Telling the truth: why disclosure matters in chronic kidney disease

Abdi et al’s editorial¹ raises some important issues. Many patients with chronic kidney disease (CKD) are asymptomatic, but this differs from say, hypertension, in that end-organ damage has already occurred. Once disclosure has been made to a patient, as it should be, most would need to be guided through a risk assessment by their GP. The apposite appearance, in the same issue, of a paper on communicating risk to patients² highlights the potential difficulties of this. It is problematic with the familiar, such as cardiovascular disease (CVD), and I suspect many GPs would find the process even more complex with CKD. The highlighted statement caught my eye, that ‘Patients should be educated on preventative strategies, including … temporary cessation of medications such as renin-angiotensin blocking agents during periods of acute illness’.¹ I was reminded of an incident with a patient of mine, many years ago, when angiotensin converting enzyme (ACE) inhibitors were in their infancy in general practice. He had been prescribed an ACE inhibitor for congestive cardiac failure by his cardiologist. His renal picture fulfilled the criteria for referral to a nephrologist, confirmed at a lecture that I had recently attended. On my recommendation, my patient agreed to the referral. He was shortly after admitted to hospital with acute congestive cardiac failure, following the summary cessation of his ACE inhibitor by the nephrologist. His ACE inhibitor was restarted to beneficial effect, but he never quite regained his previous level of wellbeing. I was copied in to the subsequent animated correspondence between hospital specialists. It was my introduction to clinical compartmentalisation.

Given that CKD is a known risk factor for CVD, each GP is likely to have a number of patients who would be within the remit of this recommendation. Clearly, my anecdote does not give an evidential basis to a contrary argument, but does raise a clinical concern. I was surprised, therefore, to find that the recommendation was not supported by references. I would need more than just an authoritative statement to change my clinical practice. Is this merely an accidental error of omission, or is it a case of Dawkins’ triad and we are in at the beginning of a new tradition?³