Dialyzer Performance During Hemodialysis Without Systemic Anticoagulation Using a Heparin-Grafted Dialyzer Combined With a Citrate-Enriched Dialysate: Results of the Randomized Crossover Noninferiority EvoCit Study

RATIONALE & OBJECTIVE

The EvoCit study was designed to evaluate performance of a heparin-grafted dialyzer during hemodialysis with and without systemic anticoagulation.

STUDY DESIGN

Randomized, crossover, noninferiority trial. Noninferiority was defined as a difference of≤10% for the primary outcome.

SETTING & PARTICIPANTS

Single hemodialysis center; 26 prevalent patients treated with 617 hemodialysis sessions.

INTERVENTIONS

Hemodialysis using a heparin-grafted dialyzer combined with a 1.0mmol/L citrate-enriched dialysate ("EvoCit") without systemic anticoagulation compared with hemodialysis performed with a heparin-grafted dialyzer with systemic heparin ("EvoHep"). Patients were randomly allocated to a first period of 4 weeks and crossed over to the alternative strategy for a second period of 4 weeks.

OUTCOMES

The primary end point was the difference in Kt/V_urea between EvoCit and EvoHep. Secondary end points were urea reduction ratio, middle molecule removal, treatment time, thrombin generation, and reduction in dialyzer blood compartment volume.

RESULTS

The estimated difference in Kt/V_urea between EvoCit and EvoHep was-0.03 (95% CI, -0.06 to-0.007), establishing noninferiority with mean Kt/V_urea of 1.47±0.05 (SE) for EvoCit and 1.50±0.05 for EvoHep. Noninferiority was also established for reduction ratios of urea and β₂-microglobulin. Premature discontinuation of dialysis was required for 4.2% of sessions among 6 patients during EvoCit and no sessions during EvoHep. Effective treatment time was 236±5 minutes for EvoCit and 238±1 minutes for EvoHep. Thrombin generation was increased and there was greater reduction in dialyzer blood compartment volume after treatments with EvoCit compared with EvoHep.

LIMITATIONS

The effects of avoiding systemic anticoagulation on clinical outcomes were not evaluated.

CONCLUSIONS

EvoCit is noninferior to EvoHep with respect to solute clearance but results in a greater number of shortened treatments, more membrane clotting, and greater thrombin generation TRIAL REGISTRATION: Registered at ClinicalTrials.gov with study number NCT03887468.

Comparison of Two Different Drugs for Overactive Bladder, Solifenacin and Mirabegron: A Prospective Randomized Crossover Study

To assess the efficacy and safety of 2 drugs for overactive bladder (OAB), solifenacin and mirabegron. Fortyseven female OAB patients were randomized into 2 groups. Twenty-three patients were initially prescribed solifenacin for 4 weeks, followed by mirabegron for 4 weeks (group S). The other 24 patients were initially prescribed mirabegron for 4 weeks, followed by solifenacin for 4 weeks (group M). Evaluations included clinical determination of the OAB symptom score (OABSS), International Prostate Symptom Score (IPSS), and Visual Analog Scale. The IPSS significantly improved after the administration of solifenacin in both groups. The OABSS significantly improved in both groups after 4 weeks. In group M, the OABSS after eight weeks was significantly improved compared to that after 4 weeks. However, in group S, it was not significantly improved. Twelve patients experienced adverse events during the solifenacin treatment, while 2 patients experienced adverse events during the mirabegron treatment. Both solifenacin and mirabegron led to improved OAB symptoms. Switching from mirabegron to solifenacin significantly improved the OABSS. However, mirabegron led to fewer adverse events than solifenacin. We recommend that mirabegron be prescribed first for OAB patients. If patients are not satisfied with mirabegron, solifenacin should be used.

A prospective, randomized crossover study comparing direct inspection by light microscopy versus projected images for teaching of hematopathology to medical students

Instruction in hematopathology at Mayo Medical School has evolved from instructor-guided direct inspection under the light microscope (laboratory method), to photomicrographs of glass slides with classroom projection (projection method). These methods have not been compared directly to date. Forty-one second-year medical students participated in this pilot study, a prospective, randomized, crossover study measuring educational performance during a hematology pathophysiology course. The students were randomized to one of two groups. All students received the same didactic lectures in the classroom and subsequent case-based review of peripheral blood smears using either laboratory or projection methods, on day one with a crossover to the other method on day two. Pre- and post-test examinations centered on morphology recognition measured educational performance on each day, followed by a questionnaire identifying the student's favored method. There was no significant difference in the pre-test and post-test scores between the two teaching methods (rank-sum P = 0.43). Students overwhelmingly preferred the projection method and perceived it as superior (76%), although post-test scores were not significantly different. Student's recommended method was split with 50% favoring the projection method, 43% favoring a combined approach, and 23% noting logistical challenges to the laboratory. In this study, the laboratory and projection method were equivalent in terms of educational performance for hematopathology among medicals students. A classroom-based approach such as the projection method is favored, given the large class sizes in undergraduate medical education, as well as the ergonomic challenges and additional resources required for large group instruction in a laboratory setting.