CANNOT MAKE THE DIAGNOSIS?

Slater, William WSlater at PHCN.VIC.GOV.AU
Wed Apr 9 23:21:41 UTC 2014


Not to mention modification of drug dosage.

Bill Slater
Physician
Melbourne AUSTRALIA

From: Hayward, Rodney (Rod) [mailto:rhayward at MED.UMICH.EDU]
Sent: Thursday, 10 April 2014 8:24 AM
To: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG
Subject: Re: [IMPROVEDX] CANNOT MAKE THE DIAGNOSIS?

Nice discussion.

1. I would go even further than Abdul and suggest that we should rarely use the term "disease" when speaking to patients. It's too value laden, and tends to suggest to pt and clinician alike that "something must be done". I refer the term "condition" for chronic processes and illness for acute conditions.
2. However, I would argue that whether something is due to "a natural" aging process or a pathological process is irrelevant when making treatment decisions. Only two things matter: what are the absolute risks of events that impact quality and/or length of life happening in the absence of intervention, and how do these risks compare to the absolute risks of these events if we intervene (including potential treatment-related harms). Of course, these need to be filtered thru pt preferences, but those are the relevant estimates to guide that pt discussion.
3. With regard to my previous comments about declining eGFR being associated with a moderate increase CV risk, this might just be a disagreement about whether a 35-45% RRI is "minimal" or "moderate" (Of course, ultimately it depends on the person's estimated CV risk before applying the multiplier.).Several investigations have replicated the findings of Alan Go (http://www.nejm.org/doi/pdf/10.1056/NEJMoa041031) and found even when you control for age and clinically diagnoses proteinuria, that a GFR of 45-60 increases CV risk by 35-45%, but that this skyrockets once GFR drops below 45.  Proteinuria is also an independent risk factor in most studies, and it is possible that subclinical proteinuria could explain this increase in the eGFR 45-60 group, but if so, it is subclinical even in high quality healthcare systems.
4. Finally, I would argue that the most important thing is that as someone's eGFR heads south of 45, it is highly important clinically regardless of why it is that low. I agree that we should emphasize in older patients that kidneys age, but their are still important clinical implications.


Rod Hayward, MD
Director, Robert Wood Johnson Foundation Clinical Scholars(r)
Professor of Medicine & Public Health, University of Michigan
Ph# 734/647-4844
Fax  734/647-3301
Assistant: Brittany Weatherwax (bweather at umich.edu<mailto:bweather at umich.edu>)

Senior Investigator
VA Ann Arbor HSR&D Center of Excellence
Ph# 734/845-3502
Fax 734/845-3250

________________________________
From: Abdul Saadi [essadii at GMAIL.COM]
Sent: Wednesday, April 09, 2014 5:14 PM
To: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG<mailto:IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>
Subject: Re: [IMPROVEDX] CANNOT MAKE THE DIAGNOSIS?

I am glad somebody brought this up. If we are talking defintions may I take it a little further and advance a motion here,  to revise the nomenclature as a whole.

The actual disgnation Chronic kidney disease is an overstatement in this occasion of decling kidney function in the elderly.

It gives the listener especially the unintiated, the patient /consumer /participant a sense of a process that had been ongoing for a awhile, "chronic" and a "disease" meaning there is an actual pathophysiology where in fact it is a condition that is solely based on a creatinine number, age and a formula. On the other hand it gives the doctor grounds to intervene and do something it is like the war on kidneys (cf war on drugs).

We will have to ask ourselves the question what do we really achieve with this designation? ..very little are there any nephrological practises that could reverse CKD of the elderly ?

Not uncommonly, I will have this comment from my patient: wait a minute what you mean I have kidney disease ? and can we do something to stop it or reverse ? or the worst ..why haven't my PCP done anything about it ? . And of course I try to explain.

The proper term should be something like "kidney aging" or something to emphasise aging not pathology. Something more descriptive and less heroic and actionable. Only then will everybody relax. Because it is aging it is not a "chronic disease of the kidneys"

Thanks

Abdul Saadi, MD
Philadelphia
On Apr 9, 2014 3:21 PM, "robert bell" <rmsbell at esedona.net<mailto:rmsbell at esedona.net>> wrote:
Thanks Alan.

Agree, agree.

Also, it seems to me that the diagnostic definitions are, in the main, proposed by Specialty Societies who MAY be biased for economic reasons. I am not sure if this is the case and would welcome comment. If it is the case, shining lights might help.

The other issue would seem to be that if there is a condition/disease that is not well defined with current parameters would a list of these published by IMPROVEDX be of any value so that others can refine things? After all, looking for Errors in diagnosis becomes hard if there are no good defined diagnostic criteria for certain diseases (which supports your thesis Alan).

Fine, kind, courteous medical/scientific interaction with Specialty Societies would be a great way to grow the organization, impart  the importance of the mission, and make an impact for all!

Position papers could make a big statement.

Rob Bell



On Apr 9, 2014, at 11:23 AM, Alan Morris <Alan.Morris at IMAIL.ORG<mailto:Alan.Morris at IMAIL.ORG>> wrote:


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
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Murray, Utah  84157-7000, USA

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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<tel:585-275-7424> (General Medicine Office)
Tel: 585-273-1154<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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