Five Things Physicians and Patients should question (Part 8)

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American Society of Nephrology
1. Don’t perform routine cancer screening for dialysis patients with limited life expectancies without signs or symptoms: Due to high mortality among end-stage renal disease (ESRD) patients, routine cancer screening—including mammography, colonoscopy, prostate-specific antigen (PSA) and Pap smears—in dialysis patients with limited life expectancy, such as those who are not transplant candidates, is not cost effective and does not improve survival. False-positive tests can cause harm: unnecessary procedures, overtreatment, misdiagnosis and increased stress. An individualized approach to cancer screening incorporating patients’ cancer risk factors, expected survival and transplant status is required.
2. Don’t administer erythropoiesis-stimulating agents (ESAs) to chronic kidney disease (CKD) patients with hemoglobin levels ≥10 g/dL without symptoms of anemia. Administering ESAs to CKD patients with the goal of normalizing hemoglobin levels has no demonstrated survival or cardiovascular disease benefit, and may be harmful in comparison to a treatment regimen that delays ESA administration or sets relatively conservative targets (9–11 g/dL). ESAs should be prescribed to maintain hemoglobin at the lowest level that both minimizes transfusions and best meets individual patient needs.
3. Avoid NSAIDS in individuals with hypertension or heart failure or CKD of all causes, including diabetes. The use of NSAIDS, including cyclo-oxygenase type 2 (COX-2) inhibitors, for the pharmacological treatment of musculoskeletal pain can elevate blood pressure, make antihypertensive drugs less effective, cause fluid retention and worsen kidney function in these individuals. Other agents such as acetaminophen, tramadol or short-term use of narcotic analgesics may be safer than and as effective as NSAIDs.
4. Don’t place peripherally inserted central catheters (PICC) in stage III–V CKD patients without consulting nephrology: Venous preservation is critical for stage III–V CKD patients. Arteriovenous fistulas (AVF) are the best hemodialysis access, with fewer complications and lower patient mortality, versus grafts or catheters. Excessive venous puncture damages veins, destroying potential AVF sites. PICC lines and subclavian vein puncture can cause venous thrombosis and central vein stenosis. Early nephrology consultation increases AVF use at hemodialysis initiation and may avoid unnecessary PICC lines or central/peripheral vein puncture.
5. Don’t initiate chronic dialysis without ensuring a shared decision-making process between patients, their families, and their physicians: The decision to initiate chronic dialysis should be part of an individualized, shared decision-making process between patients, their families, and their physicians. This process includes eliciting individual patient goals and preferences and providing information on prognosis and expected benefits and harms of dialysis within the context of these goals and preferences. Limited observational data suggest that survival may not differ substantially for older adults with a high burden of comorbidities who initiate chronic dialysis versus those managed conservatively.