IN THE NEWS: Nephrology NEJM showcase

Latest offerings in NEJM highlight nephrology articles:

One of them is comparing ultrafiltration to diuretic use in cardio renal syndrome(CARRESS-HF).
Interestingly, ultrafiltration performed inferiorly compared to a catered diuretic regimen in a randomized controlled trial. Does it end the role of UF? Or is SCUF still a consideration. An editorial attached still says slow and steady might be preferred.

ADPKD and treatment with aquretic treatment is the next major article. The TEMPO trial showed this using tolvaptan. Can this drug show promise in protecting renal function in ADPKD.

EVOLVE trial looked at cinacalcet in ESRD patients in a randomized trial and evaluated cardiac endpoints and found shockingly negative results.

ALTITUDE trial evaluated adding aliskiren to other renin angi inhibitors in DMII for cardio renal end points and found harm and no significant benefit.

3 negative trials
1 positive trial

Evidence based medicine keeps knocking off physiology based medicine in Nephrology.

NEJM Blog: Stroke and Bleeding in Afib with CKD

Check out a discussion on the latest news: Stroke and Bleeding in Afib with CKD

Hemodialysis Patients and and their Risky Weekends, a conversation with the author of the recent NEJM paper

An odd asymmetry of hemodialysis is that almost all patients have treatments every other day, Wednesday and then Friday or Thursday and then Saturday; but then a 2 day break over the weekend. What happens from Friday to Monday or Saturday to Tuesday, is there increased risk? ( image source:  www.tws3d.com)

Robert Foley and colleagues from the United States Renal Data System studied exactly this question. Their study was published recently in the New England Journal of Medicine (N Engl J Med 2011;365:1099-107). A total of 32,065 hemodialysis patients from the Clinical Performance Measures Project were studied from 2004-2007. The main finding was that on the day after the long interdialytic period there was an approximately 20% increase in deaths, more than a 30% increase in deaths from cardiac causes, a 30% increase in deaths from cardiac arrest and a number of other outcomes with increased risk.

This simple but elegant study places a sharp focus on what may be intuitive, hemodialysis patients are at greater risk after the long interdialytic period- usually after a weekend. Is it excessive intake of salt, potassium and other electrolytes over the weekend? Increased volume intake? A reduction in calcium with widened QT intervals? Whatever the cause, we need to think about how hemodialysis may be changed to keep patients safer.

I asked Dr. Foley about what the clinical implications of these finding are. He responded, “Like all observational studies, cause and effect can't be proven here. However, unlike most observational studies, differences in unmeasured comorbidity can't explain the findings, as the same population is being examined for outcomes on different days. Given the downward-tilted sawtooth pattern for death and cardiovascular admissions, it is hard to imagine that anything other than more frequent dialysis and avoidance of two-day intervals could change the current situation. Clearly, this would involve major philosophical and logistical shifts.”

Post by

Steven Fishbane, MD

Prof of Medicine

Hypercalcemia in Pregnancy

Check out a nice review on the NEJM Blog regarding
Hypercalcemia in Pregnancy

Tumor Lysis Syndrome

 From the NEJM Blog: Tumor Lysis Syndrome