Kidney Recommendations Cut Costs, Improve Care

Troy Brown

September 14, 2012

September 14, 2012 — The American Society of Nephrology has released new kidney disease recommendations as part of the "Choosing Wisely" campaign to avoid unnecessary healthcare spending and improve patient outcomes. Estimates suggest that unnecessary testing, procedures, and therapies account for one third of current medical care spending.

Amy W. Williams, MD, a consultant in the Division of Nephrology & Hypertension at the Mayo Clinic in Rochester, Minnesota, and colleagues describe their recommendations in an article published online September 13 in the Clinical Journal for the American Society of Nephrology.

The American Board of Internal Medicine Foundation partnered with Consumer Reports and asked national specialty medical societies to develop a list of 5 "don't do" recommendations to help clinicians make decisions. The societies were asked to evaluate best practices and evidence-based medicine to identify tests, procedures, and therapies that are either misused or overused.

"This is another indicator that things are changing, that the future is going to be based on quality indicators and measurable data, and there's going to be consequences for...physicians who don't take this seriously and who don't consider that the patient has to be involved in decision-making," Robert Heyka, MD, chairman of the Department of Nephrology Hypertension at the Glickman Urological and Kidney Institute of Cleveland Clinic in Ohio, said in a telephone interview with Medscape Medical News.

The recommendations stress the need for close collaboration between patients and physicians so physicians understand the patient's treatment goals and preferences and patients have the information about potential risks and benefits they need to make informed decisions.

This relationship will be even more important in the future, Dr. Heyka said. "The patient is going to rely on the doctor and trust in the doctor to give them the correct information so that the patient can be part of the decision-making process," Dr. Heyka said.

Recommendations

  1. Do not perform routine cancer screening for patients receiving dialysis who have limited life expectancies, without signs or symptoms.

    • Screening in this patient population does not improve survival and is not cost-effective. Patients with end-stage renal disease (ESRD) have a high mortality rate, and cancer is a relatively rare cause of death in these patients.
      Patients with occult gastrointestinal bleeding as a result of their disease may have false-positive results that, if acted on, could lead to unnecessary testing and patient distress. Similarly, women with chronic kidney disease (CKD) and ESRD may have an increased number of breast calcifications that could cause suspicious mammography results.

  2. Do not administer erythropoiesis-stimulating agents (ESAs) to patients with CKD who have hemoglobin levels 10 g/dL or higher without symptoms of anemia.

    • Because use of ESAs has been associated with an increased risk for adverse cardiovascular outcomes in this patient population, the American Society of Nephrology recommends that relatively conservative hemoglobin targets (9 - 11 g/dL) be used to guide the use of ESAs and that they be used in the smallest amounts necessary to minimize transfusions.

  3. Avoid nonsteroidal anti-inflammatory drugs (NSAIDs) in individuals with hypertension, heart failure, or CKD from all causes, including diabetes.

    • NSAIDS (including cyclooxygenase type 2 inhibitors) can increase blood pressure, reduce the effectiveness of antihypertensive drugs, cause fluid retention, and decrease kidney function in this patient population. The authors suggest that other medications, such as acetaminophen, tramadol, or short-term use of narcotic analgesics, may be safer than NSAIDS and just as effective.

  4. Do not place peripherally inserted central catheters in patients with stage 3 to 5 CKD without consulting nephrology.

    • Arteriovenous fistulas (AVFs) are the preferred method for providing hemodialysis access, with fewer complications and lower patient mortality than central venous catheters, yet central venous catheters are still being used in many patients. The use of peripherally inserted central catheter (PICC) lines and subclavian vein puncture can destroy potential AVF sites.
      When patients consult with a nephrologist early in their disease, AVF use at hemodialysis initiation is more likely, and unnecessary PICC lines — as well as central and peripheral vein puncture — may be avoided.

  5. Do not initiate chronic dialysis without ensuring a shared decision-making process between patients, their families, and their physicians.

    • "Initiation of maintenance dialysis has major implications for patients and their families as well as for the health care system as a whole," the authors write.
      Dialysis requires a significant time commitment from patients and can be disruptive for patients and their families. A significant number of patients later regret their decision to start dialysis.
      Certain patient populations, such as the elderly and infants, may not see as much of a benefit from dialysis as others. Detailed information about shared decision-making and dialysis initiation can be found in the Renal Physicians Association and American Society of Nephrology's recommendations in guidelines published on the association's Web site, the authors note.

Asked to identify 2 other recommendations that they believe are important, the authors discourage the measurement of urine microalbumin in patients with a positive urine dipstick.

"Because the test measures albumin and the result becomes positive only if the urinary albumin excretion is 300 mg/L, a positive dipstick result clearly indicates more than microalbuminuria (30–300 mg/L), and further assessment for urinary microalbumin excretion is not warranted," the authors write.

Another test that is often used needlessly in patients with CKD and ESRD is the determination of serum erythropoietin concentration. The authors explain that serum erythropoietin deficiency is frequently relative and typically does not correlate with the degree of anemia in patients with advanced CKD.

"Even in patients with kidney failure treated with dialysis, the ability to upregulate erythropoietin production in response to acute anemia is preserved. Accordingly, because the assessment of the serum erythropoietin concentration provides results that are not readily interpretable in patients with advanced CKD and are unlikely to affect care, there is no role for assessing this marker in this patient population."

These recommendations are further proof of the emphasis on evidence-based medicine, Dr. Heyka said. Where there is clear-cut information on what the best choice for the patient is, the physician has to follow that course, regardless of how they may have provided care in the past, he explained.

All the authors are members of the American Society of Nephrology Quality and Patient Safety Task Force.

The authors disclosed a variety of financial relationships including serving on scientific advisory boards and/or receipt of research funding, honoraria and/or consultancy fees from Aksys, Alexion, Amgen, Argutus, AstraZeneca, Athena Diagnostics, CellDex, Gilead, Kyrex, NxStage, Optherion, Pfizer, Sandoz, Sekisui, SQI Diagnostics, Takeda, and UpToDate. Dr. Heyka have disclosed no relevant financial relationships.

Clin J Am Soc Nephrol. Published online September 13, 2012. Abstract

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