Nephrology
Canadian Society of Nephrology Last updated: September 2021
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Administering ESAs to CKD patients with the goal of normalizing hemoglobin levels has not 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 (90–110 g/L).
Sources:
Drüeke T, et al. Normalization of hemoglobin level in patients with chronic kidney disease and anemia. N Engl J Med. 2006 Nov 16;355(20):2071-84. PMID: 17108342.
Moist LM, et al. Canadian Society of Nephrology commentary on the 2012 KDIGO Clinical Practice Guideline for Anemia in CKD. Am J Kidney Dis. 2013 Nov;62(5):860-73. PMID: 24054466.
Pfeffer MA, et al. A trial of darbepoetin alfa in type 2 diabetes and chronic kidney disease. N Engl J Med. 2009 Nov 19;361(21):2019-32. PMID: 19880844.
Singh AK, et al. Correction of anemia with epoetin alfa in chronic kidney disease. N Engl J Med. 2006 Nov 16;355(20):2085-98. PMID: 17108343.
Related Resources:
Patient Pamphlet: Chronic Kidney Disease: Making hard choices
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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 medication prescribed by a healthcare professional may be safer than and as effective as NSAIDs.
Sources:
Gooch K, et al. NSAID use and progression of chronic kidney disease. Am J Med. 2007 Mar;120(3):280.e1-7. PMID: 17349452.
National Kidney Foundation. K/DOQI clinical practice guidelines for chronic kidney disease: evaluation, classification, and stratification. Am J Kidney Dis. 2002 Feb;39(2 Suppl 1):S1-266. PMID: 11904577.
Scottish Intercollegiate Guidelines Network (sponsored by NHS Quality Improvement Scotland). Management of chronic heart failure: A national clinical guideline. [Internet]. Edinburgh (UK): Scottish Intercollegiate Guidelines Network (SIGN); 2007 Feb [cited 2014 Sep 23].
US Department of Health and Human Services. National Heart, Lung, and Blood Institute. The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure [Internet]. 2004 Aug [cited 2014 Sep 23].
Related Resources:
Patient Pamphlet: Pain Medicines: What to do if you have heart problems or kidney disease
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When used in combination ACE inhibitors and ARBs are associated with an increased risk of symptomatic hypotension, acute renal failure and hyperkalemia and may increase mortality.
Sources:
Fried LF, et al. Combined angiotensin inhibition for the treatment of diabetic nephropathy. N Engl J Med. 2013 Nov 14;369(20):1892-903. PMID: 24206457.
Heran BS, et al. Angiotensin receptor blockers for heart failure. Cochrane Database Syst Rev. 2012 Apr 18;(4):CD003040. PMID: 22513909.
Mann JF, et al. Renal outcomes with telmisartan, ramipril, or both, in people at high vascular risk (the ONTARGET study): a multicentre, randomised, double-blind, controlled trial. Lancet. 2008 Aug 16;372(9638):547-53. PMID: 18707986.
Phillips CO, et al. Adverse effects of combination angiotensin II receptor blockers plus angiotensin-converting enzyme inhibitors for left ventricular dysfunction: a quantitative review of data from randomized clinical trials. Arch Intern Med. 2007 Oct 8;167(18):1930-6. PMID: 17923591.
Yusuf S, et al. Telmisartan, ramipril, or both in patients at high risk for vascular events. N Engl J Med. 2008 Apr 10;358(15):1547-59. PMID: 18378520.
Related Resources:
Patient Pamphlet: Chronic Kidney Disease: Making hard choices
Patient Pamphlet: Pain Medicines: What to do if you have heart problems or kidney disease
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The decision to initiate chronic dialysis should be part of an individualized, shared decision-making process between patients, their families, and their nephrology health care team. 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 comorbidity who initiate chronic dialysis versus those managed conservatively.
Sources:
Chandna SM, et al. Survival of elderly patients with stage 5 CKD: comparison of conservative management and renal replacement therapy. Nephrol Dial Transplant. 2011 May;26(5):1608-14. PMID: 21098012.
Jassal SV, et al. Changes in survival among elderly patients initiating dialysis from 1990 to 1999. CMAJ. 2007 Oct 23;177(9):1033-8. PMID: 17954892.
Kurella M, et al. Octogenarians and nonagenarians starting dialysis in the United States. Ann Intern Med. 2007 Feb 6;146(3):177-83. PMID: 17283348.
Kurella Tamura M, et al. Functional status of elderly adults before and after initiation of dialysis. N Engl J Med. 2009 Oct 15;361(16):1539-47. PMID: 19828531.
Murtagh FE, et al. Dialysis or not? A comparative survival study of patients over 75 years with chronic kidney disease stage 5. Nephrol Dial Transplant. 2007 Jul;22(7):1955-62. PMID: 17412702.
Related Resources:
Patient Pamphlet: Chronic Kidney Disease: Making hard choices
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Initiating chronic dialysis before the appearance of uremic symptoms or other clinical indication is associated with significant burden and inconvenience for the patient without any clinical benefit. Recent guidelines from the Canadian Society of Nephrology recommend that patients with an estimated glomerular filtration rate (eGFR) less than 15 mls/min should be closely followed by their nephrologist and dialysis deferred until symptoms of uremia, volume overload, hyperkalemia or acidosis become an issue or the eGFR drops below 6 mls/min.
Sources:
Cooper BA, et al. A randomized, controlled trial of early versus late initiation of dialysis. N Engl J Med. 2010 Aug 12;363(7):609-19. PMID: 20581422.
Nesrallah GE, et al. Canadian Society of Nephrology 2014 clinical practice guideline for timing the initiation of chronic dialysis. CMAJ. 2014 Feb 4;186(2):112-7. PMID: 24492525.
Susantitaphong P, et al. GFR at initiation of dialysis and mortality in CKD: a meta-analysis. Am J Kidney Dis. 2012 Jun;59(6):829-40. PMID: 22465328.
Related Resources:
Patient Pamphlet: Chronic Kidney Disease: Making hard choices
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The Canadian Society of Nephrology (CSN) established its Choosing Wisely Canada recommendations by striking a Choosing Wisely Working Group from its Clinical Practice Guidelines Committee. The working group created a survey to poll the members of the society, who were asked to vote for 5 tests, 5 investigations and 5 treatments that they felt were overused, misused or had potential to cause harm. Over 400 members were surveyed with a 22% response rate. These responses were collated into themes, and ordered by their frequency of occurrence. Three members of the working group reviewed the list independently; each of whom proposed a top 10 list of recommendations derived from the survey responses. These 3 lists were then reviewed by the working group and a draft top ten list was generated based on the following criteria: strength of evidence; potential for harm; cost saving; frequency of occurrence in clinical practice and pertinence to nephrology. The draft list of ten items was presented at the CSN annual general meeting and members were asked to vote electronically on their agreement with each recommendation. In addition to the membership votes, the working group then considered the strength of evidence and potential for meaningful impact of the recommendations, and a final list of five items was agreed upon. Recommendations 1, 2, and 4 were adapted with permission from the Five Things Physicians and Patients Should Question, © 2012 American Society of Nephrology.
Chronic Kidney Disease
Making hard choices.
Pain Medicines
What to do if you have heart problems or kidney disease.