Reality at the coal face

I fear that Connor and O’Donoghue1 are too committed to their cause to appreciate Spence’s perspective.2 All my patients are assigned a chronic kidney disease (CKD) grade. Several healthy patients have been horrified to be classified as “CKD 1.” My efforts to reassure them that they are normal ring hollow. How can I know who might slide down the scale to renal failure, however unlikely? So I am trapped into a lifetime of monitoring.

They have also missed the central point.1 CKD 3 is a non-disease, with no good evidence that identifying it does more good than harm. In attempting to address Spence’s true claim that “evidence is lacking for the use of conventional cardiovascular risk treatments in chronic kidney disease, and that chronic kidney disease is not a modifiable cardiovascular risk factor” they again miss the point. They say that cardiovascular risk increases with the severity of CKD and that ameliorating progression will reduce the burden of cardiovascular disease. But we do not know this. Statins reduce cardiovascular mortality in this group, as they do in most men over 50. That is no reason to keep pursuing CKD, even if statins were imperceptibly modifying an underlying CKD process. This is unlikely because they admit that statins seem to be more effective in patients with less severe CKD.

I could go on, but unfortunately 6% of my practice list are sitting in the waiting room clutching urine samples because their eGFR was above an arbitrary value.