CANNOT MAKE THE DIAGNOSIS?

Alan Morris Alan.Morris at IMAIL.ORG
Wed Apr 9 18:23:39 UTC 2014


Those of you who have paid attention to my past suggestions about standardization might see in this exchange the problems that surface when standards are absent.  Some would assign to chronic renal insufficiency those whom others think normal.
Have  a nice day.

Alan H. Morris, M.D.
Professor of Medicine
Adjunct Prof. of Medical Informatics
University of Utah

Director of Research
Director Urban Central Region Blood Gas and Pulmonary Laboratories
Pulmonary/Critical Care Division
Sorenson Heart & Lung Center - 6th Floor
Intermountain Medical Center
5121 South Cottonwood Street
Murray, Utah  84157-7000, USA

Office Phone: 801-507-4603
Mobile Phone: 801-718-1283
Fax: 801-507-4699
e-mail: alan.morris at imail.org
e-mail: alanhmorris at gmail.com

From: Harold Szerlip <hszerlip at GMAIL.COM<mailto:hszerlip at GMAIL.COM>>
Reply-To: Society to Improve Diagnosis in Medicine <IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG<mailto:IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>>, Harold Szerlip <hszerlip at GMAIL.COM<mailto:hszerlip at GMAIL.COM>>
Date: Wednesday, April 9, 2014 10:03 AM
To: "IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG<mailto:IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>" <IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG<mailto:IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>>
Subject: Re: [IMPROVEDX] CANNOT MAKE THE DIAGNOSIS?

I think you should look at the KDIGO definition of CKD.  CKD 3 A (eGFR 45-60) without proteinuria, which would be the majority of the CKD in the elderly has a minimal increased cardiovascular risk. It is proteinuria that is associated with an increase in risk. This is likely secondary to underlying endothelia dysfunction.  The PREVEND study supports this.

Harold Szerlip, MD, FACP, FCCP, FASN, FNKF

On Apr 9, 2014, at 9:55 AM, Hayward, Rodney (Rod) <rhayward at MED.UMICH.EDU<mailto:rhayward at MED.UMICH.EDU>> wrote:

For the vast majority, the most important implication of CKD is elevated CV risk. In this regard, the current classification is suboptimal in that early stage 3 CKD (eGFR 45-60) only elevates CV risk moderately, but advanced stage 3 (eGFR 30-45) results in a dramatic increase in CV risk.

________________________________
From: Carroll, Thomas [Thomas_Carroll at URMC.ROCHESTER.EDU<mailto:Thomas_Carroll at URMC.ROCHESTER.EDU>]
Sent: Wednesday, April 09, 2014 9:23 AM
To: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG<mailto:IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>
Subject: Re: [IMPROVEDX] CANNOT MAKE THE DIAGNOSIS?

It seems to me that the definition of CKD (especially in the elderly, but I suppose in everyone) really only matters in the context of an individual’s expected survival.  If they’re very unlikely to outlive their kidney function, then it doesn’t matter and vice versa.

Thomas M. Carroll M.D., Ph.D.
Assistant Professor, General Medicine & Palliative Care
University of Rochester
thomas_carroll at urmc.rochester.edu<mailto:thomas_carroll at urmc.rochester.edu>
Pager 5-1616 #3872
Tel: 585-275-7424 (General Medicine Office)
Tel: 585-273-1154 (Palliative Care Office)

From: robert bell [mailto:rmsbell at ESEDONA.NET]
Sent: Wednesday, April 09, 2014 1:12 AM
To: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG<mailto:IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>
Subject: Re: [IMPROVEDX] CANNOT MAKE THE DIAGNOSIS?

There are a group of diagnoses where we do not have enough data/information to make a firm diagnosis.

This link relates to age and renal failure  http://www.medscape.com/viewarticle/753447_5[medscape.com]<https://urldefense.proofpoint.com/v1/url?u=http://www.medscape.com/viewarticle/753447_5&k=lmxj0uloiQslubycBXSv7A%3D%3D%0A&r=2K3rpxY%2F727qla%2FHDALAeTaA5t9cwqTMwcT7I%2FCCLB4yjtjSPaS5yPdWSZE2V06X%0A&m=1zYzMxWTkoQiB7gLrE62tYUgQ3O12LX%2BG81cFIbClVs%3D%0A&s=eaf0b349a89245375c2074b66b7706749c53ec585245383530cfd0826a4dfc18>

It is said here: "Therefore, it is not clear to what extent a decline in GFR with age is physiological and what level of GFR should be considered abnormal in older people."

So how can we say some elderly people definitely have Chronic Renal Failure?

So should the first thing be to clarify better what is Chronic Renal failure in elderly people.

Could there be Errors in Diagnosis here because the renal failure standards are incorrect?!

Rob Bell

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