Blog entry by Arif Khwaja
A few months ago I saw an 82 year old lady with very slowly progressive CKD4. She had T2DM, hypertension, a strong history of smoking and was referred by her GP as she had an eGFR of 29 mls/min ( compared to 35 mls/min 5 years ago). Her US showed slightly small kidneys and her dipstick was negative for protein and blood and immunology screen was negative. She was assumed to have ischaemic nephropathy as the cause of her CKD. She had been taking NSAIDs for 20 years for arthritis
Her BP was 152/90 and she was reasonably well - she lived independently with some support from her daughter. When I saw her her main problem was her arthritis - this was severe and she was racked with pain particularly in the morning. The nephrologist who saw her on her prevoius visit had understandbly told her to stop taking NSAIDs ( Ibuprofen 200mg tds) and instructed her family doctor to increase her anti-hypertensive medications by adding in a diuretic
The problems were two fold i) she couldnt tolerate other pain killers ( nausea, constipation and hallucinations) so she was left taking paracetamol which didnt work. ii) She was already on a number of vasodialtors which left her with significant oedema and as she had an overactive, small bladder she found that taking diuretics meant that going out was difficult and so now had to stay at home as she was afraid of being incontinent in public.
What struck when me I saw here was that two very reasonable (from a nephrologists perspective) interventions (ie. stopping NSAIDs and increasing anti-hypertensive medication) had significantly worsened the quality of her life.... which got me thinking what was the actual 'value' we were adding to her quality of life or life expectancy by seeing her? Perhaps they were the following:
i) Reducing her risk of developing ESRD? This ladys risk of developing ESRD in her lifetime is miniscule.. as shown in the GLOMMS study women of this age with no albuminuria virtually never progress to ESRD and so if our goal is to try and reduce the risk of her developing ESRD then we are trying to reduce the risk of someting that is vanishingly unlikely to happen - even if she never sees a nephrologist. This was further brilliantly highlighted in a recent publication extrapolating the effect of a putative intervention that reduces the risk of ESRD by 30% in RCT to an elderly population with CKD. The reality was that the effect would be negligible for most of the elderly as few will progress - again highlighting the importance of interpreting RCT data in the context of the patient on front of you
ii) Stopping NSAIDs will reduce her risk of developing ESRD? Given the fact that she had been taking NSAIDs for 20 years with only a slow decline in kidney function the value of stopping NSAIDs in her case on either her life expectancy or quality of life are negligible - indeed her quality of life was significantly worse after stopping NSAIDs. So perhaps a better approach would have been to tell her to continue taking her NSAIDs (stopping only if she gets intercurrently ill) and to continue monitoring her kidney function regularly. And as a recent systematic review showed the impact of NSAIDs used at a normal dosage on GFR decline is negligible.
iii) Getting better control of her BP will reduce her risk of cardiovascular disease? Putting aside the fact that at the age of 82 with a lifetime of smoking, the dice in terms of CV risk has already been cast, would lowering lowering her blood pressure really improve her CV risk? - well there is increasing evidence that treating to a ‘target’ of less than 140/90 mmHg may not only have no benefit but may for some patients be harmful. In fact the evidence base from interventional studies to support a ‘tight’ BP target in this age group is negligible.
So what did I do…. well I stopped her diuretic, told her to go back on her NSAIDs - Her BP was 152/90 and her eGFR 30mls/min and most importantly she was now happy that she could get out of the house (without worrying about incontinence) and her pain was controlled. When I started talking about CV risk and salt in her diet, her eyes glazed, she leaned forward and said “you do know I’m 82 don’t you...?"
So what did I learn? well without sounding trite the clear learning message from this case is that treating risk is not the same as treating a patient…What matters to us ( e.g reducing proteinuria and BP, stopping NSAIDs) may not matter to the patient and whilst in some cases doing things like tightly controlling BP, reducing proteinuria and stopping NSAIDs will be incredibly important, in other situations they are at at best irrelevant and at worse counterproductive.
This balance between the ‘evidence-based medicine’ and ‘patient-centred care’ has been articulated by a thought-provoking recent article by Ann O’Hare in NDT which continues on from an earlier article stressing the importance individualised rather than disease-based care - a must read for anyone who actually practises medicine and sees real-world pateints.
In other words the certainties and value of guidelines and ‘evidence-based medicine’ are only realised if you can interpret them in the context, society, healthcare system and culture in which you practice and understand their relevance to the patient sitting in front of you. Real-life clinical medicine is still an art - a balance of risks, uncertainties, trade-offs and compromises.