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|
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