PracticeUpdate Conference Series ISN WCN 2019

ACTIVE Study Finds Extended Time on Dialysis Does Not Improve Survival Still, the extended time did produce some benefits that might make it worthwhile in selected patients. E xtended time on dialysis over a 12-month period does not improve survival at 60 months, according to

The mean follow-up time for study participants was 4.25 years (95% confidence interval 4.06–4.44). During follow-up, 31 participants received renal transplants (n=17 in the extended hours group and n=14 in the standard hours hours group). Overall, 18 participants died in the extended-hours group, compared with 20 in the standard-hours group, for a hazard ratio of 0.92; 95% CI 0.49–1.74; P = .79. “After 5 years, 80% of participants were still alive. There was no difference in mortality between the two groups,” said Dr. Smyth. The findings for adjusted and trans- plant-censored analyses were similar. The non-inferiority of extended-hours compared with standard-hours dialysis could not be confirmed, however, and the research team concluded that there were no significant differences between arms in any of the pre-specified subgroups. The pre-specified test for non-inferiority was that the upper limit of the 95% confi- dence interval for the hazard ratio could be no greater than 1.10 (excluding a true mortality increase of greater than 10%). The durability of the longer dialysis inter- vention was poor after the randomized phase, although the extent to which this reflects patient, physician or institutional priorities could not be determined because patients and doctors were not asked as part of the study why they changed back to normal hours of dialysis. Investigators in China, however, indicated that it was unlikely any of their sites there would continue with longer weekly dialysis hours. “Even in Australia, New Zealand and Canada, where our sites were generally keen proponents of longer weekly dialy- sis hours, very few people continued the practice once the randomized period came to an end,” said Dr. Smyth. “Our main study showed that the intensive dialysis was associated with some small improvements in quality of life, such as physical and mental quality of life, but these benefits do not appear to have been enough for the participants to con- tinue with the practice.”

results of the Clinical Trial of IntensiVE (ACTIVE) Dialysis Study, presented at WCN 2019. Despite some demonstrated benefits, most centers did not continue extended dialysis after the study was completed. “We did not find an overwhelming reason for patients to practice either extended or standard weekly dialysis hours. This frees patients and health carers to decide on the weekly dialysis schedule that is best suited to them and their situation,” Brendan Smyth, MBBS, from the George Institute for Global Health in Newtown, New South Wales, told Elsevier’s PracticeUpdate . Earlier studies have shown that people practising more hours of hemodialysis generally live longer. At the same time, however, people in better health are more likely to undergo longer dialysis hours. “The only way to be sure about whether the long dialysis hours themselves led to better outcomes was to randomize a group of willing participants into a trial. ACTIVE is the largest and so the most reliable trial conducted on the question,” said Dr. Smyth. He noted that the longer dialysis hours resulted in slight reductions of some toxins, such as phosphate, the need for slightly fewer medications, a less restric- tive diet, and improved blood pressure. “So, for patients in whom these issues are prominent, extended-hours dialysis is likely to be quite helpful,” continued Dr. Smyth. “Patients who are already doing longer-hours dialysis and who are feeling well can feel comfortable contin- uing with their schedule.” The 200 participants in the study, who were from China, Australia, New Zealand and Canada, were randomly allocated to undergo dialysis for either 24 or 12 hours a week for a 1-year period. The subsequent outcomes and hemodialysis patterns for these participants over the 4 years fol- lowing the main study was reported on at WCN 2019.

Dr. Brendan Smyth

" Even in Australia,

New Zealand and Canada, where our sites were generally keen proponents of longer weekly dialysis hours, very few people continued the practice once the randomized period came to an end. "

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WCN 2019 • PRACTICEUPDATE CONFERENCE SERIES