Not infrequently, after spending significant amounts of time and effort working up and managing a CKD case and explaining to the patient and his/her family members that the CKD is in an advanced stage and that dialysis initiation is imminent, the patient asks, “What about my cholesterol, doc? Did you check my cholesterol?”
I then have to spend extra time to enlighten the concerned patient and family members that transition from advanced CKD to dialysis therapy has little to do with cholesterol levels.
Nevertheless, many patients still insist that I need to check and manage their cholesterol.
In many CKD patients, the cholesterol obsession is too strong to overcome by a conventional patient-physician conversation. Even during my dialysis rounds, I have to deal with the cholesterol question sporadically. Recently, in the intensive care unit, I conducted a lengthy discussion with the family members of a patient with anuric AKI and multi-organ failure, who was on multiple pressors and continuous renal replacement therapy, and who had a poor prognosis.
The family members were asking me why I had not checked the patient’s cholesterol yet. Occasionally, when I try to explain to some of my patients that a high serum cholesterol level accounts for only a small fraction of the burden of cardiovascular disease, they seek second opinion to find a better doctor who can check their cholesterol more frequently.
What is the moral of the cholesterol story? First, many lay people, likely under the influence of overzealous efforts by pharmaceutical industry, have become convinced that serum cholesterol level is the most important health metric.
Second, nephrologists have a long way to go to increase public education and awareness about the high prevalence and poor outcomes of CKD and AKI.
Third—and this is good news—the process of educating the public about the importance of blood level of a biomarker can be very effective if concerted efforts by both health care professionals and the pharmaceutical industry are realigned, as has been the case for cholesterol education.
How should the physician react when family members of a patient in critical condition with AKI or CKD in the ICU and a poor prognosis ask that the patient’s cholesterol level be checked?
The appropriate approach is to educate a patient and his/her family members that there are many more important clinical and prognostic measures than serum cholesterol level. This approach may be associated with the risk of antagonizing the patient and jeopardizing your reputation or being labeled as non-cooperative and unfriendly.
The less challenging course of action is to order a cholesterol level and finish rounds faster and more efficiently. Your choice.