Screening, monitoring, and treatment of stage 1 to 3 chronic kidney disease.


TO THE EDITOR: I do not agree with Qaseem and colleagues’ (1) recommendation not to screen asymptomatic persons for chronic kidney disease (CKD). Type 2 diabetes and hypertension are the most common conditions causing CKD. Patients with stage 3 CKD and most patients with stage 4 CKD are usually asymptomatic, and CKD can be named a “silent killer.” Chronic kidney disease in asymptomatic persons is detected earliest by measurement of the estimated glomerular filtration rate (eGFR) and urinary albumin–creatinine ratio, preferably done twice on different dates. These simple and inexpensive tests do not harm patients; I believe that the only harm may be financial. Detection of the earlier stages of CKD is vital because this condition can progress to end-stage renal disease (ESRD) without any prior signals. Once CKD is diagnosed, physicians can take necessary steps to reduce progression to ESRD. Qaseem and colleagues’ guideline recommends screening for microvascular complications, including nephropathy, upon diagnosis of type 2 diabetes because these complications may develop at the stage of prediabetes and even a decade before diagnosis of overt type 2 diabetes. I have many patients with type 2 diabetes who already have an eGFR between 30 and 59 mL/min/1.73 m and an albumin excretion rate up to 300 mg/24 h at diagnosis. Nonadherence to treatment leads some of these patients to progress to an eGFR between 15 and 29 mL/min/1.73 m and an albumin excretion rate between 30 and 300 mg/24 h within 2 years. The eGFR can decrease in patients with type 2 diabetes even in the state of normoalbuminuria, which Lane and colleagues (2) first described in 1992. In 2002, NHANES III (Third National Health and Nutrition Examination Survey) showed that the eGFR commonly decreases in normoalbuminuric patients. A decrease in the eGFR (even to 50 to 59 mL/min/1.73 m) leads to an increase in fibroblast growth factor 23 and parathyroid hormone levels, reduced conversion of 25-hydroxyvitamin D to 1,25-dihydroxyvitamin D, and hyperphosphatemia. All of these factors increase the risk for cardiovascular events. NHANES III showed that patients with type 2 diabetes with an eGFR less than 60 mL/ min/1.73 m have a 4-fold higher risk for a cardiovascular event than those with an eGFR less than 90 mL/min/1.73 m. This risk increases 10-fold in those with cardiovascular disease. I strongly believe that all asymptomatic patients with the cardiometabolic syndrome, specifically type 2 diabetes and hypertension, should be screened periodically for CKD by measurement of the eGFR and urinary albumin–creatinine ratio.

DOI: 10.7326/L14-5013

Cite this paper

@article{Dhar2014ScreeningMA, title={Screening, monitoring, and treatment of stage 1 to 3 chronic kidney disease.}, author={Gauranga Chandra Dhar}, journal={Annals of internal medicine}, year={2014}, volume={161 1}, pages={81} }