Tuesday, March 29, 2016

Pediatricization of Nephrology

I did a Med-Peds residency. Very early in residency I knew that I did not want to do general pediatrics. I saw the field as largely being a caretaker of normal growth and maturation for the vast majority of patients (can we call them patients if they do not have a medical condition?) while at the same time being supremely vigilant to find the one in a thousand kids whose fever was not otitis media or adenovirus but bacterial meningitis. Primary pediatricians were ridiculed by the house staff for being over vigilant and admitting every cough, fever and rash or being idiots for missing obvious severe illness. From my eyes it looked like a horrible job.

Fast forward two decades and I find the overwhelming majority of new consults being for CKD stage 3 that after a thorough work-up ends up being normal renal deterioration of aging. I am becoming a caretaker of normal aging and maturation. Instead of trying to pick out the bacterial meningitis from a collection of fevers, I am trying to find the GN in a seas of decreased renal functions and diabetic kidney disease.

And like pediatrics, more and more of my job is spent reassuring people that the decreased renal function on their labs is not going to mean that they will be on dialysis. My most overused metaphor:
Just because you aren't as fast a runner as you were when you were 22, doesn't mean that you will end up in a wheel chair.
I know Go and Levey tell me that the decreased renal function is associated with increased risk of death, but no one can then offer me any evidence-based interventions to affect that risk. As long as it is impossible for me to intervene I am unable to shake the conclusion that this loss of renal function is natural aging.

This is the unintended consequence of the CKD staging system. We have fetishized GFR over pathology.
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