Continuous ambulatory peritoneal dialysis versus automated peritoneal dialysis for end-stage renal disease.

BACKGROUND: Peritoneal dialysis (PD) can be performed either manually as in continuous ambulatory peritoneal dialysis (CAPD) or using mechanical devices as in automated PD (APD). APD has been considered to have several advantages over CAPD such as reduced incidence of peritonitis, mechanical complications and greater psychosocial acceptability. OBJECTIVES: To assess the comparative efficacy of CAPD and APD in patients who are dialysed for end-stage renal disease (ESRD). SEARCH STRATEGY: We searched MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials (CENTRAL), Cochrane Renal Group's specialised register and CINAHL. Authors of included studies were contacted, reference lists of identified RCTs and relevant narrative reviews were screened. Date of most recent search: May 2006 SELECTION CRITERIA: RCTs comparing CAPD with APD in patients with ESRD. DATA COLLECTION AND ANALYSIS: Data were abstracted independently by two authors onto a standard form. Relative risk (RR) for dichotomous data and a mean difference (MD) for continuous data were calculated with 95% confidence intervals (CI). MAIN RESULTS: Three trials (139 patients) were included. APD did not differ from CAPD with respect to mortality (RR 1.49, 95% CI 0.51 to 4.37), risk of peritonitis (RR 0.75, 95% CI 0.50 to 1.11), switching from original PD modality to a different dialysis modality (RR 0.50, 95% CI 0.25 to 1.02), hernias (RR 1.26, 95% interval 0.32 to 5.01), PD fluid leaks (RR 1.06, 95% CI 0.11 to 9.83), PD catheter removal (RR 0.64, 95% CI 0.27 to 1.48) or hospital admissions (RR 0.96, 95% CI 0.43 to 2.17). There was no difference between either PD modality with respect to residual renal function (MD -0.17, 95% CI -1.66 to 1.32). One study found that peritonitis rates and hospitalisation were significantly less in patients on APD when results were expressed as episodes/patient-year. Another study found that patients on APD had significantly more time for work, family and social activities. AUTHORS' CONCLUSIONS: APD has not been shown to have significant advantages over CAPD in terms of important clinical outcomes. APD may however be considered advantageous in select group of patients such as in the younger PD population and those in employment or education due to its psychosocial advantages. There is a need for a RCT comparing CAPD with APD with sufficiently large patient numbers looking at important clinical outcomes including residual renal function, accompanied by an economic evaluation to clarify the relative clinical and cost-effectiveness of both modalities.

Haemodiafiltration, haemofiltration and haemodialysis for end-stage kidney disease.

BACKGROUND: Renal replacement therapy (RRT) for end-stage kidney disease (ESKD) can be achieved by several interventions including haemodialysis (HD), peritoneal dialysis (PD) and kidney transplantation. HD, haemofiltration (HF), haemodiafiltration (HDF) and acetate-free biofiltration (AFB) are extracorporeal RRT methods. It has been suggested that HF and HDF may reduce the frequency and severity of intradialytic and post-dialytic adverse symptoms and may be more effective than HD in the removal of high molecular weight molecules. OBJECTIVES: To compare convective modes of extracorporeal RRT (HF, HDF or AFB) with HD and to establish if any of these techniques is superior to each other in patients with ESKD. SEARCH STRATEGY: We searched MEDLINE (1966-2006), EMBASE (1980-2006), Cochrane Central Register of Controlled Trials (CENTRAL, in The Cochrane Library issue 2, 2006) and CINAHL (1872-2006). Authors of included studies were contacted, reference lists of identified RCTs and relevant narrative reviews were screened. SELECTION CRITERIA: RCTs comparing HF, HDF, AFB and HD for ESKD were included. Trials enrolling any patient undergoing RRT for ESKD were included. DATA COLLECTION AND ANALYSIS: Two authors independently assessed trial quality and extracted data. Statistical analyses were performed using the random effects model and the results expressed as relative risk (RR) for dichotomous outcomes or weighted mean difference (MD) for continuous data with 95% confidence intervals (CI). Heterogeneity was measured using the Chi-square (chi(2)) and I(2) statistic. MAIN RESULTS: Twenty studies (657 patients) were included. Seventeen studies compared HF, HDF or AFB with HD, two compared HDF with AFB and one compared HF with HDF. The studies were generally small with suboptimal quality. Convective modalities (HF, HDF, AFB) did not differ significantly from HD for mortality (RR 1.68, 95% CI 0.23 to 12.13; chi(2)= 2.58, P = 0.11, I(2) = 61.2%), number of hospital admissions/year (MD 0.20, 95% CI -0.07 to 0.47) and dialysis adequacy (Kt/V: MD 0.09, 95% CI 0.02 to 0.17; chi(2) = 3.73, P = 0.29, I(2) = 19.6%). No study assessed number of dialysis treatments associated with "any adverse symptoms", sessions that were stopped early, change of dialysis modality or dialysis-related amyloidosis. AUTHORS' CONCLUSIONS: We were unable to demonstrate whether convective modalities (either HF, HDF or AFB) have significant advantages over HD with regard to clinically important outcomes of mortality, dialysis-related hypotension and hospitalisation. More adequately-powered good quality RCTs assessing clinically important outcomes (mortality, hospitalisation, quality of life) are needed.

Systematic review of randomized trials comparing rubber band ligation with excisional haemorrhoidectomy.

BACKGROUND AND METHOD: This review compares the two most popular treatments for haemorrhoids, namely rubber band ligation (RBL) and excisional haemorrhoidectomy. Randomized trials were identified from the major electronic databases. Symptom control, retreatment, postoperative pain, complications, time off work and patient satisfaction were assessed. Relative risk (RR) and weighted mean difference with 95 per cent confidence interval (c.i.) were estimated using a random-effects model for dichotomous and continuous outcomes respectively. RESULTS: Three trials met the inclusion criteria and all were of poor methodological quality. Complete remission of haemorrhoidal symptoms was better after haemorrhoidectomy (RR 1.68 (95 per cent c.i 1.00 to 2.83)). There was significant heterogeneity between the studies (I(2) = 90.5 per cent; P < 0.001). Fewer patients required retreatment after haemorrhoidectomy (RR 0.20 (95 per cent c.i 0.09 to 0.40)), but anal stenosis, postoperative haemorrhage and incontinence to flatus were more common with this operation. CONCLUSIONS: Haemorrhoidectomy produced better long-term symptom control in patients with grade III haemorrhoids, but was associated with more postoperative complications than RBL.

Cellulose, modified cellulose and synthetic membranes in the haemodialysis of patients with end-stage renal disease.

BACKGROUND: When the kidney fails the blood-borne metabolites of protein breakdown and water cannot be excreted. The principle of haemodialysis is that such substances can be removed when blood is passed over a semipermeable membrane. Natural membrane materials include cellulose or modified cellulose, more recently various synthetic membranes have been developed. Synthetic membranes are regarded as being more "biocompatible" in that they incite less of an immune response than cellulose-based membranes. OBJECTIVES: To assess the effects of different haemodialysis membrane material in patients with end-stage renal disease (ESRD). SEARCH STRATEGY: We searched MEDLINE, EMBASE, PreMEDLINE, HealthStar CINAHL, the Cochrane Central Register of Controlled Trials (CENTRAL), Biosis, SIGLE, CRIB, UK National Research Register and reference lists of relevant articles. We contacted biomedical companies, known investigators and handsearched selected journals and conference proceedings. Date of most recent search: June 2004. SELECTION CRITERIA: All randomised controlled trials (RCTs) or quasi-RCTs comparing different haemodialysis membrane material in patients with ESRD. DATA COLLECTION AND ANALYSIS: Two reviewers independently assessed the methodological quality of studies. Data was abstracted onto a standard form by one reviewer and checked by another. Relative Risk (RR) and weighted mean difference (WMD) with 95% confidence intervals (CI)) MAIN RESULTS: Thirty two studies were identified. Pre-dialysis ss(2) microglobulin concentrations were not significantly lower in patients treated with synthetic membranes (WMD -14.67, 95% CI -33.10 to 4.05). When analysed for change in ss(2) microglobulin, a fall was only noted with high-flux membranes. The incidence of amyloid was less in patients who were dialysed for six years with high-flux synthetic membranes (one study, RR 0.03, 95% CI 0.00 to 0.54). There was a significant difference in favour of the synthetic (high-flux) membrane in comparison to cellulose membranes for triglycerides (WMD -0.66; 95% CI -1.18 to -0.14) but not for modified cellulose membranes. Dialysis adequacy measured by Kt/V was marginally higher when cellulose membranes were used (WMD -0.10; 95% CI -0.16 to 0.04), whereas synthetic membranes achieved significantly higher Kt/V values when compared with modified cellulose membranes (WMD 0.20, 95% 0.11 to 0.29) . There were no data on quality of life measures. AUTHORS' CONCLUSIONS: We found no evidence of benefit when synthetic membranes were compared with cellulose/modified cellulose membranes in terms of reduced mortality no reduction in dialysis-related adverse symptoms. Despite the relatively large number of RCTs undertaken in this area none of the included studies reported any measures of quality of life.

Psychosocial interventions for depression in dialysis patients.

BACKGROUND: Depression is the most common psychological problem in the dialysis population. The diagnosis of depression in dialysis patients is confounded by the fact that several symptoms of uraemia mimic the somatic components of depression. It affects the physical, psychological and social well being of the dialysis population in several ways. OBJECTIVES: The aim of this systematic review was to assess the effectiveness of psychosocial interventions in the treatment of depression in patients who are dialysed for end-stage renal disease. SEARCH STRATEGY: A comprehensive search strategy was employed to identify all randomised controlled trials (RCTs) relevant to the treatment of depression in dialysis patients. The following databases were searched - MEDLINE (1966 - October 2003), EMBASE (1980 - October 2003), PsycINFO (1872 - October 2003) and The Cochrane Library (issue 3, 2003). Authors of potential studies were contacted, reference lists of identified RCTs and relevant narrative reviews were screened. SELECTION CRITERIA: RCTs comparing any psychosocial intervention with control intervention or no intervention in depressed dialysis patients. DATA COLLECTION AND ANALYSIS: Data were to be abstracted by two investigators independently onto a standard form and entered into Review Manager 4.2. Relative risk (RR) for dichotomous data and a (weighted) mean difference (MD) for continuous data were to be calculated with 95% confidence intervals (CI). MAIN RESULTS: Despite extensive searching, no RCTs were identified. AUTHORS' CONCLUSIONS: Data were not available to draw conclusions about the effectiveness of psychosocial interventions in the treatment of depression in the chronic dialysis population, as we did not find any RCTs of psychosocial interventions to treat depression in dialysis patients. This review highlights the need for commencing and completing adequately powered RCTs to address the issue of psychosocial interventions for depression in dialysis patients.

Rubber band ligation versus excisional haemorrhoidectomy for haemorrhoids.

BACKGROUND: Traditional treatment methods for haemorrhoids fall into two broad groups: less invasive techniques including rubber band ligation (RBL), which tend to produce minimal pain, and the more radical techniques like excisional haemorrhoidectomy (EH), which are inherently more painful. For decades, innovations in the field of haemorrhoidal treatment have centred on modifying the traditional methods to achieve a minimally invasive, less painful procedure and yet with a more sustainable result. The availability of newer techniques has reopened debate on the roles of traditional treatment options for haemorrhoids. OBJECTIVES: To review the efficacy and safety of the two most popular conventional methods of haemorrhoidal treatment, rubber band ligation and excisional haemorrhoidectomy. SEARCH STRATEGY: We searched all the major electronic databases (MEDLINE, EMBASE, CENTRAL, CINAHL). SELECTION CRITERIA: Randomised controlled trials comparing rubber band ligation with excisional haemorrhoidectomy for symptomatic haemorrhoids in adult human patients were included. DATA COLLECTION AND ANALYSIS: We extracted data on to previously designed data extraction sheet. Dichtomous data were presented as relative risk and 95% confidence intervals, and continuous outcomes as weighted mean difference and 95% confidence intervals. MAIN RESULTS: Three trials (of poor methodological quality) met the inclusion criteria. Complete remission of haemorrhoidal symptom was better with EH (three studies, 202 patients, RR 1.68, 95% CI 1.00 to 2.83). There was significant heterogeneity between the studies (I2 = 90.5%; P = 0.0001). Similar analysis based on the grading of haemorrhoids revealed the superiority of EH over RBL for grade III haemorrhoids (prolapse that needs manual reduction) (two trials, 116 patients, RR 1.23, CI 1.04 to 1.45; P = 0.01). However, no significant difference was noticed in grade II haemorrhoids (prolapse that reduces spontaneously on cessation of straining) (one trial, 32 patients, RR 1.07, CI 0.94 to 1.21; P = 0.32) Fewer patients required re-treatment after EH (three trials, RR 0.20 CI 0.09 to 0.40; P < 0.00001). Patients undergoing EH were at significantly higher risk of postoperative pain (three trials, fixed effect; 212 patients, RR 1.94, 95% CI 1.62 to 2.33, P < 0.00001). The overall delayed complication rate showed significant difference (P = 0.03) (three trials, 204 patients, RR 6.32, CI 1.15 to 34.89) between the two interventions. AUTHORS' CONCLUSIONS: The present systematic review confirms the long-term efficacy of EH, at least for grade III haemorrhoids, compared to the less invasive technique of RBL but at the expense of increased pain, higher complications and more time off work. However, despite these disadvantages of EH, patient satisfaction and patient's acceptance of the treatment modalities seems to be similar following both the techniques implying patient's preference for complete long-term cure of symptoms and possibly less concern for minor complications. So, RBL can be adopted as the choice of treatment for grade II haemorrhoids with similar results but with out the side effects of EH while reserving EH for grade III haemorrhoids or recurrence after RBL. More robust study is required to make definitive conclusions.

Physical measures for treating depression in dialysis patients.

BACKGROUND: Depression is the most common psychological problem in the chronic dialysis population. The diagnosis of depression in patients on chronic dialysis is confounded by the fact that several symptoms of uraemia mimic the somatic components of depression. It affects their physical, psychological and social well-being. Furthermore, the frequent occurrence of cardiovascular problems and the pharmacokinetic consequences of renal impairment may make drug treatment of depression difficult. OBJECTIVES: The aim of this systematic review was to assess the efficacy and safety of physical measures in the treatment of depression in patients who are dialysed for end-stage renal disease. SEARCH STRATEGY: A comprehensive search strategy was employed to identify all Randomised Controlled Trials (RCTs) relevant to the treatment of depression in patients on chronic dialysis. The following database were searched - MEDLINE (1966-March 2004), EMBASE (1980-March 2004), PSYCHINFO (1872-March 2004), The Cochrane Library (Issue 1, 2004). Authors of included studies were contacted, reference lists of identified RCTs and relevant narrative reviews were screened. SELECTION CRITERIA: RCTs comparing drugs with placebo or no treatment, or a comparison of drugs against a combination of electroconvulsive therapy and drugs. DATA COLLECTION AND ANALYSIS: Data were abstracted by two investigators independently onto a standard form and subsequently entered into Review Manager 4.2. Relative risk (RR) for dichotomous data and a (weighted) mean difference (WMD) for continuous data were calculated with 95% confidence intervals (95% CI). MAIN RESULTS: Only one trial, with a total of 12 patients and of eight weeks duration was identified. The trial compared fluoxetine against placebo in depressed patients on chronic dialysis. This study did not show any significant difference in depression scores between the treatment and control groups or safety. AUTHORS' CONCLUSIONS: Firm conclusions on the efficacy of physical methods of treatment cannot be made as we identified only one small RCT that was of short duration. More larger and longer term RCTs are needed in this area. Current screening tools for depression are recognised to have poor specificity in the medically ill due to overlap of somatic symptoms of the medical illness. The development of a valid diagnostic tool would be helpful.

Comparative evaluation of the new Sheffield table and the modified joint British societies coronary risk prediction chart against a laboratory based risk score calculation.

BACKGROUND: Management of borderline hypertension and hypercholesterolaemia is based on an individual's coronary heart disease (CHD) risk rather than arbitrary values for blood pressure or serum cholesterol. Prediction of CHD risk involves using tables, charts, or computer programs based on the Framingham equations. The new Sheffield table and modified joint British societies coronary risk prediction (JBS) chart are widely used. The JBS chart approximates age and systolic blood pressure, and the new Sheffield table dichotomises blood pressure, and these simplifications may lead to diagnostic inaccuracy. METHODS: The diagnostic performance of the charts against an individualised laboratory based CHD risk calculation in 1102 subjects in primary care were evaluated and compared. RESULTS: The new Sheffield table and modified JBS chart performed equally well with a respective diagnostic sensitivity and specificity of 91.6% (95% confidence interval 86.7% to 95.1%) and 93.8% (91.1% to 97.9%), and 93.6% (90.4% to 96.0%) and 94.7% (92.6% to 96.1%) at 10 year CHD risk of 15%; and of 95.2% (82.8% to 99.4%) and 97.9% (96.8% to 98.7%), and 90.5% (75.6% to 97.4%) and 100% (99.7% to 100%) at 10 year CHD risk of 30%. The modified JBS chart graphic display provides graded risk, which may be an advantage over the new Sheffield table, which identifies thresholds of risk. The new Sheffield table, unlike any other method, can be used as screening tool for cholesterol measurement. CONCLUSIONS: The new Sheffield table and modified JBS chart are valid for use in primary care since their diagnostic accuracy is unaffected by approximations in age and blood pressure. It is suggested that practitioners should choose whichever risk assessment tool they are comfortable with and use it.