As the year draws to a close, Journal Club is focused on the
papers published in 2011 that are likely to change practice. Choosing these papers
is a subjective process with lots of biases. Here are my top 5 choices.
1. More frequent
dialysis is better
Published in NEJM December 2010 I am squeezing this paperl into “2011”. Patients
were randomly assigned to undergo hemodialysis 6 times/wk (frequent
hemodialysis, 125 patients) or 3 times/wk (conventional hemodialysis,
120 patients) for 12 months. The two coprimary composite outcomes were death or
change (from baseline to 12 months) in left ventricular mass. Frequent
hemodialysis, as compared with conventional hemodialysis, was superior to conventional hemodialysis (lower composite outcomes of death or change in
left ventricular mass and death or change in a physical-health composite score).
But, vascular access interventions were higher with more frequent dialysis.
Clinical Implication: More
frequent dialysis should be recommended in patients on chronic hemodialysis.
The idea of continuing three times a week dialysis or in some countries twice
weekly dialysis is becoming rapidly outdated.
2. SHARP says treat
with a statin
Published in the Lancet,
this randomised double-blind trial of 9270 CKD
patients (of which 3023) with no known history of myocardial infarction or
coronary revascularisation, reduction of LDL cholesterol with simvastatin 20 mg
plus ezetimibe 10 mg daily safely reduced the incidence of major
atherosclerotic events. The study is reviewed in Journal Club.
Clinical Implication:
LDL reduction to reduce cardiovascular risk is recommended in all CKD patients,
including those on dialysis.
3. Benign hematuria is
not so benign
Published in JAMA,
this prospective cohort study of Israeli military recruits followed for a
period of 22 years, demonstrated that the Presence
of persistent asymptomatic isolated microscopic hematuria in persons aged 16
through 25 years was associated with significantly increased risk of treated
ESRD.
Clinical Implication:
Isolated microscopic hematuria is associated with a low absolute risk of
developing renal failure, however the risk is not zero. Young people with
hematuria should be followed. The study also raises the question of whether urine
dipstick testing should be considered as a simple, low-cost screening tool for
asymptomatic adolescents and all adults.
4. MMF wins over
azathioprine
Published in NEJM, mycophenalate mofetil (MMF) is demonstrated to be superior to azathioprine
in maintaining a renal response to treatment and in preventing relapse in
patients with lupus nephritis who had a response to induction therapy.
Side-effects with azathioprine are higher than those with MMF. The study is reviewed in Journal Club.
Clinical Implication:
MMF should be used in preference to azathioprine as adjunctive
immunosuppression in maintaining a remission in patients with lupus nephritis.
5. Just Say No:
Outcomes are worse with combination ACEi and ARB therapy.
Published in Circulation,
this post-hoc analysis builds on the results of the ONTARGET and TRANSCEND studies, that the use of dual renin angiotensin blockade should be avoided. The
various aspects of the debate are discussed in dozens of articles listed in pubmed. Two examples: here and here. The ONTARGET study is discussed here.
Clinical Implication:
Dual ACEi and ARB blockade should be avoided. This recommendation is further
supported by the termination of the ALTITUDE study discussed here.
