Policy Update: ASN Encourages USPSTF to Adopt CKD Screening

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Following nearly a decade of advocacy by ASN and other members of the kidney care community for federal support of routine screening to identify kidney diseases and intervene earlier to stop or slow progression, ASN was pleased to comment on the U.S. Preventive Services Task Force's (USPSTF's) Draft Research Plan: Chronic Kidney Disease: Screening (1) on February 15, 2023.

Focused on improving health across the nation, USPSTF offers evidence-based recommendations about clinical preventive services. The release of this draft research plan follows USPSTF's addition of chronic kidney disease (CKD) screening to its list of preventive services under active consideration in 2022. This is not the first time USPSTF has considered the development of screening guidelines for CKD. In 2012, USPSTF released a similar proposed research plan for CKD screening but ultimately recommended against the formation of official guidelines.

The 2023 plan released for public comment included a proposed analytic framework, key and contextual questions, an approach to accessing health equity and variation in evidence across populations, and a research approach. ASN's comments addressed both the individual elements and questions of the research plan. The comments can be grouped into nine areas of top concerns for ASN:

1. Scope of evidence review - The most robust evidence for CKD screening comes from targeting those with CKD risk factors such as hypertension and diabetes. Despite this fact, the current USPSTF proposed research plan excludes studies in which patients were selected due to these preexisting conditions. ASN expressed very strong concern regarding this exclusion and firmly recommended that the research plan be amended to review the existing evidence based around CKD screening in at-risk populations. CKDs are associated with extreme comorbidity across a wide range of conditions. The exclusion of studies that focus on these at-risk populations would lead to an incomplete and misleading assessment of CKD, ASN maintained.

2. Tests used for screening - The proposed research plan lacked clarity regarding which tests would be used to assess CKD. ASN reminded USPSTF that CKD is not merely a number, and ASN strongly recommended that USPSTF evaluate and consider CKD screening using both glomerular filtration rate estimation and proteinuria/albuminuria measurement.

3. CKD stages - ASN recommended that USPSTF add CKD stage 4 to its draft plan since the current plan only included evaluation of CKD stages 1–3. ASN acknowledged that there often is less precision and reliability in diagnosing the earlier stages of CKD and stressed the importance of considering patient preferences when screening for early indication of CKD.

4. Harm and disparities - USPSTF outlined a plan to examine the benefits and harms of CKD screening, specifically in socially disadvantaged and marginalized communities, yet ASN believes there was a lack of clarity regarding the definition of the terms “harm” and “disparities.” ASN drew attention to this issue and encouraged USPSTF to use well-defined terminology during this evaluation. ASN contended that any harms associated with screening are important to consider, but those harms must be properly assessed against the serious and potentially fatal consequences of not detecting and delaying progression of CKD.

5. Education and pharmacological and non-pharmacological interventions - ASN highlighted the fact that the proposed study failed to address patient education and pharmacological and non-pharmacological interventions. Simply identifying a disease is futile, ASN observed, unless it is linked to actions that improve clinical outcomes. Since the last time USPSTF considered CKD screening, kidney care has witnessed a revolution in novel therapeutics for CKD to slow disease progression, including 1) sodium-glucose co-transporter 2 inhibitors, 2) nonsteroidal mineralocorticoid antagonists, and 3) glucagon-like peptide-1 receptor agonists. ASN strongly urged the evidence review to address both pharmacological and non-pharmacological interventions.

6. Access to care - Individuals of at-risk populations often face challenges when it comes to accessing and affording early preventive care. ASN believes that USPSTF and the broader kidney care community need to explore this intersection of screening with access to care.

7. Social determinants of health (SDOHs) - Health systems are increasingly recognizing the importance of screening individuals for adverse SDOHs. ASN recommended that USPSTF's research explore SDOHs and their resulting impact on individuals and the progression of CKD to kidney failure to ensure a more comprehensive approach to its recommendation.

8. COVID-19 - Individuals with kidney diseases and other chronic illnesses are at higher risk of more serious illness and complications from COVID-19. ASN recommended that USPSTF incorporate a review of the potential health benefits for preventing severe COVID-19 illness (along with other serious infections) into its research plan.

9. Study time frame - USPSTF did not define a timeline for the proposed research plan. ASN stressed the importance of an extended timeline to effectively evaluate the potential harms and benefits of CKD screening.

ASN joined 16 members of the Coalition for Kidney Health, including the American Heart Association, the National Kidney Foundation, and the Renal Physicians Association, in a coalition comment letter to USPSTF at the same time (2). The comments and recommendations of both letters were closely aligned.

Kidney care is at an inflection point because of the many advancements made since the USPSTF last considered CKD screening in 2012. ASN advocated that now, more than ever, it is imperative to address kidney diseases through prevention, detection, and management. ASN wholeheartedly commended USPSTF for undertaking this important initiative and stands ready to provide assistance in any way possible. To read ASN's full comments on USPSTF's Draft Research Plan: Chronic Kidney Disease: Screening, please visit the ASN Advocacy and Public Policy home page at https://www.asn-online.org/policy/webdocs/02.15.23.USPSTF.Letter.pdf.