Citation: Hendrikse KA, Gratama JW, Jove W, et al. Low value of routine chest radiographs in a mixed medical-surgical ICU. Chest. 2007;132:823-828.
Background: Left ventricle (LV) hypertrophy, heart failure, and sudden cardiac death are responsible for significant morbidity and mortality in patients with end-stage renal disease (ESRD). In the general population, reduction of LV mass lowers risk of major cardiovascular events. Some evidence suggests that nocturnal hemodialysis reduces LV mass and blood pressure, and improves mineral metabolism.
Study design: Small randomized controlled trial.
Setting: Two university medical centers in Alberta, Canada.
Synopsis: Fifty-two hemodialysis patients were randomized to receive nocturnal hemodialysis six times weekly or conventional hemodialysis three times weekly. Cardiovascular magnetic resonance imaging assessed LV mass at the beginning and end of six months. Secondary outcomes included health-related quality of life, predialysis systolic blood pressure, and calcium-phosphate product.
LV mass decreased with nocturnal hemodialysis (p=.04). Average systolic blood pressure dropped 7 mm Hg despite antihypertensive medication reductions or discontinuation in many patients receiving nocturnal hemodialysis. The calcium-phosphate product decreased, thus reducing the need for phosphate binders and calcium supplementation. No significant effect on health-related quality of life was found in the primary analysis; however, a small improvement was seen in the nocturnal hemodialysis arm when comparing values from the time of randomization and six months.
The outcomes measured were not validated in patients with ESRD. The dose of dialysis was not compared between the two groups. Confidence intervals were wide and the duration of follow-up limited. The study was underpowered for differences in mortality, quality of life, or adverse event rates.
Bottom Line: Frequent nocturnal hemodialysis may improve cardiovascular outcomes, reduce the need for medications, and enhance quality of life for patients with ESRD having the physical and mental capacity to perform it safely.
Citation: Culleton BF, Walsh M, Klarenbach SW, et al. Effect of frequent nocturnal hemodialysis vs. conventional hemodialysis on left ventricular mass and quality of life. JAMA. 2007;298(11):1291-1299.
Background: In-hospital hyperglycemia is associated with adverse outcomes. Recent guidelines support tight glycemic control for most hospitalized patient populations. Little is known about the current practice of glycemic control in non-critically ill patients.
Study design: Retrospective cohort analysis.
Setting: A 200-bed tertiary-care U.S. teaching hospital.
Synopsis: Hospital databases were reviewed for 2,916 non-critically ill patients discharged after three days with a diagnosis of diabetes or hyperglycemia. Glycemic control was assessed by blood glucose (BG) measurement during the first 24 hours, BG prior to discharge, and overall hospital stay.
Hyperglycemia (BG more than 200 mg/dL) occurred in 20% to 25% of patients throughout the hospital stay or during the first or final 24 hours. The same percentage had at least one hypoglycemic episode (BG less than 70 mg/dL). Most patients received insulin, either alone or in combination with oral agents. Of those, 58% received short-acting bolus insulin, while only 42% were treated with basal-bolus insulin regimens. Insulin administered during the first and the final 24 hours increased in 54% of patients, decreased in 39%, and remained unchanged in 7%. Almost one-third had reductions in insulin therapy despite persistent hyperglycemia.
This single-site study did not distinguish between pre-existing diabetes, unrecognized diabetes, or stress-induced hyperglycemia. The electronic databases did not permit analysis of clinical decision-making behavior or the nutritional support utilized to explain the findings.
Bottom Line: Glycemic control in non-critically ill hospitalized patients appears limited by failure to change treatment when indicated (clinical inertia) and diminution of treatment despite ongoing hyperglycemia (negative therapeutic momentum).