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More on joint rounds, CHF/AKI

August 2019

IN YOUR “MAKING JOINT ROUNDS WORK” article (June 2019), I was disappointed to find a picture of what are obviously a Caucasian female nurse and a Caucasian male doctor. Please stop reinforcing this tiring gender/racial stereotype and be more mindful of reflecting the diversity that actually exists in medicine.

~ Barb Creighton, MD
Fairbanks, Alaska

More on CHF/AKI on CKD ping-pong

IN THE RECENTUtilization matters” commentary (June 2019), the author lists “CHF/AKI on CKD ping-pong” as one hospital practice that unnecessarily prolongs length of stay. He writes, “A minimal worsening of labs … suddenly turns into complicated medication holding and adjustment, a useless renal ultrasound, alarmist discussions about hemodialysis, IV fluids, and occasionally sending the patient back into volume overload.” He goes on to quote a cardiologist who said, “Nobody ever died of a creatinine of three.”

As a nephrologist, I believe that’s inaccurate. First, treating heart failure patients with AKI is complicated and not straightforward; it is difficult to obtain information, predict trajectories and evaluate patients’ responses to therapies. Acute kidney injury actually carries a very high mortality rate in hospital patients, especially those who are acutely ill—including those with heart failure. It is an important predictor of negative outcomes in patients with heart failure and should be managed aggressively. As nephrologists, we often find that a rush to shorten length of stay for these patients can result in worse outcomes or readmissions.

And plenty of patients have died with a creatinine of three. Many more have been dialyzed, and more patients with CKD die from CVD before they reach dialysis. It’s reckless to trivialize impairment in uremic toxin excretion and the consequent increase in CVD mortality that results from it.

~ Shivam Joshi, MD
New York

Dr. Krisa responds:

My intent was to showcase common scenarios that may provide limited value to patients and unnecessarily prolong length of stay. Active discussions among clinicians are the lifeblood of best practices and, as such, I appreciate Dr. Joshi’s comments.

CHF/AKI on CKD escapades may stem from poor recognition of baseline renal function, with inaccurate labeling of AKI. AKI diagnosis can be variable and confusing, as several definitions exist, and there may be an overemphasis on creatinine values despite any real change in GFR/CKD stage. Visualize the analogy of standing on stairs with a yo-yo: Despite expected fluctuations within a narrow range, unless you’re walking up or down the stairs while playing with the yo-yo, there is no meaningful positive or negative vertical trend. In the absence of true relevance, we fail when we treat numbers and not patients.

The commentary featured a fearful hospitalist, conservative cardiologist and an aggressive nephrologist. If roles were reversed, an aggressive cardiologist might go rogue and dangerously overdiurese. The point is: Balance and collaboration among services leads to optimal outcomes. Ceding control of a medically complex patient to one clinician “running the show” can be catastrophic. Like a maestro conductor, the adept hospitalist harmonizes the symphony by coordinating the players.

Finally, the cardiologist who told me “nobody ever died of a creatinine of three” was admittedly being playful and at least a little cavalier.

Published in the August 2019 issue of Today’s Hospitalist

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