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Today we have @DrRonWald from St Mike's presenting on "Phosphate control in the dialysis population: Settling the controversy" at @OttawaRenal Nephrology Grand Rounds
Follow along as we live tweet
Follow along as we live tweet
Dr Wald from @UnityHealthTO starts off with clinical vignettes
- patients with high PO4, controlled pTH - how high do you go on adding binders?
- patient with excellent PO4 and 16 binders pills/day complains about pill burden
Do we have any evidence for either of them?
- patients with high PO4, controlled pTH - how high do you go on adding binders?
- patient with excellent PO4 and 16 binders pills/day complains about pill burden
Do we have any evidence for either of them?
high PO4 does induce vascular calcfication
from https://pubmed.ncbi.nlm.nih.gov/11009570/
may cause a phenotypic switch
from https://pubmed.ncbi.nlm.nih.gov/11009570/
may cause a phenotypic switch
or this schematic from https://pubmed.ncbi.nlm.nih.gov/27282935/ in @Kidney_Int
that's the basic science - lets turn to clinical data now
that's the basic science - lets turn to clinical data now
From Geoff Block in @JASN_News - observational data from 2004
https://jasn.asnjournals.org/content/15/8/2208
Note U shaped curve
https://jasn.asnjournals.org/content/15/8/2208
Note U shaped curve
Or see this from @SuetoniaPalmer in @JAMA_current as of 2011 https://pubmed.ncbi.nlm.nih.gov/21406649/ a systematic review of all the observational data
Despite no trials, the @goKDIGO and other groups give recommendations for PO4 control that go way beyond the clinical evidence eg https://kdigo.org/guidelines/ckd-mbd/
restricting dietary PO4 for patients is not without harm
See where PO4 restriction ranks from Patient Priorities via @Manns2Manns @AndreasLaupacis in https://pubmed.ncbi.nlm.nih.gov/24832095/ in @cjasn
See where PO4 restriction ranks from Patient Priorities via @Manns2Manns @AndreasLaupacis in https://pubmed.ncbi.nlm.nih.gov/24832095/ in @cjasn
Even intensified dialysis improves the numbers
but should we ask someone to ask them to change their life for better numbers?
This is a question raised from the above patient priorities paper as well
but should we ask someone to ask them to change their life for better numbers?
This is a question raised from the above patient priorities paper as well
What about binders?
huge pill burden
From @SuetoniaPalmer et al in @AJKDonline https://pubmed.ncbi.nlm.nih.gov/27461851/
short follow up and no reduction in mortality from trials so far
huge pill burden
From @SuetoniaPalmer et al in @AJKDonline https://pubmed.ncbi.nlm.nih.gov/27461851/
short follow up and no reduction in mortality from trials so far
Pill burden is a priority for patients
duh
duh
In the US, we spend 1.5 Billion annually on binders with no evidence of mortality benefit
Numbers from @AJKDonline https://pubmed.ncbi.nlm.nih.gov/29195858/
Numbers from @AJKDonline https://pubmed.ncbi.nlm.nih.gov/29195858/
Sure: we do need some data about feasibility
this lead to the TARGET trial, publishe din @CJASN https://cjasn.asnjournals.org/content/12/6/965 from @DrRonWald and @lastwalsh
this lead to the TARGET trial, publishe din @CJASN https://cjasn.asnjournals.org/content/12/6/965 from @DrRonWald and @lastwalsh
In the TARGET trial
Intensive arm: Aim for < 1.50
In the liberalized group, a serum PO4e concentration of >6.20 mg/dl (2.00 mmol/L), but rescue for >7.75 mg/dl (2.50 mmol/L), was targeted
Liberal arm: most patients came off the binders!
Intensive arm: Aim for < 1.50
In the liberalized group, a serum PO4e concentration of >6.20 mg/dl (2.00 mmol/L), but rescue for >7.75 mg/dl (2.50 mmol/L), was targeted
Liberal arm: most patients came off the binders!
@DrRonWald walks through the questions for the next step they faced
HD or HD and PD/CKD
How do we manage other MBD features
What kind of outcomes do we want?
Shows @song_initiative
HD or HD and PD/CKD
How do we manage other MBD features
What kind of outcomes do we want?
Shows @song_initiative
We also want to have trials have better generalizable
RCTs in dialysis population
- more GN, less DM
- lessmortality
compared to real world data
See from https://pubmed.ncbi.nlm.nih.gov/31282924/
RCTs in dialysis population
- more GN, less DM
- lessmortality
compared to real world data
See from https://pubmed.ncbi.nlm.nih.gov/31282924/
Leads to the @PhosphateRct Design
N = 3600, Event driven (MACE, 1190)
Intensive PO4 < 1.50
vs
Liberal PO4 rescue only if PO4 > 2.50
(use diet, binders, other means) https://clinicaltrials.gov/ct2/show/NCT03573089
N = 3600, Event driven (MACE, 1190)
Intensive PO4 < 1.50
vs
Liberal PO4 rescue only if PO4 > 2.50
(use diet, binders, other means) https://clinicaltrials.gov/ct2/show/NCT03573089
