Blog entry by Meguid El Nahas

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by Meguid El Nahas - Monday, 14 March 2016, 3:34 PM
Anyone in the world

I received this letter from a US Nephrologist working in non fee for service environment...


Hello Professor Meguid El Nahas, 

I saw your article in Jama from August 2015, regarding CKD staging,

I am a practicing nephrologist in Baltimore, MD, and I practice with Kaiser, in a non fee for service environment.  I feel like the diangosis of elderly CKD pts has gotten out of control.  CKD staging was developed as an epidemiologic tool that has turned into clinical practice, and very badly.  Telling an 85 yo female, who have about 1% chance of reaching ESRD in the their lifetime that they have stage 3 CKD , is awful and unnecessary.  In fact, telling pts they have stage 3 anything, is legitimately criminal when they have little increased risk of actually needing intervention in their lifetime.  

To this end I wanted to propose a new CKD staging system that would be more pt centric:

CKI Stage 0 - GFR > 60, with some structural abn or proteinuria 
CKI stage I - GFR 45-60 mild kidney impairment 
CKI stage II - GFR 30-45 mod kidney  impairment 
CKI stage III - GFR 15- 30  severe kidney impairment 
CKI stage IV - GFR 0 -15  kidney failure

a - < 1 gm proteinuria
b - 1-3 gm proteinuria 
c - > 3 gm proteinuria 

For pts with no change to GFR by MDRD
1.  It is unlikely will be getting rid of MDRD in the near future, and now it is commonly reported with all labs. Pt get anxious when they see an abnormality in their labs. 
2.  Pts with known significant proteinuria, or structural defects, i.e. PKD, pts don't need another diagnosis of CKD.  GIving them a secondary diagnosis like IgA nephropathy and stage 1 CKD does not change their diagnosis or their prognosis, and is only useful from an epidemologic standpoint. for which CKI Stage 0 can be used. 

This model was conceived based on patient centric care, instead of epidemiology. 
The changes  have many pt centric benefits, 
1.  We stop calling patients with low GFR diseased, which is hard to justify that 30% of the adult population over 70 should be described. 
2.  When a lab is reported as abn. low GFR, this will be able to tell pts they have a mild impairment,  which is much more relieving to hear than stage 3 kidney disease.   And enough for pts to remember and dose meds accordingly. 
3.  Informing pts on stage 3 CKD , the first questions, are: what happened to stage I and 2, why wasn't I informed then? Other than explaining the complex epidemiology that led to this staging system, and that's just the way it is, there is no good reason for this.  
4.  It closely matches a 4 stage system, which patients are more familiar with, in regards to cancer staging. Stage 3  actually means something.   

I am not sure what to do with this now, as many colleagues work in a fee for service model, and seem to need the referral base, but I feel like it is ethically wrong that we have created an epidemic of kidney disease where none existed.  We have given a diagnosis to age, and the repercussions are unclear.   I would like to propose this model to someone in academics, and since I saw your article, felt you might be able to guide me in the right direction.  

Thank you for your time, 

Atif K. Jensen
  Dept of Nephrology, Towson
  office 410.339.5508 

This message implies that the notion of  "Epidemic of CKD" is linked to financial incentives for fee for service Nephrologists in the USA who aim to increase their referral basis on the back of medicalising the aging of the older population with age-related reduced kidney function and GFR...

Medicine and Money are not compatible bed fellows....


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