People should be aware of how well their kidney is functioning and share this information with other caregivers who need to know. One of those is the pharmacist that the person uses. It is not only important to know what medications may cause kidney problems, it is also important to know how kidney function may affect the benefits and harms of each medication a patient is already on or may be prescribed. Some medications are extremely dependent on the kidneys to function well and eliminate the drug from the body. Medications are researched with suggested adjustments of either the dose or the frequency the medications should be prescribed. Medications may become toxic and accumulate at the doses given when the kidney was healthy, compared to what is happening now with acute kidney damage or associated with aging. Medications are dosed at a frequency that normally allows the level of drug to fall back to a lower, or acceptable trough level before the next dose is given. With poor renal function, some drugs may stack up to higher and higher levels, because the kidney can no longer eliminate the active medication from the body within the same predictable time frame. This can lead to adverse effects. A persons serum creatinine, or calculated creatinine clearance should be kept track of and forwarded to the pharmacist. Creatinine Clearance should become one of the well known healthcare characteristics of every patient, a VITAL SIGN.
4
Thanks for an excellent article. I wonder if the author would be so kind and explain the reason behind the change of title from "Chronic Kidney Disease Can Be Dubious Diagnosis" to "For Older Adults, Questioning a Diagnosis of Chronic Kidney Disease". Some people are implying that this was dictated by pharma lobbying, which would be bad?
4
Andrew Levey, as I recall, was a speaker for Amgen at the height of the Aranesp vs Procrit marketing in the early 2000s. (These drugs were meant to be used to maintain production of red blood cells, which can decline in patients with chronic kidney disease). I haven't kept track since then, but defining when kidney disease begins _also_ defines when certain drugs are reimbursible medical expenses... For a while, it seemed like a no-brainer to try and maintain hemoglobin at "normal" levels in patients with CKD or with cancer.... it was only years later that research identified that, at least for cancer patients, erythropoetin supplementation did not prolong life.
1
The GFR score is essentially the percentage of functioning (or filtration rate) of your kidneys. When people age the filtration rate drops a bit. But nature gave us so much extra kidney function, more than we need. Consider living donor kidney donation. The required GFR threshold to donate is usually at least 80. So a donor gives one kidney thereby halving their GFR to 40. And donors do fine! They remain healthy with one kidney. If something does happen to their one remaining kidney they go to the top of the transplant waiting list. I have Polycystic Kidney Disease with a GFR of ten. Imagine a filtration rate of ten percent. True, I am going on dialysis soon but I functioned very well until about 15 %. So even though it sounds scary to be diagnosed with stage 3 CKD people function well even down 15-20%.
5
I think it's important to know whether your kidney function is out of range., no matter what your age is. Knowing impacts what kind of pharmaceuticals you get involved with, both prescription and over the counter, knowing helps you think more about hydration, knowing helps you care more about keeping your high blood pressure in check. Knowing helps you and your doctor keep an eye on the trending of the GFR numbers. If you have 1st stage kidney disease, you are not referred to a nephrologist. But, I do think knowing is much better than not knowing.
8
"Is it really possible that half of the population older than 70 has chronic kidney disease?"
Depends.
If the person being asked owns stock in a Big Pharma corporation that is developing a "treatment", the answer is a definite "yes." The more people who buy my company's product, the better.
If not, the answer is probably "no."
More importantly, since the arrival of digital TV I watch commercial-free nightly news from France 24 and NHK Japan because I can't stand the avalanche of Big Pharma pill and Detroit car commercials that make of the majority of the nightly "news" in the U.S. lamestream media (ABC, CBS, CNN, FOX, NBS).
Depends.
If the person being asked owns stock in a Big Pharma corporation that is developing a "treatment", the answer is a definite "yes." The more people who buy my company's product, the better.
If not, the answer is probably "no."
More importantly, since the arrival of digital TV I watch commercial-free nightly news from France 24 and NHK Japan because I can't stand the avalanche of Big Pharma pill and Detroit car commercials that make of the majority of the nightly "news" in the U.S. lamestream media (ABC, CBS, CNN, FOX, NBS).
4
I would not overlook the fact that many of us elderly are taking handfuls of medications chronically. It would help if patients kept copies of their lab reports and noted in a medical diary when medications are started and stopped, along with the reason. Don't expect medical record portability or recall in today's mess of half paper, half electronic records which are not shared with anyone.
I suspect that the two statins which I have taken for three and six months, respectively, have done permanent damage to my kidneys and back. My former doctor disagreed. I also take six other common medications, but the intense back pain and urine precipitates began about three months after starting each brand of statin and ended a month or two later, when each statin was stopped. My eGFR is now at 40 when several years ago it was 120. The back pain has diminished, but lingers.
I suspect that the two statins which I have taken for three and six months, respectively, have done permanent damage to my kidneys and back. My former doctor disagreed. I also take six other common medications, but the intense back pain and urine precipitates began about three months after starting each brand of statin and ended a month or two later, when each statin was stopped. My eGFR is now at 40 when several years ago it was 120. The back pain has diminished, but lingers.
8
Anything to increase fees and give a reason for research grants.
1
It's not just a matter of diagnosis but of nomenclature. Our muscles weaken with age but we don't call that Chronic Muscle Disease or CMD. Some cognitive functions show age-related deterioration but we don't call that Chronic Brain Disease. Am I no longer virile because I suffer from CPD? There are kidney diseases, some of them chronic, but I'm not sure that a gradual weakening in function should be called that.
9
Unless you have done a 24 hour urine collection, or other more complex tests, what is being looked at is not the GFR, but the estimated GFR (eGFR), which is calculated from the serum creatinine. Since this is affected by muscle mass, a formula is used that adjusts the eGFR downward for women, upward for "blacks", and by age is used to account for variations in muscle mass. But obviously a person's muscle mass is not totally determined by these variables, and a single adjustment number cannot be correct for everyone. This formula will artificially lower the eGFR for a muscular woman, for example. Physicians should pay attention to changes in the eGFR, but should also look at their patients for factors that might affect the eGFR (high protein diet, weight lifting, certain medications, etc.) Before scaring someone with the term "renal failure", a more accurate test should be performed.
24
Physicians use a medical paradigm - looking for things that are "clinically significantly abnormal".
We don't have a biological paradigm to balance this view. We need such a biological paradigm to deal with normal things, such as aging.
A biological framework allows us to deal with quantitative questions of the form how to I compare to my peers and how can I optimize my function/performance.
Stephen Rinsler, MD
We don't have a biological paradigm to balance this view. We need such a biological paradigm to deal with normal things, such as aging.
A biological framework allows us to deal with quantitative questions of the form how to I compare to my peers and how can I optimize my function/performance.
Stephen Rinsler, MD
7
Classic example of a medicalization mindset.
Aging is a normal phenomenon for humans and many other species.
Decrease in "intensity" of organ functions in older humans presumably offers an advantage to the species because it reduces metabolic "costs".
As long as the organism/person functions adequately and without symptoms associated with the decreased level of function, it is reasonable to consider an isolated change like this as a "feature, not a bug".
Stephen Rinsler, MD
Aging is a normal phenomenon for humans and many other species.
Decrease in "intensity" of organ functions in older humans presumably offers an advantage to the species because it reduces metabolic "costs".
As long as the organism/person functions adequately and without symptoms associated with the decreased level of function, it is reasonable to consider an isolated change like this as a "feature, not a bug".
Stephen Rinsler, MD
5
Glomerular Filtration Rate (GFR) as quoted in the basic metabolic panel ordered by physician's office is estimated by an equation called Modification Of Diet in Renal Disease (MDRD) equation. This MDRD equation was derived and validated among predominantly mid-age caucasian males in a landmark study led by Drs Levey, Josef Coresh et. al undertaken more than 20 years ago. It helped establish the guidelines and the classification of various stages of Chronic Kidney Disease based upon the level of the filtering function. Unfortunately, the Glomerular Filtration Rate (GFR) value as estimated by the MDRD equation tends to underestimate the actual level of kidney function in elderly patients. Further, MDRD equation was never studied among patients over 70 years old. It therefore adds to an unnecessary disease burden and the cost of care resulting from unnecessary referrals.
As a nephrologist, I am always cautious about grading an elderly patient as having CKD purely based upon MDRD equation as listed in their routine lab panel unless they have a progressively worsening kidney function over the course of several months or have other tell tale signs of CKD like increased leakage of protein in urine.
As a nephrologist, I am always cautious about grading an elderly patient as having CKD purely based upon MDRD equation as listed in their routine lab panel unless they have a progressively worsening kidney function over the course of several months or have other tell tale signs of CKD like increased leakage of protein in urine.
17
I was diagnosed with ESRD at age 27. I have a fistula in my right arm and was on Dialysis for 3 years. I now have a kidney transplant and am so very grateful. Dialysis treatments weren't as bad as I anticipated. Will be 6 years since I have had my transplant on 12-22-15.
9
My "trusted" doctor never talked to me about the lab tests clearly showing a decline in my kidney function: At the age of 48 labs showed that I had a GFR of 44, 3 years later, at the age of 51 it has dropped to GFR of 29. I discovered that my kidneys were failing on my own. I am now at GFR 17. I discovered that my kidneys are failing on my own, due to high blood pressure. I have been told that I will need to start dialysis soon. I am at the height of my career, which requires a lot of travel. There goes my income. Had I known sooner, I could have stopped the progression. I think that doctors have a responsibility to talk to their patients, regardless of age!
21
Guilty until proven innocent. Is this what Americans now want?
2
Obviously the wrong article for this comment. Sorry.
When I saw this article I was hoping that the individuals cited, and even in the comments, would address the common formula used to estimate the GFR: Cockkroft-Gualt, CKD-EPI, MDRD, etc. Not a peep although there can be a significant difference in the result.
4
The key message is in the last paragraph: "It makes sense to repeat the test to see if the G.F.R. remains stable or continues to fall; it also makes sense to test the urine for protein."
A given result is not necessarily as important as trends (directional as well as for the speed of the trajectory).
A given result is not necessarily as important as trends (directional as well as for the speed of the trajectory).
6
Thank you for this article. I have been complaining about this for years.
5
For my friend, sodium is her nephrologists' odium. She has been hospitalized at least three times in the past year with what the doctors call congestive heart failure (CHF). One piece of a nationally famous brand of fried chicken put her in the hospital the most recent time (KFC also stands for kidney failure chicken) Her doctors rate her at between stage 3 and stage 4 kidney failure. She is anemic. She also needs a medication to stimulate red blood cell production, a function normally controlled by the hormone that the kidneys produce. She needs to monitor her weight daily and needs large doses of the diuretic Bumetinide to keep water weight gain under control. The kidneys are complex organs. As much as we need to trust a docror, this doctor has clearly cherry-picked the effects of kidney failure.
2
I thought that kidney failure could also result from long-term diuretic use. If you've been taking heart-medications for a long time (such as furosemide), it will affect the kidneys. There are so many conditions that seem to be side effects of primary problems!
6
Those of us who trained in medicine in olden times, dependent on the physical exam, with minimal lab tests, just X-rays and the beginnings of ultrasound (yes, Virginia, there was such a time) are impressed and grateful for all that science and technology have wrought. However, something has been lost: treating the patient, not the numbers.
18
Why do docs need to see the GFR (a highly variable reading, BTW) to recoomend avoiding procedures and meds which can harm kidneys, for Pete's sake? Why shouldn't those recommendations be in place for all of us elderly folks,(trouble actually writing that to include myself in this demographic, but 70 is 70) with justification needed to use kidney-risking therapies?
My cardiologist and I have in fact modified meds to minimize kidney loading, with absolutely no perceptible change in daily life or disease progress, which is minimal. Why wouldn't everybody do that?
My cardiologist and I have in fact modified meds to minimize kidney loading, with absolutely no perceptible change in daily life or disease progress, which is minimal. Why wouldn't everybody do that?
7
Good point, Joel; I'll repeat it.
"Why do docs need to see the GFR (a highly variable reading, BTW)."
I'm an 83 y/o long retired academic nephrologist who knew from the beginning of his training (when we did our own creatinine determinations manually - the Phillps modification of the Jaffe reaction) the problems with any estimation of GFR based upon creatinine concentrations in blood and urine. If it were a gold standard, would there be a slew of different formulae in use for calculation of GFR?
I refer the reader to this article in Wikipedia so I won't have to waste any more of my time and his/hers. https://en.wikipedia.org/wiki/Renal_function#Measurement_using_inulin.
"Why do docs need to see the GFR (a highly variable reading, BTW)."
I'm an 83 y/o long retired academic nephrologist who knew from the beginning of his training (when we did our own creatinine determinations manually - the Phillps modification of the Jaffe reaction) the problems with any estimation of GFR based upon creatinine concentrations in blood and urine. If it were a gold standard, would there be a slew of different formulae in use for calculation of GFR?
I refer the reader to this article in Wikipedia so I won't have to waste any more of my time and his/hers. https://en.wikipedia.org/wiki/Renal_function#Measurement_using_inulin.
3
As I age, I have heard "Well, you ARE getting older, so you can expect (fill in the blank)". Being an OLDER WOMAN makes the experience even more demeaning. The result: my serious Immune Deficiency was not found (by an excellent Duke Rheumatologist) until I was 69. The treatment is IVIG, an expensive and complex treatment....and I didn't start it until I was 71.
Because of IVIG treatment I am no longer constantly suffering infections.
Defining conditions as 'you're just getting older' makes sense if there is good scientific data. BUT I think the fear of many seniors is that our health issues will be 'written off and ignored because we are older."
Because of IVIG treatment I am no longer constantly suffering infections.
Defining conditions as 'you're just getting older' makes sense if there is good scientific data. BUT I think the fear of many seniors is that our health issues will be 'written off and ignored because we are older."
13
The mantra "be your own medical manager" rings true time and time again especially when I read articles like this. I know many people can't or ignore delving into the complexities of ones health, while navigating health care systems, HMO's and the like; but in this day and age it is so important. Children of older parents need to do this not only for themselves but for their parents as well. It is extremely confusing and at times overwhelming to read one day that eating this or that is no good for you and the next a new study shows just the opposite. I guess it all comes down to taking care of yourself as best you can, filter out the daily stream of medical news, speak with your doctor when you need to and just use plain old common sense. Don't resort to popping a pill at the drop of a hat for everything that ails you! Unless otherwise directed by your physician use good common sense and take good care of yourself. You know who you are and what's bothering you or not. Just do your annual check ups, get preventive screenings, try to eat healthy and who knows maybe you'll hit 100 years old.
6
I recognize some of these nephrologists' names from my days in medical advertising. It would be good if this report looked at who received funding from major pharma companies that produce medications targeted at chronic kidney disease/end-stage renal failure. There's even one medication that is sold by one company for CKD under one label and a nearly identical substance that is permitted for sale only for for ESRD for a different company under a different label.
12
Our bodies are complex. The failure of one organ can - and will - cascade as time progresses. The failure of the pancreas to produce insulin in the advanced stages of diabetes leads to a thread of other problems, including blindness and kidney failure. Renal malfunction can also result in what the doctors call congestive heart failure (CHF). Causes are not easy to isolate, but the linkages between these and other problems such as diabetic retinopathy need to be understood. The kidneys are responsible for producing a hormone that regulates and stimulates the production of red blood cells by out bone marrow; an anemic person may have partial kidney failure and still have a high GFR. . A single diagnosis can never fully explain all the problems we have as we age.
11
Until recenlly, I had not paid much attention to the lab. test requests my PCP had given me. I was just doing some filing when I saw a copy of my lab. request. What I found out is that, unless the doctor specifies a diagnosis, he cannot get the blood test results covered by Medicare on a more frequent basis than annually without specifying a bogus diagnosis of "Stage 3 kidney failure". It seems odd that Medicare does not allow the blood work, especially if the doctor suspects a downward trend in one or more of my body functions, and that the doctor must tell a lie in order to request the tests. Perhaps the true correction is for Medicare to allow more frequent blood work.
24
Exactly my experience. And the health insurance companies are even quicker to deny coverage.
9
Age-related "norms" need to be updated. My dad, at 95 yo (with a PSA of 7) was told he needed a prostate biopsy for cancer! I asked whether his rate of increase (he was a PSA of 6 at the age of 90) was indicative of cancer or perhaps a normal for his age (this was unknown). As our population ages, lets get more informative data.
27
the real question to be asked is what are the chances that even prostate cancer (if it is there) could ever be the cause of discomfort or death (morbidity or "mortality) in a 95 year old. I expect the answer would be "highly unlikely: If that IS the answer, why subject him to a biopsy?
9
Unfortunately the longer one lives he/she has a greater chance something is going to get you: heart disease, cancer, pneumonia and I suppose a low G.F.R. and chronic kidney disease can be added to the list.
5
I would also note that the "measurement" of GFR is not often done directly, but rather a calculation based on other measurements and a formula.
3
I only have one functioning kidney. I lost the function of the other one from a walnut size stone that had grown in my right ureter about 10 years ago. I had no discomfort from it until I started to bleed profusely and it was discovered. I had to have the stone blasted out of me and the kidney was blown out from the back pressure the stone caused. Thus...an atrophied, non-functioning right kidney. I'm 78 now.
Several years ago, a yearly blood chemistry showed that my GFR of my functioning kidney was down to 42. Off to the nephrologist who informed me that I was in Stage 3 kidney failure.
My last lab work showed that I was up to 49 but I had some protein in my urine and the protein/creatine ration was in the 400s. That was caused by having to take Vancomycin for the preceding month because of a c. difficile relapse. A week later, I had another lab test and the p/c ration was in the normal range.
So I try to drink my prescribed amounts of water, take only Tylenol for pain and don't have any tests with contrast material, cut down on my salt and have normal blood pressure. I have already made up my mind that I will never go on dialysis. Kidney failure is not a bad way to die. I know as I am a hospice volunteer and have seen how peaceful it can be with the proper medical care. Being hooked up to a machine 3 days a week with the attending problems that come with that does not appeal to me...no way no how. Sayonara.
Several years ago, a yearly blood chemistry showed that my GFR of my functioning kidney was down to 42. Off to the nephrologist who informed me that I was in Stage 3 kidney failure.
My last lab work showed that I was up to 49 but I had some protein in my urine and the protein/creatine ration was in the 400s. That was caused by having to take Vancomycin for the preceding month because of a c. difficile relapse. A week later, I had another lab test and the p/c ration was in the normal range.
So I try to drink my prescribed amounts of water, take only Tylenol for pain and don't have any tests with contrast material, cut down on my salt and have normal blood pressure. I have already made up my mind that I will never go on dialysis. Kidney failure is not a bad way to die. I know as I am a hospice volunteer and have seen how peaceful it can be with the proper medical care. Being hooked up to a machine 3 days a week with the attending problems that come with that does not appeal to me...no way no how. Sayonara.
56
The good news is that with a GFR in the 40s, you are a very long way from having to consider dialysis. Honestly, it shouldn't even be on your radar at this point. You are doing everything correct to protect your remaining kidney function. Keep your BP regulated and don't get diabetes. I wish you good health.
10
Born with only one kidney which I found out at age 62 and with GFR of 47, I did the following: no Advil, no phosphate beverage (including that used for colon cleansing), less salt, less meat. My GFR is now 60.
22
The presence of large amounts of protein in the urine may be a sign of certain blood cancers, such as myeloma or lymphoma. The normal kidney filters out protein and allows the toxins and salts to pass through. If the long chain protein molecule loses its conformation and folds up, it can become sticky so that the glomeruli can't retain it. The cause may be a gene mutation, the rate of which increases geometrically after age 60.
These sticky proteins or ameyloids may lodge in the kidney, heart, and other organs. The loss of protein in the blood also triggers the liver to increase the rate of protein and cholesterol synthesis.
The Renaissance physician, Sir Thomas Browne, said: When I think of all of the myriad ills man is heir to, I thank God that I can die only once."
These sticky proteins or ameyloids may lodge in the kidney, heart, and other organs. The loss of protein in the blood also triggers the liver to increase the rate of protein and cholesterol synthesis.
The Renaissance physician, Sir Thomas Browne, said: When I think of all of the myriad ills man is heir to, I thank God that I can die only once."
15
What a shock. Another "disease" that generates millions for the medical profession. Doctors have even turned pregnancy into a disease. Why not hound the patient with many unnecessary visits and tests to find out what is normal for a patient and then test again just to make sure. Follow the money. There is little integrity in medicine. Please spare me the stories of the one in a million patients who was saved by a doctor doing too many tests. That is no reason to bankrupt the system by too much care when none is needed.
26
So much cynicism isn't good for your health.
5
My doctor told me I didn't need to do anything about my GFR of 51 and not to worry about it.
most doctors don't make money off of tests. But there are many who take the shortcut of ordering them instead of examining and listening to patients, many who feel their job is to treat disease, not people. It isn't greed , usually, in my opinion but rather laziness.
When the "old" become the norm, maybe then the natural effects on the body will no longer be considered abnormal.
12
I would suspect the most important consideration with impaired kidney function is prescription and over the counter meds, as well as diet. As a kidney donor with adequate GRF, I avoid NSAIDS and certain medications, make sure to stay hydrated, and avoid high protein diets. I question if over diagnosis in older patients leads to an increase in pharmaceutical drugs.
8
BP medications over time will affect the kidneys and the liver in negative ways. Just check your PDR and see all the side effects of these drugs and medications. Medical doctor continue to treat the symptoms high BP and not the causes such as weight, lack of exercise too much alcohol. These chronic problems patients are more likely iatrogenic than just simply getting older.
4
How do nephrologists feel about this? Seems that a big hunk of their business would disappear.....
3
Most patients with GFR between 45 and 60 are not referred to a nephrologist. There's no need. They make their money off of dialysis anyway.
4
I'll tell you how I feel.
Like many things in medicine, the definition of CKD is designed to be "sensitive" rather than "specific," meaning that many or most patients with CKD will not have any problems, but we are very unlikely to miss those that will have problems. The idea is we'd rather see 10 people that we don't need to than miss one that we do.
Given the data that exist (as discussed in article) that even relatively small drops in GFR is an independent risk factor for heart disease I think it's prudent to continue current definitions, with the understanding that we should over-worry.
As for revenue, we make very little money from clinic visits, in fact, a typical CKD 3 visit is a financial loss, so that's nothing to do with it.
Like many things in medicine, the definition of CKD is designed to be "sensitive" rather than "specific," meaning that many or most patients with CKD will not have any problems, but we are very unlikely to miss those that will have problems. The idea is we'd rather see 10 people that we don't need to than miss one that we do.
Given the data that exist (as discussed in article) that even relatively small drops in GFR is an independent risk factor for heart disease I think it's prudent to continue current definitions, with the understanding that we should over-worry.
As for revenue, we make very little money from clinic visits, in fact, a typical CKD 3 visit is a financial loss, so that's nothing to do with it.
5
Just last month my primary care physician told me I had stage 2 kidney disease, which was a complete surprise. He also told me that I would probably never need dialysis. I mentioned this to my cardiologist, who said he saw no evidence of that in my lab test results. Go figure.
Anyway, I'm grateful for this article. It sort of explains both reactions and confirms the primary care doctor's prediction.
Anyway, I'm grateful for this article. It sort of explains both reactions and confirms the primary care doctor's prediction.
12
Anecdotal: Several GFR tests in the last few months for reasons hopefully never to be repeated. With fasting, my GFR was 58 or 59. During an MRI with contrast, with GFR monitored throughout, my GFR was 75. A pre-surgery blood test several months after and my GFR was greater than 60, no specific number.
I'm believing the high numbers, which are good for my age, but why is this test done with fasting?
I'm believing the high numbers, which are good for my age, but why is this test done with fasting?
2
I have struggled with this issue for about 4-5 years. When I was 58 and had tests done for a simple unrelated problem, I turned up with blood and protein in my urine. My GFR was in the 50's and falling. Thus was I pulled "into further engagement with the health care system." Quickly I was seen by a nephrologist. Multiple visits and various tests (that I paid for) later, my GFR stabilized around 45. The nephrologist said I was dehydrated and kept urging me to drink more and continue to come in, whereas the whole exercise seemed pointless (and expensive) to me. I felt fine and was rarely thirsty.
I began to read about the "false GFR hysteria;" give people a way to calculate a number and they will decide there is a line that divides the good from the bad. I moved to a rural community this year at age 62 and my new family doctor said not to worry, it wouldn't be my kidneys that got me.
It's hard to know what to think. This article has been helpful in at least laying out the issues. I do mention it to health care professionals in the context of prescriptions and tests so that dosages can be adjusted and appropriate choice made.
I began to read about the "false GFR hysteria;" give people a way to calculate a number and they will decide there is a line that divides the good from the bad. I moved to a rural community this year at age 62 and my new family doctor said not to worry, it wouldn't be my kidneys that got me.
It's hard to know what to think. This article has been helpful in at least laying out the issues. I do mention it to health care professionals in the context of prescriptions and tests so that dosages can be adjusted and appropriate choice made.
30
I recently left the care of a very aggressive urology practice, mostly because my doctor there was disrespectful towards me, and he had a nurse problem. They were afraid of even talking to him. I needed prescriptions written in a specific way for a mail-order pharmacy, and had informed several different nurses over the course of several years about my specific Rx needs. Yet, he repeatedly would write the wrong prescriptions for me at the end of the visit. The nurses had never told him what I needed.
But what also galled me about the clinic was the fact that they gave you a questionnaire at the beginning of every visit with questions about your bladder habits. It was designed to be scanned quickly by the nurse to see if your answers fell outside of the range of the two answers in the middle of the page. The other answers supposedly indicated abnormal urination patterns, , I.E., "do you do ______ more than 50% of the times" etc.This office also insisted on a urine dipstick test at every visit, even if you had never had an abnormal result in the past, and insisted on doing an ultrasound scan of your bladder urine levels if you didn't produce a urine sample for them to test. It was obvious to me the management team for this bunch of clinics had instructed everybody who worked at them to bill for as many tests as possible.
33
You are confusing Urology and Nephrology.
3
@DK in Boston: you are making a silly distinction. I know what title my doctor and my clinic had. The rest of it is academic.
1
And: those people you were dealing with at that office were most likely NOT NURSES! They are, at best, attendants who have no professional practice standards, and most likely do not understand the ramifications of your conversations. You are wise to move on. Please do not think that the people you deal with in medical offices are Registered Nurses.
2
I think the reason to label people and saddle them with a 'disease' is to pad the bill and get the reimbursements while they're there! Patient beware. If you go in, they're looking for something. Anything. They're bound to find something. Be prepared, but be sensible, too.
16
Well, what's "normal" for the US population isn't by any means "normal" for the people of many other developed nations, and these international guidelines should be another clang of the wake-up bell for us.
When the average American has been overweight and poorly-nourished for decades, at least; takes a fistful of prescribed medications daily; and thinks not getting a parking spot near the mall entrance is a no-good very-bad day, this is how you end up.
Poor health from chronic disease--even when one has a genetic propensity towards it--is not necessarily a permanent sentence leading to earlier-than-necessary death. But you have to do more than anxiously ask your doctor "what does this mean for me?" You have to, yeah, change your lifestyle.
When the average American has been overweight and poorly-nourished for decades, at least; takes a fistful of prescribed medications daily; and thinks not getting a parking spot near the mall entrance is a no-good very-bad day, this is how you end up.
Poor health from chronic disease--even when one has a genetic propensity towards it--is not necessarily a permanent sentence leading to earlier-than-necessary death. But you have to do more than anxiously ask your doctor "what does this mean for me?" You have to, yeah, change your lifestyle.
9
And you know what comes in lock-step with the medical establishment's knee-jerk action of slapping the CKD diagnosis on someone? They immediately become uninsurable (life insurance). Even if the follow-up test says eGFR > 60, too bad, so sad, there's now this nasty little mark in your health record. Even if (even though) eGFR isn't the gold standard for determining whether there's actually problem -- it's just a cheap quick screening test.
All it seems to take to get eGFR < 60 is for you to be mildly dehydrated, and bam! The doctor tells you you're on the road to needing dialysis. They don't even bother to tell you that you should be well-hydrated and non-fasting when the blood is drawn for this.
All it seems to take to get eGFR < 60 is for you to be mildly dehydrated, and bam! The doctor tells you you're on the road to needing dialysis. They don't even bother to tell you that you should be well-hydrated and non-fasting when the blood is drawn for this.
34
Dear Mbs
do you mind me asking...were you labelled as having CKD by your Dr
do you mind me asking...were you labelled as having CKD by your Dr
You are correct about needing to be well-hydrated. But a complete metabolic panel requires fasting, if the prescriber wants to know what your fasting blood glucose is. I always explain to my patients what I am testing for and whether they need to fast or not. But I also always tell them to stay well-hydrated. Another kidney marker, BUN, is particularly affected by dehydration.
While CKD screening in general population is of questionable benefit, one needs to understand the diversity of CKD across the globe. CKD in significant number of patients can't be attributed to any of the traditional risk factors like diabetes, hypertension, or family history. It' has been well described in Central America ( Meso American nephropathy), Shrilanka (CKDu -CKD of uncertain ethology) and other parts of Asia . Affected population is generally the poor farmers in their 30s and 40s. A strong possibility of environmental toxins exist which require urgent further research. Mass Screening in such population may help to identify kidney damage early and preventing further exposure to the toxin.
4
This misclassification of normal aging into a disease class is a minor example of the overall perversion of personal healthcare into a drive to pidgeon hole patients by representing them as metadata, rather than their entire complex identities.
On the data collectors side, there is an erroneous assumption that classification of interdependent continuous variables into discrete bins will improve the understanding of someone's health.
On the care providers side, there are enormous financial and organizational pressures to accede to such oversimplification in order to get services reimbursed for themselves and for the patients.
This process will now accelerate incredibly in several weeks, with adoption of ICD-10 where further specification of diagnoses carries the reward of greater reimbursement and perceived recognition of "quality".
What this entire superstructure fails to grasp is that the professionalism that physicians and other care providers should be valued for is precisely the management of uncertain, shifting clinical situations where experience, judgment, and judicious interpretation of clinical data can lead to the best result for individual patients as well as the system as a whole. The use of physicians to stuff patients into data bins which misinterpret their clinical picture will lead to continuing distortions of their care, as well as inaccurate population data which will lead to incorrect clinical guidelines. Doctors become clerical personnel only.
On the data collectors side, there is an erroneous assumption that classification of interdependent continuous variables into discrete bins will improve the understanding of someone's health.
On the care providers side, there are enormous financial and organizational pressures to accede to such oversimplification in order to get services reimbursed for themselves and for the patients.
This process will now accelerate incredibly in several weeks, with adoption of ICD-10 where further specification of diagnoses carries the reward of greater reimbursement and perceived recognition of "quality".
What this entire superstructure fails to grasp is that the professionalism that physicians and other care providers should be valued for is precisely the management of uncertain, shifting clinical situations where experience, judgment, and judicious interpretation of clinical data can lead to the best result for individual patients as well as the system as a whole. The use of physicians to stuff patients into data bins which misinterpret their clinical picture will lead to continuing distortions of their care, as well as inaccurate population data which will lead to incorrect clinical guidelines. Doctors become clerical personnel only.
50
This is not "normal aging" when over half of elderly people don't have it. It's important for patients and physicians to know about in order to modify behavior to avoid NSAIDs, CT contrast tests etc. On the other hand it isn't the same as a decreased eGFR in a young person and should have its own classification.
1
I agree so much with your comment. I am an RN,BS MS and was shocked to read about CKD Stage 3 on my diagnosis sheet! WHen did this happen, I asked my PMD's office? The LPN,the highest level of nurse on the staff, called me and told me I was the 3rd patient who had called that day. I seems the new computer system automatically decrees this diagnosis when your GFR is below 60-mine was 59 and I am 75-the first time I had ever had a reading below 60. OI new my kidney funtion test have always been WNL and she reiterated this to me and told me now to worry.
On my next visit to my PMD I will pointedly ask him who makes the diagnosis, he or the the computer. THe LPN noting my distinct displeasure did offer me a sooner appt. but I will take it up on my next shceduled visit. Now I show this untrue diagnosis on all my medical records records and I am sure it cannot be expunged as the computer will only add it back. So much for the money the hospital associated with the group I use will make with this addition of another CKD Stage 3- what a deplorable medical system we have in this say and age.
On my next visit to my PMD I will pointedly ask him who makes the diagnosis, he or the the computer. THe LPN noting my distinct displeasure did offer me a sooner appt. but I will take it up on my next shceduled visit. Now I show this untrue diagnosis on all my medical records records and I am sure it cannot be expunged as the computer will only add it back. So much for the money the hospital associated with the group I use will make with this addition of another CKD Stage 3- what a deplorable medical system we have in this say and age.
The biggest risk factor for virtually every organ in your body is aging which is a fact of life, not a disease. Most organs have considerable reserve capacity where a lot of function can be lost before we notice the effects. But if you've taken poor care of your health over the years, everything will decline faster and the symptoms will show up sooner than they should. It's that simple.
11
A term baby is born with excess numbers of glomeruli, the vascular structures that actually filter the blood. Small numbers of these glomeruli are already undergoing involution at birth. Throughout life, glomeruli continue to undergo involution, a process which may be accelerated with some diseases such as lupus, and with smoking which causes the arteries entering the glomeruli to spasm and decrease blood flow to the glomeruli, among other things. Normal involution will lower the GFR.
I have to wonder whether the necessity for entering patient information into a computer in an expeditious, simplified yes/no manner might be a factor in 'over-diagnosis'. The patient's physicians are not the ones who developed the computer check-list program, which was likely purchased from some outside source.
I have to wonder whether the necessity for entering patient information into a computer in an expeditious, simplified yes/no manner might be a factor in 'over-diagnosis'. The patient's physicians are not the ones who developed the computer check-list program, which was likely purchased from some outside source.
5
grannychi wrote, "I have to wonder whether the necessity for entering patient information into a computer in an expeditious, simplified yes/no manner might be a factor in 'over-diagnosis.'"
It sure does. Yesterday I saw a new-to-me medical specialist. I've had a common disorder for 25 years, but it's been treated and thus no symptoms during that time... Until two months ago, when pain started... and two weeks ago when the pain became quite serious. Three days ago, I went to the ER, had a stunningly successful treatment, and the pain disappeared.
As I left the specialist's office I read the printout that was based on our conversation. I'd had to specify the duration of this disorder and my level of pain, but she'd had only ONE box to put the information into (not three, which would be necessary to specify "for 25 years," "recent," and "right now" ).
My medical history now says that I suffered quite serious pain for 25 years!
It sure does. Yesterday I saw a new-to-me medical specialist. I've had a common disorder for 25 years, but it's been treated and thus no symptoms during that time... Until two months ago, when pain started... and two weeks ago when the pain became quite serious. Three days ago, I went to the ER, had a stunningly successful treatment, and the pain disappeared.
As I left the specialist's office I read the printout that was based on our conversation. I'd had to specify the duration of this disorder and my level of pain, but she'd had only ONE box to put the information into (not three, which would be necessary to specify "for 25 years," "recent," and "right now" ).
My medical history now says that I suffered quite serious pain for 25 years!
6
You are so right about computerization making a mess of your medical record. In my physician's office, the first thing the doctor enters into the computer is automatically listed as the 'presenting complaint', though it has nothing to do with the reason I'm there.
I am 75 years old, recently diagnosed with Stage II kidney disease after four urine tests; the first ordered by a hematologist, 3 years ago, and the last 3, by my nephrologist this year.
When my nephrologist requested another urine test, I objected. He reacted by checking to see if I was correct and he canceled the requisition.
Reflecting on my kidney problem, it was my gastroenterologist who had sent me to the nephrologist, because of a high concentration of creatinine in my blood. But my creatinine levels varied from 118 to 160 MG/DL for the last 10 years. However, it was 115 MG/DL as indicated in the most recent BASIC METABOLIC PANEL test. And it is noteworthy that the reading from the last urine test was identical to the first.
Today, I believe that I am successfully managing my kidney problem after switching to a vegan diet with low salt, exercising vigorously, staying hydrated, and controlling my blood pressure and sugar. Of course, it is difficult to maintain this diet, but it is mandatory that I do. I’m convinced that I can reverse my kidney disease. The immediate goal is to convince both the nephrologist and gastroenterologist that I have.
I just may have.
The EGFR African American is 72 and the estimated reference range is >=60 ML/MIN/1.73M2
When my nephrologist requested another urine test, I objected. He reacted by checking to see if I was correct and he canceled the requisition.
Reflecting on my kidney problem, it was my gastroenterologist who had sent me to the nephrologist, because of a high concentration of creatinine in my blood. But my creatinine levels varied from 118 to 160 MG/DL for the last 10 years. However, it was 115 MG/DL as indicated in the most recent BASIC METABOLIC PANEL test. And it is noteworthy that the reading from the last urine test was identical to the first.
Today, I believe that I am successfully managing my kidney problem after switching to a vegan diet with low salt, exercising vigorously, staying hydrated, and controlling my blood pressure and sugar. Of course, it is difficult to maintain this diet, but it is mandatory that I do. I’m convinced that I can reverse my kidney disease. The immediate goal is to convince both the nephrologist and gastroenterologist that I have.
I just may have.
The EGFR African American is 72 and the estimated reference range is >=60 ML/MIN/1.73M2
4
As a primary care NP, I am of two minds about this subject. I have long felt that we needed another category of kidney disease that recognizes that many older adults have decreased GFR. Maybe "CKD of aging", or something like that. I don't want to overmedicalize something that happens slowly over time to so many people as they age. (I should add that I have a fair number of patients in their 80s with GFR well above the 60 mL/min/1.73m2 benchmark. So not everyone's kidney function declines so precipitously.)
On the other hand, this is extremely critical information for clinicians to have. A person's kidney function affects the doses and/or frequencies of their medications and makes some medications contraindicated. It makes us very wary of ordering tests with IV contrast, if we order them at all. And as the article points out, decreased kidney function greatly increases the person's risk of cardiovascular disease, for complex metabolic reasons. In fact, a far higher percentage people with CKD will die of cardiovascular disease than will die of kidney failure. So clinicians absolutely must have the conversation about cardiovascular disease with these patients.
My patients do NOT panic and think they are going to die of kidney failure. I have a conversation with them, explaining what the numbers mean and also explaining that it is something we will need to keep an eye on as the years go by. If GFR drops to a certain point, I refer to a nephrologist.
On the other hand, this is extremely critical information for clinicians to have. A person's kidney function affects the doses and/or frequencies of their medications and makes some medications contraindicated. It makes us very wary of ordering tests with IV contrast, if we order them at all. And as the article points out, decreased kidney function greatly increases the person's risk of cardiovascular disease, for complex metabolic reasons. In fact, a far higher percentage people with CKD will die of cardiovascular disease than will die of kidney failure. So clinicians absolutely must have the conversation about cardiovascular disease with these patients.
My patients do NOT panic and think they are going to die of kidney failure. I have a conversation with them, explaining what the numbers mean and also explaining that it is something we will need to keep an eye on as the years go by. If GFR drops to a certain point, I refer to a nephrologist.
32
What a sane response. This diagnosis issue is not about greedy physicians trying to make money, this is about how best to advise patients given their specific health picture. Over half of elderly people do not have reduced kidney function, it is not an inevitable consequence of aging, and those who do need to take certain precautions. Unfortunately, calling it CKD has consequences for the non-health insurance business (life insurance, long term disability insurance) and it WOULD be nice to have a different category for this illness because of these non-medical issues.
1
Excellent comment!
In the end, death is not optional - we all must die of something. Perhaps the medical community should think more about this and quit trying to treat aging as a disease. All our organs work less well than they did when we were 25. A car runs better when it's new than when it's 18 yrs old!
It would be nice if common sense could return to medicine as it once did.
It would be nice if common sense could return to medicine as it once did.
21
Heck, it would be nice if medicine became a profession again,
Key in this and many other discussions is whether the same clinical ranges should be applied to 7 year olds and 70 year olds. We are constantly reminded of the epidemics of type 2 diabetes, high blood pressure, etc (and now chronic kidney disease). But what is a 'disease' anyhow when it is present as part of the aging process by a large percentage of the population? Or is this really just a marketing ploy by the industry to sweep ever larger chunks of our retirement income into their pockets? And there are of course the side effects of these medications thrust at us... and the undiscovered country of how they interact and what biological processes they are really enhancing or suppressing? And, sadly, how many of us are destined to die at age 'x' regardless of the chemicals flushed through our systems?
6
I found this an informative, good article worth sharing.
14
Why is it that the Bostonians are always pushing disease with such passion? A trip through Kendall Square may provide some insight.
2
What the docs' should be telling their patients is
1) see your dietitian and develop a low sodium diet.
say 1850 calories, 225 gms carbo or 65 gms of sugar, 55 grams of fat, 1 gm o frotein per kilo of weight, 1500 mg of sdioum and 2350 mg of potassium and read every dam label. If it has more than 125mg sodium per serving do not buy it or eat it.
Drink 8 glass water or
stevia sweetened soda
Get a personal trainer and exercise 5 days a week.
within a year your gfr27 will turn into your gfr 62
and lose enough weight to get you blood pressure down to 120/70.
Prescribe an ace inhibitor in the meantime like carvedilol.
Or the option is keep on eating like a nut and go on dialysis and die!
Its your decision
1) see your dietitian and develop a low sodium diet.
say 1850 calories, 225 gms carbo or 65 gms of sugar, 55 grams of fat, 1 gm o frotein per kilo of weight, 1500 mg of sdioum and 2350 mg of potassium and read every dam label. If it has more than 125mg sodium per serving do not buy it or eat it.
Drink 8 glass water or
stevia sweetened soda
Get a personal trainer and exercise 5 days a week.
within a year your gfr27 will turn into your gfr 62
and lose enough weight to get you blood pressure down to 120/70.
Prescribe an ace inhibitor in the meantime like carvedilol.
Or the option is keep on eating like a nut and go on dialysis and die!
Its your decision
1
Well the medical field has lowered the normal fasting blood sugar for a diagnosis of diabetes. They have also just lowered the normal blood pressure after raising it just a few years ago. And now they have decided that half the seniors have chronic kidney disease. Go figure.
What will they lower next?
What will they lower next?
10
Whateever they can diagnose as a disease, and they and the drug companies can make money treating.
4
Really, it's a question of terminology. I suffer from "Gilbert's Syndrome". This sounds mildly scary, but all it means to the vast majority of "sufferers" (including myself) is that after seeing a PCP for the first time, the docter will pull a full liver panel because the bilirubin measure in a standard blood test will be out of whack.
I think the medical community should reserve terms, like "cancer", "disease", "syndrome", etc. that sound really scary for abnormal things that actually require action. Blood-work isn't an illness. An illness is something not working like it's supposed to. I can't argue with the idea that patients might find a "head's up" useful if certain body parts don't work like they used to, but saying that somebody suffering from a perfectly normal aging process has a "disease" is scarier than necessary. I mean, we don't diagnose everybody with the inevitable decline in muscle tone as one ages with cachexia, we just tell them to take it easy.
I think the medical community should reserve terms, like "cancer", "disease", "syndrome", etc. that sound really scary for abnormal things that actually require action. Blood-work isn't an illness. An illness is something not working like it's supposed to. I can't argue with the idea that patients might find a "head's up" useful if certain body parts don't work like they used to, but saying that somebody suffering from a perfectly normal aging process has a "disease" is scarier than necessary. I mean, we don't diagnose everybody with the inevitable decline in muscle tone as one ages with cachexia, we just tell them to take it easy.
3
You've answered a question I didn't even realize was lurking in the back of my mind, after seeing the CKD diagnosis repeated for an elderly relative, without apparent treatment.
3
If there are any elderly people out there who have been diagnosed with CKD and feel they have been 'labelled' without having a 'real' disease please let me know as I am trying to get patients perceptions on this topic