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Kang A, Arnold R, Gallagher M, Snelling P, Green J, Fernando M, Kiernan MC, Hand S, Grimley K, Burman J, Heath A, Rogers K, Bhattacharya A, Smyth B, Bradbury T, Hawley C, Perkovic V, Krishnan AV, Jardine MJ. Effect of Hemodiafiltration on the Progression of Neuropathy with Kidney Failure: A Randomized Controlled Trial. Clin J Am Soc Nephrol 2021; 16:1365-1375. [PMID: 34233923 PMCID: PMC8729572 DOI: 10.2215/cjn.17151120] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2020] [Accepted: 06/23/2021] [Indexed: 11/23/2022]
Abstract
BACKGROUND AND OBJECTIVES Neuropathy is a common complication of kidney disease that lacks proven disease-modifying treatments. Hemodiafiltration improves clearance of uremic toxins and is associated with better nerve function than hemodialysis. We aimed to determine whether hemodiafiltration reduces the progression of neuropathy in people receiving hemodialysis. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS The Filtration in the Neuropathy of End-Stage Kidney Disease Symptom Evolution (FINESSE) study was an open-label, blinded end point assessment, controlled trial that randomized maintenance hemodialysis recipients to hemodiafiltration or high-flux hemodialysis for 48 months or until death or cessation of dialysis at four study centers. The primary outcome was the mean change in the yearly modified total neuropathy score from baseline, with time points weighted equally. RESULTS A total of 124 participants were randomized and followed for a mean of 41 months. At baseline, neuropathy was present in 91 (73%) participants (modified total neuropathy score greater than or equal to two), and 38 (31%) had moderate to severe neuropathy (modified total neuropathy score 9-28). Convection volume in the hemodiafiltration arm was a median of 24.7 (interquartile range, 22.4-26.5) L. The mean modified total neuropathy score (SEM) worsened by 1.7 (0.4)/28 and 1.2 (0.4)/28 in the hemodiafiltration and hemodialysis groups, respectively, with a mean difference of 0.5 (95% confidence interval, -0.7 to 1.7; P=0.37). There was no difference in survival (hazard ratio, 1.24; 95% confidence interval, 0.61 to 2.51; log rank P=0.55) or any of the prespecified adverse events. There was no difference between groups in the number of participants who suffered an adverse event adjusted by follow-up time (relative risk, 1.05; 95% confidence interval, 0.83 to 1.32; P=0.68). CONCLUSIONS Neuropathy is still a common complication of kidney disease without disease-altering therapy. Hemodiafiltration did not affect neuropathy progression compared with hemodialysis. CLINICAL TRIAL REGISTRY NAME AND REGISTRATION NUMBER Filtration in the Neuropathy of End-Stage Kidney Disease Symptom Evolution (FINESSE), ACTRN12609000615280.
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Affiliation(s)
- Amy Kang
- Renal and Metabolic Division, The George Institute, University of New South Wales Sydney, Sydney, New South Wales, Australia.,Department of Renal Medicine, Prince of Wales Hospital, Sydney, New South Wales, Australia.,Department of Medicine, University of New South Wales Sydney, Sydney, New South Wales, Australia
| | - Ria Arnold
- Department of Medicine, University of New South Wales Sydney, Sydney, New South Wales, Australia
| | - Martin Gallagher
- Renal and Metabolic Division, The George Institute, University of New South Wales Sydney, Sydney, New South Wales, Australia.,Department of Renal Medicine, Concord Hospital, Sydney, New South Wales, Australia
| | - Paul Snelling
- Department of Renal Medicine, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
| | - Julianne Green
- Department of Renal Medicine, Sydney Adventist Hospital, Sydney, New South Wales, Australia
| | - Mangalee Fernando
- Department of Renal Medicine, Prince of Wales Hospital, Sydney, New South Wales, Australia.,Department of Medicine, University of New South Wales Sydney, Sydney, New South Wales, Australia
| | - Matthew C Kiernan
- Department of Neurology, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia.,Brain and Mind Centre, University of Sydney, Sydney, New South Wales, Australia
| | - Samantha Hand
- Department of Renal Medicine, Concord Hospital, Sydney, New South Wales, Australia
| | - Kim Grimley
- Department of Renal Medicine, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
| | - Jenny Burman
- Department of Renal Medicine, Concord Hospital, Sydney, New South Wales, Australia
| | - Anne Heath
- Department of Renal Medicine, Sydney Adventist Hospital, Sydney, New South Wales, Australia
| | - Kris Rogers
- Statistics Division, The George Institute The George Institute, University of New South Wales Sydney, Sydney, New South Wales, Australia.,Department of Statistics, University of Technology, Sydney, New South Wales, Australia
| | - Amritendu Bhattacharya
- Statistics Division, The George Institute The George Institute, University of New South Wales Sydney, Sydney, New South Wales, Australia
| | - Brendan Smyth
- Renal and Metabolic Division, The George Institute, University of New South Wales Sydney, Sydney, New South Wales, Australia.,Kidney Health Division, National Health and Medical Research Council of Australia Clinical Trials Centre, University of Sydney, Sydney, New South Wales, Australia.,Department of Renal Medicine, St. George Hospital, Sydney, New South Wales, Australia
| | - Thomas Bradbury
- Renal and Metabolic Division, The George Institute, University of New South Wales Sydney, Sydney, New South Wales, Australia
| | - Carmel Hawley
- Australasian Kidney Trials Network, University of Queensland, Brisbane, Queensland, Australia
| | - Vlado Perkovic
- Renal and Metabolic Division, The George Institute, University of New South Wales Sydney, Sydney, New South Wales, Australia.,Department of Medicine, University of New South Wales Sydney, Sydney, New South Wales, Australia
| | - Arun V Krishnan
- Department of Medicine, University of New South Wales Sydney, Sydney, New South Wales, Australia.,Department of Neurology, Prince of Wales Hospital, Sydney, New South Wales, Australia
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Smyth B, Krishnan AV, Gallagher M, Kiernan M, Snelling P, Hawley C, Fernando M, Hand S, Grimley K, Burman J, Heath A, Kang A, Perkovic V, Jardine MJ. Randomised controlled trial of the impact of haemodiafiltration on uraemic neuropathy: FINESSE study protocol. BMJ Open 2019; 9:e023736. [PMID: 30782714 PMCID: PMC6340424 DOI: 10.1136/bmjopen-2018-023736] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
INTRODUCTION The majority of patients undergoing haemodialysis (HD) show evidence of uraemic neuropathy, a condition with no known disease-modifying treatments. The pathogenesis of uraemic neuropathy is poorly understood, but may be related to cumulative exposure to middle molecules or other solutes such as potassium. It is not known whether haemodiafiltration (HDF) reduces the progression of uraemic neuropathy. METHODS AND ANALYSIS Filtration In the Neuropathy of End-Stage kidney disease Symptom Evolution (FINESSE) is a multicentre, randomised, open-label, blinded endpoint assessment, controlled trial designed to assess the impact of HDF versus HD on uraemic neuropathy. Maintenance HD patients will be randomised in a 1:1 ratio to receive HDF or HD with high-flux membranes for 4 years. The primary endpoint is the difference in the mean change in Total Neuropathy Score (TNS)-a measure of peripheral neuropathy combining symptoms, signs and nerve conduction velocity-over the study period. Secondary outcomes include change at annual timepoints in the TNS and the Neuropathy Symptom Score; and in morbidity, mortality and safety events. ETHICS AND DISSEMINATION The FINESSE trial has been approved by the Ethics Review Committee of the Sydney South West Area Health Service (HREC/09/RPAH/268) and of Adventist HealthCare Limited (2012-027). When published in a peer-reviewed journal, it will be the largest and longest reported randomised trial aimed at reducing the incidence and severity of uraemic neuropathy. It will advance the understanding of the natural history of uraemic neuropathy and the influence of convective therapies on both neurophysiological and clinical outcomes. It will also allow refinement of current hypotheses surrounding the pathogenesis of uraemic neuropathy and, most importantly, may lead to improvements in the lives of the many patients affected by this debilitating condition. TRIAL REGISTRATION NUMBER ACTRN12609000615280.
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Affiliation(s)
- Brendan Smyth
- Renal and Metabolic, The George Institute for Global Health, UNSW, Newtown, New South Wales, Australia
| | - Arun V Krishnan
- Neurology, Prince of Wales Clinical School, UNSW, Sydney, New South Wales, Australia
| | - Martin Gallagher
- Renal and Metabolic, The George Institute for Global Health, UNSW, Newtown, New South Wales, Australia
- Renal Medicine, Concord Repatriation General Hospital, Sydney, New South Wales, Australia
| | - Matthew Kiernan
- Brain and Mind Centre, University of Sydney, Sydney, New South Wales, Australia
| | - Paul Snelling
- Renal Medicine, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
| | - Carmel Hawley
- Renal Medicine, Princess Alexandra Hospital, Brisbane, Queensland, Australia
| | - Mangalee Fernando
- Renal Medicine, Prince of Wales Hospital, Sydney, New South Wales, Australia
| | - Samantha Hand
- Renal Medicine, Concord Repatriation General Hospital, Sydney, New South Wales, Australia
| | - Kim Grimley
- Renal Medicine, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
| | - Jenny Burman
- Renal Medicine, Concord Repatriation General Hospital, Sydney, New South Wales, Australia
| | - Anne Heath
- Renal Medicine, Sydney Adventist Hospital, Sydney, New South Wales, Australia
| | - Amy Kang
- Renal and Metabolic, The George Institute for Global Health, UNSW, Newtown, New South Wales, Australia
| | - Vlado Perkovic
- Renal and Metabolic, The George Institute for Global Health, UNSW, Newtown, New South Wales, Australia
| | - Meg J Jardine
- Renal and Metabolic, The George Institute for Global Health, UNSW, Newtown, New South Wales, Australia
- Renal Medicine, Concord Repatriation General Hospital, Sydney, New South Wales, Australia
- Renal Medicine, Sydney Adventist Hospital, Sydney, New South Wales, Australia
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