On World Kidney Day, efforts are underway to improve detection of CKD
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During World Kidney Day, the National Kidney Foundation emphasized its effort with the Coalition for Kidney Health to nominate targeted screening or case finding for chronic kidney disease based on risk conditions, like diabetes.
The NKF is nominating these screenings to the United States Preventive Service Task Force (USPSTF) to re-evaluate the current absence of a recommendation. This reassessment is overdue and increasingly urgent, given significant racial and ethnic inequities in the diagnosis and treatment of kidney disease worsened by the COVID-19 pandemic and socioeconomic depravation.
Screening efforts
Current evidence supports testing individuals with diabetes, hypertension and other conditions, as recommended by clinical practice guidelines from the American Diabetes Association, the Kidney Diseases Improving Global Outcomes and the Kidney Disease Outcomes Quality Initiative. The major barrier in the United States is the limited use of the quantitative urine albumin-creatinine ratio (uACR), with annual testing rates of approximately 40% for diabetes and less than 10% for hypertension in national data, supporting the need for interventions to improve targeted albuminuria testing.
The absence of a current CKD screening recommendation contributes to the low rates of testing and, in turn, suboptimal CKD diagnosis in the primary care setting.
Kidney Care for All
This year’s World Kidney Day theme was Kidney Care for All. More than 90% of Americans are unaware they have kidney disease. Health services research and the United States Renal Data System show Americans with CKD have more than 50% uncontrolled diabetes and hypertension, low rates of disease-modifying medication use, suboptimal interdisciplinary care and 80% hemodialysis catheter use at dialysis initiation.
Kidney health inequities by race and ethnicity have been documented since the 1980s. For example, African American individuals are three to four times more likely than white individuals to experience kidney failure, even though white individuals are more likely to have diabetes and hypertension.
Hispanic, Asian, Hawaiian, Pacific Islander and American Indian individuals also have documented kidney health disparities with nuances across the groups. Americans living with kidney failure have low rates of preemptive and early kidney transplantation and low access to home dialysis, particularly among socioeconomically disadvantaged populations.
Randomized trials have demonstrated kidney and cardiovascular protection using new CKD therapeutics that increase the potential outcome and cost benefits of CKD diagnosis. Overwhelming evidence from CREDENCE, DAPA-CKD and other trials shows the SGLT2 inhibitor drug class has efficacy in slowing CKD progression and reducing risk of cardiovascular events, particularly heart failure hospitalization in patients with CKD and type-2 diabetes mellitus (T2DM), as well as those without diabetes.
CVD progression
In addition to kidney protection, there are several interventions that do not necessarily modify CKD progression, but reduce risk of CVD, including statin-based therapies and the glucagon-like peptide receptor agonists (GLP-1RA) drug class for T2DM.
Finally, prioritizing the development of a USPSTF CKD screening recommendation is foundational to achieving health equity. In September 2021, the NKF-American Society of Nephrology Task Force on Reassessing the Inclusion of Race in Diagnosing Kidney Diseases recommended the adoption of a new race-free Chronic Kidney Disease Epidemiology Collaboration 2021 creatinine equation to estimate kidney function.
The aim of the new equation was to minimize potential consequences that disproportionately affect any one group of individuals. Removing race correction from clinical algorithms is important to society to avoid implying a biologic cause for race, which is a social construct.
The evidence-base supporting targeted screening in high-risk populations has grown since 2012, tipping the scales in favor of the USPSTF to revisit the recommendation.
For more information about World Kidney Day, visit www.worldkidneyday.org.
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Joseph A. Vassalotti, MD, is the chief medical officer for the NKF and a clinical professor at the Icahn School of Medicine at Mount Sinai Hospital, New York.
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