Thursday, April 12, 2012

Choose...But Choose Wisely, Part 7

Wow, up to Part 7 today.  Up today- the American Society of Nephrology- the kidney doctors.

1.  Don’t perform routine cancer screening for dialysis patients with

limited life expectancies without signs or symptoms.
This could be a tad bit controversial.  The recommendation is that routine cancer screening (mammograms and colonoscopies, for example) not be performed in dialysis patients unless they are transplant candidates.  The reason for this is that the life expectancy of a dialysis patient is very limited, unless they will be getting a transplant.  A table of the expected remaining lifetime can be found here.  For example, the average 50 year old has 30.7 years of life remaining.  The average 50 year old on dialysis has 6.2 years of life remaining.  Looking at those statistics, it just doesn't make sense to do routine cancer screening in those cases.  I'm sure some people will read that and scream, "Rationing!" and "Death Panels!"  I suppose in a way it is rationing.  I'm not sure there's anything wrong with that.  However, that's a post for another day.

2.  Don’t administer erythropoiesis-stimulating agents (ESAs) to chronic kidney disease (CKD) patients with hemoglobin levels greater than or equal to 10 g/dL without symptoms of anemia.
 This recommendation is regarding drugs that stimulate the production of red blood cells.  Many patients with kidney disease are anemic- that's because the hormone that stimulates red cell production is made in the kidneys.  In the past, ESAs were given with the goal of getting the hemoglobin to a normal range (around 12.0).  However, many studies have been done that actually show worse outcomes when the hemoglobin is "normal."  The recommendation is to not aim for a hemoglobin of greater than 10.

3.  Avoid nonsteroidal anti-inflammatory drugs (NSAIDS) in individuals with
hypertension or heart failure or CKD of all causes, including diabetes.
NSAIDS (ibuprofen, Celebrex, Mobic, naproxen, etc) are bad in people with kidney disease.  'Nuff said. 

4.  Don’t place peripherally inserted central catheters (PICC) in stage
III–V CKD patients without consulting nephrology.
A PICC is a type of IV line.  It is inserted into the arm and runs into the central veins.  It's not a good idea to put them in someone who might be needing dialysis in the near future, because it can mess up their veins and limit options for access for dialysis. 

5.  Don’t initiate chronic dialysis without ensuring a shared decision-
making process between patients, their families, and their physicians.
This one is likely to be the most controversial recommendation of all, and the one most likely to make the death panel crew pick up their pitchforks.  However, I think it's spot on.  Not every patient who has end-stage renal disease should get dialysis.  Remember that chart I showed you before?  It's here. A healthy 80 year old has an average of 8.4 years left.   A person who is a candidate for dialysis almost certainly has many other medical issues, and it's unlikely they are looking at 8.4 years- they might be looking at half of that.  The life expectancy for an 80 year old on dialysis is 2.3 years.  So, we're looking at a potential gain of perhaps 2 years, maybe a bit more or less.  Of those years, they will be in a dialysis unit for 3 to 4 hours at a time three times a week.  In 2008, one year of dialysis cost $72,000 per patient.  That's just for the dialysis, not the associated medications and treatment for other illness.  This is a big burden for patients, their families, and society- it needs to be carefully looked at.

Again with the weird formatting.  I give up.  HTML, you are my nemesis.