Blog entry by Meguid El Nahas

Anyone in the world
J Am Soc Nephrol. 2013 Dec;24(12):1934-43. doi: 10.1681/ASN.2013060632. Epub 2013 Oct 17.

Evidence-based cardiology in hemodialysis patients.

 This is an interesting review article in JASN December 2014 reviewing major CVD RCTs in CKD patients treated by HD.

Basically, it is a long list of negative trials:
Statins:
AURORA
4D
SHARP
all essentially negative.
 
Anemia correction:
Normal hematocrit Trial (1998): Negative
 
Mineral Metabolism:
DCOR
EVOLVE
NEGATIVE
 
Dialysis Dose and Membranes:
HEMO
MPO
NEGATIVE
 
as well as HDF:
CONTRAST
Turkish OIL-HDF
NEGATIVE
 
ESHOL: positive but unlikely to be a real HDF effect on survival more a case of confoundied by indication
A recent meta-analysis of HDF versus HD showed NO BENEFIT ON SURVIVAL
http://www.ncbi.nlm.nih.gov/pubmed/24434188
 
ACE inhibition:
FOSIDIAL NEGATIVE
 
etc...
 
This may be because we assume that HD patient smortality is directly linked to CAD related CVD and mortality; this may not be the case...
 
In fact, the very high mortality rate of HD patients in US in particular 20%/year with a 5 year survival of 50% only...may be due to non CAD or even CHF reversible or preventable mortality; it is more to do with the fact that more than 60% of HD patient sdie from sudden cardiac death (SCD) and the latter is associated with left ventricular hypertrophy (LVH)_ which is not always easy to reverse within the short windown of 1-3 years from HD onset. Further, we dont quite know how to address LVH and reverse it in HD:
Blood pressure control: NEGATIVE
Anemia control: NEGATIVE
Frequent HD: MAY BE but more likely ultrafiltration improvement and better fluid control. This we may have to target more aggressively and avoid chronic fluid overload in HD patients.
 
Also revisiting promising interventions may be warranted, like:
Beta Blockers: 
Atenolo may be superior to ACE inhibition in HD patients and may impact positively on LVH and mortality:
http://www.ncbi.nlm.nih.gov/pubmed/24398888
 
Anti-oxidants: Vitamin E:
Oxidant stress may be more improtant than lipids in HD patients
SPACE study was positive, may warrant further investigation.
http://www.ncbi.nlm.nih.gov/pubmed/11072938
 
More importantly, a better understanding of the causes and mechanisms of SCD is essential to address them and seek the reversible.
http://www.ncbi.nlm.nih.gov/pubmed/24256575
 
Electrolytes disturbances is a factor amongst others and may explain the higher death rate after long HD interval:
http://www.ncbi.nlm.nih.gov/pubmed/21992122
 
Also, and if SCD is the main cause of deathon HD, then ICD may be the answer in HD patients or even waerable defibrillators.
http://www.ncbi.nlm.nih.gov/pubmed/24252154
 
So clearly, a different and more critical approach to mortality on HD is warranted before more non-CKD look-alike RCTs are implemented to no avail in HD patients.
 
Perhaps, mortality will remain high on HD as by the time ESRD is reached windows of therapeutic opportunities have been shut.
PERHAPS WE ARE TRYING TO CLOSE THE HD (MORTALITY) DOOR AFTER THE HORSE (CVD COMPLICATIONS) HAVE BOLTED (SET IN...); IN THAT CASE A COMPLETELY DIFFERENT APPROACH IS WARRANTED.
[ Modified: Thursday, 1 January 1970, 1:00 AM ]