In the United States, 26 million adults have chronic kidney disease (CKD), which makes it harder for the kidneys to filter waste from the blood. CKD is an important health issue that can be under-recognized by patients and doctors, as it often progresses gradually with no obvious signs or symptoms until it has advanced to a late stage. It is often linked to diabetes or hypertension, and symptoms include decreased energy, muscle cramps, and swollen feet and ankles. It is crucial to recognize CKD in order to slow its progression and reduce patients’ chances of bad outcomes like heart attacks or renal failure.
If CKD progresses to later stages – usually stage 4 or 5 – it might affect how patients approach their overall medical care. Therapies for CKD and its consequences might be deemed more important than routine blood tests or procedures. The American Board of Internal Medicine (ABIM) has led an initiative called Choosing Wisely and collaborated with the American Society of Nephrology to make evidence-based recommendations for CKD patients. The Choosing Wisely list of “Things Physicians and Patients Should Question” is meant to help patients with CKD and their healthcare providers make wise decisions about some aspects of their medical care. All clinical decisions should be made on a patient’s specific situation, but the recommendations are meant to stimulate discussion about the need—or lack thereof—for some tests or treatments. I’ve listed 3 of these questions and their considerations below.
SHOULD I USE ANEMIA DRUGS?
CKD can cause anemia, or too few red blood cells, which in turn can make you tired. Drugs called erythropoiesis-stimulating agents, or ESAs, can help the body make new red blood cells. When the drugs (the brand names are Aranesp, Epogen, and Procrit) first became available, doctors used them aggressively to treat anemia, hoping that they would prevent problems later.
But research now shows that aggressive treatment with ESAs might actually raise the risk of heart attacks and strokes. In addition, ESAs are very expensive, costing hundreds of dollars per dose. Even with Medicare coverage, co-payments can be more than $1,500 a year.
Patients and doctors should consider ESAs only when there are symptoms of anemia, such as shortness of breath or fatigue, and those symptoms are accompanied by very low hemoglobin levels (generally under 10 g/dL). If you decide to try an ESA, you and your doctor should work to keep your hemoglobin level at the lowest level that both minimizes the need for blood transfusions and eases your symptoms.
SHOULD I CONSIDER DIALYSIS?
If CKD progresses to the point that your kidneys are close to failing, long-term dialysis is one of the treatment options. It helps make up for some of the functions of the kidneys, such as filtering out waste and keeping a safe balance of water and salts in the blood. But it’s not always easy to determine the best time to start dialysis. Starting dialysis at too early a stage — a practice that’s become widespread — provides no benefit. On the other-hand, waiting too long might lead to a bad outcome.
It’s also important to consider the time commitment and side effects of dialysis. It often requires trips to a dialysis center, usually three days a week, with each treatment session lasting three to five hours. Nausea, fatigue, and headaches are common. In some cases, dialysis might not do much to help you live longer, ease your symptoms, perform daily activities, or stay independent. That’s particularly true the older you are, and if your kidney failure is complicated by heart disease or other conditions that shorten life expectancy. Therefore, the decision to start long-term dialysis should be discussed with your family and your doctor.
IF I AM ON DIALYSIS, DO I NEED ALL THOSE CANCER SCREENINGS?
Routine screening tests such as mammography, colonoscopy, and Pap smears can save lives by detecting cancers while they are in an early, treatable stage. But many people on hemodialysis might prefer to focus on more pressing health problems, like heart disease and infections, and eliminate cancer screening tests which may no longer be useful. Health problems from CKD may pose a much greater and immediate risk than does cancer.
Moreover, advanced kidney disease can have effects on the body that make cancer screening tests less accurate. For example, kidney disease can cause breast calcifications that look like possible tumors on a mammogram. Those findings can lead to additional, unnecessary tests, such as biopsies, and increased stress and worry. In addition, preparing for a colonoscopy by fasting and taking bowel cleansing preparations can worsen malnutrition and cause dehydration as well as imbalances in water and salts, all of which pose more risk if you are on dialysis.
You should therefore make your own decision – with guidance from your doctor – about whether to have routine screening based on your cancer risk factors, symptoms and expected survival on dialysis. A screening colonoscopy could be worthwhile, for example, if you have a family history of colon cancer but you are also awaiting a kidney transplant that will significantly increase your life expectancy.