In AKI, Dialysis Works Better With Higher Creatinine

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Published: Mar 20, 2014 | Updated: Mar 21, 2014

In this large-cohort study of patients with acute kidney injury, no significant difference in mortality was observed between groups that did and did not receive dialysis.Dialysis, however, was associated with greater mortality at low serum creatinine levels and with lower mortality at high serum creatinine levels.

For patients with acute kidney injury (AKI), dialysis is associated with better survival among those with higher creatinine levels, but higher mortality for those with lower levels, researchers found.

In a single-center study, risk of death with dialysis initiation fell by about 20% with each mg/dL increase in creatinine (P=0.001), Perry Wilson, MD, of the University of Pennsylvania in Philadelphia, and colleagues reported in the Clinical Journal of the American Society of Nephrology.

Increased creatinine may be a marker of higher muscle mass and possibly a healthier subset of AKI patients, they said.

"Many clinicians feel that, although acute dialysis may not help a critically ill patient, it is unlikely to cause any harm," Wilson said in a statement. "Through this study, we have been able to show for the first time among an equally matched group of patients that dialysis for AKI may cause more harm than good in the subgroup of people who are frail and have lower muscle mass, and more benefit than harm in more robust patients."

There's been a dearth of evidence as to which AKI patients are likely to benefit most from starting dialysis. Nor are there any randomized trials evaluating early versus late initiation of dialysis, although early initiation has now become standard of care.

To assess which AKI patients make the best candidates for dialysis, Wilson and colleagues looked at data on adults admitted to three acute care hospitals within the University of Pennsylvania Health System over 6 years who developed severe AKI between Jan. 1, 2004 and Aug. 31, 2010.

Overall, 602 were started on dialysis, and 545 of these patients were matched with an equal number of patients who didn't receive dialysis.

In the full cohort, Wilson and colleagues found that initiation of dialysis was strongly associated with mortality (HR 3.42, 95% CI 3.09-3.78, P<0.001) -- but after propensity matching, there was no risk associated with dialysis (HR 1.01, 95% CI 0.85-1.21, P=0.89).

This indicates that patient factors account for the observed harm associated with dialysis in the full cohort, so the researchers looked further into various patient characteristics.

They found that as serum creatinine increased, the risk of death with dialysis initiation fell by 20% for each mg/dL increase in creatinine levels (P=0.001).

Among patients with creatinine levels above 4.2 mg/dL, 57% of those who weren't on dialysis died, compared with 47% of those who did get dialysis (P=0.05).

And among patients with creatinine levels below 2.8 mg/dL, 64% of those who didn't get dialysis died during hospitalization compared with 78% who did go on dialysis (P=0.005).

"Patients with a higher creatinine at initiation of dialysis fare better not only than those who initiate dialysis at a lower creatinine, but also those who do not initiate dialysis at a high creatinine," the researchers wrote. "Conversely, patients who initiate dialysis at a low creatinine do worse than matched patients who do not initiate dialysis at a low creatinine."

The difference is likely due to an increased creatinine generation rate, Wilson and colleagues wrote. It's a proxy for muscle mass, and higher levels may represent a healthier subset of patients with AKI.

Lower creatinine, on the other hand, could be a marker of frailty, with reduced muscle mass and greater weakness.

"This finding is analogous to chemotherapy for cancer," Wilson said. "If you are strong enough to cope with the adverse effects, it's good for you, but if you're weak, it may kill you."

In an accompanying editorial, Neesh Pannu, MD, of the University of Alberta in Canada, said including nondialyzed patients addresses "much of the criticism leveled at other observational studies of dialysis initiation."

But there are limitations to the degree of matching, Pannu wrote. In particular, the study didn't include urine output and other measures of fluid overload, which could have lead to residual confounding.

Still, Pannu concluded that the study is "an important contribution to the ongoing debate about the initiation of dialysis in AKI. The complexity of this analysis demonstrates the difficulty of identifying who will ultimately benefit from treatment."

Editor's Note: Lead author Perry Wilson is a medical reviewer for MedPage Today.

CORRECTION: This article, which was originally published March 20, 2014 at 5 p.m., has been corrected (March 21, 2014, at 12:14 p.m. ).

The study was supported by a grant from the National Institute of Diabetes and Digestive and Kidney Diseases.

Neither Wilson nor Pannu disclosed any relevant relationships with industry.

Primary source: Clinical Journal of the American Society of Nephrology
Source reference: Wilson FP, et al "Dialysis versus nondialysis in patients with AKI: A propensity-matched cohort study" Clin J Am Soc Nephrol 2014; DOI: 10.2215/CNJ.07630713.

Additional source: Clinical Journal of the American Society of Nephrology
Source reference:Pannu N "Which patients benefit from initiation of dialysis for AKI?" Clin J Am Soc Nephrol 2014; DOI: 10.2215/CJN.01730214.

Kristina Fiore joined MedPage Today after earning a degree in science, health, and environmental reporting from NYU. She's had bylines in newspapers and trade and consumer magazines including Newsday, ABC News, New Jersey Monthly, and Earth Magazine. At MedPage Today, she reports with a focus on diabetes, nutrition, and addiction medicine.

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Women find sex with ex better than current lover

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The survey found that about 38 percent of women, who took part in the poll, confessed that they had the best sex of their lives in a previous relationship, the Daily Star reported.

However, just 29 percent of men said that their best sex was with an ex.

Sex toy retailer Lovehoney, who polled 1,100 men and women, found that 62percent of women and 71percent of men said their best sex was with their current partner.

It was also found that 7 percent of both women and men named their first love as their best lover, while 7 percent of women and 4 percent of men said a friend was their best lover.

Around 4 percent of women and 3 percent said their best sex was a one night stand, while just 1 percent of men and women name a holiday fling as their best sex.

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Does sex get better with age?

 

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Good sex is the preserve of feisty 20-year-olds with great bodies and rocket-fuelled sex drives. At least, that’s what most people think.

But a new survey begs to differ. According to a US poll of over 2,000 men and women, sex really does get better with age - and that’s particularly true for men. The study found that men are the most confident in bed between the ages of 50 and 69, while women experience their peak of sexual confidence between 18 and 29.

So as men get older, their confidence in the bedroom increases, making sex more fun, less stressful and more satisfying. Here are a few more reasons why your sex life will only get better.

Men worry less

You may worry a bit about the odd grey hair or the laughter lines around your eyes (nothing’s that funny, eh?) but you worry far less about getting older than your partner does.

According to the poll, only 34 percent of men are worried about the physical signs of ageing - compared to 56 percent of women.

The poll also found that the word most associated with men and grey hair was “distinguished”, while with women it’s “old”.

Why is any of this good for your sex life past 30? For a start, it means men are less self-conscious in bed, leaving them freer to enjoy the experience. As we age we no longer feel the need to show our 'best side' or hide wobbly bits. We’re much more likely to think: take me how I am.

The other upside to all this is that our partners spend a lot of time and effort warding off the ravages of age. From a purely selfish perspective, many 35- or 40-year-old women have never looked so good. Some research even suggests that the ‘cougar’ phenomenon is driven by a subconscious confusion: young men are primed by evolution to go for long, luscious locks, clear skin and sparkling eyes, the genetic signals of youth. All of which are increasingly found on older women.

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More travel means better sex

 

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According to a survey commissioned by the US Travel Association, travelling together will improve a couple’s sex life.
The survey found that the romance and better sex enjoyed during travel lasts long after the trip is over, CNN News reported.
For the survey, Edge Research interviewed 1,100 about adults of which some 72 per cent of the couples said that travel inspires romance, and 63 per cent said that a weekend getaway is more romantic than receiving large or small gifts.
Approximately 77 per cent of people who travelled with a significant other reported a good sex life, compared with 63 per cent of couples who don’t.

Plus:

Do’s and don'ts of having casual sex after divorce
Sex `pleasurable with or without use of condom or lubricant`
How stress can negatively affect your sex life

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Exercise May Make Life Better for Those With Arthritis

SATURDAY, Oct. 26 (HealthDay News) -- Regular exercise boosts quality of life and reduces health care costs for people with arthritis, a new study shows.

Researchers found that meeting national physical activity guidelines could add up to 20 days of good health in one year for these patients.

However, many Americans are not getting the recommended 150 minutes of moderate to vigorous activity a week, in bouts lasting at least 10 minutes each.

The findings were scheduled to be presented this week at the American College of Rheumatology annual meeting in San Diego.

"Regular physical activity improves health and reduces mortality in the general population. Furthermore, physical activity promotes arthritis-specific health benefits including improving symptoms, function and psychosocial outcomes, as well as reduced disability," study author Dr. Kai Sun, a medical resident and research trainee at Northwestern Feinberg School of Medicine in Chicago, said in a news release from the American College of Rheumatology.

"Despite these benefits," Sun noted, "the majority of adults in the U.S. do not attain the recommended amounts of physical activity."

One type of arthritis -- osteoarthritis -- which is most common among middle-aged or older adults, causes progressive damage to the cartilage, or cushioning at the end of long bones. This damage can lead to pain, swelling or limited movements around the joint.

Knee osteoarthritis is one form of the joint disease that may be worsened by excess weight. A person's age, certain injuries, stress on the joints and having a family history of the condition also increase people's risk for osteoarthritis.

Using results from a nationwide study sponsored by the U.S. National Institutes of Health, a team of researchers examined physical activity levels and the quality-adjusted life years (a standard measurement of quality of life and cost-effectiveness of medical treatment) of 4,700 adults diagnosed with or at risk for arthritis of the knee.

The researchers measured the physical activity levels of the participants for one week using a device called an accelerometer. They then divided the participants into three groups: One group included those who were meeting national physical activity guidelines; the second group included participants who were not active enough, but did engage in some moderate to vigorous activity; and the third group included those who were inactive.

The researchers measured the participants' physical activity level and quality-adjusted life years when the study began, and again two years later.

Over the course of the study period, the quality-adjusted life years of participants who met the guidelines for physical activity were higher than those who were somewhat active or inactive, the investigators found.

The difference translated into between 10 and 20 more days of good health in one year. The researchers noted that even if the national guidelines are not met, increasing physical activity in any way could enhance quality of life, add years of health and lower overall health care costs for people with arthritis.

Research presented at meetings should be viewed as preliminary until published in a peer-reviewed medical journal.

-- Mary Elizabeth Dallas
Copyright © 2013 HealthDay. All rights reserved. SOURCE: American College of Rheumatology, news release, October 2013

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HIV Drugs Getting Better (CME/CE)

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Published: Jul 5, 2013

Note that this study was published as an abstract and presented at a conference. These data and conclusions should be considered to be preliminary until published in a peer-reviewed journal.
Note that this large meta-analysis demonstrated that preferred HIV regimens are indeed superior to alternative regimens in terms of suppressing viral replication.There is a suggestion that the newer integrase inhibitors are more efficacious than other classes when added to the standard backbone of HIV therapy.

KUALA LUMPUR -- The efficacy of HIV drugs in clinical trials has increased markedly over time, according to a meta-analysis of 144 studies with more than 40,000 participants.

Efficacy -- defined as the proportion of patients able to suppress HIV to undetectable levels -- was about 47% in trials conducted before 2000, according to Frederick Lee, MD, of the St. Vincent's Centre for Applied Medical Research, Sydney, in Australia.

In studies after 2008, efficacy was about 82%, Lee reported at the 7th International AIDS Society Conference on HIV Pathogenesis, Treatment, and Prevention.

Interestingly, the so-called "preferred" regimens of the U.S. Department of Health and Human Services (DHHS) guidelines panel outperformed the "alternative" regimens, which in turn did better than other combinations, Lee reported.

Lee noted that guidelines are based on serial assessments of individual trials, so a meta-analysis of all available trials should increase the ability to evaluate outcomes in subpopulations of patients and identify predictors of treatment success.

He and colleagues looked at all reported prospective drug trials in treatment-naive HIV patients with at least 48 weeks of follow-up and an intent-to-treat efficacy analysis.

All told, they found 144 phase II, III, and IV studies with 216 treatment groups, starting with 10 trials from the pre-1996 era through to 17 in 2009 and 2010.

On average, follow-up was 82 weeks and efficacy on treatment was 60%, Lee reported. About 25% of participants stopped treatment during their trial, usually because of adverse events and less commonly because the drugs weren't working to suppress the virus.

The nucleoside reverse transcriptase inhibitor backbone of tenofovir and emtricitabine was significantly more efficacious than most other backbones, with the exception of emtricitabine and didanosine, which was equally good, Lee and colleagues found.

The third drug in triple-drug therapy until recently has usually been either a non-nucleoside reverse transcriptase inhibitor or a protease inhibitor, and analysis suggested they were equally efficacious at 61% and 67%, respectively.

Considered as a group the new integrase inhibitors yield efficacy of about 81%, Lee and colleagues found, which was significantly better (at P=0.002) than either of the other two classes.

Finally, an analysis of preferred DHHS regimens over time showed efficacy of 75%, compared with 65% for alternative regimens, and 55% for other treatment options.

The difference between the preferred and alternative regimens was significant (P<0.001), Lee reported.

The study finding delivers good news in one sense, commented Dan Kuritzkes, MD, of Brigham and Women's Hospital in Boston -- it shows that guidelines committees are doing a good job.

As a member of the DHHS guidelines panel, Kuritzkes said he was gratified to find that "it turns out that a bunch of experts sitting around and looking at data actually get it right."

The study "is confirmatory that we are having better drugs, more friendly drugs, and easier (drugs) to use," commented Pedro Cahn, MD, of Fundación Huesped in Buenos Aires and a former president of the IAS.

Those improvements are "the reason we are seeing increasing efficacy over time," he told MedPage Today.

The study was supported by the National Health and Medical Reserach Council of Australia. Lee made no disclosures.

Cahn has reported financial links with Abbott, Pfizer, GlaxoSmithKline, Pharmacia, and Roche.

Primary source: International AIDS Society
Source reference:
Lee FJ, et al "Efficacy of initial antiretroviral therapy: a meta-analysis of 40,124 adults with up to 144 weeks' follow-up" IAS 2013; Abstract WEAB0104.

North American Correspondent for MedPage Today, is a three-time winner of the Science and Society Journalism Award of the Canadian Science Writers' Association. After working for newspapers in several parts of Canada, he was the science writer for the Toronto Star before becoming a freelancer in 1994. His byline has appeared in New Scientist, Science, the Globe and Mail, United Press International, Toronto Life, Canadian Business, the Toronto Star, Marketing Computers, and many others. He is based in Toronto, and when not transforming dense science into compelling prose he can usually be found sailing.

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Better design tests needed for medical devices, say engineers

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