Calculated estimates of GFR are an improvement over ClCr estimation. On balance, the MDRD formula does not improve the estimate of GFR compared with the Cockcroft and Gault formula in older Caucasian patients with chronic renal insufficiency.
Falls among inpatients are the most frequently reported safety incident in NHS hospitals. 30-50% of falls result in some physical injury and fractures occur in 1-3%. No fall is harmless, with psychological sequelae leading to lost confi dence, delays in functional recovery and prolonged hospitalisation. Yet falls are not true accidents and there is evidence that a coordinated multidisciplinary clinical team approach can reduce their incidence. Identifi cation of multiple underlying risk factors coupled with clear interventions to ameliorate the impact of each has been shown to reduce the incidence of inpatient falls by 20-30%. The implementation of complex multiprofessional interventions is challenging and successful schemes seek to nurture a culture of vigilant safety consciousness in all staff at the clinical interface. Strong leadership and organisational oversight help to combine this cultural evolution with relevant evidence and rigorous measurement of performance in order to improve patient safety. The results of national audit suggest that NHS acute hospitals could do more to reduce the incidence of falls among inpatients.
Background It is recommended that measurement of serum creatinine should be supplemented with a creatinine-based estimation of glomerular filtration rate (GFR). The influence of creatinine methodology on these estimates is not always appreciated. We have studied differences in creatinine methods and their influence on GFR estimation specifically in older people.
Aims To assess whether cystatin C, a new serum marker of renal function, is a better index of creatinine or digoxin clearance than serum creatinine in older people. Methods Twenty-two volunteers over the age of 65 years (mean 73t5) were recruited from a healthy elderly volunteer database. None of the volunteers was taking digoxin or other medication known to interfere with digoxin kinetics or assay.Digoxin was infused at a dose of 7-10 mg kg x1 and blood samples were taken over the following 48 h and assayed for serum digoxin. Serum cystatin C, creatinine and creatinine clearance were measured and a calculated creatinine clearance was estimated using the Cockcroft Gault formula. Digoxin clearance was calculated using a pharmacokinetic software package. All values were log transformed to normalize their distribution. Results Of the 22 volunteers enrolled into the study, 18 completed the study. Serum cystatin C ranged between 0.72 and 1.89 mg l x1 and serum creatinine ranged from 69.6 to 153.9 mmol l x1 . Measured creatinine clearance ranged from 38 to 123 ml min x1 and calculated creatinine clearance from 29.5 to 88.0 ml min x1 .Digoxin clearance ranged from 51.0 to 103.5 ml min
x1. Cystatin C correlated extremely well with creatinine (r=0.93, P<0.001, 95% CI 0.82, 0.97) and with creatinine clearance (r=0.67, P=0.002, 95% CI 0.3, 0.87). Neither serum cystatin C nor serum creatinine correlated with digoxin clearance (r=0.25, P=0.31, 95% CI x0.25, 0.64 and r=0.44, P=0.068, 95% CI x0.03, 0.75, respectively). Measured creatinine clearance, however, did correlate well with digoxin clearance (r=0.55, P=0.018, 95% CI 0.11, 0.81). Conclusions Serum cystatin C and serum creatinine show very similar correlations with creatinine and digoxin clearances. Serum cystatin C does not offer any advantages in this respect. It remains to be seen whether cystatin C offers any advantage over creatinine in elderly people in other respects.
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