How to manage discrepancy between diagnosed and prevalent Chronic Kidney Disease (CKD)?

Managing Discrepancy Between Diagnosed and Prevalent Chronic Kidney Disease

To address the discrepancy between diagnosed and prevalent CKD, implement systematic screening of high-risk populations and establish confirmatory testing protocols to ensure all cases are properly identified and treated early. 1

Understanding the Problem

The gap between diagnosed and prevalent CKD represents a significant public health challenge. Current data shows that CKD is substantially underdiagnosed, with less than half of patients with type 2 diabetes being screened for albuminuria in a typical year in the US 1. This underdiagnosis leads to missed opportunities for early intervention that could prevent disease progression and reduce complications.

Systematic Approach to Closing the Gap

1. Targeted Screening Protocols

Implement systematic screening for specific high-risk populations:

• Diabetes patients:

  • Type 1 diabetes: Annual screening starting 5 years after diagnosis
  • Type 2 diabetes: Annual screening starting at diagnosis 1

• Other high-risk groups:

  • Hypertension
  • Cardiovascular disease
  • Family history of kidney disease 1

2. Comprehensive Testing Methodology

• Required tests:

  • Estimated glomerular filtration rate (eGFR)
  • Urine albumin-to-creatinine ratio (UACR) 1

• Enhanced precision:

  • Consider adding cystatin C measurement to improve GFR estimation accuracy, especially in patients where creatinine-based estimates may be inaccurate (e.g., abnormal muscle mass) 1
  • Use the 2021 CKD-EPI equation without race coefficient for more equitable assessment 1

3. Confirmation Protocol

CKD diagnosis requires persistence of abnormalities for at least 3 months:

• Repeat abnormal tests to confirm findings
• Evaluate temporary causes of abnormalities (e.g., urinary tract infection, acute illness)
• Document persistence of either:
  • eGFR <60 mL/min/1.73 m²
  • UACR ≥30 mg/g
  • Other evidence of kidney damage 1

4. Addressing System-Level Barriers

Several barriers must be overcome to close the diagnosis gap:

• Provider level:

  • Implement clinical decision support tools
  • Create standardized order sets (e.g., "kidney profile" with both eGFR and UACR)
  • Provide education on CKD guidelines and interpretation of results 1

• System level:

  • Utilize point-of-care testing in underserved areas
  • Leverage community pharmacies for screening
  • Implement quality measures tied to CKD screening 1

• Patient level:

  • Improve patient education about kidney disease
  • Address financial barriers to testing
  • Provide culturally appropriate educational materials 1

Implementation Strategy

1. Leverage electronic health records:

   • Create automatic alerts for high-risk patients due for screening
   • Implement standing orders for annual kidney function testing in diabetes patients

2. Standardize diagnostic criteria:

   • Use consistent definitions across healthcare systems
   • Ensure proper documentation of CKD diagnosis when criteria are met

3. Establish follow-up protocols:

   • Create registries of patients with abnormal results requiring confirmation
   • Implement systematic recall systems for patients needing repeat testing

4. Initiate early treatment:

   • Start evidence-based interventions immediately upon diagnosis
   • Focus on RAAS blockade, SGLT2 inhibitors, and other kidney-protective therapies 1

Common Pitfalls to Avoid

1. Relying solely on eGFR without albuminuria testing:

   • Both measurements are essential for proper CKD diagnosis and staging
   • Many patients with normal eGFR have albuminuria indicating early kidney damage 1

2. Failure to confirm abnormal results:

   • Single abnormal tests can be misleading
   • Confirmation over 3 months is required for diagnosis 1

3. Missing non-diabetic kidney disease:

   • Consider alternative diagnoses when:
     • Type 1 diabetes duration <5 years
     • Active urine sediment
     • Rapidly declining eGFR
     • Absence of retinopathy in type 1 diabetes 1

4. Delayed specialist referral:

   • Refer to nephrology when:
     • eGFR <30 mL/min/1.73 m²
     • Continuously increasing albuminuria
     • Continuously decreasing eGFR 1

By implementing this systematic approach to CKD detection and confirmation, healthcare systems can significantly reduce the gap between diagnosed and prevalent CKD, leading to earlier intervention and improved outcomes for patients.