The FHN trial of 6-times versus 3-times a week in-center dialysis was famously a modestly positive trial. It was not powered to show a mortality benefit and as expected, it did not show a mortality benefit. This year at Kidney Week, Chertow and the FHN Team presented a poster with subsequent follow-up of the randomized patients. While almost all of the patient migrated back to conventional 3-days a week dialysis after the trial, they found that patients randomized to daily in-center hemodialysis have had a better survival than patients randomized to 3-times a week dialysis. The Hazard ratio was a healthy 0.54!
How did this not get an oral presentation?
You can find it on page 442 of the 2013 abstract supplement, which you can download here.
Just about anyone who was pre-med at the University of Michigan in the 80’s and 90’s probably took Biochemistry 411. It was a unique class, that used the Keller Plan, an early experiment in flipped classrooms. Professor Robert Beyer created a course book which laid out explicitly what the expectations were for each of 15 modules. Students would study on their own until they understood the expectations and then take a test demonstrating mastery of the material. If they had questions they could work with student proctors to get the answers.
It was an awesome class, it was the only A+ I ever received. The class was essential med school prep because it taught me how much crap I could stuff into short term memory for a test. You can see an overview of the class Dr. Beyers wrote for an education journal here.
Dr. Beyer offered optional lecture sessions if you wanted to learn additional ancillary information and I went to a few of them. He did an awesome lecture on the benign medical nature of marajuana. He did a lecture on the importance of free radical scavengers (he was a huge Linus Pauling fan, who he called the great brain). Here is some lay press on some of his research on free radicals. And he had a few pet molecules that he loved, one was Co-enzyme Q10. I knew more about Co-Enzyme Q than I ever thought I would need and I was pleasantly surprised to see it pop back up as a relevant medical drug twenty years later.
Another pet molecule (or I guess, element in this case) was selenium, he gave a convincing lecture that increased selenium was the key to preventing cancer. This has not worked out so well. The Select trial randomized 35,000 men to placebo, vitamin E, selenium or both vitamin E and selenium. The lowest prostate cancer rate was with placebo. Sorry Dr. Beyer.
The Journal of National Cancer Institute this week released a nested case control analysis
of the same data and found that selenium and vitamin E increased the risk of prostate cancer by 90% in some patients.
Sure, take a vitamin a day, how could it hurt (besides doubling your risk of prostate cancer) http://t.co/gQCNr1YmyF H/t @drarcox
— Joel Topf (@kidney_boy) February 23, 2014
Jason Prosek has submitted another DreamRCT. Jason is an assistant professor of nephrology at the Wexner Medical Center at the Ohio State University. He is a general nephrologist with particular clinical interests in onco-nephrology and heart failure / ultrafiltration. He is also heavily involved in fellow education.
Jason’s RCT is trying to actually put Tessin’s hemodialysis strategy to the test. It is an interesting trial and an ambitious idea. Check it out on Medium.
Jason can be found on Twitter.
For the past few weeks a few contributors have posted their personal ideas about the biggest
questions in nephrology. These ideas were presented in the form of proposed randomized controlled trials. Here is the cohort of #DreamRCTs so far:
I am grateful to each one of them that took up the call and contributed to this endeavor. For their time each one has received a DreamRCT mug or t-shirt.
has collected all of the ideas and listed them together for the community to rank these ideas. But additionally, and importantly, they have provided a mechanism for everyone to contribute their own ideas for a DreamRCT. Go to the site, check it out and contribute. Nephrology is full of dark neglected corners that could use the bright light of a well conceived, randomized controlled trial.
In the past I have posted my Apple predictions on PBFluids, but I am going to keep this blog kidney focussed, so I posted my 2014 Apple Predictions on Medium, a fantastic blogging platform if anyone is looking to start writing online.
Swapnil Hiremath, a nephrologist from the great white north has taken up the call and has submitted the sixth #DreamRCT. I met Swapnil on Twitter where he is quite clever and insightful about nephrology research. Swapnil works in Ottawa, which is apparently Canada’s capital.
He writes, “In Ottawa, we are not fazed with the polar vortex – in fact our annual winter festival, the Winterlude is going on now.” He is a true citizen of the world who made it to Ottawa from Mumbai, where he trained at King Edward Memorial Hospital. After Mumbai he proceeded to Boston to pick up an MPH from Harvard. He is currently an Assistant Professor in the faculty of Medicine at the University of Ottawa. His turn-ons are epidemiological studies in acute kidney injury, resistant hypertension and vascular access. See his citations at Google Scholar.
His DreamRCT takes a swap at the high rate of CV death in dialysis patients by randomizing ICDs to them. Clever and important idea. I love that he didn’t dream small and took a shot at one of the most important issues in dialysis. His post is hosted at Medium. Read it here.
That was fast, moments after posting my plea for more entries, Pascale Lane posted her entry:
Andin the grand tradition of big science, she already has the follow-up study planned before unrolling patient 1 in the first study. I can’t wait for NOMAD. Read it. Great work.
Her T-Shirt is in the mail.
You could be next.
Get’em done. Post’em up.
We want to open the voting for the DreamRCT a week from tomorrow, but we are running into an obvious problem, we only have 4 entries which seems a little light:
- The Uric Acid causes CKD RCT that I did
- The Phosphate trial that Jordan did
- The IMAGINE trial by Paul Phelan at the Renal Fellow Network
- PHANTOM-1 trial of anticoagulation in ESRD by Ed El Sayed
Every nephrologist I know complains about the woeful state of evidence in nephrology, but in my mind if you can’t come up with a a DreamRCT, you have no legs to stand on.
Please write it up because if we don’t get it done Jordan has all kinds of Plan B’s that I don’t want to consider.
To sweeten the deal, we have DreamRCT t-shirts. The next six people to post their dream RCT will get a T-shirt complements of yours truly. Time to raid my wallet. Write your damn DreamRCT already.
What? You say you don’t have a blog to publish it?
No problem, I’ll host it here at PBFluids.
What? You say you would never post it to PBFluids, because Joel was once a dick on Twitter?
No problem, tweet at Jordan Weinstein (@UKidney) I’m sure you two can work something out, or go post it to Medium.
What? You say you have enough T-shirts?
No problem, I’ll send you a mug instead.