Telling the truth: why disclosure matters in chronic kidney disease

Your editorial in the April BJGP is very thought provoking but unfortunately misses the mark.¹ Primary care workers are considerably more sophisticated and well trained in the art of evidence than they were in 1960s. It was at this time that mild hypertension and its risks began to surface. In some ways hypertension and chronic kidney disease (CKD) are similar. Neither makes people feel sick and both are risk factors for heart disease and organ failure. In the 1960s the treatment of hypertension was unsophisticated with no good understanding of what impact we might have been having. It feels the same with CKD now.

Hypertension has since grown an evidence base that shows treatment has an impact on outcome. It has still been badly managed and guidance has been poor too; many practitioners have railed against old guidelines that took no notice of the patients blood pressure readings in the real world or did nothing to look at other factors. I remember too being shocked when I discovered the number needed to treat (NNT) for a middle-aged male with hypertension to prevent a stroke was 850. A move towards multiple measurements of blood pressure and looking at risk overall are steps in the right direction at trying to ensure we advise/treat those most at risk.

Now lets look at CKD.

Detection is unsophisticated and currently inadequate; the guidance that 3 months is enough is not good enough and draws parallels with hypertension detection.

Current evidence on intervention and effectiveness seems very light. I have asked everyone (including this journal) to provide me with a NNT for a patient with CKD III who need detecting and intervening with to prevent either a cardiovascular event or end-stage renal failure and nobody has so far managed. Could I ask you?

‘So doctor, you want me to take more pills (or stop the only pills that give me a pain-free night's sleep). What is the benefit to me if you do this? … And don't give me that politician speak … give it to me straight.’

I fully understand the seriousness of chronic kidney disease and the cost and implications on patients. I am happy to share the truth with my patients but you need to find it and tell me it too.