Monday, January 08, 2018

Nephrology Updates in 2017?

Yes this post title is obviously over-ambitious.
For a much more informative version and with Visual abstracts please visit Neph JC on their "Top Nephro Stories of 2017".

Just to share a few updates that are particularly insightful in our clinical practice:

1. Two trials of Levosimendan  - LEVO CTS and CHEETAH, (sadly) showed that its use in cardiac surgery did not reduce RRT requirement or mortaliy. We lost another hope to improve CSA-AKI (cardiac surgery-related AKI) outcome. On the other hand, while pharmacological intervention seems not favorable, the KDIGO care bundle was shown to reduce CSA-AKI in this RCT.

2. The two RCTs of using high cut-off dialysis in myeloma cast nephropathy - EuLITE (not published yet) and MYRE are both completed and showed no difference in renal recovery outcome, but with adverse effects due to electrolyte and albumin loss. The routine use cannot be recommended.

3. Updates from IgAN classification workgroup - beside the MEST, the crescents are also predictive of outcome. So it is now MEST-C score.

4. 2017 was thought to be an exciting year for IgAN - but it turned out to be quite negative. Earlier STOP-IgAN trial did not favour immunosuppression to supportive treatment, this is further supported by recent trial showing addition of MMF/ Aza add no benefit but just more side effects. The TESTING study was terminated early due to fatal infectious events. We are now awaiting phase III trial of targeted-release Budesonide and novel agent Avacopan.

5. As compared to the good result of EMPA-REG, the CANVAS study in T2DM showed lower risk of CV events, however renal benefits are not statistically significant, and has increased risk of amputation primarily at level of toe or metatarsal. The LEADER trial - adding Liraglutide in T2DM patients with high CV risk, resulted in less newly-diagnosed macroalbuminuria but no difference in AKI, CKD progression or RRT requirement.

6. KDIGO guideline on CKD-MBD 2017 has been released.

7. Expert opinion on AKI prevention and renoprotection in ICU by European Society of Intensive Care Med (ESICM) was published - a good summary of evidence from 1966-2017 on potential protective strategies in AKI.

8. Another study supporting the evidence that UF cut off rate of >13ml/kg/hr is associated with increased cardiovascular and all-cause mortality (previously known) and intra-dialytic hypotension (in this paper).

9. After the landmark TEMPO 3:4 , the 2-year extension study (known as TEMPO 4:4) showed the sustained disease-modifying effect of Tolvaptan in ADPKD. The REPRISE study subsequently showed that use of Tolvaptan in late-stage ADPKD still slows the eGFR decline. Note the high discontinuation rate due to SE (10%) and risk of elevated ALT >3x ULN (5.6%).

10. ISPD published guideline on Encapsulating Peritoneal Sclerosis. The discussion about EPS as a potential complication of PD should be undertaken - not necessarily at the start of PD but more reasonably at the 3-4 year point of therapy.

11. PRESERVE study - RCT on 5177 patients with eGFR stage 3b-4 or 3a with DM undergoing angiography, IV isotonic bicarbonate is not better than normal saline, and Acetylcysteine is no better than placebo in terms of outcome including death, need of RRT or contrast-induced AKI. This has led to a change in recommendation in UptoDate that oral NAC is no longer recommended for prevention of CI-AKI.

12. Hypertension in adults is redefined - the change is mainly from meta-analysis of observational studis that the pre-hypertension (in old guidelines) is not benign and is assoc with higher CV risk.

13. Early initiation of RRT (defined as within 8 hours of KDIGO stage 2 AKI) led to 15% less 90-day mortality and shorter lenght of stay. The long-term clinical outcome study subsequently showed the early initiation further led to 20% all-cause mortality at 1 year and 35% less risk of renal non-recovery at 1 year. Note this is in AKI with risk of progression only (risk stratified by using NGAL biomarker).

14. After the CARI guidelines on ADPKD in 2015, European ADPKD forum has published their position statements focusing on patient-centered approach and multi-disciplinary coordination in care of ADPKD patients.

Recommended great topic reviews on:
1. Infection in Organ Transplantation - the timeline chart is now with relative risk at different time point!

2. Nutritional Management in CKD

3. Chronic Kidney Disease - from global prevalance to practice recommendations and future potential therapies.

4. Intravenous fluids - physiology, concepts and evidence-based prescription.

Let's look forward to 2018 and we shall always be hopeful in breakthroughs in better care of our renal patients!


Choy CK said...

What an excellent review..thanks for the effort Dr Darren! I will definitely subscribe to this blog for my updates in knowledge

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Anonymous medical student said...

Hi dr darren, I was one of the renal elective student attached to your clinic a year ago. Thanks for being so pro teaching, really learnt alot from your clinic. You left sgh? Where are you heading to next. All the best in your endeavours !

Darrenmagic said...

Hi! (Sorry I wish I could call you by name) Thanks for the kind words! Yes I've left SGH, just back to M'sia and currently will be at Ipoh (Perak) for several months. Hope to see you again, all the best in your studies!

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