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New treatment not necessarily better

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University of Alberta researchers looking into the most common treatments for acute kidney failure have discovered that the breakthrough technique of the day may be no more effective than the conventional approach.

According to an article, published in the February 20 issue of the Journal of the American Medical Association, Dr. Neesh Pannu, professor in the Faculty of Medicine & Dentistry, and her colleagues have reported that the much-heralded and costly continuous renal replacement therapy (CRRT) has been no more successful at improving survival rates or reducing dialysis dependence than the long-standing intermittent hemodialysis.

Both of these therapies are for bedridden patients who have complete shutdown of kidney function. Historically, physicians have provided regular hemodialysis, the same type of treatment supplied for those with chronic outpatient dialysis.

In the early ’90s, a new technology emerged with the promise of increasing the survival rate of patients with acute kidney failure, whose mortality rate was in excess of 60 per cent.

"They just didn’t do well on hemodialysis because the actual procedure involved taking blood out of the body, putting it through an artificial kidney and putting it back," said Pannu. "For patients with unstable blood pressure, who are otherwise on life support, it is very hard to deliver that treatment."

Instead of providing treatment over four to six hours, CRRT would provide slower, ongoing treatment, in effect mimicking the function of a normal kidney. The purported advantage of that was that it was a gentler form of treatment. Pannu says the new technology was very widely adopted by intensive care units across the world, with places like Australia embracing this new treatment exclusively.

"It was assumed to be better but people didn’t really wait for a study to come out to say if it was actually better. It was just kind of adopted because it was a sexy technology that made sense," said Pannu.


Because it was instantly assumed that the new CRRT technology was better, it was also assumed that withholding the treatment for the purposes of controlled studies would be unethical. Those studies that were carried out were destined to be small and underpowered.

However, over time these small studies would swell in number. Pannu and her team began to search databases for studies examining dialytic support in adults with acute renal failure that reported the incidence of clinical outcomes such as mortality, length of hospital stay, need for chronic dialysis or development of abnormally low blood pressure. Researchers were able to pool the data to the point where the results could no longer be discounted.

"To a lot of people our results were quite a surprise," said Pannu. "But do I think this is going to change practice? I’m not sure. I think the people who believe in continuous therapies are going to continue to do so."

Pannu said the bigger implication is that continuous renal therapy is an expensive technology, which could lead to a savings in places where cost is a concern.

"It you were in a hospital that didn’t have CRRT and were thinking of getting it, this may make you sit back and say ‘you know what, since it isn’t proven to be any better than the usual hemodialysis, why would we spend the extra money to do this?’" she said, adding at that intermittent dialysis has an advantage.

"Any hospital that already has chronic dialysis patients will have the machines anyway, so they can just wheel them over to the ICU and use them there."

(Source: Journal of the American Medical Association: Michael Brown: University of Alberta: February 2008)



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Posted On: 22 February, 2008
Modified On: 16 January, 2014

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