Tuesday, October 13, 2015

Please fund my #DreamRCT, it is just embarrassing how little evidence is found in hyponatremia

So I checked in at DreamRCT and noticed that my DreamRCT is no longer in the top five.

I'm a big boy and can take this (very minor) form of rejection but I do want to plead my case for a moment. You can read the entire description of my DreamRCT here. One of the dirty little secrets of nephrology is the almost total lack of prospective data on hyponatremia. There are a number of RCTs with regards to tolvaptan, conivaptan and other approved, and soon to be approved, vaptans. But after those there is an evidence desert populated by only a few mirages made up of case reports and retrospective analysis. From this scant data we have built a comprehensive and detailed model of how sodium acts in the body and the importance of osmoregulation. But thats like theoretical physics without a supercollider. We need to test the model with real data.

Think about the fact that hyponatremia is the most common electrolyte disorder. We order metabolic profiles on every patient, every day, but when it comes to interpreting those results we might as well be reading hieroglyphics.

RCTs are difficult and expensive but there are particular areas where we should require them prior to treatment. One of these corners is when we treat people with no symptoms and we are effectively treating a number. High cholesterol, high blood pressure, and low sodiums are three such areas, however hypertension and hypercholesterolemia have both gone through the right of passage called a randomized controlled trial. I am confident that my patients with asymptomatic hypertension benefit from treatment. My patients with coronary disease and hypercholesterolemia will live longer and better with treatment with a high potency statin. On the other hand, patients with sodiums of 129 and no apparent symptoms are supposed to be at higher risk of falls, have a higher mortality from heart and liver failure. Does treating them reduce these risks?


We can do better. Hyponatremia is the most common electrolyte disorder found in patients, we owe it to them to have real, prospective, data to answer these questions.

Go to UKidney to vote for my trial: No hyponatremia modification in asymptomatic hyponatremia. Thanks.
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