Freely Filtered 036: AKIKI-2, How soon is now?
Freely Filtered, a NephJC Podcast
Challenges in Dialysis Randomization
This chapter examines the complexities involved in randomizing patients for a clinical trial on dialysis treatment, focusing on eligibility criteria such as anuria and oliguria. It contrasts recent findings with earlier studies and discusses the implications of defining clinical outcomes, including renal replacement therapy-free days. The dialogue also highlights the tension between subjective clinical judgments and standardized protocols in nephrology patient care.
The Filtrate:
Joel Topf
Swapnil Hiremath
Nayan Arora
Sophie Ambruso
And special guests:
Jay L Koyner, Professor of Medicine, University of Chicago
Sarah Faubel, Professor of Medicine, University of Colorado
Editor
Nayan Arora
Show Notes:
It was Kidney 360, not Kidney Medicine. Here is the study I was thinking of: https://kidney360.asnjournals.org/content/2/1/33
SNL Five-Timers Club: https://www.youtube.com/watch?v=6bWGoWFMwKE
The Fluid and Electrolyte Companion. Download The Whole Enchilada
About the Authors from Topf and Faubel’s first book, The Microbiology Companion.
Ted Post: The Sarah Faubel of The Clinical Physiology of Acid Base and Electrolyte Disorders.
Meta analysis of early dialysis in AKI by Victor Seabra: https://pubmed.ncbi.nlm.nih.gov/18562058/
Meta analysis of early dialysis in AKI by Morgan Grimes: https://www.ajkd.org/article/S0272-6386(15)00530-2/abstract
H-index: https://en.wikipedia.org/wiki/H-index
Mortality in ARDS: ACURASYS study. The hazard ratio for death at 90 days in the cisatracurium group, as compared with the placebo group, was 0.68 https://www.nejm.org/doi/full/10.1056/nejmoa1005372
Has Mortality from Acute Respiratory Distress Syndrome Decreased over Time? A Systematic Review
It is commonly stated and assumed that mortality from acute respiratory distress syndrome (ARDS) is decreasing.
We found that mortality from ARDS has not decreased substantially since the publication of a consensus definition in 1994. Based on our findings, a baseline mortality risk from ARDS of 40 to 45% for observational studies and 35 to 40% for randomized control trials should be expected. These results highlight the need for future effective therapeutic interventions for this highly lethal syndrome.
https://www.atsjournals.org/doi/full/10.1164/rccm.200805-722oc
From Up To Date:
Numerous studies suggest that survival has improved over time [2,9,10,11]. As an example, an observational study of 2451 patients who had enrolled in ARDSNet randomized trials found a fall in mortality from 35 to 26 percent between 1996 and 2005 [10]. To the extent that mortality may be decreasing with time, several issues should be considered:
● It is not known if mortality has decreased among patients who received their care outside of a specialized center or a clinical trial.
● The improved mortality may be attributable to patients who have ARDS related to risk factors other than sepsis, such as trauma [9].
● To the extent that mortality has decreased, the reasons are uncertain. Likely causes include better supportive care and improved ventilatory strategies, such as low tidal volume ventilation [10,12,13]
Early Goal-Directed Therapy in the Treatment of Severe Sepsis and Septic Shock by Emanuel Rivers https://www.nejm.org/doi/full/10.1056/nejmoa010307
Early Goal Directed Therapy from NephMadness 2015 https://ajkdblog.org/2015/03/01/nephmadness-2015-critical-care-nephrology-region/#Early
Counter point by NSMC graduate Kamran Boka https://ajkdblog.org/2015/03/18/nephmadness-2015-process-arise-promise-and-the-promise-of-early-goal-directed-therapy/
Furosemide stress test https://jasn.asnjournals.org/content/26/8/2023
EM Crit looks at the furosemide stress test: https://emcrit.org/pulmcrit/furosemide-stress-test/
ASN Kidney Week Biomarker debate between Faubel and Koyner. https://www.asn-online.org/education/kidneyweek/2020/program-session-details.aspx?sessId=371699&sessPar=371678
NAD therapy Samir Parikh Don Seldin Young Investigator Award winner 2019.
Sarah Faubel’s Dream RCT https://ukidney.com/nephrology-resources/dream-rct-initiative/dream-rct-entries/item/nephrologist-driven-rrt-usual-late-or-early-start-for-acute-kidney-injury
Perry Wilson’s DreamRCT https://www.medpagetoday.com/Nephrology/DreamRCT/53876
Steve Coca on “Permissive AKI” with treatment of heart failure https://www.kidney-international.org/article/S0085-2538(19)30708-2/pdf
Edward Clark on HIRRT: Mechanisms for hemodynamic instability related to renal replacement therapy: a narrative review https://pubmed.ncbi.nlm.nih.gov/31407042/
Cytokine adsorption in patients with severe COVID-19 pneumonia requiring extracorporeal membrane oxygenation (CYCOV): a single centre, open-label, randomised, controlled trial https://www.thelancet.com/journals/lanres/article/PIIS2213-2600(21)00177-6/fulltext
The Handbook of Critical Care Nephrology Amazon | Target (actually not available 😩)
Sophia and Sarah Tweetorial on her Lung metabolomics in AKI study: https://twitter.com/sophia_kidney/status/1390394006366994432
AKIKI NephJC coverage | NEJM manuscript
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