THE PLOT THICKENS: KIDNEY TESTING REVISED

“The National Kidney Foundation (NKF) and the Renal Physicians Association (RPA) recommend that healthcare professionals test patients in specific high risk groups for chronic kidney disease (CKD) – particularly those with diabetes or high blood pressure--as a cost effective strategy for delaying disease progression and reducing complications.
A new guideline issued last week by the American College of Physicians (ACP) discourages routine testing for kidney disease in asymptomatic individuals with no risk factors. The National Kidney Foundation and the Renal Physicians Association are in agreement with the ACP that screening is not necessary for the general population without risk conditions.
"There is little or no evidence to suggest that screening people without symptoms or risk factors is beneficial. In addition, mass screening will increase false positive test results, which in turn will lead to unnecessary concerns, additional tests, and excess costs. However, screening risk groups is recommended by the NKF and RPA, particularly those with diabetes and/or hypertension. Screening for CKD in these risk groups was shown to be cost effective in a recent analysis," said Joseph Vassalotti, MD, National Kidney Foundation's Chief Medical Officer. ”
As we discussed last week, 2 major physicians groups, the American Society of Nephrology (ASN) and the American College of Physicians, (ACP) were involved in a debate that affects all members of the public as well as people that have a great potential to develop kidney disease. As you will recall, the ACA issued a statement that against screening for Chronic Kidney Disease in adults without symptoms and without a history of renal failure. The ACP also recommended that testing for excess protein in your blood in both asymptomatic and diabetic patients be discontinued, despite the fact that this is usually a first line indicator of kidney failure. This conflict has generated a storm of responses in the press, with the ASN calling the statement “irresponsible” and confirmed that it “strongly recommends” regular screening for kidney disease, regardless of an individual's risk factors . The ASN went on to say the guideline committee of the ACP based this recommendation, on weak with low-quality evidence . As one commentator put it, “The fact that it is a weak recommendation will be lost on insurer's who would pay for the screening. ”
The key to the ASN’s statement is that Chronic Kidney Disease (CKD) screening is simple and inexpensive but has the potential to improve and save countless lives by detecting early disease. The ASN notes that several of the ACP's recommendations reflect current clinical practice. However, the ASN disagrees with the ACP's recommendation against screening for CKD in asymptomatic adults without risk factors:
"Early detection is the key to preventing patients from progressing to relying on dialysis to stay alive," said ASN Executive Director Tod Ibrahim in the ASN news release. "ASN and its nearly 15,000 members — all of whom are experts in kidney disease — are disappointed by ACP's irresponsible recommendation. "
Concerning the ACP’s recommendation to forego testing for proteinuria in adults with or without diabetes who were being treated with either an angiotensin-converting enzyme inhibitor or an angiotensin receptor blocker, the ASN disagreed, stressing the importance of testing renal health in adults receiving antihypertensive medications because high blood pressure and diabetes are the 2 leading risk factors for developing CKD. According to the Centers for Disease Control and Prevention, more than 1 in 5 hypertensive persons older than 20 years has CKD. Furthermore, US prevalence of diabetes exceeds 25 million, and nearly 180,000 persons have renal failure secondary to diabetes:
"While acknowledging the need for further and larger scale clinical research into CKD and how the disease progresses in its early stages, ASN believes current evidence strongly supports the value of early detection of, and screening for, chronic kidney disease," the society's statement concludes. ”
The ASN’s President summed it up best:
“If detected early in its progression, kidney disease can be slowed and the transition to dialysis delayed. This evidence-based fact is why regular screening and early intervention by a nephrologist is so important to stemming the epidemic of kidney disease in the United States and why ASN strongly recommends it,.. This vicious cycle must be stopped. " said ASN President Bruce A. Molitoris, MD, FASN. (Emphasis added).
I saw a video recently of a Dr. Peter McCullough, speaking from the 2013 National Kidney Foundation meeting in Orlando. He is a cardiologist from the St. John Providence Health System in Detroit who specializes in CKD shared his thoughts on why patients should screen for CKD based on information gathered from the NKF KEEP program. He stated that the KEEP program had screened over 165,000 people in 12 years and that in the process of screening they had learned the following:
• Of the population with high blood pressure, diabetes or history of kidney disease in their family, 25% of this group will develop kidney disease to the extent of suffering from End Stage Renal Disease(ESRD) or kidney failure;
• Of this group, the diagnosis of kidney failure comes as a total & complete surprise 80% of the time;
• The incidence of CKD in the general population is high coupled with a high unawareness of CKD;
• Knowledge obtained from simple tests for CKD can make a remarkable difference in the quality of life by simple medication adjustments, avoiding other meds, avoidance of additional kidney insults, including taking ibuprofen & avoiding contrast based studies;
• Early screening, detection and protection provide the basis for easier renal replacement therapy (dialysis or transplant);
• It lessens the complications of ESRD and dialysis;
• CKD is a disease that is easily screened for and detected. Compared to the risks and complications of kidney failure, it is relatively easy to detect, delay or prevent. The screening methods (urine & blood testing) are commonly in place at your family doctor;
• The results of screening, protection and prevention lead to very favorable results.
At the end of the video, there is a poll, where almost 70% of the voters felt that general population screening was necessary.
To add to this controversy, the National Kidney Foundation recently issued the following statement:
“National Kidney Foundation, Renal Physicians Association Urge Screening for those at Risk for Kidney Disease
New York, NY (November 1, 2013) – The National Kidney Foundation (NKF) and the Renal Physicians Association (RPA) recommend that healthcare professionals test patients in specific high risk groups for chronic kidney disease (CKD) – particularly those with diabetes or high blood pressure--as a cost effective strategy for delaying disease progression and reducing complications. (Emphasis added)
A new guideline issued last week by the American College of Physicians (ACP) discourages routine testing for kidney disease in asymptomatic individuals with no risk factors. The National Kidney Foundation and the Renal Physicians Association are in agreement with the ACP that screening is not necessary for the general population without risk conditions. (Emphasis added).
"There is little or no evidence to suggest that screening people without symptoms or risk factors is beneficial. In addition, mass screening will increase false positive test results, which in turn will lead to unnecessary concerns, additional tests, and excess costs. However, screening risk groups is recommended by the NKF and RPA, particularly those with diabetes and/or hypertension. Screening for CKD in these risk groups was shown to be cost effective in a recent analysis," said Joseph Vassalotti, MD, National Kidney Foundation's Chief Medical Officer.
"In addition, NKF and RPA recommend screening for other risk groups to promote early detection and management, including African Americans and at- risk ethnic groups, those age 60 and older and those with family history of kidney failure. CKD detection drives patient awareness and changes management -- that is why testing is so important. Control of hypertension can slow progression or loss of kidney function over time, delaying the onset of kidney failure. Management of CKD also includes a patient safety approach to drug prescription practices for certain medications cleared by the kidneys. Avoiding certain medications and judicious use of iodinated contrast media for imaging can prevent acute kidney injury in those at risk with CKD. Lastly, timely nephrology referral and preparation for dialysis and kidney transplantation are dependent on primary care detection," continued Vassalotti. (Emphasis added).
According to RPA President Robert Kossmann, MD, "Screening those at risk is cost-effective because it can help delay progression of kidney disease for some and properly prepare those who do progress to kidney failure for dialysis and or transplant, resulting in fewer hospitalizations and medical interventions. However, screening those not at risk is unnecessary. Coincident with recent years' CKD screening efforts, the 2013 USRDS has shown a decrease in the number of incident dialysis patients. Our hope is that this represents identification of CKD patients at a point in their disease process that has allowed interventions to prevent or delay ESRD. In a time of escalating healthcare costs, we need to focus on interventions that improve outcomes and make a real difference in people's lives." (Emphasis added).
The ACP's new guideline also advises against testing for high levels of protein in the urine in people with or without diabetes who are taking certain blood pressure drugs, such as an ACE inhibitor or an ARB.
The National Kidney Foundation and Renal Physicians Association differ from the ACP on the above recommendation. NKF and RPA recommend monitoring of proteinuria, or protein in the urine (one of the very earliest signs of kidney damage) at least annually in those with major risk factors such as diabetes, even if they are taking a blood pressure drug. (Emphasis added)
"If proteinuria increases that could be a reason to intensify therapy with one of the kidney- protective blood pressure drugs, ACE inhibitors or ARBs. In addition, if a person has hypertension, severely increased proteinuria may be a reason to consider referral to a kidney specialist for a biopsy to look for a cause of kidney disease other than high blood pressure," said Vassalotti. ”
There’s that word again, costs. Cost efficient. Cost effective. Cost effective strategy. Considering that between 1980 and 2009 the incidence of CKD rose by 600% or from 290 to 1,738 cases per million, I would think costs would be one of the last things considered. That saving lives, making for easier dialysis, and increasing the chance for a transplant would be more important considerations.
This was compounded by a decision made by the National Kidney Foundation recently. This is where the plot thickens. The NKF and a group calling itself the Renal Physicians Associates (RPA) issued a statement, declaring that they agreed with part of the statement by the American College of Physicians, and disagreed in part. The National Kidney Foundation and the Renal Physicians Association are in agreed with the ACP that screening is not necessary for the general population without risk conditions. Both the Chief Medical Officer for the NKF and the President for the RPA cited screening for CKD in only at risk groups as “cost effective” and avoiding “excess costs” as a factor. They did disagree with the ACP on the issue of testing for protein in urine, calling that “a reason to consider referral to a kidney specialist for a biopsy to look for a cause of kidney disease other than high blood pressure. ” This statement of testing only at risk persons carries an inconsistent statement, “Coincident with recent years' CKD screening efforts, the 2013 USRDS has shown a decrease in the number of incident dialysis patients. Our hope is that this represents identification of CKD patients at a point in their disease process that has allowed interventions to prevent or delay ESRD. In a time of escalating healthcare costs, we need to focus on interventions that improve outcomes and make a real difference in people's lives. " (Emphasis added). In other words, the recent emphasis on increased testing, including testing of the asymptomatic is working. This seems inconsistent with the goal of lessoning the impact of escalating cases of kidney disease.
It also seems inconsistent with prior statements by the NKF. Recently, the indicated that 1 in 2 persons could be afflicted with CKD. Further, they tell us that 59% of all Americans will develop kidney disease in their lifetime. They have told us that in the future 135.8 Americans will develop kidney disease in their lifetimes. Most importantly they have told us that 26 million American adults are estimated to have CKD; many do not know it. Early signs are hard to detect and are easily missed. It seems inconsistent with a program called the KEEP Fund (KIDNEY EARLY EVALUATIONS PROGRAM), which from August 2000 and June 2013, emphasized early screening, free testing, detection and prevention of kidney disease. To me, this all adds up to one thing: even if you have no symptoms, early testing and detection can only benefit you, while ignoring the problem has the potential for a life on dialysis, playing the multiple transplant game or even more extreme, death. I just do not see how the benefits of being “cost-effective” should be the deciding factor over a lifetime of pursuing what the medical people call “renal replacement therapy.” I remain your advocate.

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