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Bad medicine: chronic kidney disease

Advocates of chronic kidney disease deploy the typical doomsday predictions that are based on flawed epidemiology, simplistic modelling, and the views of experts with vested interests. So does treating it prevent renal failure? Certainly, treating people with diabetes and proteinuria with an angiotensin converting enzyme inhibitor delays progression, but this represents a minority of cases. Only 1% of patients with stage 3 chronic kidney disease progress to end stage renal failure within eight years.1 So, assuming that a quarter of this 1% do not progress,2 as a result of aggressive blood pressure management, this would still give crude numbers needed to treat of 3200 patients a year. Add in the increasing concern about the risks associated with dual renin-angiotensin blockade (a common intervention),3 treatment seems not merely illogical but stupid.

Surely there must be good evidence that managing chronic kidney disease reduces deaths from ischaemic heart disease? There is not.4 Indeed, there is nothing to add to the current cluster bomb drug treatment for cardiovascular risk. Consider also the rapidly declining incidence of ischaemic heart disease—chronic kidney disease is simply not a modifiable risk factor for ischaemic heart disease.

General practitioners are quietly sceptical about chronic kidney disease. With only 4% of “sufferers” currently on registers, it has been suggested that doctors need more education to help them spot unmet need. But the QOF is in fact a hugely powered clinical study, and after four years we should have evidence that managing chronic kidney disease has a benefit—so where is it? It is simply not a disease. Pursuing it will make 10% of the population “patients,” filtering out yet more of society’s wellbeing. Why are we blind to the harm we do? Chronic kidney disease is a failed experiment, a mockery of evidence based medicine, and just more bad modern medicine.

 

References

Hallan SI, Dahl K, Oien CM, Grootendorst DC, Aasberg A, Holmen J, et al. Screening strategies for chronic kidney disease in the general population: follow-up of cross sectional health survey. BMJ2006;333:1047.

Effects of ramipril on cardiovascular and microvascular outcomes in people with diabetes mellitus: results of the HOPE study and MICRO-HOPE substudy. Lancet2000;355:253-9.

Ku E, Park J, Vidhun J, Campese V. The hazards of dual renin-angiotensin blockade in chronic kidney disease. Arch Intern Med2009;169:1015-8.


Strippoli GFM, Navaneethan SD, Johnson DW, Perkovic V, Pellegrini F, Nicolucci A, et al. Effects of statins in patients with chronic kidney disease: meta-analysis and meta-regression of randomised controlled trials. BMJ2008;

Lees meer:
http://www.bmj.com/content/341/bmj.c4903.full

 

 

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