Blog — NephJC

NephJC Rewind: ADVOR

NephJC covered the most important manuscripts in nephrology for over ten years. With a decade of history, NephJC has covered a significant amount of the evidence used in day-to-day clinical care. Many of us find ourselves repeatedly sending links to old NephJC summaries. NephJC Rewind is an attempt to resurface some of these older yet still relevant summaries.

Last week I tweeted about this year old trial of dapa versus metolazone in diuretic resistant fluid overload.

Here is the “visual abstract” from the journal for the trial

The tweet triggered a lot of interesting commentary, but I was struck by this post in particular

We covered the ADVOR trial when it was published in 2022. I think a critical difference between ADVOR and the above trial of dapa v metolazone is that ADVOR added acetazolamide to furosemide and compared it to furosemide plus placebo. The title of the ten-tweet-NephJC got it right “More Diuretics = More Diuresis.” ADVOR pitted a diuretic against placebo and found that adding more diuretic got more diuresis (and natriuresis).

It is interesting that the decongestion score developed for ADVOR was used in this dapa v metolazone trial also. Listen to the Freely Filtered Episode for a breakdown of why The Filtrate found this score problematic.

How often are you able to clear pleural effusions and ascites in three days of diuresis?

Regardless of the concerns some had about the ADVOR trial, it is clear it has changed practice patterns and expanded peoples conception of sequential nephron blockade beyond the convoluted tubule.

NephJC Rewind: PATH-BP

We have been doing NephJC for over ten years and we feel, in that time we have covered the most important manuscripts in nephrology. With a decade of history NephJC has covered a large amount of the clinical evidence used in day to day clinical care. In fact I find myself sending links to old NephJC summaries pretty commonly and we would like to surface some of these older summaries from time to time. So here is out first NephJC Rewind

Last week JAMA Internal Medicine published this manuscript any Tim Anderson, Management of Elevated Blood Pressure in the Hospital—Rethinking Current Practice. Here, Dr. Anderson is trying to operationalize the work he has been doing for quite some time demonstrating the lack of efficacy and frank harm caused by treating inpatient hypertension. This has been explored in NephJC, Freely Filtered, and NephMadness. As part of this manuscript he supplied a flow chart that showed acetaminophen as a cause of hypertension:

I tweeted about this and a number of people asked about acetaminophen being listed as a cause of drug induced hypertension. This is where PATH-BP comes in (MacIntyre, Circulation 2022). This was a well done cross over trial with a two week washout. Patients took a gram of acetaminophen four times a day or a matched placebo.

The primary outcome was a change in mean daytime systolic ambulatory BP.

There was a statistically significant increase in mean daytime systolic ambulatory BP of 4.7 mm Hg (95% CI, 2.9-6.6; P<0.0001) with acetaminophen compared with placebo.

This was not a mechanistic study so we don’t no why but it is possible that acetaminophen blocks renal prostaglandin synthesis just like NSAIDs do.

Take a look at NephJC’s discussion as well as the original paper.