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Nephrology High Value Care Recommendations The American College of Physicians, in collaboration with ¢ The treatment of isovolemic hypernatremia is water, pref- multiple other organizations, is engaged in a worldwide erably orally or by nasogastric tube if the patient is inca- initiative to promote the practice of High Value Care (HVC). pable of drinking, rather than intravenously (see Item 60). The goals of the HVC initiative are to improve health care e Baseline echocardiography is not routinely recommended outcomes by providing care of proven benefit and reducing but should be performed if examination or ECG suggest costs by avoiding unnecessary and even harmful interven- cardiac hypertrophy or to evaluate the need for therapy tions. The initiative comprises several programs that inte- in patients with white coat hypertension. grate the important concept of health care value (balancing e Adults with stage 1 hypertension who have an estimated clinical benefit with costs and harms) for a given interven- 10-year atherosclerotic cardiovascular disease event risk tion into a broad range of educational materials to address of <10% should be managed initially with nonpharmaco- the needs of trainees, practicing physicians, and patients. logic therapy (see Item 52). ¢ Treatment of chronic hypertension (<160/110 mm Hg) HVC content has been integrated into MKSAP 19 in several during pregnancy is not associated with improved fetal important ways. MKSAP 19 includes HVC-identified key outcomes (see Item 13). points in the text, HVC-focused multiple-choice questions, ¢ In most patients with renal artery stenosis, the primary ther- and, in MKSAP Digital, an HVC custom quiz. From the text apeutic intervention is medical management (see Item 18). and questions, we have generated the following list of HVC e For patients with suspected renal artery fibromuscular recommendations that meet the definition below of high dysplasia, CT angiography is preferred to MRI as the initial value care and bring us closer to our goal of improving imaging modality of choice (see Item 48). patient outcomes while conserving finite resources. e In younger patients with IgA nephropathy, recurrent High Value Care Recommendation: A recommendation to hematuria in the absence of proteinuria usually portends choose diagnostic and management strategies for patients a benign clinical course and treatment is conservative in specific clinical situations that balance clinical benefit (see Item 41). with cost and harms with the goal of improving patient e Serologic testing for anti-phospholipase A2 receptor anti- outcomes. bodies in patients with suspected primary membranous nephropathy can eliminate the need for kidney biopsy in Below are the High Value Care Recommendations for the patients with preserved kidney function and no evidence Nephrology section of MKSAP 19. of secondary causes (see Item 75). e The random (spot) urine protein-creatinine ratio and e Primary membranous nephropathy is typically treated albumin-creatinine ratio correlate with 24-hour urine with conservative therapy before initiating immunosup- collections and are sufficiently accurate for screening and pression for patients with persistent nephrotic-range monitoring proteinuria. proteinuria to allow for spontaneous remission, which There is no need to monitor urine protein excretion in occurs in approximately 30% of patients. patients who are taking an ACE inhibitor or angiotensin e Contrast-associated nephropathy prophylaxis is not receptor blocker. indicated for patients with a stable estimated glomerular In the treatment of diabetic kidney disease, combining filtration rate >45 mL/min/1.73 m? (see Item 2). any two renin-angiotensin system drug classes (ACE e There is no proven benefit to early administration of renal inhibitors, angiotensin receptor blockers, or direct replacement therapy versus timing based on usual clini- renin inhibitors) is not recommended, as side effects are cal criteria in critically ill patients or those with sepsis. increased and there is no additional clinical benefit. e In the diagnosis of nephrolithiasis, ultrasonography does Urinalysis should not be used for urothelial cancer not expose patients to radiation, has a lower cost com- screening in asymptomatic adults. pared with CT, and is the preferred modality during preg- CT urography is preferred to MRI as the diagnostic test of nancy (see Item 69). choice for patients with unexplained hematuria (see Item 59). ¢ The most effective treatment to facilitate the passage of In the treatment of symptomatic hyponatremia, simul- uric acid stones is urinary alkalinization with potassium taneous administration of desmopressin with 3% saline citrate (see Item 54). infusion results in a more predictable and safer increase ¢ Use of potassium binders in patients with chronic kidney in serum sodium (see Item 90). disease may allow continuation of essential medications,

The American College of Physicians, in collaboration with ¢ The treatment of isovolemic hypernatremia is water, pref- multiple other organizations, is engaged in a worldwide erably orally or by nasogastric tube if the patient is inca- initiative to promote the practice of High Value Care (HVC). pable of drinking, rather than intravenously (see Item 60). The goals of the HVC initiative are to improve health care e Baseline echocardiography is not routinely recommended outcomes by providing care of proven benefit and reducing but should be performed if examination or ECG suggest costs by avoiding unnecessary and even harmful interven- cardiac hypertrophy or to evaluate the need for therapy tions. The initiative comprises several programs that inte- in patients with white coat hypertension. grate the important concept of health care value (balancing e Adults with stage 1 hypertension who have an estimated clinical benefit with costs and harms) for a given interven- 10-year atherosclerotic cardiovascular disease event risk tion into a broad range of educational materials to address of <10% should be managed initially with nonpharmaco- the needs of trainees, practicing physicians, and patients. logic therapy (see Item 52). ¢ Treatment of chronic hypertension (<160/110 mm Hg) HVC content has been integrated into MKSAP 19 in several during pregnancy is not associated with improved fetal important ways. MKSAP 19 includes HVC-identified key outcomes (see Item 13). points in the text, HVC-focused multiple-choice questions, ¢ In most patients with renal artery stenosis, the primary ther- and, in MKSAP Digital, an HVC custom quiz. From the text apeutic intervention is medical management (see Item 18). and questions, we have generated the following list of HVC e For patients with suspected renal artery fibromuscular recommendations that meet the definition below of high dysplasia, CT angiography is preferred to MRI as the initial value care and bring us closer to our goal of improving imaging modality of choice (see Item 48). patient outcomes while conserving finite resources. e In younger patients with IgA nephropathy, recurrent High Value Care Recommendation: A recommendation to hematuria in the absence of proteinuria usually portends choose diagnostic and management strategies for patients a benign clinical course and treatment is conservative in specific clinical situations that balance clinical benefit (see Item 41). with cost and harms with the goal of improving patient e Serologic testing for anti-phospholipase A2 receptor anti- outcomes. bodies in patients with suspected primary membranous nephropathy can eliminate the need for kidney biopsy in Below are the High Value Care Recommendations for the patients with preserved kidney function and no evidence Nephrology section of MKSAP 19. of secondary causes (see Item 75). e The random (spot) urine protein-creatinine ratio and e Primary membranous nephropathy is typically treated albumin-creatinine ratio correlate with 24-hour urine with conservative therapy before initiating immunosup- collections and are sufficiently accurate for screening and pression for patients with persistent nephrotic-range monitoring proteinuria. proteinuria to allow for spontaneous remission, which There is no need to monitor urine protein excretion in occurs in approximately 30% of patients. patients who are taking an ACE inhibitor or angiotensin e Contrast-associated nephropathy prophylaxis is not receptor blocker. indicated for patients with a stable estimated glomerular In the treatment of diabetic kidney disease, combining filtration rate >45 mL/min/1.73 m? (see Item 2). any two renin-angiotensin system drug classes (ACE e There is no proven benefit to early administration of renal inhibitors, angiotensin receptor blockers, or direct replacement therapy versus timing based on usual clini- renin inhibitors) is not recommended, as side effects are cal criteria in critically ill patients or those with sepsis. increased and there is no additional clinical benefit. e In the diagnosis of nephrolithiasis, ultrasonography does Urinalysis should not be used for urothelial cancer not expose patients to radiation, has a lower cost com- screening in asymptomatic adults. pared with CT, and is the preferred modality during preg- CT urography is preferred to MRI as the diagnostic test of nancy (see Item 69). choice for patients with unexplained hematuria (see Item 59). ¢ The most effective treatment to facilitate the passage of In the treatment of symptomatic hyponatremia, simul- uric acid stones is urinary alkalinization with potassium taneous administration of desmopressin with 3% saline citrate (see Item 54). infusion results in a more predictable and safer increase ¢ Use of potassium binders in patients with chronic kidney in serum sodium (see Item 90). disease may allow continuation of essential medications, xiii

such as inhibitors of the renin-angiotensin system (see of improved mortality and quality of life and decreased Item 106). health care costs. Erythropoiesis-stimulating agents should not be used for Patients who receive preparatory renal replacement most patients with chronic kidney disease and hemo- therapy (RRT) education before they are diagnosed with globin >11 g/dL (110 g/L) because of an increased risk for end-stage kidney disease are more likely to select a home serious cardiovascular events and stroke. modality for RRT, be listed for a kidney transplant, or For older patients with end-stage kidney disease and receive a preemptive kidney transplant and may have a those who are not transplant candidates, screening for mortality benefit compared with patients who do not renal cell carcinoma is not recommended, even in the receive similar education (see Item 46). presence of known acquired cystic kidney disease (see Non-dialytic palliative therapy is a reasonable option for Item 5). older patients with end-stage kidney disease and multi- For eligible patients, kidney transplantation is the pre- ple comorbidities, with treatment focusing on symptom ferred treatment for end-stage kidney disease because management and quality of life. xiv