The case for early identification and intervention of chronic kidney disease: conclusions from a Kidney Disease: Improving Global Outcomes (KDIGO) Controversies Conference

Chronic kidney disease (CKD) causes substantial global morbidity and increases cardiovascular all-cause mortality. Unlike other chronic diseases with established strategies for screening, there has been no consensus on whether health systems governments should prioritize early identification intervention CKD. Guidelines evaluating managing CKD are available but have not universally adopted in the absence of incentives or quality measures prioritizing care. The burden falls disproportionately upon persons lower socioeconomic status, who a higher prevalence CKD, limited access to treatment, poorer outcomes. Therefore, identifying treating at earliest stages is an equity imperative. In 2019, Kidney Disease: Improving Global Outcomes (KDIGO) held controversies conference entitled “Early Identification Intervention CKD.” Participants identified risk stratification, treatment key system economic factors implementing these processes. A emerged that screening coupled stratification be implemented immediately high-risk this ideally occur primary community care settings tailoring local context. Nearly 700 million worldwide (CKD), socially disadvantaged vulnerable groups.1Bikbov B. Purcell C.A. Levey A.S. et al.Global, regional, national disease, 1990–2017: systematic analysis Burden Disease Study 2017.Lancet. 2020; 395: 709-733Abstract Full Text PDF PubMed Scopus (634) Google Scholar many regions, status outcomes.2Palmer Alves T. Lewis J. Racial differences end-stage renal (ESRD) United States: social dilemma.Clin Nephrol. 2010; 74: S72-S77PubMed Scholar, 3Caskey F.J. Prevalence incidence communities Europe.Clin 2016; 86: 34-36Crossref (0) 4Garcia M. Hernandez Ellington T.G. al.A lack decline major nontraumatic amputations Texas: contemporary trends, factor associations, impact revascularization.Diabetes Care. 2019; 42: 1061-1066Crossref 5Crews D.C. Bello A.K. Saadi G. 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Microvascular complications foot care: standards medical diabetes—2020.Diabetes 43: S135-S151Crossref (181) To address ongoing controversy, October Controversies Conference Meeting participants represented multidisciplinary panel clinicians scientists. rationale was evaluated within context Health Organization (WHO) principles disease.11Wilson J.M.G. Jungner OrganizationPrinciples disease. 1968.https://apps.who.int/iris/handle/10665/37650Date accessed: 22, 2019Google Scholar,12Andermann Blancquaert I. Beauchamp Dery V. Revisiting Wilson genomic age: review criteria over past 40 years.Bull Organ. 2008; 317-319Crossref (490) Four topics were then addressed: (i) selection populations (ii) relative diagnostic predictive characteristics tests (iii) evidence base treatments progression (iv) implementation programs determining resource allocation cost-effectiveness. agenda, discussion questions, plenary session presentations KDIGO website: https://kdigo.org/conferences/early-identification/. 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Coresh Lifetime 3–5 States.Am 62: 245-252Abstract (177) 33Nelson R.G. Ballew S.H. al.Development prediction incident disease.JAMA. 322: 2104-2114Crossref (32) Scholar). Furthermore, program considered imperative, particularly because experience disproportionate least likely receive improve outcomes.34Crews Boulware Disparities burden, outcomes, disease.Curr 23: 298-305Crossref 35Morton R.L. Schlackow al.The disadvantage moderate-to-severe equity-focused review.Nephrol Dial Transplant. 31: 46-56Crossref (49) 36Nicholas S.B. Kalantar-Zadeh Norris K.C. Socioeconomic disease.Adv 22: 6-15Abstract ScholarTable 1Key conclusions InterventionPopulations Conclusion 1. Persons hypertension, diabetes, screened 2. also based comorbidities, environmental exposures, genetic factors. 3. initiation, frequency, cessation individualized profiles preferences.Measurements 4. must consist dual estimated glomerular filtration rate (eGFR) (UACR). 5. Accurate GFR estimation includes both creatinine cystatin C measurements initial staging. 6. combination creatinine, C, UACR affordable high-income settings.Interventions 7. availability interventions delay risk. 8. staging necessary utilize effectively. 9. Patient engagement critical component efforts CKD.Health 10. require multi-stakeholder overcome barriers high-quality 11. Financial nonfinancial need aligned 12. cost-effective. 13. approaches may differ LMIC countries.CKD, disease; eGFR, rate; GFR, LMICs, low- middle-income countries; UACR, albumin-to-creatinine ratio. Open table new tab Table 2CKD meets WHO’s diseaseWHO criteriaCKD screening1.The condition sought important public problem.•CKD highly prevalent, costly, increasing.1Bikbov Scholar2.There recognized disease.•Treatments during accepted, effective. Use ACEi/ARBs reduces failure. trials showed ACEi/ARB therapy lowered odds failure 30%–39% CVD 18%–24%.13Xie Scholar•Statin use shown significantly decrease CKD.14Herrington Scholar•In trials, intensified reduced rates fatal nonfatal mortality.15Wright long-term glycemic CKD.16Ruospo beneficial earlier stages.17Coca Scholar•SGLT2 30%–40%.18Perkovic Scholar,19Neal Scholar3.Facilities available.•CKD could primary-care practices community-based settings.4.There recognizable latent symptomatic stage.•CKD asymptomatic until late stages. contributes low diagnosis.20Tuot shift recognition into much current practice.5.There suitable test examination.•There Serum estimate GFR. Quantitative sensitive measurement damage, whereas dipstick lower-cost sensitivity.21White Scholar6.The acceptable population.•Testing population. tested through venipuncture non-invasive testing, express preference communication about diagnosis.22Wright Scholar7.The natural history condition, including declared adequately understood.•The consequences inadequate well-understood. large body If treated, progress failure, predicted using equations.23Go Scholar,24Tangri Scholar8.There policy whom patients.•There clear guidelines detection. recommend nondiabetic adults albumin excretion >300 mg/24 hours (or equivalent), suggest 30–300 equivalent).25Kidney recommended above age 50 intermediate atherosclerotic risk, enhancer borderline disease.26Wanner Scholar,27Grundy Scholar•Current (ACC/AHA) hypertension placed category treated BP less than 130/80 mm Hg, without delaying nonpharmacologic interventions.28Whelton Forthcoming will advocate targeting systolic < 120 Hg.•SGLT2 CKD.10American Scholar9.The cost case-finding (including diagnosed) economically balanced relation possible expenditure whole.•CKD Several analyses found cost-effective simulation models.29Boulware Scholar,30Komenda Given tailored resources specific system, targets.31Wolf Scholar10.Case-finding continuing process “once all” project.•If implemented, repeated detect negative screen. One-time does capture lifetime CKD.32Grams Scholar•An efficient tailor timing next testing probability results.33Nelson ScholarACEi, angiotensin-converting enzyme inhibitor; ARB, angiotensin receptor blocker; BP, pressure; CVD, KDIGO, Outcomes; SGLT2, sodium-glucose cotransporter-2; ratio; WHO, Organization. ACEi, Two additional themes emerge serve underlying strategies. First, highlighted patient representatives advocates, strong belief overwhelmingly prefer education self-management prognosis. Second, significant evident given costs individuals, systems, society. For example, States alone, Medicare spending those 114 billion dollars annually.37United Renal Data System2018 USRDS annual report: epidemiology States. National Institute Digestive Diseases, Institutes Health, Bethesda, MD2018https://www.usrds.org/annual-data-report/previous-adrs/Google acute middle income countries (LMICs); 188 people catastrophic annually result across greatest any group.38Essue B.M. Laba T.-L. Knaul al.Economic ill injuries households low-and countries.in: Jamison D.T. Gelband H. Horton Control Priorities: Reducing Poverty. 3rd ed. International Bank Reconstruction Development/World Bank, Washington, DC2017Crossref Specific components optimal described sections follow. reviewed different objectives initiatives: maximize yield, most complications. Additional included definitions frequency rescreening. concluded population-level having experiencing inform Decisions concerning initiate repeat time forgo factors, preferences, life expectancy. first expected individuals. cases would complete improving population-wide noted drawbacks, greater targeted screening. common This per case miss attributable unrecognized