Hello. This is Jeffrey Berns, editor-in-chief of Medscape Nephrology. By the time this video airs on Medscape, I will no longer be president of the National Kidney Foundation (NKF) and will have turned the torch over to Dr Michael Choi, who is going to become the next president of the NKF.
Over the past couple of years in this role with the NKF, I have had many discussions in a variety of different forms about the role of screening patients for chronic kidney disease (CKD) in primary care practices. I was forced to think about this again as I reviewed a paper[1] that was recently published. The details of the paper are not that important in terms of where it was done, because the patient population was very different from ours in the United States.
The study was conducted in primary care practices in the United Kingdom, so it was not at all demographically like the patient population we see here in the United States. It involved primarily older groups, with a mean age of 73 years. The estimated glomerular filtration rate (eGFR) in the group was 53 mL/min/1.73 m2 using the Modification of Diet in Renal Disease study equation. Only 17% were diabetic and they generally had reasonably well-controlled blood pressure. Also, very much like our patient population, the mean weight was only 78 kg.
The investigators followed this cohort of patients for a 5-year period. It was not a huge study, with only about 1700 patients. What was interesting, and made me think about what we should be talking about in terms of screening for CKD, was that over this 5-year period, 14.2% of patients died, 17.7% had progression of CKD, but only 0.2% developed end-stage renal disease (ESRD). Of the remainder of the group, 34.1% had stable CKD and didn't do much of anything over a 5-year period, [and 19.3% were in remission]. An observation that hasn't been talked about too much is that 20% of patients had remission of their CKD. In other words, they were identified once as having an eGFR < 60 mL/min/1.73 m2 or having albuminuria, and then on subsequent follow-up those were no longer present. Once they went into remission, it seemed to be sustained.
An observation was made before (similar to this group of patients) that for most patients who had stage 3 CKD to begin with, ESRD is not the most common outcome. It's death and, as shown in this study to almost an equal extent, progression of CKD, but not to ESRD.
So, it forced me to think again about what we should be doing and what we should be talking about when we talk about screening. It's probably not wise to be screening everybody in the population for CKD, including the elderly population, even though age itself is a risk factor. What this cohort study showed is that low GFR at baseline predicts CKD, with serum creatinine, eGFR, and albumin-to-creatinine ratio. Some measure of albuminuria was important and diabetes was important. We know that hypertension is important, but it wasn't a major focus of this paper, in part because the patients had reasonably well-controlled blood pressures at the beginning.
So again, as we talk with our primary care colleagues, whether they be physicians or advanced practice nurses or others, we should really be focusing our efforts on screening for CKD using serum creatinine and eGFR calculation as well as albumin-to-creatinine ratio, ideally, if not some other measure of albuminuria in people who are at risk. "At risk" means those who have diabetes, those who are elderly, racial minorities in the United States, and so forth. Screening everybody in the population is probably not very cost-effective or useful. Screening those who are at risk is more helpful. And then, we should use that information to help identify those who are at greatest risk for progression based on the level of serum creatinine or albuminuria, their blood pressure, and so forth. We should also be able to identify a group of patients who are at very, very low risk for progression, who don't need to see a nephrologist, and who can be managed very conservatively by primary care providers.
Thanks for listening. This is Jeffrey Berns, editor-in-chief of Medscape Nephrology, from the Perelman School of Medicine at the University of Pennsylvania in Philadelphia.
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Any views expressed above are the author's own and do not necessarily reflect the views of WebMD or Medscape.
Cite this: CKD Screening Is Not for Everyone - Medscape - Oct 19, 2016.
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