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More Dialysis May Not Be Better

In the ACTIVE trial, patients aiming for 24 hours per week of dialysis saw no improvements in quality of life compared with those who did a standard number of hours per week, Meg Jardine, MD, of the George Institute for Global Health in Australia, and colleagues reported during a late-breaking trials session at Kidney Week.

“They did manage to have twice as much dialysis, but there was still no difference in quality of life,” Jardine told MedPage Today.

Observational studies have suggested a relationship between increased dialysis hours and better clinical outcomes. But Jardine explained that these studies couldn’t show whether it’s the extra dialysis that confers the benefit — versus something else about the population that dialyzes more.

To assess the impact of extended weekly dialysis hours on quality of life and clinical outcomes, Jardine and colleagues randomized 200 patients, mean age 52, to extended or standard dialysis for 1 year. Extended dialysis involved a target of 24 hours per week, while standard dialysis was targeted to 12 to 15 hours per week.

 Saiba mais sobre insuficiência renal

[tabs style=”v3″ icon_color=”#db6d32″ icon_current_color=”#81d742″]

[tab title=”O que é” ] É a perda das funções dos rins, podendo ser aguda ou crônica.[/tab]

[tab title=”Insuficiência Renal Aguda]A insuficiência renal aguda é caracterizada por redução rápida da função dos rins que se mantém por períodos variáveis, resultando na inabilidade de os rins exercerem suas funções básicas. Em muitas ocasiões o paciente necessita ser mantido com tratamento por diálise até que os rins voltem a funcionar. Em outros casos, os rins não tem sua função reestabelecida e o paciente precisa ser mantido em diálise.[/tab]

[tab title=”Insuficiência Renal Crônica” ]Insuficiência renal crônica é a perda lenta, progressiva e irreversível das funções renais. Por ser lenta e progressiva, esta perda resulta em processos adaptativos que, até um certo ponto, mantêm o paciente sem sintomas da doença. Até que tenham perdido cerca de 50% de sua função renal, os pacientes permanecem quase sem sintomas. A partir daí, podem aparecer sintomas e sinais que nem sempre incomodam muito. Assim, anemia leve, pressão alta, edema (inchaço) dos olhos e pés, mudança nos hábitos de urinar (levantar diversas vezes à noite para urinar) e do aspecto da urina (urina muito clara, sangue na urina, etc). Deste ponto até que os rins estejam funcionando somente 10 a 15% da função renal normal, geralmente, pode-se tratar os pacientes com medicamentos e dieta. Quando a função renal se reduz abaixo desses valores, torna-se necessário o uso de outros métodos de tratamento da insuficiência renal: diálise (hemodiálise ou diálise peritoneal) ou transplante renal.[/tab]

[tab title=”Sinais e Sintomas” ]

Muitos são os sinais e sintomas que aparecem quando a pessoa começa a ter problemas renais. Alguns são mais frequentes, embora não sejam necessariamente consequências de problemas renais:

 

  • alteração na cor da urina (torna-se parecida com coca-cola ou sanguinolenta);
  • dor ou ardor quando estiver urinando;
  • passar a urinar toda hora;
  • levantar mais de uma vez à noite para urinar;
  • inchaço dos tornozelos ou ao redor dos olhos;
  • dor lombar;
  • pressão sanguínea elevada;
  • anemia (palidez anormal);
  • fraqueza e desânimo constante;
  • náuseas e vômitos frequentes pela manhã;

[/tab]
[tab title=”Causas” ]Diversas são as doenças que levam à insuficiência renal crônica. Tanto no Brasil como no exterior, o diabetes e a hipertensão arterial constituem as principais causas de doença renal crônica. A terceira causa em ordem de frequência, são as chamadas glomerulonefrites.[/tab]
[/tabs]

 

The primary outcome was the difference in change in quality of life betweeen baseline and 1 year using the EQ-5D questionnaire.

The mean hours achieved each week were 22.1 for the extended dialysis group compared with 14.2 hours per week in the standard care group.

Jardine reported that by the end of the trial, quality of life scores were similar between groups, and there were no differences in systolic blood pressure between groups.

Patients in the extended-hours group were, however, taking fewer blood pressure-lowering drugs than those on standard dialysis (mean difference -0.35 agents, P=0.01).

Doing longer dialysis was also associated with higher hemoglobin, lower potassium, and lower phosphate levels compared with standard care during follow-up (expressed as the mean difference from the standard dialysis group):

  • Hemoglobin: 3.51 g/L, P=0.037
  • Potassium: -0.28 mmol/L, P=0.0001
  • Phosphate: -0.17 mmol/L, P=0.002

Jardine said these may turn into longer-term improvements, but further research is required.

She and her team also found that the number of patients with vascular access events was similar in both groups — a difference from previous trials, Jardine said: “We did not find evidence of excess harm. We didn’t see extra infections or clotting.”

They concluded that extending weekly dialysis hours for a year doesn’t appear t improve quality of life, but may be a boon to some laboratory parameters and reduced blood pressure medication requriements.

Jardine said the big problem with results from the aforementioned observational studies is that they don’t necessarily capture the typical dialysis patient. Patients who do extended dialysis — which is typically done at home — tend to be healthier, younger, and have less severe disease.

It is possible, she said, that 1 year isn’t long enough to see a difference between groups, so she and her team will continue to study this population for 5 years.

But in the meantime, she said the conclusion to be drawn from the results is that “maybe treatment options need to be personalized. You cant say to all patients that [extended dialysis] is the golden bullet. You can’t give a one-size-fits-all recommendation.”

Especialidades: Nefrologia Palavras-chave: ,

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