Chronic kidney disease from screening, detection, and awareness, to prevention
Authors: Melody Sherwood, Peter A McCullough
Journal: The Lancet Global Health (2016)

A critical link exists between awareness of risk, the presence of disease, and steps taken by the patient and clinician to change the natural history of disease. Chronic illnesses such as diabetes mellitus, dyslipidaemia, anaemia and a multitude of endocrinological and rheumatological diseases are relatively silent and rely on the clinical laboratory for diagnosis, particularly in their early stages. Probably no such illness permits such a large loss of organ function before symptoms become present as chronic kidney disease (CKD).1McCullough PA Beyond serum creatinine: defining the patient with renal insufficiency and why?.Rev Cardiovasc Med. 2003; 4: S2-S6PubMed Google Scholar Thus, the considerable dependence on the laboratory to establish the diagnosis of CKD is an issue for low-income and middle-income countries (LMIC), where access to in-vitro diagnostics on a screening basis might not be universally available. Even in high-income countries where routine laboratory tests are performed, CKD seems to lag considerably behind diabetes mellitus, hypertension, and cardiovascular disease in terms of patient and clinician awareness.2Saab G Whaley-Connell AT McCullough PA Bakris GL CKD awareness in the United States: the Kidney Early Evaluation Program (KEEP).Am J Kidney Dis. 2008; 52: 382-383Summary Full Text Full Text PDF PubMed Scopus (32) Google Scholar This difference is partly due to the two-dimensional nature of CKD defined as a reduction in estimated glomerular filtration rate (eGFR) and the presence of markers of chronic kidney damage (albuminuria or imaging evidence) over 3 months time. Thus, to have the eGFR and albumin:creatinine ratio at the same time and clearly inform the patient of the potential presence of CKD is complex. With these challenges as the backdrop, Ene-Iordache and colleagues3Ene-Iordache B Perico N Bikbov B et al.Chronic kidney disease and cardiovascular risk in six regions of the world (ISN-KDDC): a cross-sectional study.Lancet Glob Health. 2016; 4: e307-e319Summary Full Text Full Text PDF PubMed Scopus (265) Google Scholar report on 75 058 individuals screened for diabetes mellitus, hypertension, and CKD from LMICs. They found 44% of people with hypertension and 31% of those with diabetes were unaware of these conditions, suggesting public health screening efforts such as those described by the authors have a very high yield when there may not be access to primary care and routine screening. A total of 14·3% of the population was confirmed to have CKD by eGFR and or proteinuria (dipstick or albumin:creatinine ratio). Awareness of CKD was less than 10% in all risk groups in line with what has been found in the US Kidney Early Evaluation Program (KEEP).4Whaley-Connell A Bomback AS McFarlane SI et al.Diabetic cardiovascular disease predicts chronic kidney disease awareness in the Kidney Early Evaluation Program.Cardiorenal Med. 2011; 1: 45-52Crossref PubMed Scopus (15) Google Scholar Importantly, less than half of those aware reported any treatment or clinical actions taken for CKD. Thus, these data seem to present a three-part challenge: (1) to screen and detect CKD, (2) to become aware of the condition, (3) to understand and act on the knowledge that controlling modifiable risk factors like blood pressure and glucose can attenuate progression of CKD. Importantly, the authors demonstrated a sharp linkage between risk of CKD and cardiovascular disease in young to middle-aged individuals from many regions in the world. Thus, the benefit of CKD screening and detection as conveyance of cardiovascular disease risk, and the opportunities to modulate this risk, is arguably a more optimistic treatment goal than attenuating the progression of CKD.5Sarnak MJ Levey AS Schoolwerth AC et al.Kidney disease as a risk factor for development of cardiovascular disease: a statement from the American Heart Association Councils on Kidney in Cardiovascular Disease, High Blood Pressure Research, Clinical Cardiology, and Epidemiology and Prevention.Circulation. 2003; 108: 2154-2169Crossref PubMed Scopus (2873) Google Scholar With the advent of cardiovascular disease risk factor reduction there can be a dramatic reduction in the binary risks of myocardial infarction, stroke, and cardiovascular death.6Yeh RW Sidney S Chandra M Sorel M Selby JV Go AS Population trends in the incidence and outcomes of acute myocardial infarction.N Engl J Med. 2010; 362: 2155-2165Crossref PubMed Scopus (1239) Google Scholar, 7Yeh RW Mauri L Wolf RE et al.Population trends in rates of coronary revascularization.JAMA Intern Med. 2015; 175: 454-456Crossref Scopus (36) Google Scholar High-income countries are witnessing sharp declines in rates of cardiovascular disease events, which are probably attributable to population changes in global risk. Additionally, blood pressure control is tightly linked to reductions in incident heart failure and stroke.8Wright Jr, JT Williamson JD et al.SPRINT Research GroupA randomized trial of intensive versus standard blood-pressure control.N Engl J Med. 2015; 373: 2103-2116Crossref PubMed Scopus (3898) Google Scholar With half of those with hypertension and a third of those with diabetes from LMIC in this report taking no medications at all for these problems, there appears to be a considerable public health opportunity from strengthened community approaches that not only screen and detect disease but also provide some basic forms of pharmacological treatment and follow-up.9McCullough PA Brown WW Gannon MR et al.Sustainable community-based CKD screening methods employed by the national kidney foundation's kidney early evaluation program (KEEP).Am J Kidney Dis. 2011; 57: S4-S8Summary Full Text Full Text PDF Scopus (20) Google Scholar Results from the present study3Ene-Iordache B Perico N Bikbov B et al.Chronic kidney disease and cardiovascular risk in six regions of the world (ISN-KDDC): a cross-sectional study.Lancet Glob Health. 2016; 4: e307-e319Summary Full Text Full Text PDF PubMed Scopus (265) Google Scholar and from over a decade of experience with KEEP suggest that hypertension, diabetes, smoking, concern for the presence of any of these risk factors, or a family history of CKD are proven high-yield criteria for individuals to undergo screening and measurement of eGFR and urine albumin.10Whaley-Connell A Kurella Tamura M McCullough PA A decade after the KDOQI CKD guidelines: impact on the National Kidney Foundation's Kidney Early Evaluation Program (KEEP).Am J Kidney Dis. 2012; 60: 692-693Summary Full Text Full Text PDF PubMed Scopus (6) Google Scholar Confirmation of hypertension or diabetes mellitus is a mandatory call to treatment. Furthermore, identification of CKD in a middle-aged individual is a signal for cardiovascular disease risk, and additional steps can be taken to reduce the rates of myocardial infarction, stroke, heart failure, and cardiovascular death (figure). It all starts with screening and detection of a silent disease, which give years of opportunity for discovery and modification of its natural history. We declare no competing interests. Chronic kidney disease and cardiovascular risk in six regions of the world (ISN-KDDC): a cross-sectional studyPrevalence of chronic kidney disease was high in general and high-risk populations from countries of low and middle income. Moreover, awareness of chronic kidney disease and other non-communicable diseases was low, and a substantial number of individuals who knew they were ill did not receive treatment. Prospective programmes with repeat testing are needed to confirm the diagnosis of chronic kidney disease and its risk factors. Furthermore, in general, health-care workforces in countries of low and middle income need strengthening. Full-Text PDF Open Access