Kidney disease is truly a global epidemic and the Philippines is no exception, with tens of thousands of Filipinos diagnosed and likely even more left unrecognized. The availability of guidelines to assist in the proper management of these patients is truly invaluable and, in the appropriate situation, allows for the further improvement of patient care as well as the amelioration of certain deficiencies in health care delivery. It brings us one step closer to bridging the gap between one’s own personal practice and the implementation of true evidence-based medicine.
The objective of this commentary is not to criticize individual KDIGO recommendations, but to describe the difficulties faced by Filipino nephrologists as we strive for their implementation. The lack of Filipino data and the fact that consensus statements were based primarily on published Western data is a given and a fact I would prefer not to dwell on. It is obvious that local data are urgently needed.
Let me introduce you to a fictional patient named Juan Dela Cruz, a typical Filipino end stage renal disease (ESRD) patient on dialysis with diabetes, hypertension, and dyslipidemia. He has anemia and is receiving erythropoietin, as well as secondary hyperparathyroidism and hyperphosphatemia. Unfortunately, part of what makes him typical is that he only dialyzes twice a week, that his records show a diagnosis of “chronic glomerulonephritis,” but he has never had a biopsy performed despite a disproportionate amount of proteinuria along with his past medical history. He often has difficulty with compliance with dialysis, anemia management, and treatment of chronic kidney disease–mineral and bone disorder because at some point, putting food on the table has become more important.
The harsh reality is that due to multiple extraneous circumstances, the KDIGO guidelines have become a veritable wish list for physicians and patients in our part of the world, and merely reminds us of the things that we are unable to provide our patients.
Too many times, I’ve had to help patients choose between compliance with thrice weekly dialysis and treatment of their ESRD’s sequelae. Should we tolerate twice weekly dialysis to have some money left over for erythropoietin, vitamin D analogs, and phosphorus binders? What of the other illnesses and comorbidities? Unfortunately, as “typical” as this situation may be, there are no studies or guidelines available to help address these types of issues.
In some instances, the guidelines may even make it more difficult to care for patients. Although guidelines involving the use of generics, bioequivalents, and biosimilars are clear, they can be misinterpreted, leading some physicians to encourage patients to use more expensive innovator products and to set aside the fact that at some point, financial constraints may lead to their total and complete abandonment of treatment. Far from the intent for which these guidelines were developed, these impoverished patients now become at greater risk for mortality due to their iatrogenic adherence to the guidelines that were paradoxically developed to improve their outcomes.
The segmentation or the breaking down of the guidelines into particular topics, although convenient and ultimately necessary due to the complexity of kidney disease, may have diverted our focus from the fact that many issues often co-exist and are not exclusive of one another in the patient with kidney disease. Due to the financially challenging nature of kidney disease we must in most cases, learn to prioritize, an issue certainly needing a guideline in and of itself, but for which there is none.
KDIGO stands for Kidney Disease: Improving Global Outcomes. Its mission statement is “To improve the care and outcomes of kidney disease patients worldwide through promoting coordination, collaboration and integration of initiatives to develop and implement clinical practice guidelines.” However, when we discuss things on a global scale we must be sensitive to the fact that although most of the concepts, complications, and problems associated with kidney disease are universal, much of the world does not have the financial or technological capabilities of its first world counterparts. Therefore our challenge is to establish guidelines that are equally implementable in areas of the world where access to medical resources for, whatever reason, is limited. Only then can we truly say that we are focused on “Improving Global Outcomes.”