Guest guest Posted July 31, 2012 Report Share Posted July 31, 2012 THis just shows the stupidity of this system, clearly it is done by either a computer that can't reason or a high school graduate who doesn't know any better. I routinely throw these away, too stupid to look at most of the time. CCote To: "" < >Sent: Tuesday, July 31, 2012 9:11:30 AMSubject: vent/rant Why would a stupid insurance company send you a recommendation to put your diabetic patient on an ACE inhibitor if he is getting dialysis 3 days a week for end-stage renal failure?????? They say it is based on claims analysis, don't they see their claims for dialysis treatment?Margaret Quote Link to comment Share on other sites More sharing options...
Guest guest Posted July 31, 2012 Report Share Posted July 31, 2012 That is why we shred all of those " recommendations " from the insurance companies. Steve doesn't even look at them any more, with one exception for one patient because we know she will talk to him about every " recommendation " from her insurance co, and he wants to be prepared as to why we are or are not doing what they recommend! Why would a stupid insurance company send you a recommendation to put your diabetic patient on an ACE inhibitor if he is getting dialysis 3 days a week for end-stage renal failure?????? They say it is based on claims analysis, don't they see their claims for dialysis treatment? Margaret -- Pratt Quote Link to comment Share on other sites More sharing options...
Guest guest Posted July 31, 2012 Report Share Posted July 31, 2012 Here’s why (for example): http://www.ncbi.nlm.nih.gov/pubmed/12407648 From: [mailto: ] On Behalf Of magnetdoctor@...Sent: Tuesday, July 31, 2012 10:16 AMTo: Subject: Re: vent/rant THis just shows the stupidity of this system, clearly it is done by either a computer that can't reason or a high school graduate who doesn't know any better. I routinely throw these away, too stupid to look at most of the time. CCoteTo: " " < >Sent: Tuesday, July 31, 2012 9:11:30 AMSubject: vent/rant Why would a stupid insurance company send you a recommendation to put your diabetic patient on an ACE inhibitor if he is getting dialysis 3 days a week for end-stage renal failure?????? They say it is based on claims analysis, don't they see their claims for dialysis treatment?Margaret Quote Link to comment Share on other sites More sharing options...
Guest guest Posted July 31, 2012 Report Share Posted July 31, 2012 Thanks but he is over 65 and the recommendation said to help with microalbuminuria. vent/rant  Why would a stupid insurance company send you a recommendation to put your diabetic patient on an ACE inhibitor if he is getting dialysis 3 days a week for end-stage renal failure?????? They say it is based on claims analysis, don't they see their claims for dialysis treatment? Margaret Quote Link to comment Share on other sites More sharing options...
Guest guest Posted July 31, 2012 Report Share Posted July 31, 2012 In general, use of ACE inhibitors or ARBs is strongly indicated in dialysis patients (among others, including most notably diabetics and heart failure patients) for a number of reasons. They are not just indicated in those less than 65, although that’s where you might expect to see the most profound outcome differences in mortality, which might be why that preliminary study from 2002 studied only that population. As your insurance company noted, preservation of residual kidney function through reduction of microalbuminuria is indeed an important factor in the survival of dialysis patients who are not already anuric. Above and beyond the renal issues, ACE inhibitors and ARBS are important (and similar to statins) in that they limit inflammation, particularly vascular inflammation. In short, they significantly decrease cardiovascular mortality in at-risk populations, and not just through their direct effects on blood pressure. From: [mailto: ] On Behalf Of Margaret CoughlanSent: Tuesday, July 31, 2012 11:00 AMTo: Subject: Re: vent/rant Thanks but he is over 65 and the recommendation said to help with microalbuminuria. vent/rant Why would a stupid insurance company send you a recommendation to put your diabetic patient on an ACE inhibitor if he is getting dialysis 3 days a week for end-stage renal failure?????? They say it is based on claims analysis, don't they see their claims for dialysis treatment? Margaret Quote Link to comment Share on other sites More sharing options...
Guest guest Posted August 1, 2012 Report Share Posted August 1, 2012 OK I'm going back to the books cuz I was always, always taught you keep the ACE on until the Cr starts climbing and you stop it because now that dog that was helping will turn around and bite you! I did a month with the renal docs. So your information is definately a flag for me to go check it out. Thanks. From: Ken Stone To: Sent: Tuesday, July 31, 2012 11:34 AM Subject: RE: vent/rant In general, use of ACE inhibitors or ARBs is strongly indicated in dialysis patients (among others, including most notably diabetics and heart failure patients) for a number of reasons. They are not just indicated in those less than 65, although that’s where you might expect to see the most profound outcome differences in mortality, which might be why that preliminary study from 2002 studied only that population. As your insurance company noted, preservation of residual kidney function through reduction of microalbuminuria is indeed an important factor in the survival of dialysis patients who are not already anuric. Above and beyond the renal issues, ACE inhibitors and ARBS are important (and similar to statins) in that they limit inflammation, particularly vascular inflammation. In short, they significantly decrease cardiovascular mortality in at-risk populations, and not just through their direct effects on blood pressure. From: [mailto: ] On Behalf Of Margaret CoughlanSent: Tuesday, July 31, 2012 11:00 AMTo: Subject: Re: vent/rant Thanks but he is over 65 and the recommendation said to help with microalbuminuria. vent/rant Why would a stupid insurance company send you a recommendation to put your diabetic patient on an ACE inhibitor if he is getting dialysis 3 days a week for end-stage renal failure?????? They say it is based on claims analysis, don't they see their claims for dialysis treatment? Margaret Quote Link to comment Share on other sites More sharing options...
Guest guest Posted August 1, 2012 Report Share Posted August 1, 2012 Kinda sorta. The way I learned it is that ACE inhibitors and ARBs are actually fine in most chronic kidney disease.  In the setting of albuminuria, they’re particularly indicated, because filtered protein rips bigger holes in the glomeruli as it passes through them (negative charges on protein interacting with negatively charged proteins in the podocytes, IIRC) and that protein filtration can destroy kidneys very quickly. Although they decrease GFR, the ACEIs/ARBs are helping the glomeruli to heal in that situation by decreasing filtration pressure. But yeah, since ACEIs and ARBs work by lowering the GFR, they do cause the scales to tip in the wrong direction in CKD, with increases in Cr and BUN. That’s not the same as causing damage, though. This mostly becomes an issue in CKD4 when you want to delay initiation of dialysis and the presence of an ACEI/ARB causes their GFR to dip below the magic threshold that separates where the kidneys are just barely getting enough flow to get the job done from where they aren’t. But again, I don’t think that means the ACEIs/ARBs are doing additional damage in that situation; they’re merely highlighting the severe damage that is already present.  Once the patient is getting dialysis anyway, it would be reasonable to restart them if there are good reasons to do so (e.g. preservation of renal function in diabetic nephropathy). That biting dog you referred to from ACEIs comes into play mostly in the setting of acute kidney injuries, typically shock/hypotension, where the kidneys are trying to recover from hypoxia and inadequate blood flow. In that setting, ACEIs are indeed very, very, bad. I’m sure there are a few exceptions here and there to these general principles (most notably e.g. in renovascular disease); if you happen to discover something markedly different in your studies from what I’ve outlined above, please correct my misunderstanding. Thanks, Ken From: [mailto: ] On Behalf Of MyriaSent: Tuesday, July 31, 2012 8:09 PMTo: Subject: Re: vent/rant OK I'm going back to the books cuz I was always, always taught you keep the ACE on until the Cr starts climbing and you stop it because now that dog that was helping will turn around and bite you! I did a month with the renal docs. So your information is definately a flag for me to go check it out. Thanks. To: Sent: Tuesday, July 31, 2012 11:34 AMSubject: RE: vent/rant In general, use of ACE inhibitors or ARBs is strongly indicated in dialysis patients (among others, including most notably diabetics and heart failure patients) for a number of reasons. They are not just indicated in those less than 65, although that’s where you might expect to see the most profound outcome differences in mortality, which might be why that preliminary study from 2002 studied only that population. As your insurance company noted, preservation of residual kidney function through reduction of microalbuminuria is indeed an important factor in the survival of dialysis patients who are not already anuric. Above and beyond the renal issues, ACE inhibitors and ARBS are important (and similar to statins) in that they limit inflammation, particularly vascular inflammation. In short, they significantly decrease cardiovascular mortality in at-risk populations, and not just through their direct effects on blood pressure. From: [mailto: ] On Behalf Of Margaret CoughlanSent: Tuesday, July 31, 2012 11:00 AMTo: Subject: Re: vent/rant Thanks but he is over 65 and the recommendation said to help with microalbuminuria. vent/rant Why would a stupid insurance company send you a recommendation to put your diabetic patient on an ACE inhibitor if he is getting dialysis 3 days a week for end-stage renal failure?????? They say it is based on claims analysis, don't they see their claims for dialysis treatment? Margaret Quote Link to comment Share on other sites More sharing options...
Guest guest Posted August 1, 2012 Report Share Posted August 1, 2012 On a brief review of the literature to confirm what I thought I “knew†re:  RAAS blockade in dialysis patients, I found that I overstated my case. Rather than yet saying that ACE inhibitors or ARBs are strongly indicated in most HD patients, it would be more fair to say there is emerging evidence there, but it’s probably still too early to call it “strong.â€One meta-analysis was able to clearly show a statistically significant reduction of LV mass in HD patients, but the reduction of CV events, while impressive at first glance (RR of 0.66 in the treated group), did not reach statistical significance. Ken From: [mailto: ] On Behalf Of Margaret CoughlanSent: Tuesday, July 31, 2012 11:00 AMTo: Subject: Re: vent/rant Thanks but he is over 65 and the recommendation said to help with microalbuminuria. vent/rant Why would a stupid insurance company send you a recommendation to put your diabetic patient on an ACE inhibitor if he is getting dialysis 3 days a week for end-stage renal failure?????? They say it is based on claims analysis, don't they see their claims for dialysis treatment? Margaret Quote Link to comment Share on other sites More sharing options...
Guest guest Posted August 1, 2012 Report Share Posted August 1, 2012 ACEI cause pre-renal renal failure (as far as I know) through their interaction with the R-A-A. It does not produce kidney injury. I think we were all told to stop ACEI in the context of developing new CRF (those of us who were old enough to be around when the ACEI came out) due to Lack of knowledge of the exact mechanism. If you look at the current KDOQI guidelines (for CRF) they encourage use of ACEI, which may be the reason you got the note that started this conversation Izquierdo-Porrera MD PhDExecutive Director & Co-founderCare for Your Health, IncPhone Fax www.care4yourhealth.org " Don't ever let injustice go by unchallenged. " Help us make our community healthy -> http://www.care4yourhealth.org/wanttohelp.php From: [mailto: ] On Behalf Of Ken StoneSent: Tuesday, July 31, 2012 10:25 PMTo: Subject: RE: vent/rant Kinda sorta. The way I learned it is that ACE inhibitors and ARBs are actually fine in most chronic kidney disease. In the setting of albuminuria, they’re particularly indicated, because filtered protein rips bigger holes in the glomeruli as it passes through them (negative charges on protein interacting with negatively charged proteins in the podocytes, IIRC) and that protein filtration can destroy kidneys very quickly. Although they decrease GFR, the ACEIs/ARBs are helping the glomeruli to heal in that situation by decreasing filtration pressure. But yeah, since ACEIs and ARBs work by lowering the GFR, they do cause the scales to tip in the wrong direction in CKD, with increases in Cr and BUN. That’s not the same as causing damage, though. This mostly becomes an issue in CKD4 when you want to delay initiation of dialysis and the presence of an ACEI/ARB causes their GFR to dip below the magic threshold that separates where the kidneys are just barely getting enough flow to get the job done from where they aren’t. But again, I don’t think that means the ACEIs/ARBs are doing additional damage in that situation; they’re merely highlighting the severe damage that is already present. Once the patient is getting dialysis anyway, it would be reasonable to restart them if there are good reasons to do so (e.g. preservation of renal function in diabetic nephropathy). That biting dog you referred to from ACEIs comes into play mostly in the setting of acute kidney injuries, typically shock/hypotension, where the kidneys are trying to recover from hypoxia and inadequate blood flow. In that setting, ACEIs are indeed very, very, bad. I’m sure there are a few exceptions here and there to these general principles (most notably e.g. in renovascular disease); if you happen to discover something markedly different in your studies from what I’ve outlined above, please correct my misunderstanding. Thanks, Ken From: [mailto: ] On Behalf Of MyriaSent: Tuesday, July 31, 2012 8:09 PMTo: Subject: Re: vent/rant OK I'm going back to the books cuz I was always, always taught you keep the ACE on until the Cr starts climbing and you stop it because now that dog that was helping will turn around and bite you! I did a month with the renal docs. So your information is definately a flag for me to go check it out. Thanks. To: Sent: Tuesday, July 31, 2012 11:34 AMSubject: RE: vent/rant In general, use of ACE inhibitors or ARBs is strongly indicated in dialysis patients (among others, including most notably diabetics and heart failure patients) for a number of reasons. They are not just indicated in those less than 65, although that’s where you might expect to see the most profound outcome differences in mortality, which might be why that preliminary study from 2002 studied only that population. As your insurance company noted, preservation of residual kidney function through reduction of microalbuminuria is indeed an important factor in the survival of dialysis patients who are not already anuric. Above and beyond the renal issues, ACE inhibitors and ARBS are important (and similar to statins) in that they limit inflammation, particularly vascular inflammation. In short, they significantly decrease cardiovascular mortality in at-risk populations, and not just through their direct effects on blood pressure. From: [mailto: ] On Behalf Of Margaret CoughlanSent: Tuesday, July 31, 2012 11:00 AMTo: Subject: Re: vent/rant Thanks but he is over 65 and the recommendation said to help with microalbuminuria. vent/rant Why would a stupid insurance company send you a recommendation to put your diabetic patient on an ACE inhibitor if he is getting dialysis 3 days a week for end-stage renal failure?????? They say it is based on claims analysis, don't they see their claims for dialysis treatment? Margaret No virus found in this message.Checked by AVG - www.avg.comVersion: 2012.0.2197 / Virus Database: 2437/5168 - Release Date: 07/31/12No virus found in this message.Checked by AVG - www.avg.comVersion: 2012.0.2197 / Virus Database: 2437/5168 - Release Date: 07/31/12 Quote Link to comment Share on other sites More sharing options...
Guest guest Posted August 1, 2012 Report Share Posted August 1, 2012 Definitely recommendations have changed since ACEs first came out. And you are now to expect a slight rise in creatinine when you start it and it’s OK. I just listed to an AAFP Audio on this and I think a 20% rise is OK. More than 20% than get scared there’s bilateral renal artery stenosis and rule that out. The initial note is something we all deal with. The insurance companies see Diabetes on the diagnosis and then send the letter if they are not on an ACE. It’s automatic. They don’t study the individual person. But I have a question. If you have someone who is well controlled diabetic on diet and exercise ( no meds). Doesn’t have hypertension. Doesn’t have microalbuminuria.. Is there any benefit to starting an ACE. Most of my patients are very resistant to taking meds if they “don’t have toâ€. I start it as soon as there is hypertension or microalbuminuria but I really don’t know if there is evidence that starting it earlier has benefit. Kathy Saradarian, MDNJ From: [mailto: ] On Behalf Of Dr. Izquierdo-Porrera MD PhDSent: Wednesday, August 01, 2012 7:07 AMTo: Subject: RE: vent/rant ACEI cause pre-renal renal failure (as far as I know) through their interaction with the R-A-A. It does not produce kidney injury. I think we were all told to stop ACEI in the context of developing new CRF (those of us who were old enough to be around when the ACEI came out) due to Lack of knowledge of the exact mechanism. If you look at the current KDOQI guidelines (for CRF) they encourage use of ACEI, which may be the reason you got the note that started this conversation Izquierdo-Porrera MD PhDExecutive Director & Co-founderCare for Your Health, IncPhone Fax www.care4yourhealth.org " Don't ever let injustice go by unchallenged. " Help us make our community healthy -> http://www.care4yourhealth.org/wanttohelp.php From: [mailto: ] On Behalf Of Ken StoneSent: Tuesday, July 31, 2012 10:25 PMTo: Subject: RE: vent/rant Kinda sorta. The way I learned it is that ACE inhibitors and ARBs are actually fine in most chronic kidney disease. In the setting of albuminuria, they’re particularly indicated, because filtered protein rips bigger holes in the glomeruli as it passes through them (negative charges on protein interacting with negatively charged proteins in the podocytes, IIRC) and that protein filtration can destroy kidneys very quickly. Although they decrease GFR, the ACEIs/ARBs are helping the glomeruli to heal in that situation by decreasing filtration pressure. But yeah, since ACEIs and ARBs work by lowering the GFR, they do cause the scales to tip in the wrong direction in CKD, with increases in Cr and BUN. That’s not the same as causing damage, though. This mostly becomes an issue in CKD4 when you want to delay initiation of dialysis and the presence of an ACEI/ARB causes their GFR to dip below the magic threshold that separates where the kidneys are just barely getting enough flow to get the job done from where they aren’t. But again, I don’t think that means the ACEIs/ARBs are doing additional damage in that situation; they’re merely highlighting the severe damage that is already present. Once the patient is getting dialysis anyway, it would be reasonable to restart them if there are good reasons to do so (e.g. preservation of renal function in diabetic nephropathy). That biting dog you referred to from ACEIs comes into play mostly in the setting of acute kidney injuries, typically shock/hypotension, where the kidneys are trying to recover from hypoxia and inadequate blood flow. In that setting, ACEIs are indeed very, very, bad. I’m sure there are a few exceptions here and there to these general principles (most notably e.g. in renovascular disease); if you happen to discover something markedly different in your studies from what I’ve outlined above, please correct my misunderstanding. Thanks, Ken From: [mailto: ] On Behalf Of MyriaSent: Tuesday, July 31, 2012 8:09 PMTo: Subject: Re: vent/rant OK I'm going back to the books cuz I was always, always taught you keep the ACE on until the Cr starts climbing and you stop it because now that dog that was helping will turn around and bite you! I did a month with the renal docs. So your information is definately a flag for me to go check it out. Thanks. To: Sent: Tuesday, July 31, 2012 11:34 AMSubject: RE: vent/rant In general, use of ACE inhibitors or ARBs is strongly indicated in dialysis patients (among others, including most notably diabetics and heart failure patients) for a number of reasons. They are not just indicated in those less than 65, although that’s where you might expect to see the most profound outcome differences in mortality, which might be why that preliminary study from 2002 studied only that population. As your insurance company noted, preservation of residual kidney function through reduction of microalbuminuria is indeed an important factor in the survival of dialysis patients who are not already anuric. Above and beyond the renal issues, ACE inhibitors and ARBS are important (and similar to statins) in that they limit inflammation, particularly vascular inflammation. In short, they significantly decrease cardiovascular mortality in at-risk populations, and not just through their direct effects on blood pressure. From: [mailto: ] On Behalf Of Margaret CoughlanSent: Tuesday, July 31, 2012 11:00 AMTo: Subject: Re: vent/rant Thanks but he is over 65 and the recommendation said to help with microalbuminuria. vent/rant Why would a stupid insurance company send you a recommendation to put your diabetic patient on an ACE inhibitor if he is getting dialysis 3 days a week for end-stage renal failure?????? They say it is based on claims analysis, don't they see their claims for dialysis treatment? Margaret No virus found in this message.Checked by AVG - www.avg.comVersion: 2012.0.2197 / Virus Database: 2437/5168 - Release Date: 07/31/12No virus found in this message.Checked by AVG - www.avg.comVersion: 2012.0.2197 / Virus Database: 2437/5168 - Release Date: 07/31/12 Quote Link to comment Share on other sites More sharing options...
Guest guest Posted August 1, 2012 Report Share Posted August 1, 2012 Although I agree with you that there doesn’t seem to be a compelling indication in that situation, after looking around a little bit, yeah, there actually could be some theoretical benefit to using the ACEI—it could buy your patient some time before development of frank diabetes. Among the things that ACEIs apparently do is to increase insulin sensitivity and help prevent Type 2 DM.  If they are the typical pill-averse patient you mentioned, it’s not a battle I would bother to fight. For the vitamin-popping patient who is looking for “everything possible that’s reasonable†to be done, I think it’s very reasonable to consider adding a low-dose ACEI (or metformin) in that situation. From: [mailto: ] On Behalf Of Kathy SaradarianSent: Wednesday, August 01, 2012 8:25 AMTo: Subject: RE: vent/rant Definitely recommendations have changed since ACEs first came out. And you are now to expect a slight rise in creatinine when you start it and it’s OK. I just listed to an AAFP Audio on this and I think a 20% rise is OK. More than 20% than get scared there’s bilateral renal artery stenosis and rule that out. The initial note is something we all deal with. The insurance companies see Diabetes on the diagnosis and then send the letter if they are not on an ACE. It’s automatic. They don’t study the individual person. But I have a question. If you have someone who is well controlled diabetic on diet and exercise ( no meds). Doesn’t have hypertension. Doesn’t have microalbuminuria.. Is there any benefit to starting an ACE. Most of my patients are very resistant to taking meds if they “don’t have toâ€. I start it as soon as there is hypertension or microalbuminuria but I really don’t know if there is evidence that starting it earlier has benefit. Kathy Saradarian, MDNJ From: [mailto: ] On Behalf Of Dr. Izquierdo-Porrera MD PhDSent: Wednesday, August 01, 2012 7:07 AMTo: Subject: RE: vent/rant ACEI cause pre-renal renal failure (as far as I know) through their interaction with the R-A-A. It does not produce kidney injury. I think we were all told to stop ACEI in the context of developing new CRF (those of us who were old enough to be around when the ACEI came out) due to Lack of knowledge of the exact mechanism. If you look at the current KDOQI guidelines (for CRF) they encourage use of ACEI, which may be the reason you got the note that started this conversation Izquierdo-Porrera MD PhDExecutive Director & Co-founderCare for Your Health, IncPhone Fax www.care4yourhealth.org " Don't ever let injustice go by unchallenged. " Help us make our community healthy -> http://www.care4yourhealth.org/wanttohelp.php From: [mailto: ] On Behalf Of Ken StoneSent: Tuesday, July 31, 2012 10:25 PMTo: Subject: RE: vent/rant Kinda sorta. The way I learned it is that ACE inhibitors and ARBs are actually fine in most chronic kidney disease. In the setting of albuminuria, they’re particularly indicated, because filtered protein rips bigger holes in the glomeruli as it passes through them (negative charges on protein interacting with negatively charged proteins in the podocytes, IIRC) and that protein filtration can destroy kidneys very quickly. Although they decrease GFR, the ACEIs/ARBs are helping the glomeruli to heal in that situation by decreasing filtration pressure. But yeah, since ACEIs and ARBs work by lowering the GFR, they do cause the scales to tip in the wrong direction in CKD, with increases in Cr and BUN. That’s not the same as causing damage, though. This mostly becomes an issue in CKD4 when you want to delay initiation of dialysis and the presence of an ACEI/ARB causes their GFR to dip below the magic threshold that separates where the kidneys are just barely getting enough flow to get the job done from where they aren’t. But again, I don’t think that means the ACEIs/ARBs are doing additional damage in that situation; they’re merely highlighting the severe damage that is already present. Once the patient is getting dialysis anyway, it would be reasonable to restart them if there are good reasons to do so (e.g. preservation of renal function in diabetic nephropathy). That biting dog you referred to from ACEIs comes into play mostly in the setting of acute kidney injuries, typically shock/hypotension, where the kidneys are trying to recover from hypoxia and inadequate blood flow. In that setting, ACEIs are indeed very, very, bad. I’m sure there are a few exceptions here and there to these general principles (most notably e.g. in renovascular disease); if you happen to discover something markedly different in your studies from what I’ve outlined above, please correct my misunderstanding. Thanks, Ken From: [mailto: ] On Behalf Of MyriaSent: Tuesday, July 31, 2012 8:09 PMTo: Subject: Re: vent/rant OK I'm going back to the books cuz I was always, always taught you keep the ACE on until the Cr starts climbing and you stop it because now that dog that was helping will turn around and bite you! I did a month with the renal docs. So your information is definately a flag for me to go check it out. Thanks. To: Sent: Tuesday, July 31, 2012 11:34 AMSubject: RE: vent/rant In general, use of ACE inhibitors or ARBs is strongly indicated in dialysis patients (among others, including most notably diabetics and heart failure patients) for a number of reasons. They are not just indicated in those less than 65, although that’s where you might expect to see the most profound outcome differences in mortality, which might be why that preliminary study from 2002 studied only that population. As your insurance company noted, preservation of residual kidney function through reduction of microalbuminuria is indeed an important factor in the survival of dialysis patients who are not already anuric. Above and beyond the renal issues, ACE inhibitors and ARBS are important (and similar to statins) in that they limit inflammation, particularly vascular inflammation. In short, they significantly decrease cardiovascular mortality in at-risk populations, and not just through their direct effects on blood pressure. From: [mailto: ] On Behalf Of Margaret CoughlanSent: Tuesday, July 31, 2012 11:00 AMTo: Subject: Re: vent/rant Thanks but he is over 65 and the recommendation said to help with microalbuminuria. vent/rant Why would a stupid insurance company send you a recommendation to put your diabetic patient on an ACE inhibitor if he is getting dialysis 3 days a week for end-stage renal failure?????? They say it is based on claims analysis, don't they see their claims for dialysis treatment? Margaret No virus found in this message.Checked by AVG - www.avg.comVersion: 2012.0.2197 / Virus Database: 2437/5168 - Release Date: 07/31/12No virus found in this message.Checked by AVG - www.avg.comVersion: 2012.0.2197 / Virus Database: 2437/5168 - Release Date: 07/31/12 Quote Link to comment Share on other sites More sharing options...
Guest guest Posted August 1, 2012 Report Share Posted August 1, 2012 and others,Gosh we are starting to sound old (I practiced BEFORE ACE inhibitors!). How did that happen? :)Sharon Sharon McCoy MDRenaissance Family Medicine10 McClintock Court; Irvine, CA 92617PH: (949)387-5504 Fax: (949)281-2197 Toll free phone/fax: www.SharonMD.com Although I agree with you that there doesn’t seem to be a compelling indication in that situation, after looking around a little bit, yeah, there actually could be some theoretical benefit to using the ACEI—it could buy your patient some time before development of frank diabetes. Among the things that ACEIs apparently do is to increase insulin sensitivity and help prevent Type 2 DM. If they are the typical pill-averse patient you mentioned, it’s not a battle I would bother to fight. For the vitamin-popping patient who is looking for “everything possible that’s reasonable” to be done, I think it’s very reasonable to consider adding a low-dose ACEI (or metformin) in that situation. From: [mailto: ] On Behalf Of Kathy Saradarian Sent: Wednesday, August 01, 2012 8:25 AMTo: Subject: RE: vent/rant Definitely recommendations have changed since ACEs first came out. And you are now to expect a slight rise in creatinine when you start it and it’s OK. I just listed to an AAFP Audio on this and I think a 20% rise is OK. More than 20% than get scared there’s bilateral renal artery stenosis and rule that out. The initial note is something we all deal with. The insurance companies see Diabetes on the diagnosis and then send the letter if they are not on an ACE. It’s automatic. They don’t study the individual person. But I have a question. If you have someone who is well controlled diabetic on diet and exercise ( no meds). Doesn’t have hypertension. Doesn’t have microalbuminuria.. Is there any benefit to starting an ACE. Most of my patients are very resistant to taking meds if they “don’t have to”. I start it as soon as there is hypertension or microalbuminuria but I really don’t know if there is evidence that starting it earlier has benefit. Kathy Saradarian, MDNJ From: [mailto: ] On Behalf Of Dr. Izquierdo-Porrera MD PhD Sent: Wednesday, August 01, 2012 7:07 AMTo: Subject: RE: vent/rant ACEI cause pre-renal renal failure (as far as I know) through their interaction with the R-A-A. It does not produce kidney injury. I think we were all told to stop ACEI in the context of developing new CRF (those of us who were old enough to be around when the ACEI came out) due to Lack of knowledge of the exact mechanism. If you look at the current KDOQI guidelines (for CRF) they encourage use of ACEI, which may be the reason you got the note that started this conversation Izquierdo-Porrera MD PhD Executive Director & Co-founderCare for Your Health, Inc Phone Fax www.care4yourhealth.org " Don't ever let injustice go by unchallenged. " Help us make our community healthy -> http://www.care4yourhealth.org/wanttohelp.php From: [mailto: ] On Behalf Of Ken Stone Sent: Tuesday, July 31, 2012 10:25 PMTo: Subject: RE: vent/rant Kinda sorta. The way I learned it is that ACE inhibitors and ARBs are actually fine in most chronic kidney disease. In the setting of albuminuria, they’re particularly indicated, because filtered protein rips bigger holes in the glomeruli as it passes through them (negative charges on protein interacting with negatively charged proteins in the podocytes, IIRC) and that protein filtration can destroy kidneys very quickly. Although they decrease GFR, the ACEIs/ARBs are helping the glomeruli to heal in that situation by decreasing filtration pressure. But yeah, since ACEIs and ARBs work by lowering the GFR, they do cause the scales to tip in the wrong direction in CKD, with increases in Cr and BUN. That’s not the same as causing damage, though. This mostly becomes an issue in CKD4 when you want to delay initiation of dialysis and the presence of an ACEI/ARB causes their GFR to dip below the magic threshold that separates where the kidneys are just barely getting enough flow to get the job done from where they aren’t. But again, I don’t think that means the ACEIs/ARBs are doing additional damage in that situation; they’re merely highlighting the severe damage that is already present. Once the patient is getting dialysis anyway, it would be reasonable to restart them if there are good reasons to do so (e.g. preservation of renal function in diabetic nephropathy). That biting dog you referred to from ACEIs comes into play mostly in the setting of acute kidney injuries, typically shock/hypotension, where the kidneys are trying to recover from hypoxia and inadequate blood flow. In that setting, ACEIs are indeed very, very, bad. I’m sure there are a few exceptions here and there to these general principles (most notably e.g. in renovascular disease); if you happen to discover something markedly different in your studies from what I’ve outlined above, please correct my misunderstanding. Thanks, Ken From: [mailto: ] On Behalf Of Myria Sent: Tuesday, July 31, 2012 8:09 PMTo: Subject: Re: vent/rant OK I'm going back to the books cuz I was always, always taught you keep the ACE on until the Cr starts climbing and you stop it because now that dog that was helping will turn around and bite you! I did a month with the renal docs. So your information is definately a flag for me to go check it out. Thanks. To: Sent: Tuesday, July 31, 2012 11:34 AMSubject: RE: vent/rant In general, use of ACE inhibitors or ARBs is strongly indicated in dialysis patients (among others, including most notably diabetics and heart failure patients) for a number of reasons. They are not just indicated in those less than 65, although that’s where you might expect to see the most profound outcome differences in mortality, which might be why that preliminary study from 2002 studied only that population. As your insurance company noted, preservation of residual kidney function through reduction of microalbuminuria is indeed an important factor in the survival of dialysis patients who are not already anuric. Above and beyond the renal issues, ACE inhibitors and ARBS are important (and similar to statins) in that they limit inflammation, particularly vascular inflammation. In short, they significantly decrease cardiovascular mortality in at-risk populations, and not just through their direct effects on blood pressure. From: [mailto: ] On Behalf Of Margaret Coughlan Sent: Tuesday, July 31, 2012 11:00 AMTo: Subject: Re: vent/rant Thanks but he is over 65 and the recommendation said to help with microalbuminuria. vent/rant Why would a stupid insurance company send you a recommendation to put your diabetic patient on an ACE inhibitor if he is getting dialysis 3 days a week for end-stage renal failure?????? They say it is based on claims analysis, don't they see their claims for dialysis treatment? Margaret No virus found in this message.Checked by AVG - www.avg.comVersion: 2012.0.2197 / Virus Database: 2437/5168 - Release Date: 07/31/12 No virus found in this message.Checked by AVG - www.avg.comVersion: 2012.0.2197 / Virus Database: 2437/5168 - Release Date: 07/31/12 Quote Link to comment Share on other sites More sharing options...
Guest guest Posted August 2, 2012 Report Share Posted August 2, 2012 I tested ACE inhibitors in medical school (vasotec)..the money was good and my BP is still well controlled. > > > ** > > > > > > Although I agree with you that there doesn't seem to be a compelling > > indication in that situation, after looking around a little bit, yeah, > > there actually could be some theoretical benefit to using the ACEI—it could > > buy your patient some time before development of frank diabetes. Among the > > things that ACEIs apparently do is to increase insulin sensitivity and help > > prevent Type 2 DM. If they are the typical pill-averse patient you > > mentioned, it's not a battle I would bother to fight. For the > > vitamin-popping patient who is looking for " everything possible that's > > reasonable " to be done, I think it's very reasonable to consider adding a > > low-dose ACEI (or metformin) in that situation.**** > > > > **** > > > > ** ** > > > > *From:* [mailto: > > ] *On Behalf Of *Kathy Saradarian > > *Sent:* Wednesday, August 01, 2012 8:25 AM > > > > *To:* > > *Subject:* RE: vent/rant**** > > > > ** ** > > > > **** > > > > Definitely recommendations have changed since ACEs first came out. And > > you are now to expect a slight rise in creatinine when you start it and > > it's OK. I just listed to an AAFP Audio on this and I think a 20% rise is > > OK. More than 20% than get scared there's bilateral renal artery stenosis > > and rule that out.**** > > > > **** > > > > The initial note is something we all deal with. The insurance companies > > see Diabetes on the diagnosis and then send the letter if they are not on > > an ACE. It's automatic. They don't study the individual person. But I > > have a question. If you have someone who is well controlled diabetic on > > diet and exercise ( no meds). Doesn't have hypertension. Doesn't have > > microalbuminuria.. Is there any benefit to starting an ACE. Most of my > > patients are very resistant to taking meds if they " don't have to " . I > > start it as soon as there is hypertension or microalbuminuria but I really > > don't know if there is evidence that starting it earlier has benefit.**** > > > > **** > > > > Kathy Saradarian, MD > > NJ**** > > > > **** > > > > *From:* > > [mailto: ] *On Behalf Of *Dr. > > Izquierdo-Porrera MD PhD > > *Sent:* Wednesday, August 01, 2012 7:07 AM > > *To:* > > *Subject:* RE: vent/rant**** > > > > **** > > > > **** > > > > ACEI cause pre-renal renal failure (as far as I know) through their > > interaction with the R-A-A. It does not produce kidney injury. I think we > > were all told to stop ACEI in the context of developing new CRF (those of > > us who were old enough to be around when the ACEI came out) due to Lack of > > knowledge of the exact mechanism. If you look at the current KDOQI > > guidelines (for CRF) they encourage use of ACEI, which may be the reason > > you got the note that started this conversation**** > > > > **** > > > > Izquierdo-Porrera MD PhD**** > > > > Executive Director & Co-founder**** > > > > Care for Your Health, Inc**** > > > > Phone **** > > > > Fax **** > > > > www.care4yourhealth.org**** > > > > * ***** > > > > * " Don't ever let injustice go by unchallenged. " ***** > > > > **** > > > > Help us make our community healthy -> > > http://www.care4yourhealth.org/wanttohelp.php**** > > > > **** > > > > [image: Care_your_health.jpg]**** > > > > **** > > > > *From:* > > [mailto: ] *On Behalf Of *Ken Stone > > *Sent:* Tuesday, July 31, 2012 10:25 PM > > *To:* > > *Subject:* RE: vent/rant**** > > > > **** > > > > **** > > > > Kinda sorta. **** > > > > **** > > > > The way I learned it is that ACE inhibitors and ARBs are actually fine in > > most chronic kidney disease. In the setting of albuminuria, they're > > particularly indicated, because filtered protein rips bigger holes in the > > glomeruli as it passes through them (negative charges on protein > > interacting with negatively charged proteins in the podocytes, IIRC) and > > that protein filtration can destroy kidneys very quickly. Although they > > decrease GFR, the ACEIs/ARBs are helping the glomeruli to heal in that > > situation by decreasing filtration pressure. **** > > > > **** > > > > But yeah, since ACEIs and ARBs work by lowering the GFR, they do cause the > > scales to tip in the wrong direction in CKD, with increases in Cr and BUN. > > That's not the same as causing damage, though. This mostly becomes an > > issue in CKD4 when you want to delay initiation of dialysis and the > > presence of an ACEI/ARB causes their GFR to dip below the magic threshold > > that separates where the kidneys are just barely getting enough flow to get > > the job done from where they aren't. But again, I don't think that means > > the ACEIs/ARBs are doing additional damage in that situation; they're > > merely highlighting the severe damage that is already present. Once the > > patient is getting dialysis anyway, it would be reasonable to restart them > > if there are good reasons to do so (e.g. preservation of renal function in > > diabetic nephropathy).**** > > > > **** > > > > That biting dog you referred to from ACEIs comes into play mostly in the > > setting of acute kidney injuries, typically shock/hypotension, where the > > kidneys are trying to recover from hypoxia and inadequate blood flow. In > > that setting, ACEIs are indeed very, very, bad. **** > > > > **** > > > > I'm sure there are a few exceptions here and there to these general > > principles (most notably e.g. in renovascular disease); if you happen to > > discover something markedly different in your studies from what I've > > outlined above, please correct my misunderstanding.**** > > > > **** > > > > Thanks,**** > > > > **** > > > > Ken**** > > > > **** > > > > *From:* [ > > mailto: < \ >] > > *On Behalf Of *Myria > > *Sent:* Tuesday, July 31, 2012 8:09 PM > > *To:* > > *Subject:* Re: vent/rant**** > > > > **** > > > > **** > > > > OK I'm going back to the books cuz I was always, always taught you keep > > the ACE on until the Cr starts climbing and you stop it because now that > > dog that was helping will turn around and bite you! I did a month with the > > renal docs. So your information is definately a flag for me to go check it > > out. Thanks. **** > > > > **** > > > > *From:* Ken Stone > > *To:* > > *Sent:* Tuesday, July 31, 2012 11:34 AM > > *Subject:* RE: vent/rant**** > > > > **** > > > > **** > > > > **** > > > > In general, use of ACE inhibitors or ARBs is strongly indicated in > > dialysis patients (among others, including most notably diabetics and heart > > failure patients) for a number of reasons. They are not just indicated in > > those less than 65, although that's where you might expect to see the most > > profound outcome differences in mortality, which might be why that > > preliminary study from 2002 studied only that population. As your > > insurance company noted, preservation of residual kidney function through > > reduction of microalbuminuria is indeed an important factor in the survival > > of dialysis patients who are not already anuric. Above and beyond the > > renal issues, ACE inhibitors and ARBS are important (and similar to > > statins) in that they limit inflammation, particularly vascular > > inflammation. In short, they significantly decrease cardiovascular > > mortality in at-risk populations, and not just through their direct effects > > on blood pressure.**** > > > > **** > > > > *From:* > > [mailto: ] *On Behalf Of *Margaret > > Coughlan > > *Sent:* Tuesday, July 31, 2012 11:00 AM > > *To:* > > *Subject:* Re: vent/rant**** > > > > **** > > > > **** > > > > Thanks but he is over 65 and the recommendation said to help with > > microalbuminuria. > > > > vent/rant > > > > > > > > Why would a stupid insurance company send you a recommendation to put your > > diabetic patient on an ACE inhibitor if he is getting dialysis 3 days a > > week for end-stage renal failure?????? They say it is based on claims > > analysis, don't they see their claims for dialysis treatment? > > > > Margaret **** > > > > **** > > ------------------------------ > > > > No virus found in this message. > > Checked by AVG - www.avg.com > > Version: 2012.0.2197 / Virus Database: 2437/5168 - Release Date: 07/31/12* > > *** > > > > No virus found in this message. > > Checked by AVG - www.avg.com > > Version: 2012.0.2197 / Virus Database: 2437/5168 - Release Date: 07/31/12* > > *** > > > > **** > > > > > > > Quote Link to comment Share on other sites More sharing options...
Guest guest Posted August 2, 2012 Report Share Posted August 2, 2012 Yes, Sharon. I remember when Aldomet, Inderal, and Esidrix were the " go-to " meds for HTN. Esidrix still is, but we call it HCTZ.---Sharlene > > > ** > > > > > > Although I agree with you that there doesn't seem to be a compelling > > indication in that situation, after looking around a little bit, yeah, > > there actually could be some theoretical benefit to using the ACEI—it could > > buy your patient some time before development of frank diabetes. Among the > > things that ACEIs apparently do is to increase insulin sensitivity and help > > prevent Type 2 DM. If they are the typical pill-averse patient you > > mentioned, it's not a battle I would bother to fight. For the > > vitamin-popping patient who is looking for " everything possible that's > > reasonable " to be done, I think it's very reasonable to consider adding a > > low-dose ACEI (or metformin) in that situation.**** > > > > **** > > > > ** ** > > > > *From:* [mailto: > > ] *On Behalf Of *Kathy Saradarian > > *Sent:* Wednesday, August 01, 2012 8:25 AM > > > > *To:* > > *Subject:* RE: vent/rant**** > > > > ** ** > > > > **** > > > > Definitely recommendations have changed since ACEs first came out. And > > you are now to expect a slight rise in creatinine when you start it and > > it's OK. I just listed to an AAFP Audio on this and I think a 20% rise is > > OK. More than 20% than get scared there's bilateral renal artery stenosis > > and rule that out.**** > > > > **** > > > > The initial note is something we all deal with. The insurance companies > > see Diabetes on the diagnosis and then send the letter if they are not on > > an ACE. It's automatic. They don't study the individual person. But I > > have a question. If you have someone who is well controlled diabetic on > > diet and exercise ( no meds). Doesn't have hypertension. Doesn't have > > microalbuminuria.. Is there any benefit to starting an ACE. Most of my > > patients are very resistant to taking meds if they " don't have to " . I > > start it as soon as there is hypertension or microalbuminuria but I really > > don't know if there is evidence that starting it earlier has benefit.**** > > > > **** > > > > Kathy Saradarian, MD > > NJ**** > > > > **** > > > > *From:* > > [mailto: ] *On Behalf Of *Dr. > > Izquierdo-Porrera MD PhD > > *Sent:* Wednesday, August 01, 2012 7:07 AM > > *To:* > > *Subject:* RE: vent/rant**** > > > > **** > > > > **** > > > > ACEI cause pre-renal renal failure (as far as I know) through their > > interaction with the R-A-A. It does not produce kidney injury. I think we > > were all told to stop ACEI in the context of developing new CRF (those of > > us who were old enough to be around when the ACEI came out) due to Lack of > > knowledge of the exact mechanism. If you look at the current KDOQI > > guidelines (for CRF) they encourage use of ACEI, which may be the reason > > you got the note that started this conversation**** > > > > **** > > > > Izquierdo-Porrera MD PhD**** > > > > Executive Director & Co-founder**** > > > > Care for Your Health, Inc**** > > > > Phone **** > > > > Fax **** > > > > www.care4yourhealth.org**** > > > > * ***** > > > > * " Don't ever let injustice go by unchallenged. " ***** > > > > **** > > > > Help us make our community healthy -> > > http://www.care4yourhealth.org/wanttohelp.php**** > > > > **** > > > > [image: Care_your_health.jpg]**** > > > > **** > > > > *From:* > > [mailto: ] *On Behalf Of *Ken Stone > > *Sent:* Tuesday, July 31, 2012 10:25 PM > > *To:* > > *Subject:* RE: vent/rant**** > > > > **** > > > > **** > > > > Kinda sorta. **** > > > > **** > > > > The way I learned it is that ACE inhibitors and ARBs are actually fine in > > most chronic kidney disease. In the setting of albuminuria, they're > > particularly indicated, because filtered protein rips bigger holes in the > > glomeruli as it passes through them (negative charges on protein > > interacting with negatively charged proteins in the podocytes, IIRC) and > > that protein filtration can destroy kidneys very quickly. Although they > > decrease GFR, the ACEIs/ARBs are helping the glomeruli to heal in that > > situation by decreasing filtration pressure. **** > > > > **** > > > > But yeah, since ACEIs and ARBs work by lowering the GFR, they do cause the > > scales to tip in the wrong direction in CKD, with increases in Cr and BUN. > > That's not the same as causing damage, though. This mostly becomes an > > issue in CKD4 when you want to delay initiation of dialysis and the > > presence of an ACEI/ARB causes their GFR to dip below the magic threshold > > that separates where the kidneys are just barely getting enough flow to get > > the job done from where they aren't. But again, I don't think that means > > the ACEIs/ARBs are doing additional damage in that situation; they're > > merely highlighting the severe damage that is already present. Once the > > patient is getting dialysis anyway, it would be reasonable to restart them > > if there are good reasons to do so (e.g. preservation of renal function in > > diabetic nephropathy).**** > > > > **** > > > > That biting dog you referred to from ACEIs comes into play mostly in the > > setting of acute kidney injuries, typically shock/hypotension, where the > > kidneys are trying to recover from hypoxia and inadequate blood flow. In > > that setting, ACEIs are indeed very, very, bad. **** > > > > **** > > > > I'm sure there are a few exceptions here and there to these general > > principles (most notably e.g. in renovascular disease); if you happen to > > discover something markedly different in your studies from what I've > > outlined above, please correct my misunderstanding.**** > > > > **** > > > > Thanks,**** > > > > **** > > > > Ken**** > > > > **** > > > > *From:* [ > > mailto: < \ >] > > *On Behalf Of *Myria > > *Sent:* Tuesday, July 31, 2012 8:09 PM > > *To:* > > *Subject:* Re: vent/rant**** > > > > **** > > > > **** > > > > OK I'm going back to the books cuz I was always, always taught you keep > > the ACE on until the Cr starts climbing and you stop it because now that > > dog that was helping will turn around and bite you! I did a month with the > > renal docs. So your information is definately a flag for me to go check it > > out. Thanks. **** > > > > **** > > > > *From:* Ken Stone > > *To:* > > *Sent:* Tuesday, July 31, 2012 11:34 AM > > *Subject:* RE: vent/rant**** > > > > **** > > > > **** > > > > **** > > > > In general, use of ACE inhibitors or ARBs is strongly indicated in > > dialysis patients (among others, including most notably diabetics and heart > > failure patients) for a number of reasons. They are not just indicated in > > those less than 65, although that's where you might expect to see the most > > profound outcome differences in mortality, which might be why that > > preliminary study from 2002 studied only that population. As your > > insurance company noted, preservation of residual kidney function through > > reduction of microalbuminuria is indeed an important factor in the survival > > of dialysis patients who are not already anuric. Above and beyond the > > renal issues, ACE inhibitors and ARBS are important (and similar to > > statins) in that they limit inflammation, particularly vascular > > inflammation. In short, they significantly decrease cardiovascular > > mortality in at-risk populations, and not just through their direct effects > > on blood pressure.**** > > > > **** > > > > *From:* > > [mailto: ] *On Behalf Of *Margaret > > Coughlan > > *Sent:* Tuesday, July 31, 2012 11:00 AM > > *To:* > > *Subject:* Re: vent/rant**** > > > > **** > > > > **** > > > > Thanks but he is over 65 and the recommendation said to help with > > microalbuminuria. > > > > vent/rant > > > > > > > > Why would a stupid insurance company send you a recommendation to put your > > diabetic patient on an ACE inhibitor if he is getting dialysis 3 days a > > week for end-stage renal failure?????? They say it is based on claims > > analysis, don't they see their claims for dialysis treatment? > > > > Margaret **** > > > > **** > > ------------------------------ > > > > No virus found in this message. > > Checked by AVG - www.avg.com > > Version: 2012.0.2197 / Virus Database: 2437/5168 - Release Date: 07/31/12* > > *** > > > > No virus found in this message. > > Checked by AVG - www.avg.com > > Version: 2012.0.2197 / Virus Database: 2437/5168 - Release Date: 07/31/12* > > *** > > > > **** > > > > > > > Quote Link to comment Share on other sites More sharing options...
Guest guest Posted August 2, 2012 Report Share Posted August 2, 2012 HCTZ? Yuck! Phooey! (choose chlorthalidone instead; it has a longer half-life that provides full 24-hour coverage, is significantly more potent than HCTZ and is much more likely to actually control hypertension as a single agent, and the studies that validated “thiazide-type diuretics” as a good treatment choice for HTN with mortality benefit were pretty much all done with chlorthalidone, not HCTZ.) Just sayin’. Ken From: [mailto: ] On Behalf Of sharkinnSent: Wednesday, August 01, 2012 7:51 PMTo: Subject: Re: vent/rant Yes, Sharon. I remember when Aldomet, Inderal, and Esidrix were the " go-to " meds for HTN. Esidrix still is, but we call it HCTZ.---Sharlene> > > **> >> >> > Although I agree with you that there doesn't seem to be a compelling> > indication in that situation, after looking around a little bit, yeah,> > there actually could be some theoretical benefit to using the ACEI—it could> > buy your patient some time before development of frank diabetes. Among the> > things that ACEIs apparently do is to increase insulin sensitivity and help> > prevent Type 2 DM. If they are the typical pill-averse patient you> > mentioned, it's not a battle I would bother to fight. For the> > vitamin-popping patient who is looking for " everything possible that's> > reasonable " to be done, I think it's very reasonable to consider adding a> > low-dose ACEI (or metformin) in that situation.****> >> > ****> >> > ** **> >> > *From:* [mailto:> > ] *On Behalf Of *Kathy Saradarian> > *Sent:* Wednesday, August 01, 2012 8:25 AM> >> > *To:* > > *Subject:* RE: vent/rant****> >> > ** **> >> > ****> >> > Definitely recommendations have changed since ACEs first came out. And> > you are now to expect a slight rise in creatinine when you start it and> > it's OK. I just listed to an AAFP Audio on this and I think a 20% rise is> > OK. More than 20% than get scared there's bilateral renal artery stenosis> > and rule that out.****> >> > ****> >> > The initial note is something we all deal with. The insurance companies> > see Diabetes on the diagnosis and then send the letter if they are not on> > an ACE. It's automatic. They don't study the individual person. But I> > have a question. If you have someone who is well controlled diabetic on> > diet and exercise ( no meds). Doesn't have hypertension. Doesn't have> > microalbuminuria.. Is there any benefit to starting an ACE. Most of my> > patients are very resistant to taking meds if they " don't have to " . I> > start it as soon as there is hypertension or microalbuminuria but I really> > don't know if there is evidence that starting it earlier has benefit.****> >> > ****> >> > Kathy Saradarian, MD> > NJ****> >> > ****> >> > *From:* > > [mailto: ] *On Behalf Of *Dr. > > Izquierdo-Porrera MD PhD> > *Sent:* Wednesday, August 01, 2012 7:07 AM> > *To:* > > *Subject:* RE: vent/rant****> >> > ****> >> > ****> >> > ACEI cause pre-renal renal failure (as far as I know) through their> > interaction with the R-A-A. It does not produce kidney injury. I think we> > were all told to stop ACEI in the context of developing new CRF (those of> > us who were old enough to be around when the ACEI came out) due to Lack of> > knowledge of the exact mechanism. If you look at the current KDOQI> > guidelines (for CRF) they encourage use of ACEI, which may be the reason> > you got the note that started this conversation****> >> > ****> >> > Izquierdo-Porrera MD PhD****> >> > Executive Director & Co-founder****> >> > Care for Your Health, Inc****> >> > Phone ****> >> > Fax ****> >> > www.care4yourhealth.org****> >> > * *****> >> > * " Don't ever let injustice go by unchallenged. " *****> >> > ****> >> > Help us make our community healthy ->> > http://www.care4yourhealth.org/wanttohelp.php****> >> > ****> >> > [image: Care_your_health.jpg]****> >> > ****> >> > *From:* > > [mailto: ] *On Behalf Of *Ken Stone> > *Sent:* Tuesday, July 31, 2012 10:25 PM> > *To:* > > *Subject:* RE: vent/rant****> >> > ****> >> > ****> >> > Kinda sorta. ****> >> > ****> >> > The way I learned it is that ACE inhibitors and ARBs are actually fine in> > most chronic kidney disease. In the setting of albuminuria, they're> > particularly indicated, because filtered protein rips bigger holes in the> > glomeruli as it passes through them (negative charges on protein> > interacting with negatively charged proteins in the podocytes, IIRC) and> > that protein filtration can destroy kidneys very quickly. Although they> > decrease GFR, the ACEIs/ARBs are helping the glomeruli to heal in that> > situation by decreasing filtration pressure. ****> >> > ****> >> > But yeah, since ACEIs and ARBs work by lowering the GFR, they do cause the> > scales to tip in the wrong direction in CKD, with increases in Cr and BUN.> > That's not the same as causing damage, though. This mostly becomes an> > issue in CKD4 when you want to delay initiation of dialysis and the> > presence of an ACEI/ARB causes their GFR to dip below the magic threshold> > that separates where the kidneys are just barely getting enough flow to get> > the job done from where they aren't. But again, I don't think that means> > the ACEIs/ARBs are doing additional damage in that situation; they're> > merely highlighting the severe damage that is already present. Once the> > patient is getting dialysis anyway, it would be reasonable to restart them> > if there are good reasons to do so (e.g. preservation of renal function in> > diabetic nephropathy).****> >> > ****> >> > That biting dog you referred to from ACEIs comes into play mostly in the> > setting of acute kidney injuries, typically shock/hypotension, where the> > kidneys are trying to recover from hypoxia and inadequate blood flow. In> > that setting, ACEIs are indeed very, very, bad. ****> >> > ****> >> > I'm sure there are a few exceptions here and there to these general> > principles (most notably e.g. in renovascular disease); if you happen to> > discover something markedly different in your studies from what I've> > outlined above, please correct my misunderstanding.****> >> > ****> >> > Thanks,****> >> > ****> >> > Ken****> >> > ****> >> > *From:* [> > mailto: < >]> > *On Behalf Of *Myria> > *Sent:* Tuesday, July 31, 2012 8:09 PM> > *To:* > > *Subject:* Re: vent/rant****> >> > ****> >> > ****> >> > OK I'm going back to the books cuz I was always, always taught you keep> > the ACE on until the Cr starts climbing and you stop it because now that> > dog that was helping will turn around and bite you! I did a month with the> > renal docs. So your information is definately a flag for me to go check it> > out. Thanks. ****> >> > ****> >> > *From:* Ken Stone > > *To:* > > *Sent:* Tuesday, July 31, 2012 11:34 AM> > *Subject:* RE: vent/rant****> >> > ****> >> > ****> >> > ****> >> > In general, use of ACE inhibitors or ARBs is strongly indicated in> > dialysis patients (among others, including most notably diabetics and heart> > failure patients) for a number of reasons. They are not just indicated in> > those less than 65, although that's where you might expect to see the most> > profound outcome differences in mortality, which might be why that> > preliminary study from 2002 studied only that population. As your> > insurance company noted, preservation of residual kidney function through> > reduction of microalbuminuria is indeed an important factor in the survival> > of dialysis patients who are not already anuric. Above and beyond the> > renal issues, ACE inhibitors and ARBS are important (and similar to> > statins) in that they limit inflammation, particularly vascular> > inflammation. In short, they significantly decrease cardiovascular> > mortality in at-risk populations, and not just through their direct effects> > on blood pressure.****> >> > ****> >> > *From:* > > [mailto: ] *On Behalf Of *Margaret> > Coughlan> > *Sent:* Tuesday, July 31, 2012 11:00 AM> > *To:* > > *Subject:* Re: vent/rant****> >> > ****> >> > ****> >> > Thanks but he is over 65 and the recommendation said to help with> > microalbuminuria.> >> > vent/rant> >> >> >> > Why would a stupid insurance company send you a recommendation to put your> > diabetic patient on an ACE inhibitor if he is getting dialysis 3 days a> > week for end-stage renal failure?????? They say it is based on claims> > analysis, don't they see their claims for dialysis treatment?> >> > Margaret ****> >> > ****> > ------------------------------> >> > No virus found in this message.> > Checked by AVG - www.avg.com> > Version: 2012.0.2197 / Virus Database: 2437/5168 - Release Date: 07/31/12*> > ***> >> > No virus found in this message.> > Checked by AVG - www.avg.com> > Version: 2012.0.2197 / Virus Database: 2437/5168 - Release Date: 07/31/12*> > ***> >> > ****> >> > > >> Quote Link to comment Share on other sites More sharing options...
Guest guest Posted August 2, 2012 Report Share Posted August 2, 2012 I don’t have the reference right now, but a study has recently been done to test whether simply starting ACEI’s on type 2 diabetics who do not have hypertension or microalbuminuria, as a primary prevention strategy, was worthwhile.  The study showed no benefit in terms of preventing end stage renal disease.   On the other hand, the Hope trial showed that treating pre-diabetics who were not hypertensive with Ramipril reduced their risk of heart attacks and strokes. For that matter, the data on type 2 diabetics for preventing progression from microalbuminuria to ESRD is mostly with ARBS. I don’t think there is any ACEI data on this except for type 1 diabetics. dts From: [mailto: ] On Behalf Of Kathy SaradarianSent: Wednesday, August 01, 2012 5:25 AMTo: Subject: RE: vent/rant Definitely recommendations have changed since ACEs first came out. And you are now to expect a slight rise in creatinine when you start it and it’s OK. I just listed to an AAFP Audio on this and I think a 20% rise is OK. More than 20% than get scared there’s bilateral renal artery stenosis and rule that out. The initial note is something we all deal with. The insurance companies see Diabetes on the diagnosis and then send the letter if they are not on an ACE. It’s automatic. They don’t study the individual person. But I have a question. If you have someone who is well controlled diabetic on diet and exercise ( no meds). Doesn’t have hypertension. Doesn’t have microalbuminuria.. Is there any benefit to starting an ACE. Most of my patients are very resistant to taking meds if they “don’t have toâ€. I start it as soon as there is hypertension or microalbuminuria but I really don’t know if there is evidence that starting it earlier has benefit. Kathy Saradarian, MDNJ From: [mailto: ] On Behalf Of Dr. Izquierdo-Porrera MD PhDSent: Wednesday, August 01, 2012 7:07 AMTo: Subject: RE: vent/rant ACEI cause pre-renal renal failure (as far as I know) through their interaction with the R-A-A. It does not produce kidney injury. I think we were all told to stop ACEI in the context of developing new CRF (those of us who were old enough to be around when the ACEI came out) due to Lack of knowledge of the exact mechanism. If you look at the current KDOQI guidelines (for CRF) they encourage use of ACEI, which may be the reason you got the note that started this conversation Izquierdo-Porrera MD PhDExecutive Director & Co-founderCare for Your Health, IncPhone Fax www.care4yourhealth.org " Don't ever let injustice go by unchallenged. " Help us make our community healthy -> http://www.care4yourhealth.org/wanttohelp.php From: [mailto: ] On Behalf Of Ken StoneSent: Tuesday, July 31, 2012 10:25 PMTo: Subject: RE: vent/rant Kinda sorta. The way I learned it is that ACE inhibitors and ARBs are actually fine in most chronic kidney disease. In the setting of albuminuria, they’re particularly indicated, because filtered protein rips bigger holes in the glomeruli as it passes through them (negative charges on protein interacting with negatively charged proteins in the podocytes, IIRC) and that protein filtration can destroy kidneys very quickly. Although they decrease GFR, the ACEIs/ARBs are helping the glomeruli to heal in that situation by decreasing filtration pressure. But yeah, since ACEIs and ARBs work by lowering the GFR, they do cause the scales to tip in the wrong direction in CKD, with increases in Cr and BUN. That’s not the same as causing damage, though. This mostly becomes an issue in CKD4 when you want to delay initiation of dialysis and the presence of an ACEI/ARB causes their GFR to dip below the magic threshold that separates where the kidneys are just barely getting enough flow to get the job done from where they aren’t. But again, I don’t think that means the ACEIs/ARBs are doing additional damage in that situation; they’re merely highlighting the severe damage that is already present. Once the patient is getting dialysis anyway, it would be reasonable to restart them if there are good reasons to do so (e.g. preservation of renal function in diabetic nephropathy). That biting dog you referred to from ACEIs comes into play mostly in the setting of acute kidney injuries, typically shock/hypotension, where the kidneys are trying to recover from hypoxia and inadequate blood flow. In that setting, ACEIs are indeed very, very, bad. I’m sure there are a few exceptions here and there to these general principles (most notably e.g. in renovascular disease); if you happen to discover something markedly different in your studies from what I’ve outlined above, please correct my misunderstanding. Thanks, Ken From: [mailto: ] On Behalf Of MyriaSent: Tuesday, July 31, 2012 8:09 PMTo: Subject: Re: vent/rant OK I'm going back to the books cuz I was always, always taught you keep the ACE on until the Cr starts climbing and you stop it because now that dog that was helping will turn around and bite you! I did a month with the renal docs. So your information is definately a flag for me to go check it out. Thanks. To: Sent: Tuesday, July 31, 2012 11:34 AMSubject: RE: vent/rant In general, use of ACE inhibitors or ARBs is strongly indicated in dialysis patients (among others, including most notably diabetics and heart failure patients) for a number of reasons. They are not just indicated in those less than 65, although that’s where you might expect to see the most profound outcome differences in mortality, which might be why that preliminary study from 2002 studied only that population. As your insurance company noted, preservation of residual kidney function through reduction of microalbuminuria is indeed an important factor in the survival of dialysis patients who are not already anuric. Above and beyond the renal issues, ACE inhibitors and ARBS are important (and similar to statins) in that they limit inflammation, particularly vascular inflammation. In short, they significantly decrease cardiovascular mortality in at-risk populations, and not just through their direct effects on blood pressure. From: [mailto: ] On Behalf Of Margaret CoughlanSent: Tuesday, July 31, 2012 11:00 AMTo: Subject: Re: vent/rant Thanks but he is over 65 and the recommendation said to help with microalbuminuria. vent/rant Why would a stupid insurance company send you a recommendation to put your diabetic patient on an ACE inhibitor if he is getting dialysis 3 days a week for end-stage renal failure?????? They say it is based on claims analysis, don't they see their claims for dialysis treatment? Margaret No virus found in this message.Checked by AVG - www.avg.comVersion: 2012.0.2197 / Virus Database: 2437/5168 - Release Date: 07/31/12No virus found in this message.Checked by AVG - www.avg.comVersion: 2012.0.2197 / Virus Database: 2437/5168 - Release Date: 07/31/12 Quote Link to comment Share on other sites More sharing options...
Guest guest Posted August 2, 2012 Report Share Posted August 2, 2012 I heard that HCTZ became so popular because docs could use the abbreviation HCTZ that was made up by the drug companies. Quicker than writing out chlorthalidone. Yet another BIg Pharma influence for their good and not patient's benefit.I have been using chlorthalidone for a few years and am pretty wow'ed by it's effect. I can often get by with rx'ing 12.5 mg.Deborah Ginsburg, MDHealing Oceans Family Wellness Center Helping Families Thrivewww.healing-oceans.com Sent from my iPad HCTZ? Yuck! Phooey! (choose chlorthalidone instead; it has a longer half-life that provides full 24-hour coverage, is significantly more potent than HCTZ and is much more likely to actually control hypertension as a single agent, and the studies that validated “thiazide-type diuretics†as a good treatment choice for HTN with mortality benefit were pretty much all done with chlorthalidone, not HCTZ.) Just sayin’. Ken From: [mailto: ] On Behalf Of sharkinnSent: Wednesday, August 01, 2012 7:51 PMTo: Subject: Re: vent/rant Yes, Sharon. I remember when Aldomet, Inderal, and Esidrix were the "go-to" meds for HTN. Esidrix still is, but we call it HCTZ.---Sharlene> > > **> >> >> > Although I agree with you that there doesn't seem to be a compelling> > indication in that situation, after looking around a little bit, yeah,> > there actually could be some theoretical benefit to using the ACEI—it could> > buy your patient some time before development of frank diabetes. Among the> > things that ACEIs apparently do is to increase insulin sensitivity and help> > prevent Type 2 DM. If they are the typical pill-averse patient you> > mentioned, it's not a battle I would bother to fight. For the> > vitamin-popping patient who is looking for "everything possible that's> > reasonable" to be done, I think it's very reasonable to consider adding a> > low-dose ACEI (or metformin) in that situation.****> >> > ****> >> > ** **> >> > *From:* [mailto:> > ] *On Behalf Of *Kathy Saradarian> > *Sent:* Wednesday, August 01, 2012 8:25 AM> >> > *To:* > > *Subject:* RE: vent/rant****> >> > ** **> >> > ****> >> > Definitely recommendations have changed since ACEs first came out. And> > you are now to expect a slight rise in creatinine when you start it and> > it's OK. I just listed to an AAFP Audio on this and I think a 20% rise is> > OK. More than 20% than get scared there's bilateral renal artery stenosis> > and rule that out.****> >> > ****> >> > The initial note is something we all deal with. The insurance companies> > see Diabetes on the diagnosis and then send the letter if they are not on> > an ACE. It's automatic. They don't study the individual person. But I> > have a question. If you have someone who is well controlled diabetic on> > diet and exercise ( no meds). Doesn't have hypertension. Doesn't have> > microalbuminuria.. Is there any benefit to starting an ACE. Most of my> > patients are very resistant to taking meds if they "don't have to". I> > start it as soon as there is hypertension or microalbuminuria but I really> > don't know if there is evidence that starting it earlier has benefit.****> >> > ****> >> > Kathy Saradarian, MD> > NJ****> >> > ****> >> > *From:* > > [mailto: ] *On Behalf Of *Dr. > > Izquierdo-Porrera MD PhD> > *Sent:* Wednesday, August 01, 2012 7:07 AM> > *To:* > > *Subject:* RE: vent/rant****> >> > ****> >> > ****> >> > ACEI cause pre-renal renal failure (as far as I know) through their> > interaction with the R-A-A. It does not produce kidney injury. I think we> > were all told to stop ACEI in the context of developing new CRF (those of> > us who were old enough to be around when the ACEI came out) due to Lack of> > knowledge of the exact mechanism. If you look at the current KDOQI> > guidelines (for CRF) they encourage use of ACEI, which may be the reason> > you got the note that started this conversation****> >> > ****> >> > Izquierdo-Porrera MD PhD****> >> > Executive Director & Co-founder****> >> > Care for Your Health, Inc****> >> > Phone ****> >> > Fax ****> >> > www.care4yourhealth.org****> >> > * *****> >> > *"Don't ever let injustice go by unchallenged."*****> >> > ****> >> > Help us make our community healthy ->> > http://www.care4yourhealth.org/wanttohelp.php****> >> > ****> >> > [image: Care_your_health.jpg]****> >> > ****> >> > *From:* > > [mailto: ] *On Behalf Of *Ken Stone> > *Sent:* Tuesday, July 31, 2012 10:25 PM> > *To:* > > *Subject:* RE: vent/rant****> >> > ****> >> > ****> >> > Kinda sorta. ****> >> > ****> >> > The way I learned it is that ACE inhibitors and ARBs are actually fine in> > most chronic kidney disease. In the setting of albuminuria, they're> > particularly indicated, because filtered protein rips bigger holes in the> > glomeruli as it passes through them (negative charges on protein> > interacting with negatively charged proteins in the podocytes, IIRC) and> > that protein filtration can destroy kidneys very quickly. Although they> > decrease GFR, the ACEIs/ARBs are helping the glomeruli to heal in that> > situation by decreasing filtration pressure. ****> >> > ****> >> > But yeah, since ACEIs and ARBs work by lowering the GFR, they do cause the> > scales to tip in the wrong direction in CKD, with increases in Cr and BUN.> > That's not the same as causing damage, though. This mostly becomes an> > issue in CKD4 when you want to delay initiation of dialysis and the> > presence of an ACEI/ARB causes their GFR to dip below the magic threshold> > that separates where the kidneys are just barely getting enough flow to get> > the job done from where they aren't. But again, I don't think that means> > the ACEIs/ARBs are doing additional damage in that situation; they're> > merely highlighting the severe damage that is already present. Once the> > patient is getting dialysis anyway, it would be reasonable to restart them> > if there are good reasons to do so (e.g. preservation of renal function in> > diabetic nephropathy).****> >> > ****> >> > That biting dog you referred to from ACEIs comes into play mostly in the> > setting of acute kidney injuries, typically shock/hypotension, where the> > kidneys are trying to recover from hypoxia and inadequate blood flow. In> > that setting, ACEIs are indeed very, very, bad. ****> >> > ****> >> > I'm sure there are a few exceptions here and there to these general> > principles (most notably e.g. in renovascular disease); if you happen to> > discover something markedly different in your studies from what I've> > outlined above, please correct my misunderstanding.****> >> > ****> >> > Thanks,****> >> > ****> >> > Ken****> >> > ****> >> > *From:* [> > mailto: < >]> > *On Behalf Of *Myria> > *Sent:* Tuesday, July 31, 2012 8:09 PM> > *To:* > > *Subject:* Re: vent/rant****> >> > ****> >> > ****> >> > OK I'm going back to the books cuz I was always, always taught you keep> > the ACE on until the Cr starts climbing and you stop it because now that> > dog that was helping will turn around and bite you! I did a month with the> > renal docs. So your information is definately a flag for me to go check it> > out. Thanks. ****> >> > ****> >> > *From:* Ken Stone > > *To:* > > *Sent:* Tuesday, July 31, 2012 11:34 AM> > *Subject:* RE: vent/rant****> >> > ****> >> > ****> >> > ****> >> > In general, use of ACE inhibitors or ARBs is strongly indicated in> > dialysis patients (among others, including most notably diabetics and heart> > failure patients) for a number of reasons. They are not just indicated in> > those less than 65, although that's where you might expect to see the most> > profound outcome differences in mortality, which might be why that> > preliminary study from 2002 studied only that population. As your> > insurance company noted, preservation of residual kidney function through> > reduction of microalbuminuria is indeed an important factor in the survival> > of dialysis patients who are not already anuric. Above and beyond the> > renal issues, ACE inhibitors and ARBS are important (and similar to> > statins) in that they limit inflammation, particularly vascular> > inflammation. In short, they significantly decrease cardiovascular> > mortality in at-risk populations, and not just through their direct effects> > on blood pressure.****> >> > ****> >> > *From:* > > [mailto: ] *On Behalf Of *Margaret> > Coughlan> > *Sent:* Tuesday, July 31, 2012 11:00 AM> > *To:* > > *Subject:* Re: vent/rant****> >> > ****> >> > ****> >> > Thanks but he is over 65 and the recommendation said to help with> > microalbuminuria.> >> > vent/rant> >> >> >> > Why would a stupid insurance company send you a recommendation to put your> > diabetic patient on an ACE inhibitor if he is getting dialysis 3 days a> > week for end-stage renal failure?????? They say it is based on claims> > analysis, don't they see their claims for dialysis treatment?> >> > Margaret ****> >> > ****> > ------------------------------> >> > No virus found in this message.> > Checked by AVG - www.avg.com> > Version: 2012.0.2197 / Virus Database: 2437/5168 - Release Date: 07/31/12*> > ***> >> > No virus found in this message.> > Checked by AVG - www.avg.com> > Version: 2012.0.2197 / Virus Database: 2437/5168 - Release Date: 07/31/12*> > ***> >> > ****> >> > > >> Quote Link to comment Share on other sites More sharing options...
Guest guest Posted August 2, 2012 Report Share Posted August 2, 2012 Really? Sent from my iPhone I don’t have the reference right now, but a study has recently been done to test whether simply starting ACEI’s on type 2 diabetics who do not have hypertension or microalbuminuria, as a primary prevention strategy, was worthwhile. The study showed no benefit in terms of preventing end stage renal disease. On the other hand, the Hope trial showed that treating pre-diabetics who were not hypertensive with Ramipril reduced their risk of heart attacks and strokes. For that matter, the data on type 2 diabetics for preventing progression from microalbuminuria to ESRD is mostly with ARBS. I don’t think there is any ACEI data on this except for type 1 diabetics. dts From: [mailto: ] On Behalf Of Kathy SaradarianSent: Wednesday, August 01, 2012 5:25 AMTo: Subject: RE: vent/rant Definitely recommendations have changed since ACEs first came out. And you are now to expect a slight rise in creatinine when you start it and it’s OK. I just listed to an AAFP Audio on this and I think a 20% rise is OK. More than 20% than get scared there’s bilateral renal artery stenosis and rule that out. The initial note is something we all deal with. The insurance companies see Diabetes on the diagnosis and then send the letter if they are not on an ACE. It’s automatic. They don’t study the individual person. But I have a question. If you have someone who is well controlled diabetic on diet and exercise ( no meds). Doesn’t have hypertension. Doesn’t have microalbuminuria.. Is there any benefit to starting an ACE. Most of my patients are very resistant to taking meds if they “don’t have toâ€. I start it as soon as there is hypertension or microalbuminuria but I really don’t know if there is evidence that starting it earlier has benefit. Kathy Saradarian, MDNJ From: [mailto: ] On Behalf Of Dr. Izquierdo-Porrera MD PhDSent: Wednesday, August 01, 2012 7:07 AMTo: Subject: RE: vent/rant ACEI cause pre-renal renal failure (as far as I know) through their interaction with the R-A-A. It does not produce kidney injury. I think we were all told to stop ACEI in the context of developing new CRF (those of us who were old enough to be around when the ACEI came out) due to Lack of knowledge of the exact mechanism. If you look at the current KDOQI guidelines (for CRF) they encourage use of ACEI, which may be the reason you got the note that started this conversation Izquierdo-Porrera MD PhDExecutive Director & Co-founderCare for Your Health, IncPhone Fax www.care4yourhealth.org "Don't ever let injustice go by unchallenged." Help us make our community healthy -> http://www.care4yourhealth.org/wanttohelp.php <image001.jpg> From: [mailto: ] On Behalf Of Ken StoneSent: Tuesday, July 31, 2012 10:25 PMTo: Subject: RE: vent/rant Kinda sorta. The way I learned it is that ACE inhibitors and ARBs are actually fine in most chronic kidney disease. In the setting of albuminuria, they’re particularly indicated, because filtered protein rips bigger holes in the glomeruli as it passes through them (negative charges on protein interacting with negatively charged proteins in the podocytes, IIRC) and that protein filtration can destroy kidneys very quickly. Although they decrease GFR, the ACEIs/ARBs are helping the glomeruli to heal in that situation by decreasing filtration pressure. But yeah, since ACEIs and ARBs work by lowering the GFR, they do cause the scales to tip in the wrong direction in CKD, with increases in Cr and BUN. That’s not the same as causing damage, though. This mostly becomes an issue in CKD4 when you want to delay initiation of dialysis and the presence of an ACEI/ARB causes their GFR to dip below the magic threshold that separates where the kidneys are just barely getting enough flow to get the job done from where they aren’t. But again, I don’t think that means the ACEIs/ARBs are doing additional damage in that situation; they’re merely highlighting the severe damage that is already present. Once the patient is getting dialysis anyway, it would be reasonable to restart them if there are good reasons to do so (e.g. preservation of renal function in diabetic nephropathy). That biting dog you referred to from ACEIs comes into play mostly in the setting of acute kidney injuries, typically shock/hypotension, where the kidneys are trying to recover from hypoxia and inadequate blood flow. In that setting, ACEIs are indeed very, very, bad. I’m sure there are a few exceptions here and there to these general principles (most notably e.g. in renovascular disease); if you happen to discover something markedly different in your studies from what I’ve outlined above, please correct my misunderstanding. Thanks, Ken From: [mailto: ] On Behalf Of MyriaSent: Tuesday, July 31, 2012 8:09 PMTo: Subject: Re: vent/rant OK I'm going back to the books cuz I was always, always taught you keep the ACE on until the Cr starts climbing and you stop it because now that dog that was helping will turn around and bite you! I did a month with the renal docs. So your information is definately a flag for me to go check it out. Thanks. To: Sent: Tuesday, July 31, 2012 11:34 AMSubject: RE: vent/rant In general, use of ACE inhibitors or ARBs is strongly indicated in dialysis patients (among others, including most notably diabetics and heart failure patients) for a number of reasons. They are not just indicated in those less than 65, although that’s where you might expect to see the most profound outcome differences in mortality, which might be why that preliminary study from 2002 studied only that population. As your insurance company noted, preservation of residual kidney function through reduction of microalbuminuria is indeed an important factor in the survival of dialysis patients who are not already anuric. Above and beyond the renal issues, ACE inhibitors and ARBS are important (and similar to statins) in that they limit inflammation, particularly vascular inflammation. In short, they significantly decrease cardiovascular mortality in at-risk populations, and not just through their direct effects on blood pressure. From: [mailto: ] On Behalf Of Margaret CoughlanSent: Tuesday, July 31, 2012 11:00 AMTo: Subject: Re: vent/rant Thanks but he is over 65 and the recommendation said to help with microalbuminuria. vent/rant Why would a stupid insurance company send you a recommendation to put your diabetic patient on an ACE inhibitor if he is getting dialysis 3 days a week for end-stage renal failure?????? They say it is based on claims analysis, don't they see their claims for dialysis treatment? Margaret No virus found in this message.Checked by AVG - www.avg.comVersion: 2012.0.2197 / Virus Database: 2437/5168 - Release Date: 07/31/12No virus found in this message.Checked by AVG - www.avg.comVersion: 2012.0.2197 / Virus Database: 2437/5168 - Release Date: 07/31/12 Quote Link to comment Share on other sites More sharing options...
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