tag:blogger.com,1999:blog-4230162007222918868.post4536646228492092240..comments2023-09-19T05:50:03.130-04:00Comments on Renal Fellow Network: Follow the patient, not the numberGearoid McMahonhttp://www.blogger.com/profile/08049723797363526138noreply@blogger.comBlogger9125tag:blogger.com,1999:blog-4230162007222918868.post-92215696434643455882011-04-17T10:06:23.785-04:002011-04-17T10:06:23.785-04:00Let me add a developing country perspective too. W...Let me add a developing country perspective too. When RENAL CARE appears to be impossible to be funded by Insurance (public or private), imagine funding it out of pocket. It is the reality in India. Add a higher prevalence of vegetarian diet - like prevalent in India. You can actually stretch conservative care quite a number of years. IDEAL trial only vindicated patient choice in this part of world and also assured Nephrologists that they may making the right choice scientifically too.Anonymousnoreply@blogger.comtag:blogger.com,1999:blog-4230162007222918868.post-49833072354630217352010-07-10T13:20:03.085-04:002010-07-10T13:20:03.085-04:00Agreed completely with you about this. I think thi...Agreed completely with you about this. I think this is also a good point to make. Looking at an ESTIMATED GFR value, especially at this low of renal function, is likely not very accurate. The editorial points this out as well. Again, another reason we cannot just look at the number. I have seen in many instances were the MDRD eGFR can fluctuate between 2-4 points in a few months. I think the real point to make is that picking an arbitrary number to start RRT is incorrect, but looking at multiple issues and choosing to start RRT is more of an individual patient by patient decision. The paper has flaws for sure, but this trial represents the first real randomized attempt to look at this fundamental question.Matt Sparkshttps://www.blogger.com/profile/16723646412313444698noreply@blogger.comtag:blogger.com,1999:blog-4230162007222918868.post-45082144775684843612010-07-10T13:06:18.130-04:002010-07-10T13:06:18.130-04:00how sensitive is the MDRD equation in differentiat...how sensitive is the MDRD equation in differentiating between 12cc/min and 9.8 cc/min? to me, the delta in GFR between the 2 groupd was not enough to justify any real conclusions.Anonymousnoreply@blogger.comtag:blogger.com,1999:blog-4230162007222918868.post-85652811724947363972010-07-08T23:59:38.054-04:002010-07-08T23:59:38.054-04:00From my read of the study rationale and design
ht...From my read of the study rationale and design<br /><br />http://www.pdiconnect.com/cgi/content/abstract/24/2/176?ijkey=d1115ded3ca257ddbafbf92583b679da4c0f019e&keytype2=tf_ipsecsha<br /><br />"QOL data was collected in both groups every 3 months". Although the data was not expressed in table/figure form. It was mentioned in the NEJM text that no difference was seen in both groups."No significant difference in fluid and electrolyte disturbances was seen between the study groups, and no difference in quality of life was observed between the groups at any stage of the study"Matt Sparkshttps://www.blogger.com/profile/16723646412313444698noreply@blogger.comtag:blogger.com,1999:blog-4230162007222918868.post-77096060683698028332010-07-08T21:56:43.785-04:002010-07-08T21:56:43.785-04:00The QOL index was not used to measure quality of l...The QOL index was not used to measure quality of life during the 'wait period' for the late initiation group (about six months). It appears it was for the post initiation follow-up of both the groups after they had been on HD for a total follow-up of about 3 years. I think it would have been important to see how the QOL compared between early initiation and waiting, during the 'wait period'.-TarunTarunhttps://www.blogger.com/profile/02674154928191744404noreply@blogger.comtag:blogger.com,1999:blog-4230162007222918868.post-5974519569427250992010-07-08T17:54:58.752-04:002010-07-08T17:54:58.752-04:00Thanks Matt. Excellent post and well put.
Like a...Thanks Matt. Excellent post and well put. <br /><br />Like a lot of my colleagues, I am usually very comfortable waiting 'as long as possible'. Of course, it is necessary to make sure that the patients symptoms (if any) are mild / very much tolerable, their labs are non-life threatening and they are reliable with their diets / follow up appointments. <br /><br />I often explain this to patients as the "gray-zone" and explain the pros / cons of waiting longer... I find it is important to encourage a partnership with the patient in regards to the decision to start RRT.<br /><br />This study has limitations.. But, a study like this I believe can make us feel more comfortable about waiting longer, which as we know.. may patients prefer. <br /><br />Thanks again for the mention.. and keep up the great work here!<br /><br />SimonAnonymoushttps://www.blogger.com/profile/03460983023759293165noreply@blogger.comtag:blogger.com,1999:blog-4230162007222918868.post-15938095564733604642010-07-08T13:10:15.756-04:002010-07-08T13:10:15.756-04:00Actually, the late dialysis group had more tempora...Actually, the late dialysis group had more temporary catheter use than the early group. However, I do not know about the hospitalization issue for uremic sx/volume overload. Good point.Matt Sparkshttps://www.blogger.com/profile/16723646412313444698noreply@blogger.comtag:blogger.com,1999:blog-4230162007222918868.post-8149530725416762182010-07-08T13:07:24.952-04:002010-07-08T13:07:24.952-04:00actually a quality of life score was measured duri...actually a quality of life score was measured during this trial. "No significant difference was observed between the two groups in quality of life, as measured by the Assessment of Quality of Life instrument during the follow-up period of the trial"- taken from the article.Matt Sparkshttps://www.blogger.com/profile/16723646412313444698noreply@blogger.comtag:blogger.com,1999:blog-4230162007222918868.post-55373680590102135542010-07-08T13:03:49.127-04:002010-07-08T13:03:49.127-04:00I think an important question is quality of life t...I think an important question is quality of life that is not addressed in this study. does starting a patient early allow an easier transition to dialysis, save on cost of hospitalization for uremic sx/vol overload. Mortality is a very important but lets not forget quality of life.Anonymousnoreply@blogger.com