ACP Guideline Recommends Against CKD Screening

Additional Guidance Covers Other Testing, Pharmacologic Therapies

October 28, 2013 03:31 pm Matt Brown

In its new clinical practice guideline(annals.org), the American College of Physicians (ACP) makes several recommendations, including a recommendation against screening for chronic kidney disease (CKD) in asymptomatic adults without risk factors. The ACP graded the recommendation as weak, however, noting that it is based on low-quality evidence.

"No randomized, controlled trials have evaluated the harms of systematic CKD screening," the ACP said in its recommendation. "Expert opinion suggests that the harms of CKD screening include misclassification of patients owing to false-positive test results, adverse effects of unnecessary testing, psychological effects of being labeled with CKD, adverse events associated with pharmacologic treatment changes after CKD diagnosis, and possible financial ramifications of CKD diagnosis."

Story highlights
  • In its new clinical practice guideline, the American College of Physicians (ACP) recommends against screening for chronic kidney disease (CKD) in asymptomatic adults without risk factors.
  • The ACP also recommends against testing for proteinuria in adults with or without diabetes currently taking an angiotensin-converting enzyme (ACE) inhibitor or an angiotensin II–receptor blocker (ARB).
  • The ACP does recommend that clinicians select pharmacologic therapy that includes either an ACE inhibitor or ARB in patients with hypertension and stage 1 to 3 CKD, as well as choose statin therapy to manage elevated low-density lipoprotein in patients with stage 1 to 3 CKD.

Published Oct. 22 in the Annals of Internal Medicine, the guideline also recommends that clinicians

  • not test for proteinuria in adults with or without diabetes who are currently taking an angiotensin-converting enzyme (ACE) inhibitor or an angiotensin II-receptor blocker (ARB) (weak recommendation; low-quality evidence);
  • select pharmacologic therapy that includes either an ACE inhibitor (moderate-quality evidence) or ARB (high-quality evidence) in patients with hypertension and stage 1 to 3 CKD (strong recommendation); and
  • choose statin therapy to manage elevated LDL in patients with stage 1 to 3 CKD (strong recommendation; moderate-quality evidence).

In their own 2012 recommendations, the AAFP and the U.S. Preventive Services Task Force(www.uspreventiveservicestaskforce.org) (USPSTF) both concluded that the evidence was insufficient to assess the balance of benefits and harms of routine CKD screening in asymptomatic adults.

In August 2012, family physician and USPSTF member Joy Melnikow, M.D., M.P.H., of Sacramento, Calif., told AAFP News Now that the task force's recommendation did not cover testing for and monitoring CKD for the purposes of chronic disease management, including testing and monitoring patients with diabetes or hypertension, which often are associated with CKD.

"This statement refers to the lack of evidence for the practice of getting renal function tests or urinalysis as a routine screening test," Melnikow said at that time. "Obviously, these tests are used frequently in managing symptoms and managing chronic diseases, but that is a different situation."

Doug Campos-Outcalt, M.D., M.P.A., of Phoenix, the AAFP liaison to the USPSTF, said in a recent interview with AAFP News Now that it is not clear whether the AAFP would assess the ACP recommendations for possible endorsement.

"I've not yet had a chance to do a complete review of the evidence report, but that said, the ACP recommendations, on the whole, look to be pretty reasonable," he said. "But given that the USPSTF's 'I' recommendation was revised just last year, I do not think we will be changing our recommendation on screening for chronic kidney disease."

Campos-Outcalt described the other recommendations in the guideline as "sensible."

"These all three align with standard practice," he said. "There are some groups that recommend that you continue to check for proteinuria when you have a patient on an ACE inhibitor or ARB, but I believe the ACP recommendation is a good one."


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