More on the invisibility of chronic kidney disease… and counting

The impact of population ageing on the burden of chronic kidney disease

The burden of chronic kidney disease (CKD) and its risk factors are projected to rise in parallel with the rapidly ageing global population. By 2050, the prevalence of CKD category G3-G5 may exceed 10% in some regions, resulting in substantial health and economic burdens that will disproportionately affect lower-income countries. The extent to which the CKD epidemic can be mitigated depends largely on the uptake of prevention efforts to address modifiable risk factors, the implementation of cost-effective screening programmes for early detection of CKD in high-risk individuals and widespread access and affordability of new-generation kidney-protective drugs to prevent the development and delay the progression of CKD. Older patients require a multidisciplinary integrated approach to manage their multimorbidity, polypharmacy, high rates of adverse outcomes, mental health, fatigue and other age-related symptoms. In those who progress to kidney failure, comprehensive conservative management should be offered as a viable option during the shared decision-making process to collaboratively determine a treatment approach that respects the values and wishes of the patient. Interventions that maintain or improve quality of life, including pain management and palliative care services when appropriate, should also be made available.

Clinical and Economic Impact of Early Diagnosis of Chronic Kidney Disease in General Practice: The Endorse Study

Introduction

The underdiagnosis of chronic kidney disease (CKD) remains a significant public health concern. The Early chroNic kiDney disease pOint of caRe Screening (ENDORSE) project aimed to evaluate the clinical and economic implications of a targeted training intervention for general practitioners (GPs) to enhance CKD awareness and early diagnosis.

Methods

Data on estimated Glomerular Filtration Rate (eGFR) and Urinary Albumin-Creatinine Ratio (uACR) were collected by 53 Italian GPs from 112,178 patients at baseline and after six months. The intervention involved six months of hybrid training provided by 11 nephrologists, which included formal lectures, instant messaging support, and joint visits for complex cases.

Results

The results demonstrated a substantial increase in the use of eGFR (+44.7%) and uACR (+95.2%) tests. This led to a 128.9% rise in the number of individuals screened for CKD using the KDIGO classification, resulting in a 62% increase in CKD diagnoses. The intervention's impact was particularly notable in high-risk groups, including patients with type 2 diabetes, hypertension, and heart failure.

Discussion

A budget impact analysis projected cumulative five-year savings of €1.7 million for the study cohort. When these findings were extrapolated to the entire Italian CKD population, potential savings were estimated at €106.6 million, highlighting significant cost savings for the national health service. The clinical simulation assumed that early diagnosed CKD patients would be treated according to current indications for dapagliflozin, which slows disease progression.

Conclusion

The ENDORSE model demonstrated that targeted training for GPs can significantly improve early CKD detection, leading to better patient outcomes and considerable economic benefits. This approach shows promise for broader implementation to address the underdiagnosis of CKD on a national and potentially international scale.

Projecting the clinical burden of chronic kidney disease at the patient level (Inside CKD): a microsimulation modelling study

Background

Chronic kidney disease (CKD) is a global concern that presents significant challenges for disease management. Several factors drive CKD prevalence, including primary risk factors, such as type 2 diabetes and hypertension, and an ageing population. Inside CKD is an international initiative that aims to raise awareness of the substantial burden incurred by CKD.

Methods

Using a peer-reviewed microsimulation method, the clinical burden of CKD was estimated from 2022 to 2027. Demographic data from the Americas, Europe, and Asia-Pacific/Middle East were used to generate virtual populations and to project the prevalence of CKD, kidney replacement therapy, associated cardiovascular complications, comorbid conditions, and all-cause mortality in the CKD population over the modelled time frame.

Findings

Across the 31 participating countries/regions, the total prevalence of CKD was projected to rise to 436.6 million cases by 2027 (an increase of 5.8% from 2022), with most cases (∼80%) undiagnosed. Inside CKD projected a mean of 8859 cases of heart failure, 10,244 of myocardial infarction, and 7797 of stroke per 100,000 patients with CKD by 2027.

Interpretation

The clinical impact of CKD is substantial and likely to increase; the high prevalence of undiagnosed cases and associated complications may benefit from the implementation of health policy interventions that promote screening, earlier diagnosis, and interventions to improve outcomes.

Funding

AstraZeneca.

Kidney transplants from elderly donors: what we have learned 20 years after the Crystal City consensus criteria meeting

Based on the current projection of the general population and the combined increase in end-stage kidney disease with age, the number of elderly donors and recipients is increasing, raising crucial questions about how to minimize the discard rate of organs from elderly donors and improve graft and patient outcomes. In 2002, extended criteria donors were the focus of a meeting in Crystal City (VA, USA), with a goal of maximizing the use of organs from deceased donors. Since then, extended criteria donors have progressively contributed to a large number of transplanted grafts worldwide, posing specific issues for allocation systems, recipient management, and therapeutic approaches. This review analyzes what we have learned in the last 20 years about extended criteria donor utilization, the promising innovations in immunosuppressive management, and the molecular pathways involved in the aging process, which constitute potential targets for novel therapies.

Meta-analysis of traditional Chinese medicine on chronic kidney disease

OBJECTIVE

To explore the effect of traditional Chinese medicine (TCM) on the treatment of chronic kidney disease (CKD).

METHODS

Databases were used for literature research until 16 December 2022, including PubMed, Cochrane Library, China National Knowledge Infrastructure (CNKI), and Embase. After full-text screening, data were extracted by two researchers independently. The Cochrane ROB tool was applied for quality assessment. The heterogeneity was tested using the Chi-squared-based Q statistic test and the I2 statistic.

RESULTS

The findings revealed that the use of TCM significantly improved the total effective rate (pooled odds ratio (OR) = 1.35, 95% confidence interval (CI) = [1.15, 1.57]), reduced the serum creatinine (SCr) level (pooled mean difference (MD) = -0.11, 95% CI = [-0.20, -0.03]), and increased the estimated glomerular filtration rate (eGFR, pooled MD = 3.76, 95% CI = [2.66, 4.87]) in patients with CKD, compared with non-TCM treatment. Meanwhile, TCM performed better effect on 24-h proteinuria (pooled MD = 0.17, 95% CI = [0.04, 0.31]) than non-TCM. No significant difference in the incidence of adverse events was found between TCM and non-TCM treatment (pooled OR = 0.63, 95% CI = [0.32, 1.24]). Sensitivity analysis demonstrated the stability of the pooled estimates.

CONCLUSION

TCM has the advantage over non-TCM treatment and is worth popularizing and applying in the prevention and cure of CKD.

PROSPERO REGISTRATION NUMBER

CRD42021279281.

Selective glomerular hypofiltration syndrome

The estimated glomerular filtration rate (eGFR) provides insight into cardiovascular disease (CVD) risk stratification and proactive management. Accumulating evidence suggests that combining eGFR calculated from serum cystatin C (eGFRcys) and from serum creatinine (eGFRcrea) improves CVD risk stratification over eGFRcrea alone. The term selective glomerular hypofiltration syndrome (SGHS) or shrunken pore syndrome has been proposed to define an eGFRcys:eGFRcrea ratio <1, which is hypothesized to result from a reduced glomerular filtration of 5- to 30-kDa molecules as compared with smaller molecules. SGHS may be identified in people with normal or reduced measured GFR, but the prevalence depends on the cut-off value of the eGFRcys:eGFRcrea ratio used, which is not yet standardized. SGHS is strongly associated with increased CVD and mortality risks and it may offer an opportunity to expand our understanding of the mechanisms linking GFR disorders with CVD risk (e.g. an altered plasma proteome), which may guide treatment decisions. However, muscle wasting may also contribute to a reduced eGFRcys:eGFRcrea ratio and there are open questions regarding the pathophysiology of a reduced eGFRcys:eGFRcrea ratio, the reference cut-off values of the ratio to define the syndrome and its clinical implications. We now critically review the SGHS concept, its pathophysiological basis and links to CVD and the potential consequences for clinical practice and propose a research agenda.

Chronic kidney disease: the missing concept in the 2019 EULAR/ERA-EDTA recommendations for lupus nephritis

Chronic kidney disease (CKD) is diagnosed when glomerular filtration rate (GFR) falls below 60 ml/min/1.73 m2 or urinary albumin:creatinine ratio (UACR) reaches ≥30 mg/g, as these two thresholds indicate a higher risk of adverse health outcomes, including cardiovascular mortality. CKD is classified as mild, moderate or severe, based on GFR and UACR values, and the latter two classifications convey a high or very high cardiovascular risk, respectively. Additionally, CKD can be diagnosed based on abnormalities detected by histology or imaging. Lupus nephritis (LN) is a cause of CKD. Despite the high cardiovascular mortality of patients with LN, neither albuminuria nor CKD are discussed in the 2019 European League Against Rheumatism (EULAR)/European Renal Association-European Dialysis and Transplant Association recommendations for the management of LN or the more recent 2022 EULAR recommendations for cardiovascular risk management in rheumatic and musculoskeletal diseases. Indeed, the proteinuria target values discussed in the recommendations may be present in patients with severe CKD and a very high cardiovascular risk who may benefit from guidance detailed in the 2021 European Society of Cardiology guidelines on cardiovascular disease prevention in clinical practice. We propose that the recommendations should move from a conceptual framework of LN as an entity separate from CKD to a framework in which LN is considered a cause of CKD and evidence generated from large CKD trials applies unless demonstrated otherwise.

The Spanish Scientific Societies before the ESC 2021 guidelines on vascular disease prevention: Generalizing the measurement of albuminuria to identify vascular risk and prevent vascular disease

The 2021 guidelines on the prevention of vascular disease (VD) in clinical practice published by the European Society of Cardiology (ESC) and supported by 13 other European scientific societies recognize the key role of screening for chronic kidney disease (CKD) in the prevention of VD. Vascular risk in CKD is categorized based on measurements of estimated glomerular filtration rate (eGFR) and urine albumin to creatinine ratio (ACR). Thus, moderate CKD is associated with a high vascular risk and severe CKD with a very high vascular risk requiring therapeutic action, and there is no need to apply other vascular risk scores when vascular risk is already very high due to CKD. Moreover, the ESC indicates that vascular risk assessment and the subsequent decision algorithm should start with measurement of eGFR and ACR. To optimize the implementation of the ESC 2021 guidelines on the prevention of CVD in Spain, we consider that: 1) Urine testing for albuminuria using ACR should be part of the clinical routine at the same level as blood glucose, cholesterolemia, and GFR estimation when these are used to make decisions on CVD risk. 2) Spanish public and private health services should have the necessary means and resources to optimally implement the ESC 2021 guidelines for the prevention of CVD in Spain, including ACR testing.

Prevention of cardiorenal damage: importance of albuminuria

Chronic kidney disease (CKD) is projected to become a leading global cause of death by 2040, and its early detection is critical for effective and timely management. The current definition of CKD identifies only advanced stages, when kidney injury has already destroyed &gt;50% of functioning kidney mass as reflected by an estimated glomerular filtration rate &lt;60 mL/min/1.73 m2 or a urinary albumin/creatinine ratio &gt;six-fold higher than physiological levels (i.e. &gt; 30 mg/g). An elevated urinary albumin-excretion rate is a known early predictor of future cardiovascular events. There is thus a ‘blind spot’ in the detection of CKD, when kidney injury is present but is undetectable by current diagnostic criteria, and no intervention is made before renal and cardiovascular damage occurs. The present review discusses the CKD ‘blind spot’ concept and how it may facilitate a holistic approach to CKD and cardiovascular disease prevention and implement the call for albuminuria screening implicit in current guidelines. Cardiorenal risk associated with albuminuria in the high-normal range, novel genetic and biochemical markers of elevated cardiorenal risk, and the role of heart and kidney protective drugs evaluated in recent clinical trials are also discussed. As albuminuria is a major risk factor for cardiovascular and renal disease, starting from levels not yet considered in the definition of CKD, the implementation of opportunistic or systematic albuminuria screening and therapy, possibly complemented with novel early biomarkers, has the potential to improve cardiorenal outcomes and mitigate the dismal 2040 projections for CKD and related cardiovascular burden.

Timed-averaged blood pressure showed a J-curve association with stroke in elderly chronic kidney disease patients

BACKGROUND

The risk factors for stroke in elderly patients with chronic kidney disease (CKD) are not well understood. This study aimed to explore the influence of systolic blood pressure (SBP) on the risk of stroke in a large cohort of elderly patients with stage 3-5 CKD.

METHODS

We retrospectively identified 665 patients hospitalized in Beijing Friendship Hospital from January 2000 to December 2021. Patients were followed up until the occurrence of stroke or death. Multivariate logistic regression analysis and Cox proportional hazard models were used to analyze the risk factors for stroke according to the presence or absence of CKD. The association between CKD and stroke was further evaluated regarding the role of SBP in the hypertensive population.

RESULTS

In individuals with CKD, a J-shaped relationship was observed between SBP levels and the risk of stroke. Participants with CKD and an SBP less than 125 mmHg had a significantly higher cumulative stroke survival rate than those whose SBP was between 125 and 139 mmHg. The cumulative stroke survival rate increased progressively for those with SBP higher than 140 mmHg. This J-shaped relationship was not found in patients without CKD.

CONCLUSION

In elderly patients with CKD, those with the lowest BP are at increased risk for incident stroke. This phenomenon could be different from that in the general population.

A focus on CKD reporting and inappropriate prescribing among older patients discharged from geriatric and nephrology units throughout Italy: A nationwide multicenter retrospective cross-sectional study

Older hospitalized patients with chronic kidney disease (CKD) are part of the geriatric population with a substantial risk of potentially inappropriate medication (PIM) use. The high rates of multimorbidity and polypharmacy, along with the progressive decline of eGFR, contribute to increasing the risk of drug–drug and drug–disease interactions, overdosing, and adverse drug reactions (ADRs). In this multicenter cross-sectional study, we aimed to evaluate the prevalence of CKD under-reporting and PIMs among older patients discharged from acute geriatric and nephrology units throughout Italy. Renal function was determined by estimated glomerular filtration rate (eGFR) through the Berlin Initiative Study (BIS) equation; the prevalence of PIMs was calculated by revising drug prescriptions at discharge according to STOPP criteria, Beers criteria, and summaries of product characteristics (smPCs). A descriptive analysis was performed to compare the clinical and pharmacological characteristics of patients in the two distinct settings; univariate and multivariate logistic regression models were performed to explore factors associated with CKD under-reporting in the discharge report forms and PIM prevalence. Overall, the study population consisted of 2,057 patients, aged 83 (77–89) years, more commonly women, with a median of seven (5–10) drugs prescribed at discharge. CKD under-reporting was present in 50.8% of the study population, with higher rates in geriatric vs. nephrology units (71.1% vs. 10.2%, p < 0.001). 18.5% of the study population was discharged with at least one renally inappropriate medication; factors associated with at least one contraindicated drug at discharge were the number of drugs (PR 1.09, 95% CI 1.14–1.19); atrial fibrillation (PR 1.35, 95% CI 1.01–1.81); diabetes (PR 1.61, 95% CI 1.21–2.13); being hospitalized in nephrology units (PR 1.62, 95% CI 1.14–2.31), CKD stage 3b (PR 2.35, 95% CI 1.34–4.13), and stage 4–5 (PR 14.01, 95% CI 7.36–26.72). Conversely, CKD under-reporting was not associated with the outcome. In summary, CKD under-reporting and inappropriate medication use were common in older patients discharged from hospital; the relatively high number of PIMs in both nephrology and geriatric settings underlines the need to improve appropriate prescribing during hospital stay and to decrease the risk of ADRs and side effects in this highly vulnerable population.

Benchmarking CKD: incidence of CKD in a European country with low prevalence of CKD and kidney replacement therapy

Iceland was one of six European countries with an adjusted incidence of kidney replacement therapy (KRT) in 2018 lower than 100 per million persons (pmp), along with Estonia, Montenegro, Russia, Serbia and Finland. It was also one of 10 countries with an adjusted KRT prevalence <900 pmp. Furthermore, the prevalence of chronic kidney disease (CKD) in Iceland is up to 2.44-fold lower and the death rate from CKD up to 3.44-fold lower than in other countries with a low incidence of KRT, suggesting that the low KRT incidence actually reflects a low need for KRT rather than low uptake or availability of KRT. This identifies Iceland as a benchmark for countries trying to reduce KRT incidence. Iceland also represents one of the best genetically characterized populations in the world, facilitating studies on the influence of the genetic background versus environment and lifestyle on CKD. This issue of CKJ reports the incidence and risk factors for CKD in Icelandic adults. Diabetes, acute kidney injury, hypertension, cardiovascular disease, chronic lung disease, malignancy and major psychiatric illness were associated with an increased risk of incident CKD, as were obesity and sleep apnea in women. However, in 75% of incident CKD cases, CKD was first detected in category G3 or higher, emphasizing the need for new tools that allow an earlier diagnosis of CKD that precedes the loss of >50% of the functioning kidney mass and/or wider use of albuminuria as a screening tool. The European Society of Cardiology just recommended assessing albuminuria for routine cardiovascular risk workups for all.