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Clinical predictors of diagnostic testing utility in the initial evaluation of chronic kidney disease.

ABSTRACT: No evidence-based approach to the evaluation of CKD has been established. We sought to identify clinical criteria to guide a rational diagnostic approach for the initial evaluation of CKD.We conducted a retrospective cohort study of 1487 patients presenting for initial evaluation of CKD over 3?years (1/2010-1/2013) to academic nephrology clinics. We utilized the electronic medical record to determine tests ordered, abnormal results and testing that affected diagnosis and/or management. Diagnostic and management yield of testing was defined as the percentage of tests that affected diagnosis and/or management. High yield for a given test was defined as an increased likelihood of the test affecting diagnosis and/or management.We identified clinical criteria predictive of high yield for paraprotein-related testing (one of the following: history of monoclonal disease, high risk of CKD progression, hypercalcemia or haemoglobin ?500?mg/gm). A prior history of hydronephrosis and renal artery stenosis was predictive of high yield of abnormal renal ultrasound. Higher yield of testing was associated with higher risk progression categories for ANA, SPEP, urine sediment, calcium, PTH, haemoglobin, iron and ferritin. We estimate that initial CKD evaluation costs range from $28 to $109 million/year in US-Medicare expenditure.Numerous tests without significant clinical utility are obtained in initial CKD evaluation. Identifying criteria that can guide diagnostic testing may lead to a more informed and cost-effective approach to evaluation.

SUBMITTER: Mendu ML

PROVIDER: S-EPMC4969233 | biostudies-literature | 2016 Oct

REPOSITORIES: biostudies-literature

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Clinical predictors of diagnostic testing utility in the initial evaluation of chronic kidney disease.

Mendu Mallika L ML Lundquist Andrew A Aizer Ayal A AA Leaf David E DE Robinson Emily E Steele David J R DJ Waikar Sushrut S SS

Nephrology (Carlton, Vic.) 20161001 10

<h4>Aim</h4>No evidence-based approach to the evaluation of CKD has been established. We sought to identify clinical criteria to guide a rational diagnostic approach for the initial evaluation of CKD.<h4>Methods</h4>We conducted a retrospective cohort study of 1487 patients presenting for initial evaluation of CKD over 3 years (1/2010-1/2013) to academic nephrology clinics. We utilized the electronic medical record to determine tests ordered, abnormal results and testing that affected diagnosis ...[more]

PMID: 26610178

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Project description:Rationale & objectiveThe identification of pathogenic variants in genes associated with chronic kidney disease can provide patients and nephrologists with actionable information to guide diagnoses and therapeutic plans. However, many nephrologists do not use genetic testing despite costs decreasing over time and more widespread availability.Study designWe conducted a survey to uncover the perceptions of general adult nephrologists about the utility of and barriers to genetic testing in clinical practice.Setting & participantsThe online survey was administered to board-certified nephrologists (n = 10,054) in the United States.Analytical approachWe analyzed demographic characteristics of the survey respondents and their responses in the context of their use of genetic testing in routine clinical practice.ResultsA total of 149 nephrologists completed the survey, with 72% (107 of 149) reporting genetic test use in their practice. On average, tests were ordered for 3.8% of their patient population. Thirty-five percent of responses from nephrologists without a history of genetic test use ranked perceived barriers as "extremely significant" compared with 23% of responses from those who had previously used genetic tests. However, both users and nonusers of genetic tests indicated high cost (users: 46%, 49 of 107; nonusers 69%, 29 of 42) and poor availability or lack of ease (users: 33%, 35 of 107; nonusers: 57%; 24 of 42) of genetic testing as the most significant perceived barriers to implementation.LimitationsThe survey used in this study was not previously validated; additionally, because of the relatively small number of responses, there might have been a selection bias among the responders.ConclusionsAlthough most nephrologists reported using genetic tests in clinical practice, high costs and poor availability or the lack of ease of use were perceived as the most important barriers to routine adoption. These observations indicate that educational programs that cover a range of topics, from genetics of chronic kidney disease to selection of the test, may help mitigate these barriers and enhance the use of genetic testing in nephrology practice.

Project description:The evaluation of chronic wrist pain can be a diagnostic dilemma. Lidocaine injections combined with corticosteroids are often used for both diagnosis and therapy. The purpose of this study was to determine if a midcarpal injection of lidocaine could serve as a diagnostic tool in patients with chronic wrist pain. Specifically, the relationship of pain relief from the injection and improvement of grip strength were compared to the presence of intracarpal pathology as confirmed by wrist arthroscopy. Forty-five patients with chronic wrist pain underwent a midcarpal injection of lidocaine with or without corticosteroids. Forty of the 45 underwent comcomitant steroid injections; a majority of the 40 patients reported relief of pain for two or more weeks. Improvement of pain and improvement of grip strength were determined. Each of these patients subsequently underwent a radiocarpal and midcarpal arthroscopy, and the pathologic findings of arthroscopy were compared to the improvement of pain and grip strength. These data were compared to a cohort of six volunteers without history of wrist pain or trauma that underwent midcarpal injection of lidocaine. Statistical analysis was performed using Receiver-Operator-Characteristic analysis. The average age of patients with chronic pain was 30.3 years, with an average of 9.8 months of wrist pain. The ultimate diagnoses included 35 patients with carpal instability dissociative, two with nondissociative instability, seven with complex instability of the carpus, three with extensor carpi ulnaris tendonitis and one with deQuervain's tenosynovitis. After lidocaine injection, the normal cohort had a mean loss of 2 kg (-5.3%) (p = 0.02) in grip strength, whereas the experimental cohort had a mean improvement in grip strength of 5.73 kg (34.4%). Improvement of pain after injection did not correlate with pathologic arthroscopic findings (p = 0.92). Improvement in grip strength after midcarpal lidocaine injection of 6 kg or 28% had a 73% sensitivity and a 70% specificity (p = 0.02) of having intracarpal pathology at the time of arthroscopy. Of the chronic wrist pain patients, only four had a normal arthroscopy, and the remainder had at least one area of significant pathology attributing to their pain. We conclude that a midcarpal injection of lidocaine can serve as an effective diagnostic tool in the evaluation of the patient with chronic wrist pain. Improvement of grip of 28% with or without relief of pain is highly correlated with intracarpal pathology.

Project description:Fractures across the stages of chronic kidney disease (CKD) could be due to osteoporosis, some form of renal osteodystrophy defined by specific quantitative histomorphometry or chronic kidney disease-mineral and bone disorder (CKD-MBD). CKD-MBD is a systemic disease that links disorders of mineral and bone metabolism due to CKD to either one or all of the following: abnormalities of calcium, phosphorus, parathyroid hormone or vitamin D metabolism; abnormalities in bone turnover, mineralization, volume, linear growth or strength; or vascular or other soft-tissue calcification. Osteoporosis, as defined by The National Institutes of Health, may coexist with renal osteodystrophy or CKD-MBD. Differentiation among these disorders is required to manage correctly the correct disorder to reduce the risk of fractures. While the World Health Organization (WHO) BMD criteria for osteoporosis can be used in patients with stages 1-3 CKD, the disorders of bone turnover become so aberrant by stages 4 and 5 CKD that neither the WHO criteria nor the occurrence of a fragility fracture can be used for the diagnosis of osteoporosis. The diagnosis of osteoporosis in stages 4 and 5 CKD is one of the exclusion-excluding either renal osteodystrophy or CKD-MBD as the cause of low BMD or fragility fractures. Differentiations among the disorders of renal osteodystrophy, CKD-MBD or osteoporosis are dependent on the measurement of specific biochemical markers, including serum parathyroid hormone (PTH) and/or quantitative bone histomorphometry. Management of fractures in stages 1-3 CKD does not differ in persons with or without CKD with osteoporosis assuming there is no evidence for CKD-MBD, clinically suspected by elevated PTH, hyperphosphatemia or fibroblast growth factor 23 due to CKD. Treatment of fractures in persons with osteoporosis and stages 4 and 5 CKD is not evidence based, with the exception of post hoc analysis suggesting efficacy and safety of specific osteoporosis therapies (alendronate, risedronate and denosumab) in stage 4 CKD. This review also discusses how to diagnose and manage fragility fractures across the five stages of CKD.

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Clinical predictors of diagnostic testing utility in the initial evaluation of chronic kidney disease.

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Clinical predictors of diagnostic testing utility in the initial evaluation of chronic kidney disease.

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