#CSN16: A Nephrology Listicle

A special session at the #CSN16 was a review of recently published, clinically relevant research in the nephrology world. It was indeed challenging for the two speakers to choose a select few papers given the large number of papers published every year. Hence, rather than using the impact factor of the journal in which the research was published or the number of citations (or Altmetric count, even), these speakers created subjective, opinion-based lists.

christopher-mcintyreChris McIntyre, now at the University of Western Ontario (London, Ontario) presented his top 5 list for papers published in hemodialysis. He mentioned that although since 2014, 12,722 papers have been published that include the term “hemodialysis,” most nephrology researchers and providers remain unexcited about research in this area. For his selections, he used the following criteria: simplicity, unexpected results, concreteness of the findings, emotional appeal, and quality of the narrative arc. His list includes:

  • A randomized trial of cognitive behavioural therapy that delivered the intervention in the form of ten 60-minute sessions spread out over 3 months, while the patients were being dialysed. The selection included patients who had a self-reported Beck Depression Inventory scale (BDI-II) greater than ten. The intervention significantly improved patient-reported outcome measures (the BDI-II score, quality of life measured with the Kidney Disease Quality of Life Instrument [KDQOL]) as well as lowered inter-dialytic weight gain.
  • A report of two randomized phase III trials that used dialysate to deliver iron (CRUISE 1 and CRUISE 2). The dialysate iron was in the form of ferric pyrophosphate citrate (FPC; Triferic), which is added to the liquid bicarbonate concentrate. After dilution and mixing with the acid concentrate, the concentration in the dialysate is 2µM. The theoretical advantage is that the direct delivery via FPC donates iron to transferring and avoids hepcidin-induced sequestration within the reticuloendothelial system. In the study, the FPC and placebo groups both received constant doses of erythropoietin, and no oral or intravenous iron. However, hemoglobin levels remained constant in the FPC group and dropped in the placebo group.
  • An analysis using data from the Hemodialysis (HEMO) study and adding data from a large dialysis organization; it examined the association of different definitions of intradialytic hypotension with survival. Interestingly, the researchers found that the nadir blood pressure was a stronger predictor than symptoms of or interventions for hypotension. For patients with a predialysis systolic blood pression (SBP) < 160, the threshold was <90, while for those with predialysis SBP > 160, the number was SBP < 100, which was associated with mortality. Dr. McIntyre added a note of caution: citing abstracts from #SCM16 on the “U-shaped” mortality association with pre-dialysis SBP, he recommended not using that data to judge therapeutic decisions.
  • A systematic review of convective therapies (hemodiafiltration or hemofiltration) compared with hemodialysis in patients with chronic kidney failure, published in the Journal. This high quality analysis reported no difference in important outcomes of cardiovascular events or mortality. There was a difference in some surrogate outcomes, such as β-2 microglobulin levels, and most of the trials were of suboptimal quality. Again, Dr. McIntyre suggested a note of caution: some other analyses suggest there is a benefit of convective therapies with higher dose, but he recommended looking closely at the author disclosures. Further, Dr. Daniel Coyne (via twitter) suggested those analyses are suspect of dose-targeting bias.
  • A randomized trial of dialysate cooling by Dr. McIntyre himself, comparing 37 °C to 0.5 °C below patients body temperature. Though a small trial, this simple intervention resulted in decreased brain white matter changes suggestive of ischemic brain injury during dialysis. Even more exciting, Dr. McIntyre introduced the MyTEMP trial (Major Cardiovascular and Other Patient-important Outcomes With Personalized dialysate Temperature), a cluster randomized controlled trial including most dialysis centres in Ontario, using a similar intervention (individualized dialysate temperature) that promises to be the largest trial in hemodialysis.

ainslie-hildebrandAinslie Hildebrand from Edmonton chose her select publications in the glomerulonephritis literature based on similar subjective criteria. Of interest, she showed a filter that she developed, which allows one to select studies of glomerular disease from Pubmed, Medline and Embase. Her selections were:

  • The STOP-IgA nephropathy trial, which compared immunosuppressive therapy to conservative care in 177 patients with a glomerular filtration rate of 30 or more and with proteinuria in the range of 0.75 g to 3.5 g/day. The trial was negative overall, showing no significant different between the two groups (see #NephJC coverage for more details). Her take-home message was to stress the importance of optimal conservative care. Interestingly, there is another larger, ongoing, and recently completed trial that will presented at the European Renal Association – European Dialysis and Transplant Association (ERA-EDTA) meeting next week (May 21-24, 2016).
  • The MAINRITSAN trial, which compared rituximab with azathioprine among patients with anti-neutrophil cytoplasmic antibody vasculitis in remission after intravenous cyclophosphamide, and reported a significant superiority of rituximab (number needed to treat, 4) for avoiding relapse. There are some caveats to be considered (see #NephJC coverage for discussion), and Dr. Hildebrand pointed to the RITAZAREM trial as well as the follow-up of MAINRITSAN as something to look forward to.
  • Lastly, Dr. Hildebrand chose a trial that compared standard therapy (intravenous cyclophosphamide and) to multitarget therapy (tacrolimus, mycophenolate and steroids) in lupus nephritis. The intervention (multitarget therapy) was significantly superior to cyclophospamide in induction of remission, with similar adverse events. Caveats to consider were the long-term nephrotoxicity of tacrolimus, the possibility of the remission being driven due to the hemodynamic anti-proteinuric effect of tacrolimus rather than immunomodulation, and concerns about generalizing the data from this predominantly Chinese population to other ethnicities.

Post written by Dr. Swapnil Hiremath, AJKD Blog Contributor.

Check out more AJKD blog coverage of the CSN’s 2016 General Meeting!

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