The edition · Top Clinical Updates
Intermittent dialysis first in critical AKI was linked to more deaths than continuous therapy
A French trial stopped early on a mortality signal, a European study ranks liver fibrosis tests against biopsy, injectable HIV therapy holds up in people who struggle with pills, and conduction-system pacing cut heart failure events.
The edition in brief
ICRAKI (NEJM, 14 October) randomised 554 critically ill adults with acute kidney injury needing renal replacement therapy to start on intermittent haemodialysis or continuous therapy. It was stopped early for higher mortality with intermittent haemodialysis: 90-day death was 63% against 54% (HR 1.30, 95% CI 1.04 to 1.63), and it did not meet non-inferiority for its composite kidney outcome. LITMUS (Lancet, 31 October) tested 30 non-invasive markers against central histology in 1590 adults with MASLD; multimarker panels did best, with AUCs of 0.84 to 0.92 for advanced fibrosis, while single markers were weaker for at-risk steatohepatitis. IMPALA (NEJM, 15 October) found two-monthly injectable cabotegravir plus rilpivirine non-inferior to oral dolutegravir-based therapy in 537 African adults with adherence difficulties (91.0% vs 89.2% suppressed), with five confirmed virological failures on the injectable and none on oral therapy. The pearl covers FIB-4 as the first step in fatty liver. LEAP-Block (JAMA, 28 October) closes the edition: in 482 patients with AV block and preserved ejection fraction, left bundle-branch area pacing cut death, heart failure events or biventricular upgrade from 12.5% to 2.4% at two years compared with right ventricular pacing.
Starting with intermittent haemodialysis in critical AKI was associated with higher mortality
Where continuous dialysis is available, consider it the first choice for critically ill patients with AKI.
Multimarker panels outperformed single tests for fibrosis in fatty liver disease
For fatty liver, assess fibrosis stepwise; combined tests beat any single marker.
Two-monthly HIV injections matched oral therapy in people who struggle with adherence
Injectable HIV therapy is a reasonable option for people with adherence difficulties, with close viral load monitoring.
FIB-4 is the first step in fatty liver, and it needs only routine bloods
Calculate FIB-4 for every patient with fatty liver; refer for elastography if it is 1.3 or above.
Left bundle-branch area pacing cut heart failure events over right ventricular pacing
For heart block needing frequent pacing, conduction-system pacing reduced heart failure events compared with standard pacing.
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