Latest data suggest commonly used CKD definition inflates burden of disease
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The diagnostic criteria for chronic kidney disease that uses the standard estimated glomerular filtration rate threshold of 60 mL/min/1.73 m2 regardless of one’s age may lead to overdiagnosis, researchers wrote.
Ping Liu, PhD, a postdoctoral scholar in the department of medicine at the University of Calgary in Alberta, Canada, and colleagues found that older patients with an estimated glomerular filtration rate (eGFR) below the standard threshold were more than 900 times “likely to die than to develop kidney failure with older age.”
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The National Institute of Diabetes and Digestive and Kidney Diseases, American Society of Nephrology and Kidney Disease: Improving Global Outcomes all use the threshold of an eGFR 60mL/min/1.73 m2 or lower to diagnose chronic kidney disease (CKD), according to the organizations.
Liu and colleagues conducted a population-based cohort study to compare outcomes among 127,132 adults diagnosed with incident CKD as defined by the standard eGFR threshold of 60mL/min/1.73 m2 or lower (fixed-threshold cohort) and 81,209 adults with incident CKD diagnosed via an age-adapted threshold of 75 mL/min/1.73 m2, 60 mL/min/1.73 m2 and 45 mL/min/1.73 m2 for adults aged younger than 40 years, between 40 to 64 years and 65 years or older (age-adjusted cohort). The study participants were mostly white, and all were followed for a maximum of 10 years.
Liu and colleagues wrote that for every 100,000 person years, there were 537 new cases of CKD in the fixed-threshold cohort and 343 new CKD cases among the age-adapted cohort. The fixed-threshold cohort also had lower risks for kidney failure (1.7% vs. 3%) and death (21.9% vs. 25.4%) at 5 years than the age-adapted cohort. There were 54,342 adults in the fixed-threshold group who were aged older than 65 years and had baseline eGFR of 45 to 59 mL/min/1.73 m2 with normal to mild albuminuria, according to the researchers. Among them, 74.7% were aged 65 years or older and had a baseline eGFR of 45 mL/min/1.73 m2 to 59 mL/min/1.73 m2 with normal to mild albuminuria. These adults “were increasingly more likely to die than to develop kidney failure with older age,” from 69 times for adults aged 65 to 69 years to 122 times for adults aged 70 to 74 years, 279 times for those aged 75 to 79 years and 935 times for those aged 80 years and older.
The results suggest that “the current CKD definition that does not consider age-related eGFR decline may inflate the burden of CKD by classifying many elderly people with normal kidney aging as having a disease,” Liu and colleagues wrote.
In an invited commentary, Ann M. O’Hare, MA, MD, a professor in the division of nephrology at the University of Washington, and colleagues wrote that concerns regarding the overdiagnosis of CKD in older adults have existed for at least a decade.
“This history reminds us of the importance of ensuring that the guideline development process is responsive not only to emerging evidence but to divergent viewpoints, fresh insights and lessons learned when guidelines are applied in real-world clinical settings,” they wrote. “It is time to move beyond a case definition that leads to systematic and widespread overdiagnosis of CKD in older adults.”
References:
Delanaye P, et al. J Am Soc Nephrol. 2019;doi:10.1681/ASN. 2019030238.
Henry Ford Health Systems. Chronic Kidney Disease (CKD) clinical practice recommendations for primary care physicians and healthcare providers. https://www.asn-online.org/education/training/fellows/HFHS_CKD_V6.pdf. Accessed Aug. 27, 2021.
Kidney Disease: Improving Global Outcomes. Chronic Kidney Disease Guidelines. https://kdigo.org/wp-content/uploads/2017/02/KDIGO_2012_CKD_GL.pdf. Accessed Aug. 27, 2021.
Liu P, et al. JAMA Intern Med. 2021;doi:10.1001/jamainternmed.2021.4813.
National Institutes of Diabetes and Digestive and Kidney Diseases. Chronic Kidney Disease Tests & Diagnosis. https://www.niddk.nih.gov/health-information/kidney-disease/chronic-kidney-disease-ckd/tests-diagnosis. Accessed Aug. 27, 2021.
O’Hare AM, et al. JAMA Int Med. 2021;doi:10.1001/jamainternmed.2021.4823.