ASN President's Update. Close the Gap—Time for a Kidney Health Check

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“Doc, I was told I have stage 5 kidney disease. What happened to stages 1 through 4?”

Almost every nephrologist, including myself, has had this heartbreaking and far too common question asked of them by patients receiving their diagnosis of kidney disease for the first time. Even worse: A patient first learns about kidney function coincident with placement of a catheter to initiate urgent dialysis.

Not surprisingly, these diagnoses trigger a mixture of emotions: fear, anxiety, disbelief … anger. It is time we do better.

The first diagnosis of kidney disease as kidney failure is truly a failure—of the system. It should come as no surprise that underserved communities with lack of access to health care services and timely intervention are vastly over-represented in this category.

One decade ago, the US Preventive Services Task Force (USPSTF) reviewed the literature and current knowledge available (at that time) to support population-based screening for chronic kidney disease (CKD). In its summary statement, the task force concluded that no data existed to support a recommendation that intervening early in CKD is beneficial (1).

In 2013, the American College of Physicians (ACP) published its guidelines on screening for kidney diseases in the Annals of Internal Medicine, advising against testing for proteinuria in adults with or without diabetes who are currently taking an angiotensin-converting enzyme inhibitor (ACEi) or an angiotensin II receptor blocker (ARB) (2). Bruce A. Molitoris, MD, FASN, ASN president at the time, responded with an article highlighting the potential dangers, weaknesses, and risks inherent in the recommendations by ACP (3).

Ten years later, in February 2022, USPSTF added “Screening for CKD” to the list of preventive services topics under “active consideration” following nomination and wide support from ASN, the National Kidney Foundation (NKF), other members of the kidney community, and members of Congress (4). Although the task force's decision to re-evaluate its decade-old finding is a hopeful advance for patients and the community, there is no guarantee that CKD screening will be prioritized this year. In its response letter, the task force acknowledged that kidney diseases are a serious public health issue and emphasized that kidney diseases disproportionately affect communities of color but did not indicate a timeline for reconsidering its position.

It is important to recognize that several members of the kidney community have argued against screening of asymptomatic patients, citing studies that identifying CKD does not alter management of patients as long as blood pressure and glucose are controlled (5). Of course, these studies report on those lucky enough—no, those privileged enough—to have access to health care when they received their diagnoses of hypertension or diabetes and who were lucky and privileged enough to receive appropriate treatments. As outlined in the KDIGO (Kidney Disease: Improving Global Outcomes) report, which makes the case for CKD screening in at-risk individuals, the authors point out that the burden of CKD falls on the socially disadvantaged and vulnerable (6).

Furthermore, the studies that do not support screening predate the overwhelming and numerous positive clinical trials demonstrating the power of “flozins” (sodium glucose co-transporter 2 inhibitors [SGLT2i]) to prevent mortality, kidney function decline, and cardiovascular disease in people with kidney diseases, regardless of whether the patient has diabetes (see EMPA-REG and CREDENCE trials) (7). In fact, data from the DAPA-CKD trial were so spectacular that the US Food and Drug Administration (FDA) granted breakthrough status for the use of this SGLT2i in patients with CKD, with or without diabetes—the first time ever for a kidney-targeted therapy. Recently, the flozins have been joined by additional classes of medications, including the nonsteroidal mineralocorticoid receptor antagonists and glucagon-like peptide 1 (GLP1) agonists, which have been added to the ever-growing menu of beneficial kidney treatments (see FIDELIO trial) (Figure 1).

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Timeline: Options for managing chronic kidney disease

Citation: Kidney News 14, 4

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Indeed, the ACP guidelines that recommended against screening for proteinuria in patients with diabetes and CKD (i.e., diabetic kidney disease [DKD]) contradict more current guidelines from the American Diabetes Association and KDIGO, which recommend SGLT2i and/or finerenone for patients with proteinuria on therapeutic renin-angiotensin system (RAS) blockade. (Please note that ACP's guidelines expired after 10 years and are no longer in effect.) The outdated belief that “early identification of CKD is pointless because we have no therapies” no longer applies.

That is not to say screening of the general population—particularly low-risk individuals—is automatically warranted or that the importance of having USPSTF revisit the issue should be discounted. However, it is hard to imagine that screening the one in three Americans at risk of kidney diseases—so-called “case finding”—is not warranted. The use of creatinine in combination with urine albumin (uACR) measurement in patients at risk formed the basis of the request to USPSTF by ASN, NKF, other members of the kidney community, and members of Congress.

In the United States, a majority of “crash starts” for dialysis in hospitals occur in patients from underserved communities, where social and political determinants of health determine who has access to care and to treatments that can protect the kidneys and save lives. The failure to detect kidney diseases in these populations is yet one more example of pervasive racism in the health care system. How can we do better?

In Canada, the Can-SOLVE CKD Network launched a program to promote kidney health in First Nations communities (8). Kidney Check provides point-of-care testing for kidney function (creatinine and urine protein), hypertension, and diabetes. Built on the central symbol of Meyayawin (getting better), the project is guided by an Elder, with truth and reconciliation recommendations, a diverse and inclusive team, and shared concepts, such as Two-Eyed Seeing, which recognizes that Indigenous and Western knowledge can exist in parallel (9). A single finger-prick blood sample and urine protein analysis on-site provide real-time results and a kidney health plan, tailored to the patient's needs (10).

Similar to at-risk communities in the United States, the First Nations communities are at higher risk of kidney diseases and kidney failure than the general population. In both Canada and the United States, one in every 10 people is estimated to have kidney diseases, whereas in Canadian First Nations communities, that number increases to one in three. In the United States, individuals of Black race or African Americans are almost four times more likely to develop kidney failure than Americans of White race, even though their CKD prevalence is not higher overall—an unacceptable statistic (11).