Issue 2 • 2021

New Evolve recommendations focus on nephrology

© 2021 The Royal Australasian College of Physicians
Kidney function and kidney disease impact human health across an array of systems and specialties. The new Evolve recommendations on low-value practices in nephrology span and interact with a wide range of conditions, populations and disciplines.
View the latest Evolve ‘Top-5’ Recommendations on low-value practices in nephrology.
The Australian and New Zealand Society of Nephrology (ANZSN), which is a not-for-profit organisation representing the interests of health professionals committed to the prevention and treatment of kidney disease, partnered with Evolve on these new recommendations.
Dr Paul Collett FRACP, a nephrologist at the Royal North Shore Hospital in Sydney, was the initial Lead Fellow in the development of these recommendations on behalf of ANZSN, with Dr David Tunnicliffe, a researcher interested in the generation and implementation of evidence into clinical practice in nephrology, now having taken over the role.
“The ANZSN and Evolve have identified areas that are of low-value care, that don’t improve patient outcomes and could actually be harmful. We recognised that to ensure patient outcomes are improved and that healthcare costs are reduced, we need to practice medicine based on evidence,” says Dr Tunnicliffe.
The new recommendations have identified topics that are multi-disciplinary. Dr Tunnicliffe explains, “The topics covered may be managed by different specialties outside of nephrology, and that’s where this list of recommendations is important. We identified specific areas where there’s evidence in the nephrology space, that may not be well known in other areas of clinical medicine. For example, some patients might be seen by paediatricians for the UTI type issue. These recommendations help to reduce the variability that is seen across specialties and the variation of care, and as a result improve patient outcomes.”
One topic tackled by the fifth recommendation is chronic kidney disease, a well‐known independent cardiovascular risk factor. The fifth recommendation states:
Do not prescribe aspirin therapy for primary prevention of cardiovascular disease in patients with stage 1-3 chronic kidney disease as there is no proven benefit and it is associated with increased risk of impaired haemostasis.
Aspirin is used quite broadly in the primary prevention of cardiovascular disease and is shown to reduce cardiovascular events and death in patients. Hence, is seen as an important intervention. However, the evidence in chronic kidney disease (CKD) patients is not as robust.
“The best evidence we have comes from a sub-group analysis and post hoc analysis done by Professor Meg Jardine FRACP on the Hypertension Optimal Treatment (HOT) trial, which essentially showed that in patients with CKD, with varying ranges of kidney function, that the use of aspirin had no benefit. In particular, for patients with earlier CKD, that is, stages 1 to 3, there was no benefit on the cardiovascular outcomes or preventing death. In conjunction with that, there is also an increased risk of bleeding because CKD patients have some impaired control of haemostasis, due to their disease. As a result, there’s very little evidence of benefit, but there is an increased risk of harm.
“Additionally, meta-analysis of trials have confirmed this finding that there is no real change in the effect of cardiovascular events or death, but there could be a doubling of bleeding risk in these patients which obviously is a large concern.” Other antithrombotic agents should be considered in patients with early CKD, stages 1 to 3.
“Medicine is a science and there is evidence for things that work based on clinical trials etc. However, it is also an artform, there’s also including patient characteristics, their preferences into clinical care and management. We need to be guided in certain situations by what has been done outside our specialty or outside our expertise. These Evolve recommendations focus on those areas that we think are particularly contentious, where people may react just through instinct or what’s happened previously, but we’ve tried to ground these recommendations in what we know and the potential complications for patients. Not practicing medicine according to the evidence could lead to harm for the patients and additionally a waste of resources,” concludes Dr Tunnicliffe.