Blog | Thursday, August 1, 2013

QD: News Every Day--CKD guidelines may lead to overdiagnosis, overtreatment

Defining chronic kidney disease (CKD) based on estimated glomerular filtration rate (eGFR) has led to one in eight people being labeled as having the condition. Compare this to the treatment rate of one person for every 3,000 to 5,000 being treated for end-stage renal disease, which had been the very condition that the definition was trying to prevent.

The discrepancy is causing overdiagnosis and overtreatment of people unlikely to ever progress, reviewers said in an analysis published July 30 in BMJ that suggested several ways to handle CKD management with patients:
--share uncertainty about diagnostic thresholds and measurements with patients,
--look for potential evidence of anemia, abnormal urinalysis results, or abnormalities on renal ultrasonography,
--be aware of the variability of results when testing eGFR and albuminuria, and of the need to repeat the tests, soon after the first and again after three months,
--avoid the label of CKD for people aged 65 years and older with eGFR stage 3A and no albuminuria,
--recognize that older people with stable but modestly reduced eGFR of 45-59 ml/min/1.73 m2 are unlikely to have a high risk unless they have persistent overt albuminuria.

Under a 2002 guideline, anyone with an eGFR below 60 ml/min/1.73 m2 for three months or longer could be diagnosed as having chronic kidney disease stage 3A or greater, even if they have no other signs of kidney disease. This definition has resulted in almost 14% of U.S. adults being labeled as having CKD.

The goal had been to capture patients who progressed all the way to end-stage renal disease unchecked, especially in the African-American community, the reviewers wrote. But now a third of the people who meet the new definition of CKD also meet the definition of stage 3A, most older than 65, and many with an eGFR that falls within the normal range (5th to 95th percentile) for their age. About 75% have no urine markers of kidney damage, such as albuminuria.

Reviewers concluded, "A review should be conducted by a panel with broad representation from specialty and primary care, population health, patient organizations, and civil society with minimal conflicts of interest."