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22 October 2013 Annals of Internal Medicine Tip Sheet

Below is information about articles being published in the September 17 issue of Annals of Internal Medicine. The information is not intended to substitute for the full article as a source of information. Annals of Internal Medicine attribution is required for all coverage.

1. ACP recommends against routine screening for chronic kidney disease

ACP’s new guideline presents evidence-based recommendations for screening, monitoring, and treatment of adults with stage 1-3 chronic kidney disease

Finding no direct evidence that addresses the benefits of screening for stage 1-3 chronic kidney disease (CKD) and citing potential harms of tests, the American College of Physicians (ACP) recommends against screening for CKD in asymptomatic adults without risk factors. ACP found the evidence inconclusive for CKD screening in asymptomatic adults with risk factors and for periodic monitoring of patients diagnosed with stage 1-3 CKD. Major risk factors for CKD include diabetes, hypertension, and cardiovascular disease. Based on the evidence, ACP recommends against testing for proteinuria in adults with or without diabetes who are currently taking an angiotensin-converting-enzyme (ACE) inhibitor or an angiotensin II receptor blocker (ARB). ACP recommends treating patients with hypertension and stage 1-3 CKD with either an ACE inhibitor or an ARB. ACP recommends a statin therapy to manage elevated low density lipoprotein in patients with stage 1-3 CKD. Head-to-head trials showed no difference in the outcomes between ACE inhibitors or ARBs. The risk of adverse effects significantly increased with an ACE inhibitor combined with an ARB combination therapy, including cough, hyperkalemia, hypotension, and acute kidney failure requiring dialysis. ACP’s guideline also includes advice to help physicians practice high value care.

2. Screening may adequately detect early dementia, but benefit is still unknown

A review of published evidence suggests that brief screening tests for cognitive impairment that can be implemented in the primary care setting may be useful for detecting dementia. However, there is no evidence that early diagnosis of cognitive impairment improves decision-making or outcomes. Mild cognitive impairment is a decline in cognitive function that is not severe enough to interfere with independence in daily life, however it may be useful in predicting dementia. Earlier identification and medical management of cognitive impairment may improve prognosis and decrease patient and caregiver morbidity. Researchers reviewed published research on the diagnostic accuracy of brief cognitive screening instruments and the benefits and harms of pharmacologic and nonpharmacologic interventions for early cognitive impairment. Evidence suggests that several brief screening tools are effective at detecting cognitive impairment, but only a few of them were studied in more than one study applicable to primary care. There was not enough published evidence to adequately assess the potential harms associated with screening and no trials directly assessed whether screening could affect decision-making, patient or caregiver, or societal outcomes. Based on the evidence, it was also unclear whether medications, caregiver interventions, cognitive interventions, or exercise interventions in persons with earlier detected cognitive impairment would have a clinically significant effect on outcomes. The evidence review was conducted by researchers for the United States Preventive Services Task Force (USPSTF) to update its previous recommendation. In 2003, the USPSTF found insufficient evidence to recommend for or against routine screening for dementia in older adults.