Chronic Kidney Disease: Detection and Evaluation
Am Fam Physician. 2017 Dec 15;96(12):776-783.
Patient information: See related handout on chronic kidney disease, written by the authors of this article.
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Chronic kidney disease affects 47 million people in the United States and is associated with significant health care costs, morbidity, and mortality. Because this disease can silently progress to advanced stages, early detection is critical for initiating timely interventions. Multiple guidelines recommend at least annual screening with serum creatinine, urine albumin/creatinine ratio, and urinalysis for patients with risk factors, particularly diabetes mellitus, hypertension, and a history of cardiovascular disease. The U.S. Preventive Services Task Force found insufficient evidence to assess the balance of benefits and harms of screening for chronic kidney disease in the general population, and the American College of Physicians recommends against screening asymptomatic adults without risk factors. Persistently elevated serum creatinine and albuminuria are diagnostic and prognostic hallmarks of chronic kidney disease. Lower levels of albuminuria are associated with adverse renal and cardiovascular outcomes. Serum cystatin C is a novel biomarker that is most useful when a false-positive decreased estimated glomerular filtration rate calculated from serum creatinine is suspected. New guidelines incorporate albuminuria into the classification framework for chronic kidney disease and elaborate on identification of the disease, the frequency of follow-up, and recommendations for nephrology referral. Nephrology consultation is indicated for patients with an estimated glomerular filtration rate less than 30 mL per minute per 1.73 m2, persistent urine albumin/creatinine ratio greater than 300 mg per g or urine protein/creatinine ratio greater than 500 mg per g, or if there is evidence of a rapid loss of kidney function. A multidisciplinary approach between primary care physicians, nephrologists, and other subspecialists for implementing early interventions, providing education, and planning for advanced renal disease is key for effective management.
Chronic kidney disease (CKD) is a major public health concern that affects approximately 47 million persons in the United States, or 14.8% of the U.S. adult population.1 It is associated with significant health care costs, morbidity, and mortality.1,2 The presence of CKD increases the risk of hospitalization, cardiovascular events, and death.3,4 Recent data show that the prevalence of CKD has largely stabilized since 2004, possibly because of better awareness and treatment of obesity, hypertension, and diabetes mellitus.5 A 2014 report showed that Medicare spending for patients with CKD was more than $52 billion, which represents 20% of all Medicare costs.6 The per-person per-year Medicare expense for CKD rises with increasing disease severity, ranging from $1,700 for stage 2 to $12,700 for stage 4, with costs rising exponentially in end-stage renal disease.2,6 Thus, early detection of CKD is critical to slow disease progression, prevent long-term morbidity and mortality, and decrease health care spending. The 2012 Kidney Disease: Improving Global Outcomes (KDIGO) Work Group published updated guidelines on the detection, evaluation, classification, and management of CKD.7 This article reviews current recommendations for the primary care physician.
SORT: KEY RECOMMENDATIONS FOR PRACTICE
|Clinical recommendation||Evidence rating||References|
The initial evaluation of GFR should include measurement of serum creatinine and estimation of the GFR using a creatinine-based equation.
An early morning spot urine albumin/creatinine ratio is the preferred initial test to measure proteinuria in patients undergoing CKD evaluation.
Serum cystatin C should be measured to determine whether decreased GFR represents a false positive in patients who have elevated serum creatinine levels, but no known CKD, no risk factors for CKD, and no albuminuria.
CKD should be classified using the estimated GFR and the degree of albuminuria.
Patients with CKD should have serum hemoglobin measured at least annually, and more often depending on the severity of CKD.
Routine evaluation of bone density should not be performed in patients with an estimated GFR < 45 mL per minute per 1.73 m2 because results may be inaccurate.
The evaluation of patients with stage 3a to 5 CKD (estimated GFR < 45 mL per minute per 1.73 m2) should include measurement of serum calcium, phosphorus, parathyroid hormone, alkaline phosphatase, and 25-hydroxyvitamin D levels.
CKD = chronic kidney disease; GFR = glomerular filtration rate.
A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to http://www.aafp.org/afpsort.
SORT: KEY RECOMMENDATIONS FOR PRACTICE
|Clinical recommendation||Evidence rating||References|
REFERENCESshow all references
1. United States Renal Data System. 2016 Annual data report, chapter 1: CKD in the general population. https://www.usrds.org/2016/view/v1_01.aspx. Accessed January 20, 2017....
2. Honeycutt AA, Segel JE, Zhuo X, Hoerger TJ, Imai K, Williams D. . Medical costs of CKD in the Medicare population J Am Soc Nephrol. 2013;24(9):1478–1483.
3. Townsend RR. Stroke in chronic kidney disease: prevention and management. Clin J Am Soc Nephrol. 2008;3(suppl 1):S11–S16.
4. Go AS, Chertow GM, Fan D, McCulloch CE, Hsu CY. Chronic kidney disease and the risks of death, cardiovascular events, and hospitalization [published correction appears in N Engl J Med 2008;18(4):4]. N Engl J Med. 2004;351(13):1296–1305.
5. Murphy D, McCulloch CE, Lin F, et al.; Centers for Disease Control and Prevention Chronic Kidney Disease Surveillance Team. Trends in prevalence of chronic kidney disease in the United States. Ann Intern Med. 2016;165(7):473–481.
6. United States Renal Data System. 2016 Annual Data Report. Vol 1, Ch 6: Medicare expenditures for persons with CKD. https://www.usrds.org/2016/view/v1_06.aspx. Accessed January 21, 2017.
7. Kidney Disease: Improving Global Outcomes (KDIGO) CKD Work Group. KDIGO 2012 clinical practice guideline for the evaluation and management of chronic kidney disease. Kidney Int Suppl. 2013;3(1): 1–150.
8. Giatras I, Lau J, Levey AS; Angiotensin-Converting-Enzyme Inhibition and Progressive Renal Disease Study Group. Effect of angiotensin-converting enzyme inhibitors on the progression of nondiabetic renal disease: a meta-analysis of randomized trials. Ann Intern Med. 1997;127(5):337–345.
9. Pereira BJ. Optimization of pre-ESRD care: the key to improved dialysis outcomes. Kidney Int. 2000;57(1):351–365.
10. Centers for Disease Control and Prevention. Chronic kidney disease (CKD) surveillance system. https://nccd.cdc.gov/CKD/data.aspx. Accessed January 20, 2017.
11. American Diabetes Association. 3. Comprehensive medical evaluation and assessment of comorbidities [published correction appears in Diabetes Care. 2017;40(7):985]. Diabetes Care. 2017;40(suppl 1):S25–S32.
12. Moyer VA; U.S. Preventive Services Task Force. Screening for chronic kidney disease: U.S. Preventive Services Task Force recommendation statement. Ann Intern Med. 2012;157(8):567–570.
13. Qaseem A, Hopkins RH Jr, Sweet DE, Starkey M, Shekelle P; Clinical Guidelines Committee of the American College of Physicians. Screening, monitoring, and treatment of stage 1 to 3 chronic kidney disease: a clinical practice guideline from the American College of Physicians. Ann Intern Med. 2013;159(12):835–847.
14. American Academy of Family Physicians. Clinical practice guideline: chronic kidney disease. http://www.aafp.org/patient-care/clinical-recommendations/all/chronic-kidney-disease.html. Accessed October 26, 2017.
15. Chau K, Hutton H, Levin A. Laboratory assessment of kidney disease: glomerular filtration rate, urinalysis, and proteinuria. In: Skorecki K, et al., eds. Brenner & Rector's The Kidney. 10th ed. Philadelphia, Pa.: Elsevier; 2016:780–803.
16. Fan L, Inker LA, Rossert J, et al. Glomerular filtration rate estimation using cystatin C alone or combined with creatinine as a confirmatory test. Nephrol Dial Transplant. 2014;29(6):1195–1203.
17. Ninomiya T, Perkovic V, de Galan BE, et al.; ADVANCE Collaborative Group. Albuminuria and kidney function independently predict cardiovascular and renal outcomes in diabetes. J Am Soc Nephrol. 2009;20(8):1813–1821.
18. Cockcroft DW, Gault MH. Prediction of creatinine clearance from serum creatinine. Nephron. 1976;16(1):31–41.
19. Levey AS, Bosch JP, Lewis JB, Greene T, Rogers N, Roth D; Modification of Diet in Renal Disease Study Group. A more accurate method to estimate glomerular filtration rate from serum creatinine: a new prediction equation. Ann Intern Med. 1999;130(6):461–470.
20. Levey AS, Stevens LA, Schmid CH, et al.; CKD-EPI (Chronic Kidney Disease Epidemiology Collaboration). A new equation to estimate glomerular filtration rate [published correction appears in Ann Intern Med 2011;155(6):408]. Ann Intern Med. 2009;150(9):604–612.
21. Baumgarten M, Gehr T. Chronic kidney disease: detection and evaluation. Am Fam Physician. 2011;84(10):1138–1148.
22. National Kidney Foundation. K/DOQI clinical practice guidelines for chronic kidney disease: evaluation, classification, and stratification. Am J Kidney Dis. 2002;39(2 suppl 1):S1–S266.
23. National Kidney Foundation. KDOQI clinical practice guideline for diabetes and CKD: 2012 update [published correction appears in Am J Kidney Dis. 2013;61(6):1049]. Am J Kidney Dis. 2012;60(5):850–886.
24. Stevens LA, Coresh J, Schmid CH, et al. Estimating GFR using serum cystatin C alone and in combination with serum creatinine: a pooled analysis of 3,418 individuals with CKD. Am J Kidney Dis. 2008;51(3):395–406.
25. Inker LA, Schmid CH, Tighiouart H, et al.; CKD-EPI Investigators. Estimating glomerular filtration rate from serum creatinine and cystatin C [published corrections appear in N Engl J Med. 2012;367(7):681, and N Engl J Med. 2012;367(21):2060]. N Engl J Med. 2012;367(1):20–29.
26. Barr EL, Reutens A, Magliano DJ, et al. Cystatin C estimated glomerular filtration rate and all-cause and cardiovascular disease mortality risk in the general population: AusDiab study. Nephrology (Carlton). 2017; 22(3):243–250.
27. Tangri N, Grams ME, Levey AS, et al.; CKD Prognosis Consortium. Multinational assessment of accuracy of equations for predicting risk of kidney failure: a meta-analysis [published correction appears in JAMA. 2016;315(8):822]. JAMA. 2016;315(2):164–174.
28. Hillege HL, Fidler V, Diercks GF, et al.; Prevention of Renal and Vascular End Stage Disease (PREVEND) Study Group. Urinary albumin excretion predicts cardiovascular and noncardiovascular mortality in general population. Circulation. 2002;106(14):1777–1782.
29. Astor BC, Matsushita K, Gansevoort RT, et al.; Chronic Kidney Disease Prognosis Consortium. Lower estimated glomerular filtration rate and higher albuminuria are associated with mortality and end-stage renal disease. A collaborative meta-analysis of kidney disease population cohorts. Kidney Int. 2011;79(12):1331–1340.
30. Moghazi S, Jones E, Schroepple J, et al. Correlation of renal histopathology with sonographic findings. Kidney Int. 2005;67(4):1515–1520.
31. Kidney Disease: Improving Global Outcomes (KDIGO) Lipid Work Group. KDIGO clinical practice guideline for lipid management in chronic kidney disease. Kidney Int Suppl. 2013;3(3):259–305.
32. Kidney Disease: Improving Global Outcomes (KDIGO) Anemia Work Group. KDIGO clinical practice guideline for anemia in chronic kidney disease. Kidney Int Suppl. 2012;2(4):279–335.
33. Kidney Disease: Improving Global Outcomes (KDIGO) CKD-MBD Update Work Group. KDIGO 2017 clinical practice guideline update for the diagnosis, evaluation, prevention, and treatment of chronic kidney disease–mineral and bone disorder (CKD-MBD). Kidney Int Suppl. 2017;7(1):1–59.
34. Kidney Disease: Improving Global Outcomes (KDIGO) Acute Kidney Injury Work Group. KDIGO clinical practice guideline for acute kidney injury. Kidney Int Suppl. 2012;2(1):1–138.
35. Snyder S, Pendergraph B. Detection and evaluation of chronic kidney disease. Am Fam Physician. 2005;72(9):1723–1732.
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