These three European Trials come as a major surprise to me.
Two of them deal with the Mtor inhibitors and a clinical trial showing major disappointment in terms of decreasing GFR when used for polycystic kidney disease.
Its not the first time that the basic science data is contradicting clinical data. A nice editorial in NEJM also gives some insightful thoughts on this topic. For now, we have to await some more trails, perhaps longer term to see where we go with this drug.
Another shocker was the IDEAL trial.
This compared early initiation vs late initiation. In this study, planned early initiation of dialysis in patients with stage V chronic kidney disease was not associated with an improvement in survival or clinical outcomes.
This is an interesting study. It compared starting dialysis at 5-7ml/min vs standard practice right now and showed no difference. This goes back to the olden days when people started dialysis when patients got symptomatic rather than just a number. Perhaps we might be just going around in circles.
But some other bloggers have good comments to say.
Take a look
https://www.pediatric-nephrology.com/home/2010/06/29/233-mtoradpkd.html
https://www.pediatric-nephrology.com/home/2010/06/29/232-dialysisckdv.html
http://www.uremicfrost.com/2010/06/does-early-initiation-of-dialysis-help_27.html
http://www.uremicfrost.com/2010/06/early-vs-late-hd-initiation-video.html
http://www.uremicfrost.com/2010/06/does-early-initiation-of-dialysis-help.html
References:
http://www.ncbi.nlm.nih.gov/pubmed/20581422( IDEAL TRIAL)
http://www.ncbi.nlm.nih.gov/pubmed/20581393 ( EDITORIAL NEJM MTOR)
http://www.ncbi.nlm.nih.gov/pubmed/20581392
http://www.ncbi.nlm.nih.gov/pubmed/20581391
I'm not sure what IDEAL adds to our knowledge/understanding of dialysis. The original KDOQI guidelines suggest initiating RRT once eGFR is less than 15ml/min due to the belief that large mol/IC sequestered toxin clearance is important enough to initiate at this time and that it makes no sense to withhold when GFR is less than what is provided by standard RRT (i.e. 15ml/min of clearance).
ReplyDeleteAdditionally understand what this paper is suggesting. Over 75% pts were initiated on dialysis before their target start (eGFR 5 - 7ml/min) due to physician discretion (uremic symptoms/complications), but that beginning 6months later is okay since it made no difference in hard outcomes.... so essentially suggesting that waiting for a few months is okay (i.e. patient will not succumb to more CV events) but the patient may be sick...
This will continue to be debated but I'm not exactly sure what this adds