The edition · Nephrology
High-dose vitamin C doubled 28-day mortality in severe burns, and correcting acidosis still did nothing for the kidneys
VICTORY was stopped early for harm, with 28-day mortality of 15.0% against 7.6%; a new histologic class identifies the fastest progressors in diabetic nephropathy; pre-filter haemodiafiltration clears middle molecules better in children but raises blood pressure; and measured GFR clears testosterone of driving age-related decline.
The edition in brief
The VICTORY trial randomised 238 adults with deep burns covering 20% or more of body surface area, across 24 burn centres on four continents, to intravenous vitamin C 50 mg/kg six-hourly for 96 hours or placebo. It was stopped at the first prespecified interim analysis for futility and harm: the composite of 28-day mortality and persistent organ dysfunction occurred in 40.8% against 29.7% (adjusted RR 1.28, 95% CI 0.99-1.65), and 28-day mortality was 15.0% against 7.6% (adjusted RR 1.96, 1.32-2.90). A reanalysis of the TRIDENT cohort of 176 patients with diabetes undergoing indicated kidney biopsy, validated in 101 more, added a Class 5 defined by visceral epithelial hyperplasia to the Renal Pathology Society classification, improving two-year prediction from an AUC of 0.71 to 0.75. In a randomised crossover trial, 21 children on maintenance dialysis achieved median convection volumes of 36.2 against 14.3 l/m2 per session on pre-filter versus post-filter haemodiafiltration, with lower alpha-1-microglobulin, beta-2-microglobulin, myoglobin and inflammatory markers, but higher diastolic blood pressure. The Renal Iohexol Clearance Survey followed 800 men aged 50-62 with iohexol-measured GFR for a median of 10.9 years and found no association between testosterone, free testosterone or sex hormone-binding globulin and the rate of GFR decline. The edition closes on SODa-BIC, in which sodium bicarbonate did not reduce major adverse kidney events in vasopressor-dependent metabolic acidosis.
VICTORY stopped early: high-dose intravenous vitamin C doubled 28-day mortality in severe burns
Stop high-dose intravenous vitamin C in severe burns — mortality at 28 days was double that of placebo, and the trial was halted for harm.
A new histologic class separates the fastest progressors in diabetic nephropathy
Look for visceral epithelial hyperplasia on the diabetic nephropathy biopsy report; it marks the group that progresses fastest to kidney failure.
Pre-filter haemodiafiltration cleared middle molecules better in children — and raised diastolic pressure
Pre-filter haemodiafiltration clears middle molecules substantially better in children, but plan for the sodium load and watch the diastolic pressure.
Measured GFR clears testosterone of driving age-related kidney function decline
Testosterone is not a driver of age-related GFR decline — the earlier signal was a creatinine artefact of muscle mass.
When the creatinine and the patient disagree, the creatinine is usually wrong
In a frail or cachectic patient, a normal creatinine can conceal substantial kidney impairment — check cystatin C before dosing a renally cleared drug.
Sodium bicarbonate did not reduce major adverse kidney events in vasopressor-dependent acidosis
Stop correcting metabolic acidosis with bicarbonate in shocked patients; it did not reduce death, dialysis or persistent renal dysfunction.
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