Bad medicine: chronic kidney diseaseBMJ 2010; 340 doi: https://doi.org/10.1136/bmj.c3188 (Published 16 June 2010) Cite this as: BMJ 2010;340:c3188
- Des Spence, general practitioner, Glasgow
There was a time when the NHS had more money than sense. So in 2006 chronic kidney disease was added to the NHS’s quality and outcomes framework (QOF). Most general practitioners had no idea why this was. We assumed it was a way to identify those with kidney disease and to modify progression. However, we were then told that a staggering 10% of the population had the disease, even though most GPs have only a handful of patients with end stage renal failure. Were we really going to treat so many patients to prevent an extremely rare outcome? Later it was suggested that chronic kidney disease was an independent and new risk factor for ischaemic heart disease. Confused, we did what we were told and set up disease registers. This served only to scare patients witless, who assumed that they would soon be on a dialysis machine, and to overwhelm local renal clinics with nervous patients and needless referrals. After four years, what is opportunistic screening for the disease all about?
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.
Cite this as: BMJ 2010;340:c3188