randomization, (2) severity, (3) baseline characteristics, (4) baseline risk of the adverse event of interest, and (5) risk of major vascular event. FINDINGS The hazard ratio (HR) for new-onset diabetes with niacin/laropiprant was 1.32 (95% CI, 1.16-1.51; P < .001), which corresponded to an absolute excess of 4 people (95% CI, 2-6) developing diabetes per 1000 person-years in the study population as a whole. Among the 8299 participants with diabetes at baseline, the HR for serious disturbances in diabetes control was 1.56 (95% CI, 1.35-1.80), corresponding to an absolute excess of 12 (95% CI, 8-16) per 1000 person-years. The HR was 1.38 (95% CI, 1.17-1.63; P < .001) for serious bleeding, corresponding to an absolute excess of 2 (95% CI, 1-3) per 1000 person-years and 1.22 (95% CI, 1.11-1.34; P < .001) for serious infection, corresponding to an absolute excess of 4 (95% CI, 2-6) per 1000 person-years. The excess risks of these serious adverse events were larger in the first year after starting niacin-laropiprant therapy than in later years (except for the excess of infection, which did not appear to attenuate with time), and the risks of nonfatal and fatal events were similarly increased. The absolute excesses of each of these adverse effects were similar regardless of the baseline risk of the outcome. IMPLICATIONS Practitioners or patients considering the use of niacin (in addition to, or instead of, a statin) despite the lack of evidence of cardiovascular benefits (at least when added to effective statin therapy) should take account of the significant risks of these serious adverse effects when making such decisions. ClinicalTrials.gov identifier: NCT00461630.
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Affiliation(s)
- Richard Haynes
- MRC Population Health Research Unit, Nuffield Department of Population Health, University of Oxford, Oxford, United Kingdom; Clinical Trial Service Unit, Nuffield Department of Population Health, University of Oxford, Oxford, United Kingdom.
| | - Elsa Valdes-Marquez
- Clinical Trial Service Unit, Nuffield Department of Population Health, University of Oxford, Oxford, United Kingdom
| | - Jemma C Hopewell
- Clinical Trial Service Unit, Nuffield Department of Population Health, University of Oxford, Oxford, United Kingdom
| | - Fang Chen
- Clinical Trial Service Unit, Nuffield Department of Population Health, University of Oxford, Oxford, United Kingdom
| | - Jing Li
- National Centre for Cardiovascular Disease, Beijing, China
| | - Sarah Parish
- MRC Population Health Research Unit, Nuffield Department of Population Health, University of Oxford, Oxford, United Kingdom; Clinical Trial Service Unit, Nuffield Department of Population Health, University of Oxford, Oxford, United Kingdom
| | - Martin J Landray
- MRC Population Health Research Unit, Nuffield Department of Population Health, University of Oxford, Oxford, United Kingdom; Clinical Trial Service Unit, Nuffield Department of Population Health, University of Oxford, Oxford, United Kingdom
| | - Jane Armitage
- MRC Population Health Research Unit, Nuffield Department of Population Health, University of Oxford, Oxford, United Kingdom; Clinical Trial Service Unit, Nuffield Department of Population Health, University of Oxford, Oxford, United Kingdom
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32
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Schlackow I, Kent S, Herrington W, Emberson J, Haynes R, Reith C, Collins R, Landray MJ, Gray A, Baigent C, Mihaylova B. Cost-effectiveness of lipid lowering with statins and ezetimibe in chronic kidney disease. Kidney Int 2019; 96:170-179. [PMID: 31005271 PMCID: PMC6595178 DOI: 10.1016/j.kint.2019.01.028] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2018] [Revised: 01/08/2019] [Accepted: 01/10/2019] [Indexed: 12/30/2022]
Abstract
Statin-based treatments reduce cardiovascular disease (CVD) risk in patients with non-dialysis chronic kidney disease (CKD), but it is unclear which regimen is the most cost-effective. We used the Study of Heart and Renal Protection (SHARP) CKD-CVD policy model to evaluate the effect of statins and ezetimibe on quality-adjusted life years (QALYs) and health care costs in the United States (US) and the United Kingdom (UK). Net costs below $100,000/QALY (US) or £20,000/QALY (UK) were considered cost-effective. We investigated statin regimens with or without ezetimibe 10 mg. Treatment effects on cardiovascular risk were estimated per 1-mmol/L reduction in low-density lipoprotein (LDL) cholesterol as reported in the Cholesterol Treatment Trialists' Collaboration meta-analysis, and reductions in LDL cholesterol were estimated for each statin/ezetimibe regimen. In the US, atorvastatin 40 mg ($0.103/day as of January 2019) increased life expectancy by 0.23 to 0.31 QALYs in non-dialysis patients with stages 3B to 5 CKD, at a net cost of $20,300 to $78,200/QALY. Adding ezetimibe 10 mg ($0.203/day) increased life expectancy by an additional 0.05 to 0.07 QALYs, at a net cost of $43,600 to $91,500/QALY. The cost-effectiveness findings and policy implications in the UK were similar. In summary, in patients with non-dialysis-dependent CKD, the evidence suggests that statin/ezetimibe combination therapy is a cost-effective treatment to reduce the risk of CVD.
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Affiliation(s)
- Iryna Schlackow
- Health Economics Research Centre, Nuffield Department of Population Health, University of Oxford, UK
| | - Seamus Kent
- Health Economics Research Centre, Nuffield Department of Population Health, University of Oxford, UK
| | - William Herrington
- Clinical Trial Service Unit and Epidemiological Studies Unit, Nuffield Department of Population Health, University of Oxford, UK; Medical Research Council Population Health Research Unit, Nuffield Department of Population Health, University of Oxford, UK
| | - Jonathan Emberson
- Clinical Trial Service Unit and Epidemiological Studies Unit, Nuffield Department of Population Health, University of Oxford, UK; Medical Research Council Population Health Research Unit, Nuffield Department of Population Health, University of Oxford, UK
| | - Richard Haynes
- Clinical Trial Service Unit and Epidemiological Studies Unit, Nuffield Department of Population Health, University of Oxford, UK; Medical Research Council Population Health Research Unit, Nuffield Department of Population Health, University of Oxford, UK
| | - Christina Reith
- Clinical Trial Service Unit and Epidemiological Studies Unit, Nuffield Department of Population Health, University of Oxford, UK
| | - Rory Collins
- Clinical Trial Service Unit and Epidemiological Studies Unit, Nuffield Department of Population Health, University of Oxford, UK
| | - Martin J Landray
- Clinical Trial Service Unit and Epidemiological Studies Unit, Nuffield Department of Population Health, University of Oxford, UK; Medical Research Council Population Health Research Unit, Nuffield Department of Population Health, University of Oxford, UK
| | - Alastair Gray
- Health Economics Research Centre, Nuffield Department of Population Health, University of Oxford, UK
| | - Colin Baigent
- Clinical Trial Service Unit and Epidemiological Studies Unit, Nuffield Department of Population Health, University of Oxford, UK; Medical Research Council Population Health Research Unit, Nuffield Department of Population Health, University of Oxford, UK
| | - Borislava Mihaylova
- Health Economics Research Centre, Nuffield Department of Population Health, University of Oxford, UK; Centre for Primary Care and Public Health, Blizard Institute, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, UK.
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Herrington WG, Preiss D, Haynes R, von Eynatten M, Staplin N, Hauske SJ, George JT, Green JB, Landray MJ, Baigent C, Wanner C. Erratum: The potential for improving cardio-renal outcomes by sodium-glucose co-transporter-2 inhibition in people with chronic kidney disease: a rationale for the EMPA-KIDNEY study. Clin Kidney J 2019; 13:722. [PMID: 32905262 PMCID: PMC7467589 DOI: 10.1093/ckj/sfz009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023] Open
Abstract
[This corrects the article DOI: 10.1093/ckj/sfy090.].
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Armitage J, Baigent C, Barnes E, Betteridge DJ, Blackwell L, Blazing M, Bowman L, Braunwald E, Byington R, Cannon C, Clearfield M, Colhoun H, Collins R, Dahlöf B, Davies K, Davis B, de Lemos J, Downs JR, Durrington P, Emberson J, Fellström B, Flather M, Ford I, Franzosi MG, Fulcher J, Fuller J, Furberg C, Gordon D, Goto S, Gotto A, Halls H, Harper C, Hawkins CM, Herrington W, Hitman G, Holdaas H, Holland L, Jardine A, Jukema JW, Kastelein J, Kean S, Keech A, Kirby A, Kjekshus J, Knatterud (deceased) G, Knopp (deceased) R, Koenig W, Koren M, Krane V, Landray MJ, LaRosa J, Lonn E, MacFarlane P, MacMahon S, Maggioni A, Marchioli R, Marschner I, Mihaylova B, Moyé L, Murphy S, Nakamura H, Neil A, Newman C, O'Connell R, Packard C, Parish S, Pedersen T, Peto R, Pfeffer M, Poulter N, Preiss D, Reith C, Ridker P, Robertson M, Sacks F, Sattar N, Schmieder R, Serruys P, Sever P, Shaw J, Shear C, Simes J, Sleight P, Spata E, Tavazzi L, Tobert J, Tognoni G, Tonkin A, Trompet S, Varigos J, Wanner C, Wedel H, White H, Wikstrand J, Wilhelmsen L, Wilson K, Young R, Yusuf S, Zannad F. Efficacy and safety of statin therapy in older people: a meta-analysis of individual participant data from 28 randomised controlled trials. Lancet 2019; 393:407-415. [PMID: 30712900 PMCID: PMC6429627 DOI: 10.1016/s0140-6736(18)31942-1] [Citation(s) in RCA: 428] [Impact Index Per Article: 85.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/24/2017] [Revised: 08/13/2018] [Accepted: 08/14/2018] [Indexed: 01/19/2023]
Abstract
BACKGROUND Statin therapy has been shown to reduce major vascular events and vascular mortality in a wide range of individuals, but there is uncertainty about its efficacy and safety among older people. We undertook a meta-analysis of data from all large statin trials to compare the effects of statin therapy at different ages. METHODS In this meta-analysis, randomised trials of statin therapy were eligible if they aimed to recruit at least 1000 participants with a scheduled treatment duration of at least 2 years. We analysed individual participant data from 22 trials (n=134 537) and detailed summary data from one trial (n=12 705) of statin therapy versus control, plus individual participant data from five trials of more intensive versus less intensive statin therapy (n=39 612). We subdivided participants into six age groups (55 years or younger, 56-60 years, 61-65 years, 66-70 years, 71-75 years, and older than 75 years). We estimated effects on major vascular events (ie, major coronary events, strokes, and coronary revascularisations), cause-specific mortality, and cancer incidence as the rate ratio (RR) per 1·0 mmol/L reduction in LDL cholesterol. We compared proportional risk reductions in different age subgroups by use of standard χ2 tests for heterogeneity when there were two groups, or trend when there were more than two groups. FINDINGS 14 483 (8%) of 186 854 participants in the 28 trials were older than 75 years at randomisation, and the median follow-up duration was 4·9 years. Overall, statin therapy or a more intensive statin regimen produced a 21% (RR 0·79, 95% CI 0·77-0·81) proportional reduction in major vascular events per 1·0 mmol/L reduction in LDL cholesterol. We observed a significant reduction in major vascular events in all age groups. Although proportional reductions in major vascular events diminished slightly with age, this trend was not statistically significant (ptrend=0·06). Overall, statin or more intensive therapy yielded a 24% (RR 0·76, 95% CI 0·73-0·79) proportional reduction in major coronary events per 1·0 mmol/L reduction in LDL cholesterol, and with increasing age, we observed a trend towards smaller proportional risk reductions in major coronary events (ptrend=0·009). We observed a 25% (RR 0·75, 95% CI 0·73-0·78) proportional reduction in the risk of coronary revascularisation procedures with statin therapy or a more intensive statin regimen per 1·0 mmol/L lower LDL cholesterol, which did not differ significantly across age groups (ptrend=0·6). Similarly, the proportional reductions in stroke of any type (RR 0·84, 95% CI 0·80-0·89) did not differ significantly across age groups (ptrend=0·7). After exclusion of four trials which enrolled only patients with heart failure or undergoing renal dialysis (among whom statin therapy has not been shown to be effective), the trend to smaller proportional risk reductions with increasing age persisted for major coronary events (ptrend=0·01), and remained non-significant for major vascular events (ptrend=0·3). The proportional reduction in major vascular events was similar, irrespective of age, among patients with pre-existing vascular disease (ptrend=0·2), but appeared smaller among older than among younger individuals not known to have vascular disease (ptrend=0·05). We found a 12% (RR 0·88, 95% CI 0·85-0·91) proportional reduction in vascular mortality per 1·0 mmol/L reduction in LDL cholesterol, with a trend towards smaller proportional reductions with older age (ptrend=0·004), but this trend did not persist after exclusion of the heart failure or dialysis trials (ptrend=0·2). Statin therapy had no effect at any age on non-vascular mortality, cancer death, or cancer incidence. INTERPRETATION Statin therapy produces significant reductions in major vascular events irrespective of age, but there is less direct evidence of benefit among patients older than 75 years who do not already have evidence of occlusive vascular disease. This limitation is now being addressed by further trials. FUNDING Australian National Health and Medical Research Council, National Institute for Health Research Oxford Biomedical Research Centre, UK Medical Research Council, and British Heart Foundation.
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Inker LA, Grams ME, Levey AS, Coresh J, Cirillo M, Collins JF, Gansevoort RT, Gutierrez OM, Hamano T, Heine GH, Ishikawa S, Jee SH, Kronenberg F, Landray MJ, Miura K, Nadkarni GN, Peralta CA, Rothenbacher D, Schaeffner E, Sedaghat S, Shlipak MG, Zhang L, van Zuilen AD, Hallan SI, Kovesdy CP, Woodward M, Levin A. Relationship of Estimated GFR and Albuminuria to Concurrent Laboratory Abnormalities: An Individual Participant Data Meta-analysis in a Global Consortium. Am J Kidney Dis 2019; 73:206-217. [PMID: 30348535 PMCID: PMC6348050 DOI: 10.1053/j.ajkd.2018.08.013] [Citation(s) in RCA: 42] [Impact Index Per Article: 8.4] [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] [Received: 05/03/2018] [Accepted: 08/15/2018] [Indexed: 12/20/2022]
Abstract
RATIONALE & OBJECTIVE Chronic kidney disease (CKD) is complicated by abnormalities that reflect disruption in filtration, tubular, and endocrine functions of the kidney. Our aim was to explore the relationship of specific laboratory result abnormalities and hypertension with the estimated glomerular filtration rate (eGFR) and albuminuria CKD staging framework. STUDY DESIGN Cross-sectional individual participant-level analyses in a global consortium. SETTING & STUDY POPULATIONS 17 CKD and 38 general population and high-risk cohorts. SELECTION CRITERIA FOR STUDIES Cohorts in the CKD Prognosis Consortium with data for eGFR and albuminuria, as well as a measurement of hemoglobin, bicarbonate, phosphorus, parathyroid hormone, potassium, or calcium, or hypertension. DATA EXTRACTION Data were obtained and analyzed between July 2015 and January 2018. ANALYTICAL APPROACH We modeled the association of eGFR and albuminuria with hemoglobin, bicarbonate, phosphorus, parathyroid hormone, potassium, and calcium values using linear regression and with hypertension and categorical definitions of each abnormality using logistic regression. Results were pooled using random-effects meta-analyses. RESULTS The CKD cohorts (n=254,666 participants) were 27% women and 10% black, with a mean age of 69 (SD, 12) years. The general population/high-risk cohorts (n=1,758,334) were 50% women and 2% black, with a mean age of 50 (16) years. There was a strong graded association between lower eGFR and all laboratory result abnormalities (ORs ranging from 3.27 [95% CI, 2.68-3.97] to 8.91 [95% CI, 7.22-10.99] comparing eGFRs of 15 to 29 with eGFRs of 45 to 59mL/min/1.73m2), whereas albuminuria had equivocal or weak associations with abnormalities (ORs ranging from 0.77 [95% CI, 0.60-0.99] to 1.92 [95% CI, 1.65-2.24] comparing urinary albumin-creatinine ratio > 300 vs < 30mg/g). LIMITATIONS Variations in study era, health care delivery system, typical diet, and laboratory assays. CONCLUSIONS Lower eGFR was strongly associated with higher odds of multiple laboratory result abnormalities. Knowledge of risk associations might help guide management in the heterogeneous group of patients with CKD.
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Affiliation(s)
- Lesley A Inker
- Division of Nephrology, Tufts Medical Center, Boston, MA
| | - Morgan E Grams
- Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Andrew S Levey
- Division of Nephrology, Tufts Medical Center, Boston, MA
| | - Josef Coresh
- Johns Hopkins Bloomberg School of Public Health, Baltimore, MD.
| | - Massimo Cirillo
- Department "Scuola Medica Salernitana", University of Salerno, Italy
| | - John F Collins
- Department of Renal Medicine, Auckland City Hospital, Auckland, New Zealand
| | - Ron T Gansevoort
- Department of Nephrology, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - Orlando M Gutierrez
- Division of Nephrology, Department of Medicine, University of Alabama at Birmingham, Birmingham, AL; Department of Epidemiology, University of Alabama at Birmingham, Birmingham, AL
| | - Takayuki Hamano
- Department of Comprehensive Kidney Disease Research, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Gunnar H Heine
- Department for Internal Medicine IV, Nephrology and Hypertension, Saarland University Medical Center, Homburg, Germany
| | - Shizukiyo Ishikawa
- Division of Community and Family Medicine, Center for Community Medicine, Jichi Medical University, Tochigi, Japan
| | - Sun Ha Jee
- Department of Epidemiology and Health Promotion, Graduate School of Public Health, Yonsei University, Seoul, Korea
| | - Florian Kronenberg
- Division of Genetic Epidemiology, Department of Medical Genetics, Molecular and Clinical Pharmacology, Medical University of Innsbruck, Innsbruck, Austria and German Chronic Kidney Disease Study, Oxford, United Kingdom
| | - Martin J Landray
- Medical Research Council-Population Health Research Unit, Clinical Trial Service Unit and Epidemiological Studies Unit, and Big Data Institute, Nuffield Department of Population Health, University of Oxford, Oxford, United Kingdom
| | - Katsuyuki Miura
- Department of Public Health and Center for Epidemiologic Research in Asia, Shiga University of Medical Science, Otsu, Japan
| | - Girish N Nadkarni
- Division of Nephrology, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Carmen A Peralta
- Kidney Health Research Collaborative, San Francisco VA Medical Center and University of California, San Francisco, CA
| | - Dietrich Rothenbacher
- Division of Clinical Epidemiology and Ageing Research, German Cancer Centre (DKFZ), Heidelberg; Institute of Epidemiology and Medical Biometry, Ulm University, Ulm, Germany
| | - Elke Schaeffner
- Institute of Public Health, Charite, Universitätsmedizin Berlin
| | - Sanaz Sedaghat
- Department of Epidemiology, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Michael G Shlipak
- Kidney Health Research Collaborative, San Francisco VA Medical Center and University of California, San Francisco, CA
| | - Luxia Zhang
- Peking University Institute of Nephrology, Division of Nephrology, Peking University First Hospital, Beijing, China
| | - Arjan D van Zuilen
- Department of Nephrology and Hypertension, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Stein I Hallan
- Department of Clinical and Molecular Medicine, Faculty of Medicine, Norwegian University of Science Technology, Trondheim, Norway; Division of Nephrology, Department of Medicine, St Olav University Hospital, Trondheim, Norway
| | - Csaba P Kovesdy
- Memphis Veterans Affairs Medical Center, Memphis, TN; University of Tennessee Health Science Center, Memphis, TN
| | - Mark Woodward
- Johns Hopkins Bloomberg School of Public Health, Baltimore, MD; The George Institute for Global Health, University of New South Wales, Sydney, NSW, Australia; The George Institute for Global Health, University of Oxford, Oxford, United Kingdom
| | - Adeera Levin
- BC Provincial Renal Agency and University of British Columbia, Canada
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Herrington WG, Preiss D, Haynes R, von Eynatten M, Staplin N, Hauske SJ, George JT, Green JB, Landray MJ, Baigent C, Wanner C. The potential for improving cardio-renal outcomes by sodium-glucose co-transporter-2 inhibition in people with chronic kidney disease: a rationale for the EMPA-KIDNEY study. Clin Kidney J 2018; 11:749-761. [PMID: 30524708 PMCID: PMC6275453 DOI: 10.1093/ckj/sfy090] [Citation(s) in RCA: 166] [Impact Index Per Article: 27.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2018] [Accepted: 09/03/2018] [Indexed: 02/06/2023] Open
Abstract
Diabetes is a common cause of chronic kidney disease (CKD), but in aggregate, non-diabetic diseases account for a higher proportion of cases of CKD than diabetes in many parts of the world. Inhibition of the renin–angiotensin system reduces the risk of kidney disease progression and treatments that lower blood pressure (BP) or low-density lipoprotein cholesterol reduce cardiovascular (CV) risk in this population. Nevertheless, despite such interventions, considerable risks for kidney and CV complications remain. Recently, large placebo-controlled outcome trials have shown that sodium-glucose co-transporter-2 (SGLT-2) inhibitors reduce the risk of CV disease (including CV death and hospitalization for heart failure) in people with type 2 diabetes who are at high risk of atherosclerotic disease, and these effects were largely independent of improvements in hyperglycaemia, BP and body weight. In the kidney, increased sodium delivery to the macula densa mediated by SGLT-2 inhibition has the potential to reduce intraglomerular pressure, which may explain why SGLT-2 inhibitors reduce albuminuria and appear to slow kidney function decline in people with diabetes. Importantly, in the trials completed to date, these benefits appeared to be maintained at lower levels of kidney function, despite attenuation of glycosuric effects, and did not appear to be dependent on ambient hyperglycaemia. There is therefore a rationale for studying the cardio-renal effects of SGLT-2 inhibition in people at risk of CV disease and hyperfiltration (i.e. those with substantially reduced nephron mass and/or albuminuria), irrespective of whether they have diabetes.
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Affiliation(s)
- William G Herrington
- Medical Research Council Population Health Research Unit at the University of Oxford, Nuffield Department of Population Health, University of Oxford, Oxford, UK.,Clinical Trial Service Unit and Epidemiological Studies Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - David Preiss
- Medical Research Council Population Health Research Unit at the University of Oxford, Nuffield Department of Population Health, University of Oxford, Oxford, UK.,Clinical Trial Service Unit and Epidemiological Studies Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Richard Haynes
- Medical Research Council Population Health Research Unit at the University of Oxford, Nuffield Department of Population Health, University of Oxford, Oxford, UK.,Clinical Trial Service Unit and Epidemiological Studies Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | | | - Natalie Staplin
- Medical Research Council Population Health Research Unit at the University of Oxford, Nuffield Department of Population Health, University of Oxford, Oxford, UK.,Clinical Trial Service Unit and Epidemiological Studies Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK.,Li Ka Shing Centre for Health Information and Discovery, Big Data Institute, University of Oxford, Oxford, UK
| | | | | | - Jennifer B Green
- Duke Clinical Research Institute, Duke University Medical Center, Durham, NC, USA
| | - Martin J Landray
- Medical Research Council Population Health Research Unit at the University of Oxford, Nuffield Department of Population Health, University of Oxford, Oxford, UK.,Clinical Trial Service Unit and Epidemiological Studies Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK.,Li Ka Shing Centre for Health Information and Discovery, Big Data Institute, University of Oxford, Oxford, UK
| | - Colin Baigent
- Medical Research Council Population Health Research Unit at the University of Oxford, Nuffield Department of Population Health, University of Oxford, Oxford, UK.,Clinical Trial Service Unit and Epidemiological Studies Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
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Abstract
IMPORTANCE Spontaneous pneumothorax is a common disease known to have an unusual epidemiological profile, but there are limited contemporary population-based data. OBJECTIVE To estimate the incidence of hospital admissions for spontaneous pneumothorax, its recurrence and trends over time using large, longstanding hospitalization data sets in England. DESIGN, SETTING, AND PARTICIPANTS A population-based epidemiological study was conducted using an English national data set and an English regional data set, each spanning 1968 to 2016, and including 170 929 hospital admission records of patients 15 years and older. Final date of the study period was December 31, 2016. EXPOSURES Calendar year (for incidence) and readmission to hospital for spontaneous pneumothorax (for recurrence). MAIN OUTCOMES AND MEASURES Primary outcomes were rates of hospital admissions for spontaneous pneumothorax and recurrence, defined as a subsequent hospital readmission with spontaneous pneumothorax. Record-linkage was used to identify multiple admissions per person and comorbidity. Risk factors for recurrence over 5 years of follow-up were assessed using cumulative time-to-failure analysis and Cox proportional hazards regression. RESULTS From 1968 to 2016, there were 170 929 hospital admissions for spontaneous pneumothorax (median age, 44 years [IQR, 26-88]; 73.0% male). In 2016, there were 14.1 spontaneous pneumothorax admissions per 100 000 population 15 years and older (95% CI, 13.7-14.4), a significant increase compared with earlier years, up from 9.1 (95% CI, 8.1-10.1) in 1968. The population-based rate per 100 000 population 15 years and older was higher for males (20.8 [95% CI, 20.2-21.4]) than for females (7.6 [95% CI, 7.2-7.9]). Of patients with spontaneous pneumothorax, 60.8% (95% CI, 59.5%-62.0%) had chronic lung disease. Record-linkage analysis demonstrated that the overall increase in admissions over time could be due in part to an increase in repeat admissions, but there were also significant increases in the annual rate of first-known spontaneous pneumothorax admissions in some population subgroups, for example in women 65 years and older (annual percentage change from 1968 to 2016, 4.08 [95% CI, 3.33-4.82], P < .001). The probability of recurrence within 5 years was similar by sex (25.5% [95% CI, 25.1%-25.9%] for males vs 26.0% [95% CI, 25.3%-26.7%] for females), but there was variation by age group and presence of chronic lung disease. For example, the probability of readmission within 5 years among males aged 15 to 34 years with chronic lung disease was 39.2% (95% CI, 37.7%-40.7%) compared with 19.6% (95% CI, 18.2%-21.1%) in men 65 years and older without chronic lung disease. CONCLUSIONS AND RELEVANCE This study provides contemporary information regarding the trends in incidence and recurrence of inpatient-treated spontaneous pneumothorax.
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Affiliation(s)
- Rob J. Hallifax
- Oxford Centre for Respiratory Medicine, Oxford University Hospitals National Health Service Foundation Trust, Oxford, United Kingdom
| | - Raph Goldacre
- Unit of Health-Care Epidemiology, Big Data Institute, Li Ka Shing Centre for Health Information and Discovery, Nuffield Department of Population Health, University of Oxford, Oxford, United Kingdom
| | - Martin J. Landray
- Unit of Health-Care Epidemiology, Big Data Institute, Li Ka Shing Centre for Health Information and Discovery, Nuffield Department of Population Health, University of Oxford, Oxford, United Kingdom
- Medical Research Council Population Health Research Unit, Nuffield Department of Population Health, University of Oxford, Oxford, United Kingdom
- Oxford National Institute for Health Research Biomedical Research Centre, University of Oxford, Oxford, United Kingdom
| | - Najib M. Rahman
- Oxford Centre for Respiratory Medicine, Oxford University Hospitals National Health Service Foundation Trust, Oxford, United Kingdom
- Oxford National Institute for Health Research Biomedical Research Centre, University of Oxford, Oxford, United Kingdom
| | - Michael J. Goldacre
- Unit of Health-Care Epidemiology, Big Data Institute, Li Ka Shing Centre for Health Information and Discovery, Nuffield Department of Population Health, University of Oxford, Oxford, United Kingdom
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Marthi A, Donovan K, Haynes R, Wheeler DC, Baigent C, Rooney CM, Landray MJ, Moe SM, Yang J, Holland L, di Giuseppe R, Bouma-de Krijger A, Mihaylova B, Herrington WG. Fibroblast Growth Factor-23 and Risks of Cardiovascular and Noncardiovascular Diseases: A Meta-Analysis. J Am Soc Nephrol 2018; 29:2015-2027. [PMID: 29764921 PMCID: PMC6050929 DOI: 10.1681/asn.2017121334] [Citation(s) in RCA: 118] [Impact Index Per Article: 19.7] [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] [Received: 12/28/2017] [Accepted: 03/30/2018] [Indexed: 12/20/2022] Open
Abstract
Background Fibroblast growth factor-23 (FGF-23) has been hypothesized to play a role in the increased risk of cardiovascular disease in patients with CKD.Methods We identified prospective studies reporting associations between FGF-23 concentration and risk of cardiovascular events. Maximally adjusted risk ratios (RRs) were extracted for each outcome and scaled to a comparison of the top versus bottom third of the baseline FGF-23 concentration, and the results aggregated.Results Depending on the assay used, median FGF-23 concentrations were 43-74 RU/ml and 38-47 pg/ml in 17 general population cohorts; 102-392 RU/ml in nine cohorts of patients with CKD not requiring dialysis; and 79-4212 RU/ml and 2526-5555 pg/ml in eight cohorts of patients on dialysis. Overall, comparing participants in the top and bottom FGF-23 concentration thirds, the summary RRs (95% confidence intervals [95% CIs]) were 1.33 (1.12 to 1.58) for myocardial infarction, 1.26 (1.13 to 1.41) for stroke, 1.48 (1.29 to 1.69) for heart failure, 1.42 (1.27 to 1.60) for cardiovascular mortality, and 1.70 (1.52 to 1.91) for all-cause mortality. The summary RR for noncardiovascular mortality, calculated indirectly, was 1.52 (95% CI, 1.28 to 1.79). When studies were ordered by average differences in FGF-23 concentration between the top and bottom thirds, there was no trend in RRs across the studies.Conclusions The similarly-sized associations between increased FGF-23 concentration and cardiovascular (atherosclerotic and nonatherosclerotic) and noncardiovascular outcomes, together with the absence of any exposure-response relationship, suggest that the relationship between FGF-23 and cardiovascular disease risk may be noncausal.
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Affiliation(s)
| | - Killian Donovan
- Clinical Trial Service Unit and Epidemiological Studies Unit, and
| | - Richard Haynes
- Clinical Trial Service Unit and Epidemiological Studies Unit, and
- Medical Research Council Population Health Research Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - David C Wheeler
- Centre for Nephrology, University College London, London, UK
| | - Colin Baigent
- Clinical Trial Service Unit and Epidemiological Studies Unit, and
- Medical Research Council Population Health Research Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | | | - Martin J Landray
- Clinical Trial Service Unit and Epidemiological Studies Unit, and
- Medical Research Council Population Health Research Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Sharon M Moe
- Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana
| | - Jun Yang
- Global Biostatistics Science, Amgen Inc., Thousand Oaks, California
| | - Lisa Holland
- Clinical Trial Service Unit and Epidemiological Studies Unit, and
| | - Romina di Giuseppe
- Institute of Epidemiology, Christian-Albrechts University of Kiel, Kiel, Germany
| | - Annet Bouma-de Krijger
- Department of Nephrology, Vrije Universiteit University Medical Center, Amsterdam, The Netherlands; and
| | - Borislava Mihaylova
- Health Economics Research Centre,
- Centre for Primary Care and Public Health, Queen Mary University of London, London, UK
| | - William G Herrington
- Clinical Trial Service Unit and Epidemiological Studies Unit, and
- Medical Research Council Population Health Research Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
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Haynes R, Blackwell L, Staplin N, Herrington WG, Emberson J, Judge PK, Storey BC, Landray MJ, Harden PN, Baigent C, Friend P. Campath, calcineurin inhibitor reduction, and chronic allograft nephropathy (the 3C Study) - results of a randomized controlled clinical trial. Am J Transplant 2018; 18:1424-1434. [PMID: 29226570 PMCID: PMC6001618 DOI: 10.1111/ajt.14619] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2017] [Revised: 11/21/2017] [Accepted: 11/27/2017] [Indexed: 01/25/2023]
Abstract
Calcineurin inhibitors (CNIs, eg, tacrolimus) reduce short-term kidney transplant failure, but chronic nephrotoxicity may contribute to late transplant loss. Elective conversion to inhibitors of the mammalian target of rapamycin (mTOR, eg, sirolimus) pathway might avoid long-term CNI renal damage and improve outcomes. The 3C Study was a pragmatic randomized controlled trial of sequential randomizations between alemtuzumab and basiliximab induction therapy (at the time of surgery) and between tacrolimus and sirolimus maintenance therapy at 6 months posttransplantation. The primary outcome of this analysis was estimated glomerular filtration rate (eGFR) at 18 months after maintenance therapy randomization; 197 patients were assigned sirolimus-based and 197 to tacrolimus-based therapy. Allocation to sirolimus had no significant effect on eGFR at 18 months: baseline-adjusted mean (SEM) eGFR was 53.7 (0.9) mL/min/1.73 m2 in the sirolimus group versus 54.6 (0.9) mL/min/1.73 m2 in the tacrolimus group (P = .50). Biopsy-proven acute rejection (29 [14.7%]) vs 6 [3.0%]; P < .001) and serious infections (defined as opportunistic infections or those requiring hospitalization; 95 [48.2%] vs 70 [35.5%]; P = .008) were more common among participants allocated sirolimus. Compared with tacrolimus-based therapy, sirolimus-based maintenance therapy did not improve transplant function at 18 months after conversion and was associated with significant hazards of rejection and infection. ClinicalTrials.gov identifier NCT01120028 and ISRCTN88894088.
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Affiliation(s)
| | - Richard Haynes
- MRC Population Health Research UnitNuffield Department of Population HealthUniversity of OxfordOxfordUK,Clinical Trial Service UnitNuffield Department of Population HealthUniversity of OxfordOxfordUK
| | - Lisa Blackwell
- MRC Population Health Research UnitNuffield Department of Population HealthUniversity of OxfordOxfordUK,Clinical Trial Service UnitNuffield Department of Population HealthUniversity of OxfordOxfordUK
| | - Natalie Staplin
- Clinical Trial Service UnitNuffield Department of Population HealthUniversity of OxfordOxfordUK
| | - William G. Herrington
- Clinical Trial Service UnitNuffield Department of Population HealthUniversity of OxfordOxfordUK
| | - Jonathan Emberson
- MRC Population Health Research UnitNuffield Department of Population HealthUniversity of OxfordOxfordUK,Clinical Trial Service UnitNuffield Department of Population HealthUniversity of OxfordOxfordUK
| | - Parminder K. Judge
- MRC Population Health Research UnitNuffield Department of Population HealthUniversity of OxfordOxfordUK,Clinical Trial Service UnitNuffield Department of Population HealthUniversity of OxfordOxfordUK
| | - Benjamin C. Storey
- MRC Population Health Research UnitNuffield Department of Population HealthUniversity of OxfordOxfordUK,Clinical Trial Service UnitNuffield Department of Population HealthUniversity of OxfordOxfordUK
| | - Martin J. Landray
- MRC Population Health Research UnitNuffield Department of Population HealthUniversity of OxfordOxfordUK,Clinical Trial Service UnitNuffield Department of Population HealthUniversity of OxfordOxfordUK
| | - Paul N. Harden
- Oxford University Hospitals NHS Foundation TrustOxfordUK
| | - Colin Baigent
- MRC Population Health Research UnitNuffield Department of Population HealthUniversity of OxfordOxfordUK,Clinical Trial Service UnitNuffield Department of Population HealthUniversity of OxfordOxfordUK
| | - Peter Friend
- Nuffield Department of Surgical SciencesUniversity of OxfordOxfordUK
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Storey BC, Staplin N, Harper CH, Haynes R, Winearls CG, Goldacre R, Emberson JR, Goldacre MJ, Baigent C, Landray MJ, Herrington WG. Declining comorbidity-adjusted mortality rates in English patients receiving maintenance renal replacement therapy. Kidney Int 2018; 93:1165-1174. [PMID: 29395337 PMCID: PMC5912929 DOI: 10.1016/j.kint.2017.11.020] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2017] [Revised: 10/30/2017] [Accepted: 11/16/2017] [Indexed: 01/14/2023]
Abstract
We aimed to compare long-term mortality trends in end-stage renal disease versus general population controls after accounting for differences in age, sex and comorbidity. Cohorts of 45,000 patients starting maintenance renal replacement therapy (RRT) and 5.3 million hospital controls were identified from two large electronic hospital inpatient data sets: the Oxford Record Linkage Study (1965-1999) and all-England Hospital Episode Statistics (2000-2011). All-cause and cause-specific three-year mortality rates for both populations were calculated using Poisson regression and standardized to the age, sex, and comorbidity structure of an average 1970-2008 RRT population. The median age at initiation of RRT in 1970-1990 was 49 years, increasing to 61 years by 2006-2008. Over that period, there were increases in the prevalence of vascular disease (from 10.0 to 25.2%) and diabetes (from 6.7 to 33.9%). After accounting for age, sex and comorbidity differences, standardized three-year all-cause mortality rates in treated patients with end-stage renal disease between 1970 and 2011 fell by about one-half (relative decline 51%, 95% confidence interval 41-60%) steeper than the one-third decline (34%, 31-36%) observed in the general population. Declines in three-year mortality rates were evident among those who received a kidney transplant and those who remained on dialysis, and among those with and without diabetes. These data suggest that the full extent of mortality rate declines among RRT patients since 1970 is only apparent when changes in comorbidity over time are taken into account, and that mortality rates in RRT patients appear to have declined faster than in the general population.
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Affiliation(s)
- Benjamin C Storey
- Medical Research Council Population Health Research Unit, Nuffield Department of Population Health (NDPH), University of Oxford, Oxford, UK; Clinical Trial Service Unit and Epidemiological Studies Unit (CTSU), NDPH, University of Oxford, Oxford, UK
| | - Natalie Staplin
- Clinical Trial Service Unit and Epidemiological Studies Unit (CTSU), NDPH, University of Oxford, Oxford, UK
| | - Charlie H Harper
- Medical Research Council Population Health Research Unit, Nuffield Department of Population Health (NDPH), University of Oxford, Oxford, UK; Clinical Trial Service Unit and Epidemiological Studies Unit (CTSU), NDPH, University of Oxford, Oxford, UK
| | - Richard Haynes
- Medical Research Council Population Health Research Unit, Nuffield Department of Population Health (NDPH), University of Oxford, Oxford, UK; Oxford Kidney Unit, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | | | - Raph Goldacre
- Unit of Healthcare Epidemiology, Big Data Institute, Li Ka Shing Centre for Heath Information and Discovery, NDPH, University of Oxford, Oxford, UK
| | - Jonathan R Emberson
- Medical Research Council Population Health Research Unit, Nuffield Department of Population Health (NDPH), University of Oxford, Oxford, UK; Clinical Trial Service Unit and Epidemiological Studies Unit (CTSU), NDPH, University of Oxford, Oxford, UK
| | - Michael J Goldacre
- Unit of Healthcare Epidemiology, Big Data Institute, Li Ka Shing Centre for Heath Information and Discovery, NDPH, University of Oxford, Oxford, UK
| | - Colin Baigent
- Medical Research Council Population Health Research Unit, Nuffield Department of Population Health (NDPH), University of Oxford, Oxford, UK; Clinical Trial Service Unit and Epidemiological Studies Unit (CTSU), NDPH, University of Oxford, Oxford, UK
| | - Martin J Landray
- Medical Research Council Population Health Research Unit, Nuffield Department of Population Health (NDPH), University of Oxford, Oxford, UK; Clinical Trial Service Unit and Epidemiological Studies Unit (CTSU), NDPH, University of Oxford, Oxford, UK; Unit of Healthcare Epidemiology, Big Data Institute, Li Ka Shing Centre for Heath Information and Discovery, NDPH, University of Oxford, Oxford, UK
| | - William G Herrington
- Medical Research Council Population Health Research Unit, Nuffield Department of Population Health (NDPH), University of Oxford, Oxford, UK; Oxford Kidney Unit, Oxford University Hospitals NHS Foundation Trust, Oxford, UK.
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Baigent C, Herrington WG, Coresh J, Landray MJ, Levin A, Perkovic V, Pfeffer MA, Rossing P, Walsh M, Wanner C, Wheeler DC, Winkelmayer WC, McMurray JJV. Challenges in conducting clinical trials in nephrology: conclusions from a Kidney Disease-Improving Global Outcomes (KDIGO) Controversies Conference. Kidney Int 2018; 92:297-305. [PMID: 28709600 PMCID: PMC6326036 DOI: 10.1016/j.kint.2017.04.019] [Citation(s) in RCA: 92] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2017] [Revised: 04/12/2017] [Accepted: 04/18/2017] [Indexed: 12/16/2022]
Abstract
Despite the high costs of treatment of people with kidney disease and associated comorbid conditions, the amount of reliable information available to guide the care of such patients is very limited. Some treatments have been assessed in randomized trials, but most such trials have been too small to detect treatment effects of a magnitude that would be realistic to achieve with a single intervention. Therefore, KDIGO convened an international, multidisciplinary controversies conference titled "Challenges in the Conduct of Clinical Trials in Nephrology" to identify the key barriers to conducting trials in patients with kidney disease. The conference began with plenary talks focusing on the key areas of discussion that included appropriate trial design (covering identification and evaluation of kidney and nonkidney disease outcomes) and sensible trial execution (with particular emphasis on streamlining both design and conduct). Break out group discussions followed in which the key areas of agreement and remaining controversy were identified. Here we summarize the main findings from the conference and set out a range of potential solutions. If followed, these solutions could ensure future trials among people with kidney disease are sufficiently robust to provide reliable answers and are not constrained by inappropriate complexities in design or conduct.
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Affiliation(s)
- Colin Baigent
- Medical Research Council Population Health Research Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK; Clinical Trial Service Unit and Epidemiological Studies Unit (CTSU), Nuffield Department of Population Health, University of Oxford, Oxford, UK.
| | - William G Herrington
- Clinical Trial Service Unit and Epidemiological Studies Unit (CTSU), Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Josef Coresh
- Department of Epidemiology, John Hopkins University, Baltimore, Maryland, USA
| | - Martin J Landray
- Medical Research Council Population Health Research Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK; Clinical Trial Service Unit and Epidemiological Studies Unit (CTSU), Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Adeera Levin
- University of British Columbia, Vancouver, British Columbia, Canada
| | - Vlado Perkovic
- The George Institute for Global Health, University of Sydney, Sydney, New South Wales, Australia
| | - Marc A Pfeffer
- Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Peter Rossing
- Steno Diabetes Centre Copenhagen, Copenhagen, Denmark; University of Copenhagen, Copenhagen, Denmark
| | - Michael Walsh
- Population Health Research Institute, Hamilton Health Sciences/McMaster University, Hamilton, Ontario, Canada
| | | | - David C Wheeler
- Centre for Nephrology, University College London, London, UK
| | - Wolfgang C Winkelmayer
- Selzman Institute for Kidney Health, Section of Nephrology, Department of Medicine, Baylor College of Medicine, Houston, Texas, USA
| | - John J V McMurray
- British Heart Foundation Cardiovascular Research Centre, University of Glasgow, Glasgow, UK
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Hicks KA, Mahaffey KW, Mehran R, Nissen SE, Wiviott SD, Dunn B, Solomon SD, Marler JR, Teerlink JR, Farb A, Morrow DA, Targum SL, Sila CA, Thanh Hai MT, Jaff MR, Joffe HV, Cutlip DE, Desai AS, Lewis EF, Gibson CM, Landray MJ, Lincoff AM, White CJ, Brooks SS, Rosenfield K, Domanski MJ, Lansky AJ, McMurray JJ, Tcheng JE, Steinhubl SR, Burton P, Mauri L, O’Connor CM, Pfeffer MA, Hung HJ, Stockbridge NL, Chaitman BR, Temple RJ, Fitter HD, Illoh K, Cavanaugh KJ, Scirica BM, Irony I, Brown Kichline RE, Levine JG, Park A, Sacks L, Szarfman A, Unger EF, Wachter LA, Zuckerman B, Mitchel Y, Peddicord D, Shook T, Kisler B, Jaffe C, Bartley R, DeMets DL, Mencini M, Janning C, Bai S, Lawrence J, D’Agostino RB, Pocock SJ. 2017 Cardiovascular and Stroke Endpoint Definitions for Clinical Trials. J Am Coll Cardiol 2018; 71:1021-1034. [DOI: 10.1016/j.jacc.2017.12.048] [Citation(s) in RCA: 148] [Impact Index Per Article: 24.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2017] [Revised: 12/21/2017] [Accepted: 12/22/2017] [Indexed: 11/25/2022]
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Hicks KA, Mahaffey KW, Mehran R, Nissen SE, Wiviott SD, Dunn B, Solomon SD, Marler JR, Teerlink JR, Farb A, Morrow DA, Targum SL, Sila CA, Hai MTT, Jaff MR, Joffe HV, Cutlip DE, Desai AS, Lewis EF, Gibson CM, Landray MJ, Lincoff AM, White CJ, Brooks SS, Rosenfield K, Domanski MJ, Lansky AJ, McMurray JJ, Tcheng JE, Steinhubl SR, Burton P, Mauri L, O’Connor CM, Pfeffer MA, Hung HJ, Stockbridge NL, Chaitman BR, Temple RJ. 2017 Cardiovascular and Stroke Endpoint Definitions for Clinical Trials. Circulation 2018; 137:961-972. [DOI: 10.1161/circulationaha.117.033502] [Citation(s) in RCA: 214] [Impact Index Per Article: 35.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2017] [Accepted: 12/22/2017] [Indexed: 11/16/2022]
Abstract
This publication describes uniform definitions for cardiovascular and stroke outcomes developed by the Standardized Data Collection for Cardiovascular Trials Initiative and the US Food and Drug Administration (FDA). The FDA established the Standardized Data Collection for Cardiovascular Trials Initiative in 2009 to simplify the design and conduct of clinical trials intended to support marketing applications. The writing committee recognizes that these definitions may be used in other types of clinical trials and clinical care processes where appropriate. Use of these definitions at the FDA has enhanced the ability to aggregate data within and across medical product development programs, conduct meta-analyses to evaluate cardiovascular safety, integrate data from multiple trials, and compare effectiveness of drugs and devices. Further study is needed to determine whether prospective data collection using these common definitions improves the design, conduct, and interpretability of the results of clinical trials.
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Affiliation(s)
- Karen A. Hicks
- Division of Cardiovascular and Renal Products, Office of Drug Evaluation I, Center for Drug Evaluation and Research (CDER), United States Food and Drug Administration (FDA), Silver Spring, Maryland (K.A.H., S.L.T., N.L.S.)
| | - Kenneth W. Mahaffey
- Stanford Center for Clinical Research, Department of Medicine, Stanford University School of Medicine, Stanford, California (K.W.M.)
| | - Roxana Mehran
- Division of Cardiology, Icahn School of Medicine at Mount Sinai, New York, New York (R.M.)
| | - Steven E. Nissen
- Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland, Ohio (S.E.N., A.M.L.)
| | - Stephen D. Wiviott
- TIMI Study Group, Cardiovascular Division, Brigham and Women’s Hospital, Boston, Massachusetts (S.D.W., D.A.M.)
| | - Billy Dunn
- Division of Neurology Products, Office of Drug Evaluation I, Center for Drug Evaluation and Research (CDER), United States Food and Drug Administration (FDA), Silver Spring, Maryland (B.D., J.R.M.)
| | - Scott D. Solomon
- Cardiovascular Division, Brigham and Women’s Hospital, Boston, Massachusetts (S.D.S., A.S.D., E.F.L., M.A.P.)
| | - John R. Marler
- Division of Neurology Products, Office of Drug Evaluation I, Center for Drug Evaluation and Research (CDER), United States Food and Drug Administration (FDA), Silver Spring, Maryland (B.D., J.R.M.)
| | - John R. Teerlink
- Section of Cardiology, San Francisco Veterans Affairs Medical Center and School of Medicine, University of California San Francisco, San Francisco, California (J.R.T.)
| | - Andrew Farb
- Division of Cardiovascular Devices, Center for Devices and Radiological Health (CDRH), United States Food and Drug Administration (FDA), Silver Spring, Maryland (A.F.)
| | - David A. Morrow
- TIMI Study Group, Cardiovascular Division, Brigham and Women’s Hospital, Boston, Massachusetts (S.D.W., D.A.M.)
| | - Shari L. Targum
- Division of Cardiovascular and Renal Products, Office of Drug Evaluation I, Center for Drug Evaluation and Research (CDER), United States Food and Drug Administration (FDA), Silver Spring, Maryland (K.A.H., S.L.T., N.L.S.)
| | - Cathy A. Sila
- Neurological Institute, University Hospitals-Cleveland Medical Center, Cleveland, Ohio (C.A.S.)
| | - Mary T. Thanh Hai
- Office of Drug Evaluation II, Center for Drug Evaluation and Research (CDER), United States Food and Drug Administration (FDA), Silver Spring, Maryland (M.T.T.)
| | - Michael R. Jaff
- Department of Medicine, Harvard Medical School, Boston, Massachusetts (M.R.J.)
| | - Hylton V. Joffe
- Division of Bone, Reproductive and Urologic Products, Office of Drug Evaluation III, Center for Drug Evaluation and Research (CDER), United States Food and Drug Administration (FDA), Silver Spring, Maryland (H.V.J.)
| | - Donald E. Cutlip
- Cardiology Division, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts (D.E.C.)
| | - Akshay S. Desai
- Cardiovascular Division, Brigham and Women’s Hospital, Boston, Massachusetts (S.D.S., A.S.D., E.F.L., M.A.P.)
| | - Eldrin F. Lewis
- Cardiovascular Division, Brigham and Women’s Hospital, Boston, Massachusetts (S.D.S., A.S.D., E.F.L., M.A.P.)
| | - C. Michael Gibson
- Cardiovascular Division, Department of Medicine, Harvard Medical School, Boston, Massachusetts (C.M.G.)
| | - Martin J. Landray
- Clinical Trial Service Unit & Epidemiological Studies Unit (CTSU), University of Oxford, Oxford, United Kingdom (M.J.L.)
| | - A. Michael Lincoff
- Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland, Ohio (S.E.N., A.M.L.)
| | - Christopher J. White
- Department of Cardiology, Ochsner Clinical School, New Orleans, Louisiana (C.J.W.)
| | | | - Kenneth Rosenfield
- Vascular Medicine and Intervention, Corrigan Minehan Heart Center, Massachusetts General Hospital, Boston, Massachusetts (K.R.)
| | - Michael J. Domanski
- Peter Munk Cardiac Centre, University Health Network/Mount Sinai Hospital, University of Toronto, Toronto, Ontario, Canada (M.J.D.)
| | - Alexandra J. Lansky
- Department of Internal Medicine, Section of Cardiology, Yale School of Medicine, New Haven, Connecticut (A.J.L.)
| | - John J.V. McMurray
- Institute of Cardiovascular & Medical Sciences, BHF Cardiovascular Research Centre, University of Glasgow, Glasgow, Scotland (J.J.V.M.)
| | - James E. Tcheng
- Division of Cardiovascular Medicine, Duke University Medical Center, Durham, North Carolina (J.E.T.)
| | - Steven R. Steinhubl
- Division of Digital Medicine, Scripps Translational Science Institute, La Jolla, California (S.R.S.)
| | - Paul Burton
- Cardiovascular and Metabolism Medical Affairs, Janssen Pharmaceuticals Inc., Titusville, New Jersey (P.B.)
| | - Laura Mauri
- Cardiovascular Division, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts (L.M.)
| | | | - Marc A. Pfeffer
- Cardiovascular Division, Brigham and Women’s Hospital, Boston, Massachusetts (S.D.S., A.S.D., E.F.L., M.A.P.)
| | - H.M. James Hung
- Division of Biometrics I, Office of Biostatistics, Center for Drug Evaluation and Research (CDER), United States Food and Drug Administration (FDA), Silver Spring, Maryland (H.M.J.H.)
| | - Norman L. Stockbridge
- Division of Cardiovascular and Renal Products, Office of Drug Evaluation I, Center for Drug Evaluation and Research (CDER), United States Food and Drug Administration (FDA), Silver Spring, Maryland (K.A.H., S.L.T., N.L.S.)
| | - Bernard R. Chaitman
- Center for Comprehensive Cardiovascular Care, St. Louis University School of Medicine, St. Louis, Missouri (B.R.C.)
| | - Robert J. Temple
- Center for Drug Evaluation and Research (CDER), United States Food and Drug Administration (FDA), Silver Spring, Maryland (R.J.T.)
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Affiliation(s)
- William G Herrington
- 1 Medical Research Council Population Health Research Unit, Clinical Trial Service Unit and Epidemiological Studies Unit, University of Oxford, Oxford, UK
| | | | - Martin J Landray
- 1 Medical Research Council Population Health Research Unit, Clinical Trial Service Unit and Epidemiological Studies Unit, University of Oxford, Oxford, UK.,3 Big Data Institute and Oxford National Institute for Health Research Biomedical Research Centre, University of Oxford, Oxford, UK
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Mafham MM, Staplin N, Emberson J, Haynes R, Herrington W, Reith C, Wanner C, Walker R, Cass A, Levin A, Fellström B, Jiang L, Holdaas H, Kasiske B, Wheeler DC, Landray MJ, Baigent C. Prognostic utility of estimated albumin excretion rate in chronic kidney disease: results from the Study of Heart and Renal Protection. Nephrol Dial Transplant 2018; 33:257-264. [PMID: 28088776 PMCID: PMC5837220 DOI: 10.1093/ndt/gfw396] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [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: 07/01/2016] [Accepted: 10/10/2016] [Indexed: 11/14/2022] Open
Abstract
Background Estimated albumin excretion rate (eAER) provides a better estimate of 24-h albuminuria than albumin:creatinine ratio (ACR). However, whether eAER is superior to ACR in predicting end-stage renal disease (ESRD), vascular events (VEs) or death is uncertain. Methods The prognostic utility of ACR and eAER (estimated from ACR, sex, age and race) to predict mortality, ESRD and VEs was compared using Cox proportional hazards regression among 5552 participants with chronic kidney disease in the Study of Heart and Renal Protection, who were not on dialysis at baseline. Results During a median follow-up of 4.8 years, 1959 participants developed ESRD, 1204 had a VE and 1130 died (641 from a non-vascular, 369 from a vascular and 120 from an unknown cause). After adjustment for age, sex and eGFR, both ACR and eAER were strongly and similarly associated with ESRD risk. The average relative risk (RR) per 10-fold higher level was 2.70 (95% confidence interval 2.45-2.98) for ACR and 2.67 (2.43-2.94) for eAER. Neither ACR nor eAER provided any additional prognostic information for ESRD risk over and above the other. For VEs, there were modest positive associations between both ACR and eAER and risk [adjusted RR per 10-fold higher level 1.37 (1.22-1.53) for ACR and 1.36 (1.22-1.52) for eAER]. Again, neither measure added prognostic information over and above the other. Similar results were observed when ACR and eAER were related to vascular mortality [RR per 10-fold higher level: 1.64 (1.33-2.03) and 1.62 (1.32-2.00), respectively] or to non-vascular mortality [1.53 (1.31-1.79) and 1.50 (1.29-1.76), respectively]. Conclusions In this study, eAER did not improve risk prediction of ESRD, VEs or mortality.
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Affiliation(s)
- Marion M Mafham
- Clinical Trial Service Unit and Epidemiological Studies Unit, Nuffield Department of Population Health, Oxford, UK
| | - Natalie Staplin
- Clinical Trial Service Unit and Epidemiological Studies Unit, Nuffield Department of Population Health, Oxford, UK
| | - Jonathan Emberson
- Clinical Trial Service Unit and Epidemiological Studies Unit, Nuffield Department of Population Health, Oxford, UK
| | - Richard Haynes
- Clinical Trial Service Unit and Epidemiological Studies Unit, Nuffield Department of Population Health, Oxford, UK
| | - William Herrington
- Clinical Trial Service Unit and Epidemiological Studies Unit, Nuffield Department of Population Health, Oxford, UK
| | - Christina Reith
- Clinical Trial Service Unit and Epidemiological Studies Unit, Nuffield Department of Population Health, Oxford, UK
| | - Christoph Wanner
- Department of Medicine 1, Division of Nephrology, University of Wuerzburg, Wuerzburg, Germany
| | - Robert Walker
- Dunedin School of Medicine, University of Otago, Otago, New Zealand
| | - Alan Cass
- Menzies School of Health Research, Charles Darwin University, Darwin, Australia
| | - Adeera Levin
- University of British Columbia, Vancouver, British Columbia, Canada
| | | | - Lixin Jiang
- National Clinical Research Centre of Cardiovascular Diseases, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People’s Republic of China
| | - Hallvard Holdaas
- Renal Section, Department of Transplant Medicine, Oslo University Hospital, Rikshospitalet, Oslo, Norway
| | - Bertram Kasiske
- Hennepin County Medical Centre and the University of Minnesota, Minneapolis, MN, USA
| | | | - Martin J Landray
- Clinical Trial Service Unit and Epidemiological Studies Unit, Nuffield Department of Population Health, Oxford, UK
| | - Colin Baigent
- Clinical Trial Service Unit and Epidemiological Studies Unit, Nuffield Department of Population Health, Oxford, UK
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Perry B, Herrington W, Goldsack JC, Grandinetti CA, Vasisht KP, Landray MJ, Bataille L, DiCicco RA, Bradley C, Narayan A, Papadopoulos EJ, Sheth N, Skodacek K, Stem K, Strong TV, Walton MK, Corneli A. Use of Mobile Devices to Measure Outcomes in Clinical Research, 2010-2016: A Systematic Literature Review. Digit Biomark 2018; 2:11-30. [PMID: 29938250 PMCID: PMC6008882 DOI: 10.1159/000486347] [Citation(s) in RCA: 56] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2017] [Accepted: 12/13/2017] [Indexed: 01/08/2023] Open
Abstract
Background The use of mobile devices in clinical research has advanced substantially in recent years due to the rapid pace of technology development. With an overall aim of informing the future use of mobile devices in interventional clinical research to measure primary outcomes, we conducted a systematic review of the use of and clinical outcomes measured by mobile devices (mobile outcomes) in observational and interventional clinical research. Method We conducted a PubMed search using a range of search terms to retrieve peer-reviewed articles on clinical research published between January 2010 and May 2016 in which mobile devices were used to measure study outcomes. We screened each publication for specific inclusion and exclusion criteria. We then identified and qualitatively summarized the use of mobile outcome assessments in clinical research, including the type and design of the study, therapeutic focus, type of mobile device(s) used, and specific mobile outcomes reported. Results The search retrieved 2,530 potential articles of interest. After screening, 88 publications remained. Twenty-five percent of the publications (n = 22) described mobile outcomes used in interventional research, and the rest (n = 66) described observational clinical research. Thirteen therapeutic areas were represented. Five categories of mobile devices were identified: (1) inertial sensors, (2) biosensors, (3) pressure sensors and walkways, (4) medication adherence monitors, and (5) location monitors; inertial sensors/accelerometers were most common (reported in 86% of the publications). Among the variety of mobile outcomes, various assessments of physical activity were most common (reported in 74% of the publications). Other mobile outcomes included assessments of sleep, mobility, and pill adherence, as well as biomarkers assessed using a mobile device, including cardiac measures, glucose, gastric reflux, respiratory measures, and intensity of head-related injury. Conclusion Mobile devices are being widely used in clinical research to assess outcomes, although their use in interventional research to assess therapeutic effectiveness is limited. For mobile devices to be used more frequently in pivotal interventional research – such as trials informing regulatory decision-making – more focus should be placed on: (1) consolidating the evidence supporting the clinical meaningfulness of specific mobile outcomes, and (2) standardizing the use of mobile devices in clinical research to measure specific mobile outcomes (e.g., data capture frequencies, placement of device). To that aim, this manuscript offers a broad overview of the various mobile outcome assessments currently used in observational and interventional research, and categorizes and consolidates this information for researchers interested in using mobile devices to assess outcomes in interventional research.
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Affiliation(s)
- Brian Perry
- Department of Population Health Sciences, Duke University School of Medicine, Durham, North Carolina, USA.,Clinical Trials Transformation Initiative, Durham, North Carolina, USA
| | - Will Herrington
- Nuffield Department of Population Health, University of Oxford, Oxford, United Kingdom
| | - Jennifer C Goldsack
- Clinical Trials Transformation Initiative, Durham, North Carolina, USA.,Duke Clinical Research Institute, Durham, North Carolina, USA
| | - Cheryl A Grandinetti
- Center for Drug Evaluation and Research, US Food and Drug Administration, Silver Spring, Maryland, USA
| | - Kaveeta P Vasisht
- Center for Drug Evaluation and Research, US Food and Drug Administration, Silver Spring, Maryland, USA
| | - Martin J Landray
- Nuffield Department of Population Health, University of Oxford, Oxford, United Kingdom
| | - Lauren Bataille
- The Michael J. Fox Foundation for Parkinson's Research, New York, New York, USA
| | | | - Corey Bradley
- Duke University Hospital, Durham, North Carolina, USA
| | | | - Elektra J Papadopoulos
- Center for Drug Evaluation and Research, US Food and Drug Administration, Silver Spring, Maryland, USA
| | - Nirav Sheth
- MicroMedicine, Watertown, Massachusetts, USA
| | - Ken Skodacek
- Center for Devices and Radiological Health, US Food and Drug Administration, Silver Spring, Maryland, USA
| | | | | | - Marc K Walton
- Janssen Research and Development, Titusville, New Jersey, USA
| | - Amy Corneli
- Department of Population Health Sciences, Duke University School of Medicine, Durham, North Carolina, USA.,Clinical Trials Transformation Initiative, Durham, North Carolina, USA
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47
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Morton RL, Schlackow I, Gray A, Emberson J, Herrington W, Staplin N, Reith C, Howard K, Landray MJ, Cass A, Baigent C, Mihaylova B. Impact of CKD on Household Income. Kidney Int Rep 2017; 3:610-618. [PMID: 29854968 PMCID: PMC5976816 DOI: 10.1016/j.ekir.2017.12.008] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2017] [Revised: 12/11/2017] [Accepted: 12/18/2017] [Indexed: 11/30/2022] Open
Abstract
Introduction The impact of chronic kidney disease (CKD) on income is unclear. We sought to determine whether CKD severity, serious adverse events, and CKD progression affected household income. Methods Analyses were undertaken in a prospective cohort of adults with moderate-to-severe CKD in the Study of Heart and Renal Protection (SHARP), with household income information available at baseline screening and study end. Logistic regressions, adjusted for sociodemographic characteristics, smoking, and prior diseases at baseline, estimated associations during the 5-year follow-up, among (i) baseline CKD severity, (ii) incident nonfatal serious adverse events (vascular or cancer), and (iii) CKD treatment modality (predialysis, dialysis, or transplanted) at study end and the outcome “fall into relative poverty.” This was defined as household income <50% of country median income. Results A total of 2914 SHARP participants from 14 countries were included in the main analysis. Of these, 933 (32%) were in relative poverty at screening; of the remaining 1981, 436 (22%) fell into relative poverty by study end. Compared with participants with stage 3 CKD at baseline, the odds of falling into poverty were 51% higher for those with stage 4 (odds ratio [OR]: 1.51; 95% confidence interval [CI]: 1.09–2.10), 66% higher for those with stage 5 (OR: 1.66; 95% CI: 1.11–2.47), and 78% higher for those on dialysis at baseline (OR: 1.78, 95% CI: 1.22–2.60). Participants with kidney transplant at study end had approximately half the risk of those on dialysis or those with CKD stages 3 to 5. Conclusion More advanced CKD is associated with increased odds of falling into poverty. Kidney transplantation may have a role in reducing this risk.
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Affiliation(s)
- Rachael L Morton
- NHMRC Clinical Trials Centre, The University of Sydney, Sydney, Australia.,Health Economics Research Centre, Nuffield Department of Population Health, University of Oxford, UK
| | - Iryna Schlackow
- Health Economics Research Centre, Nuffield Department of Population Health, University of Oxford, UK
| | - Alastair Gray
- Health Economics Research Centre, Nuffield Department of Population Health, University of Oxford, UK
| | - Jonathan Emberson
- Clinical Trial Service Unit and Epidemiological Studies Unit, Nuffield Department of Population Health, University of Oxford, UK
| | - William Herrington
- Clinical Trial Service Unit and Epidemiological Studies Unit, Nuffield Department of Population Health, University of Oxford, UK
| | - Natalie Staplin
- Clinical Trial Service Unit and Epidemiological Studies Unit, Nuffield Department of Population Health, University of Oxford, UK
| | - Christina Reith
- Clinical Trial Service Unit and Epidemiological Studies Unit, Nuffield Department of Population Health, University of Oxford, UK
| | - Kirsten Howard
- School of Public Health, The University of Sydney, Sydney, Australia
| | - Martin J Landray
- Clinical Trial Service Unit and Epidemiological Studies Unit, Nuffield Department of Population Health, University of Oxford, UK
| | - Alan Cass
- Menzies School of Health Research, Charles Darwin University, Darwin, Australia
| | - Colin Baigent
- Clinical Trial Service Unit and Epidemiological Studies Unit, Nuffield Department of Population Health, University of Oxford, UK.,Medical Research Council Population Health Research Unit, Nuffield Department of Population Health, University of Oxford, UK
| | - Borislava Mihaylova
- Health Economics Research Centre, Nuffield Department of Population Health, University of Oxford, UK
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48
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Storey BC, Staplin N, Haynes R, Reith C, Emberson J, Herrington WG, Wheeler DC, Walker R, Fellström B, Wanner C, Landray MJ, Baigent C. Lowering LDL cholesterol reduces cardiovascular risk independently of presence of inflammation. Kidney Int 2017; 93:1000-1007. [PMID: 29146277 PMCID: PMC5978933 DOI: 10.1016/j.kint.2017.09.011] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2017] [Revised: 08/23/2017] [Accepted: 09/07/2017] [Indexed: 02/06/2023]
Abstract
Markers of inflammation, including plasma C-reactive protein (CRP), are associated with an increased risk of cardiovascular disease, and it has been suggested that this association is causal. However, the relationship between inflammation and cardiovascular disease has not been extensively studied in patients with chronic kidney disease. To evaluate this, we used data from the Study of Heart and Renal Protection (SHARP) to assess associations between circulating CRP and LDL cholesterol levels and the risk of vascular and non-vascular outcomes. Major vascular events were defined as nonfatal myocardial infarction, cardiac death, stroke or arterial revascularization, with an expanded outcome of vascular events of any type. Higher baseline CRP was associated with an increased risk of major vascular events (hazard ratio per 3x increase 1.28; 95% confidence interval 1.19-1.38). Higher baseline LDL cholesterol was also associated with an increased risk of major vascular events (hazard ratio per 0.6 mmol/L higher LDL cholesterol; 1.14, 1.06-1.22). Higher baseline CRP was associated with an increased risk of a range of non-vascular events (1.16, 1.12-1.21), but there was a weak inverse association between baseline LDL cholesterol and non-vascular events (0.96, 0.92-0.99). The efficacy of lowering LDL cholesterol with simvastatin/ezetimibe on major vascular events, in the randomized comparison, was similar irrespective of CRP concentration at baseline. Thus, decisions to offer statin-based therapy to patients with chronic kidney disease should continue to be guided by their absolute risk of atherosclerotic events. Estimation of such risk may include plasma biomarkers of inflammation, but there is no evidence that the relative beneficial effects of reducing LDL cholesterol depends on plasma CRP concentration.
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Affiliation(s)
- Benjamin C Storey
- Medical Research Council Population Health Research Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK; Clinical Trial Service Unit and Epidemiological Studies Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Natalie Staplin
- Clinical Trial Service Unit and Epidemiological Studies Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Richard Haynes
- Medical Research Council Population Health Research Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK; Clinical Trial Service Unit and Epidemiological Studies Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Christina Reith
- Clinical Trial Service Unit and Epidemiological Studies Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Jonathan Emberson
- Medical Research Council Population Health Research Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK; Clinical Trial Service Unit and Epidemiological Studies Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - William G Herrington
- Clinical Trial Service Unit and Epidemiological Studies Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - David C Wheeler
- Centre for Nephrology, University College London, London, UK
| | - Robert Walker
- Department of Medicine, University of Otago, Dunedin, New Zealand
| | - Bengt Fellström
- Renal Unit, Department of Medicine, University of Uppsala, Uppsala, Sweden
| | | | - Martin J Landray
- Medical Research Council Population Health Research Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK; Clinical Trial Service Unit and Epidemiological Studies Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK; Big Data Institute, Lia Ka Shing Centre for Health Information and Discovery, University of Oxford, Oxford, UK
| | - Colin Baigent
- Medical Research Council Population Health Research Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK; Clinical Trial Service Unit and Epidemiological Studies Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK.
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49
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Bowman L, Hopewell JC, Chen F, Wallendszus K, Stevens W, Collins R, Wiviott SD, Cannon CP, Braunwald E, Sammons E, Landray MJ. Effects of Anacetrapib in Patients with Atherosclerotic Vascular Disease. N Engl J Med 2017; 377:1217-1227. [PMID: 28847206 DOI: 10.1056/nejmoa1706444] [Citation(s) in RCA: 635] [Impact Index Per Article: 90.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND Patients with atherosclerotic vascular disease remain at high risk for cardiovascular events despite effective statin-based treatment of low-density lipoprotein (LDL) cholesterol levels. The inhibition of cholesteryl ester transfer protein (CETP) by anacetrapib reduces LDL cholesterol levels and increases high-density lipoprotein (HDL) cholesterol levels. However, trials of other CETP inhibitors have shown neutral or adverse effects on cardiovascular outcomes. METHODS We conducted a randomized, double-blind, placebo-controlled trial involving 30,449 adults with atherosclerotic vascular disease who were receiving intensive atorvastatin therapy and who had a mean LDL cholesterol level of 61 mg per deciliter (1.58 mmol per liter), a mean non-HDL cholesterol level of 92 mg per deciliter (2.38 mmol per liter), and a mean HDL cholesterol level of 40 mg per deciliter (1.03 mmol per liter). The patients were assigned to receive either 100 mg of anacetrapib once daily (15,225 patients) or matching placebo (15,224 patients). The primary outcome was the first major coronary event, a composite of coronary death, myocardial infarction, or coronary revascularization. RESULTS During the median follow-up period of 4.1 years, the primary outcome occurred in significantly fewer patients in the anacetrapib group than in the placebo group (1640 of 15,225 patients [10.8%] vs. 1803 of 15,224 patients [11.8%]; rate ratio, 0.91; 95% confidence interval, 0.85 to 0.97; P=0.004). The relative difference in risk was similar across multiple prespecified subgroups. At the trial midpoint, the mean level of HDL cholesterol was higher by 43 mg per deciliter (1.12 mmol per liter) in the anacetrapib group than in the placebo group (a relative difference of 104%), and the mean level of non-HDL cholesterol was lower by 17 mg per deciliter (0.44 mmol per liter), a relative difference of -18%. There were no significant between-group differences in the risk of death, cancer, or other serious adverse events. CONCLUSIONS Among patients with atherosclerotic vascular disease who were receiving intensive statin therapy, the use of anacetrapib resulted in a lower incidence of major coronary events than the use of placebo. (Funded by Merck and others; Current Controlled Trials number, ISRCTN48678192 ; ClinicalTrials.gov number, NCT01252953 ; and EudraCT number, 2010-023467-18 .).
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Affiliation(s)
- Louise Bowman
- Clinical Trial Service Unit, University of Oxford, Oxford, United Kingdom
| | - Jemma C Hopewell
- Clinical Trial Service Unit, University of Oxford, Oxford, United Kingdom
| | - Fang Chen
- Clinical Trial Service Unit, University of Oxford, Oxford, United Kingdom
| | - Karl Wallendszus
- Clinical Trial Service Unit, University of Oxford, Oxford, United Kingdom
| | - William Stevens
- Clinical Trial Service Unit, University of Oxford, Oxford, United Kingdom
| | - Rory Collins
- Clinical Trial Service Unit, University of Oxford, Oxford, United Kingdom
| | - Stephen D Wiviott
- Thrombolysis in Myocardial Infarction Study Group, Brigham and Women’s Hospital
- Harvard Medical School, Boston
| | - Christopher P Cannon
- Thrombolysis in Myocardial Infarction Study Group, Brigham and Women’s Hospital
- Harvard Medical School, Boston
| | - Eugene Braunwald
- Thrombolysis in Myocardial Infarction Study Group, Brigham and Women’s Hospital
- Harvard Medical School, Boston
| | - Emily Sammons
- Clinical Trial Service Unit and Medical Research Council Population Health Research Unit, University of Oxford, Oxford, United Kingdom
| | - Martin J Landray
- Clinical Trial Service Unit and Medical Research Council Population Health Research Unit, University of Oxford, Oxford, United Kingdom
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50
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Schlackow I, Kent S, Herrington W, Emberson J, Haynes R, Reith C, Wanner C, Fellström B, Gray A, Landray MJ, Baigent C, Mihaylova B. A policy model of cardiovascular disease in moderate-to-advanced chronic kidney disease. Heart 2017; 103:1880-1890. [PMID: 28780579 PMCID: PMC5749372 DOI: 10.1136/heartjnl-2016-310970] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2016] [Revised: 04/19/2017] [Accepted: 04/24/2017] [Indexed: 02/01/2023] Open
Abstract
OBJECTIVE To present a long-term policy model of cardiovascular disease (CVD) in moderate-to-advanced chronic kidney disease (CKD). METHODS A Markov model with transitions between CKD stages (3B, 4, 5, on dialysis, with kidney transplant) and cardiovascular events (major atherosclerotic events, haemorrhagic stroke, vascular death) was developed with individualised CKD and CVD risks estimated using the 5 years' follow-up data of the 9270 patients with moderate-to-severe CKD in the Study of Heart and Renal Protection (SHARP) and multivariate parametric survival analysis. The model was assessed in three further CKD cohorts and compared with currently used risk scores. RESULTS Higher age, previous cardiovascular events and advanced CKD were the main contributors to increased individual disease risks. CKD and CVD risks predicted by the state-transition model corresponded well to risks observed in SHARP and external cohorts. The model's predictions of vascular risk and progression to end-stage renal disease were better than, or comparable to, those produced by other risk scores. As an illustration, at age 60-69 years, projected survival for SHARP participants in CKD stage 3B was 13.5 years (10.6 quality-adjusted life years (QALYs)) in men and 14.8 years (10.7 QALYs) in women. Corresponding projections for participants on dialysis were 7.5 (5.6 QALYs) and 7.8 years (5.4 QALYs). A non-fatal major atherosclerotic event reduced life expectancy by about 2 years in stage 3B and by 1 year in dialysis. CONCLUSIONS The SHARP CKD-CVD model is a novel resource for evaluating health outcomes and cost-effectiveness of interventions in CKD. TRIAL REGISTRATION NUMBER NCT00125593 and ISRCTN54137607; Post-results.
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Affiliation(s)
- Iryna Schlackow
- Health Economics Research Centre, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Seamus Kent
- Health Economics Research Centre, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - William Herrington
- Clinical Trial Service Unit and Epidemiological Studies Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Jonathan Emberson
- Clinical Trial Service Unit and Epidemiological Studies Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Richard Haynes
- Clinical Trial Service Unit and Epidemiological Studies Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Christina Reith
- Clinical Trial Service Unit and Epidemiological Studies Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Christoph Wanner
- Division of Nephrology, Department of Medicine, University Hospital of Würzburg, Würzburg, Germany
| | | | - Alastair Gray
- Health Economics Research Centre, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Martin J Landray
- Clinical Trial Service Unit and Epidemiological Studies Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Colin Baigent
- Clinical Trial Service Unit and Epidemiological Studies Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK.,Medical Research Council Population Health Research Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Borislava Mihaylova
- Health Economics Research Centre, Nuffield Department of Population Health, University of Oxford, Oxford, UK
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