Posted by Peter Morris on March 6, 2014
Neil Russell, who was one of the two first Research Fellows at the CET, has finished his surgical training at Addenbrooke’s Hospital in Cambridge and has just been appointed as a consultant abdominal transplant surgeon there. We were all delighted to hear the news. He is the first CET Research Fellow to reach consultant status. He successfully completed his MCh thesis at the CET, directed at Cyclosporine sparing in renal transplantation.
Posted by Simon Knight on March 3, 2014
The March 2014 edition of the Transplant Trial Watch is now available online and via the CET’s app for iPhone, iPad and Android.
This month, trials include the effects of cyclosporin A and tacrolimus on fibrosis following liver transplantation for hepatitis C, intravesical vs. extravesical ureteroneocystostomy in renal transplantation and the use of sitagliptin in new-onset diabetes after renal transplantation.
Posted by Peter Morris on February 21, 2014
There was an interesting editorial by Richard Smith and Drummond Rennie in the BMJ recently. The editorial is based on two interviews of pioneers in this field by Richard Smith, the former editor of the BMJ. In the first oral history he interviews Iain Chalmers, Muir Gray and David Sackett. They said that authors from a previous generation were inspirational, namely Thomas C Chalmers, Alvan Feinstein and Archibald Cochrane. David Sackett tells us that he read Chalmers’ 1955 report of a randomised factorial trial of bed rest and diet for hepatitis and said:
“Reading this paper not only changed my treatment plan for my patient, it forever changed my attitude towards conventional wisdom, uncovered by latent iconoclasm and inaugurated my career and what I later labelled clinical epidemiology”
Iain Chalmers, cofounder of the Cochrane Collaboration, tells us that he was working in Gaza as a GP and realised he did not have the evidence to help him treat his patients and that is what stimulated him to go down the path that he eventually did. David Sackett, perhaps regarded by many as the father of evidence based medicine, came to Oxford from McMaster as Director of the newly established Centre for Evidence in Medicine, having been recruited by Iain Chalmers and Muir Gray. He had a rough time in Oxford at the start, particularly when he criticised data in the Oxford Textbook of Medicine for being wildly out of date for not citing relevant randomised trials. However gradually he converted everyone to the concept of practicing medicine on as good evidence as one could obtain. He did not coin the phrase evidence based medicine, but says that Gordon Guyatt, Professor of Epidemiology, Biostatistics and Medicine at McMaster University, after he took over as Director of the Internal Medicine Residency Programme in 1999 , at first suggested Scientific medicine as the appropriate term for this new discipline but this also created antagonism and he changed it to evidence based medicine.
There is a second interview by Richard smith, hosted by JAMA in which he interviews Gordon Guyatt, Drummond Rennie, Brian Haynes, Paul Glasziou and Kay Dickersin, all pioneers in the development of evidence based medicine. This is quite a long interview, the best part of 50 minutes but well worth the time. Some interesting points struck me, namely that Brian Haynes felt that everyone should try to provide the best evidence, but Kay Dickersin commented that because of the push from “the academic reward system” there was a lot of junk published and this makes it so much more difficult to obtain relevant evidence. She also made the point that observational studies and their appraisal needs more attention and there is a need for much more attention on safety of interventions. Doug Rennie was adamant that money had to be taken out of the system and he enlarges on that in the interview. Paul Glasziou in looking to the future made two points, firstly that systematic reviews are done too slowly, taking at least two years to complete in the Cochrane organisation for example, and one needed a system that could produce a systematic review within two weeks. The second point he made was that the bulk of the work was directed at pharmacointerventions and there needs to be much more study of nonpharmacological interventions. Guyatt felt that there has to be much more of pre-processed information available and I must say that the Transplant Library fits in exactly to what he would like to see develop in the future.
The editorial gives you the main thrust of the interviews but for people who are generally interested in the origins of evidence based medicine and where it might go in the future these videos are required watching. Richard Smith in summary feels that there is still a long way to go. I would recommend watching these splendid interviews.
Posted by Liset Pengel on February 13, 2014
The deadline to register for the Evidence in Transplantation (EVIT) course has been extended and you can now apply for one of the last few places of this highly rated course. EVIT last call
The EVIT course is organised in collaboration with ESOT and will run on 21 and 22 March 2014 at the Royal College of Surgeons, London, UK. The two-day course is aimed at professionals from all disciplines actively involved in organ and tissue transplantation who want to increase their skills in evidence-based decision-making.
All lectures and small group sessions will use examples from the area of transplantation. The participants will learn how the validity and applicability of research evidence can be appraised and will carry out part of a systematic review.
To apply, visit the ESOT website.
Posted by Peter Morris on February 9, 2014
An increased incidence of deep vein thrombosis in kidney transplant recipients was first reported from Oxford by Richard Allen in 1987.This is confirmed in a single centre study from Montreal over an 11 year period, where they used a nested case control study comparing patients with and without thromboembolism. Amongst 930 kidney transplant recipients there were 68 thromboembolic events. The standardised incidence ratio of thromboembolism in kidney transplant recipients was 7.9 compared with the general population over the duration of follow up. This 8-fold increased risk occurs particularly in the first post-transplant year or during any subsequent hospitalisation, but was also associated with the use of sirolimus and steroids for immunosuppression and malignancy in the transplant patient.
It is now generally accepted that there is an increased risk of deep vein thrombosis, sometimes associated with pulmonary embolism, in kidney transplant recipients particularly in the first year. Most units would regard prophylaxis against thromboembolism as being necessary in all our kidney transplant recipients and especially if they are being readmitted for any reason, and particularly surgery.
Posted by Peter Morris on February 7, 2014
A very interesting observational study of 453 HLA identical living related transplants is from Minneapolis has recently been reported . The authors have examined the outcome of HLA identical living related donor transplants in 3 eras. Era 1, up to 1984, induction with ALG was used and maintenance immunosuppression comprised azathioprine and prednisone; era 2a – from 1984 to 1999, calcineurin inhibitors were added and induction was changed from ALG to thymoglobulin and azathioprine for maintenance was changed to mycophenolate; era 2b – there was a rapid discontinuation of prednisone after thymoglobulin induction, and maintenance immunosuppression was a CNI and mycophenolate. There was no difference in patient or graft survival in the three eras, but graft loss from chronic allograft nephropathy and hypertension were greater in the two CNI eras. Surprisingly renal function is no different although one would have expected it to be rather better in the azathioprine-prednisone era. The authors also review the available literature, but there are no RCTs only observational studies and the outcome of most of these reports is compatible with the findings of the Minneapolis group. The authors conclude that the addition of a CNI, either with or without steroids, to immunosuppressive regimens does not offer any additional benefit in recipients of HLA identical LRD kidneys in comparison with the older immunosuppression with azathioprine and prednisolone, and in fact there may be more problems with the use of a calcineurin inhibitor. Thus the authors suggest that perhaps mono-therapy or early discontinuation of CNI should be given serious consideration in these patients. But I fail to see why their conclusion isn’t for us to go back to azathioprine and prednisone immunosuppression in recipients of HLA identical LRD kidneys. There is certainly a need to look at this issue again and perhaps a large multicentre RCT might be justified.
Posted by Peter Morris on February 4, 2014
Recently, the Centre for Evidence in Transplantation published an analysis of compliance with the CONSORT statement in reports of randomised controlled trials (RCTs) in transplantation, and found that the compliance left much to desire. A recent article in the Annals of Surgery analysed Consort compliance in 150 recently published RCTs in surgery, most of these being in General Surgery, Orthopaedic Surgery and Cardiothoracic surgery. The authors conclude that there was much room for improvement for the reporting of surgical intervention trials. This is very similar to the CET analysis of RCTs in organ transplantation. Thus we have to do better if we are to provide robust evidence in surgery and organ transplantation.
Posted by Liset Pengel on February 4, 2014
The research assistant will provide administrative and research support to the CEO of the CET. Exceptional attention to detail is essential, as are strong MS Office and IT skills, and the ability to communicate effectively with colleagues and partners both within and outside the CET.
For more information and to apply click here. Closing date is 24th February 2014.
Posted by Simon Knight on February 3, 2014
This month, new trials include the use of octreotide in liver transplantation, B-cell induction therapy in high-risk kidney transplant recipients and conversion from tacrolimus to sirolimus in renal transplantation.
Posted by Peter Morris on January 31, 2014
My co-editor (Stuart Knechtle) and I are delighted to announce that the 7th edition of this textbook has appeared.
This edition is accompanied by access to an electronic edition which is a first for this book and has all relevant illustrations in colour together with a number of video clips.
I published the first edition in 1978 and the 7 editions since then span some 35 years, providing almost a modern history of renal transplantation!