Background: Despite technological improvements over the last 40 years, hemodialysis is still associated with significant morbidity, mortality, and decreased quality of life. The optimal frequency of hemodialysis remains uncertain.
Study design: Randomized clinical trial with blinded analysis.
Setting: Eleven university-based and 54 community-based hemodialysis facilities in North America.
Synopsis: Researchers randomized 245 patients with end-stage renal disease to receive hemodialysis either three times per week or six times per week. Composite of death or one-year increase in left ventricular mass as assessed by cardiac MR was one primary outcome; composite outcome of death or one-year decrease in self-reported physical health was a co-primary outcome.
Frequent hemodialysis was associated with benefits in both composite primary outcomes (hazard ratio [HR] 0.61 for death/increase in left ventricular mass; HR 0.70 for death/decreased physical health). Notably, patients with frequent dialysis were more likely to undergo interventions related to vascular access than with conventional dialysis (HR 1.71). Blood pressure control (P<0.001) and hyperphosphotemia (P=0.002) also were improved with frequent dialysis.
Depression, cognitive performance, albumin, and anemia did not improve. Direct impact on mortality and hospital admission could not be assessed. Results might not be generalizable.
Bottom line: More frequent hemodialysis was associated with a significant reduction in left ventricular mass, improvement in self-reported physical health, and a reduction in mortality using combined composite outcomes. Further cost-benefit and quality-of-life analyses are needed to determine optimal dosing of hemodialysis.
Citation: FHN Trial Group. In-center hemodialysis six times per week versus three times per week. N Engl J Med. 2010;363:2287-2300.
BNP Testing in the Emergency Department Might Decrease Hospital Length Of Stay
Clinical question: Does BNP testing of patients presenting to the ED with acute dyspnea reduce admissions, shorten length of stay (LOS), or improve short-term survival?
Background: B-type natriuretic peptide (BNP) and the N-terminal peptide of its precursor, pro-BNP, are widely used to evaluate patients with acute dyspnea to distinguish cardiac from noncardiac causes. However, clinical outcomes related to this commonly used test are not clearly understood.
Study design: Systematic review and meta-analysis of randomized trials.
Setting: Five randomized controlled trials in EDs in five hospitals (Switzerland, Canada, the Netherlands, United States, and Australia) involving 2,513 patients.
Synopsis: Studies compared BNP testing with routine testing and clinical assessment and described >1 of three clinical outcomes: hospital admission rate, LOS, and mortality. Nonrandomized and retrospective studies and subgroup analyses of larger studies were excluded.
Testing with BNP decreased LOS by a mean of 1.22 days and critical-care-unit stay was modestly reduced (-0.56 days). This change was attributed to improved acute management and more rapid discharge with knowledge of BNP values. There was a nonsignificant trend toward decreased hospital admission from the ED in the BNP group (odds ratio 0.82). The effect of BNP testing on mortality was inconclusive.
Bottom line: BNP testing in the ED is associated with decreased hospital LOS, as well as a trend toward decreased admission rates from the ED. There is no conclusive effect on mortality.
Citation: Lam LL, Cameron PA, Schneider HG, Abramson MJ, Müller C, Krum H. Meta-analysis: effect of B-type natriuretic peptide testing on clinical outcome in patients with acute dyspnea in the emergency setting. Ann Intern Med. 2010;153:728-735.