Diagnosing CKD
Explore the diagnosis of chronic kidney disease (CKD) and find:
- Expert interviews with Professor Hiddo Heerspink, Professor Vlado Perkovic and Dr George Bakris on the need for earlier diagnosis of chronic kidney disease and management of comorbidities
- Why early diagnosis of CKD is important to optimal care
- The importance of CKD screening in patients with comorbid conditions such as diabetes and hypertension
- Strategies for CKD diagnosis and screening that may help improve your patient’s quality of life
The need for early chronic kidney disease diagnosis
Professor Vlado Perkovic from Australia stresses that early diagnosis of chronic kidney disease (CKD) is critical to slowing disease progression
Chronic kidney disease (CKD) is a significantly burdensome condition that substantially impacts people around the world through increased morbidity as well as cardiovascular and all-cause mortality1.
As the burden of CKD is immense, highly prevalent, and disproportionately impactful on people of lower socioeconomic status, strategies for identifying and treating CKD at the earliest stages are essential1.
Is chronic kidney disease underdiagnosed?
As CKD is a progressive disease that leads to a gradual loss of kidney function, people living with CKD can be unaware of the disease until it advances to later stages (Figure 1)2. Indeed, up to 82% of people with CKD stage 3 (moderately decreased kidney function) have not received a diagnosis of CKD (Figure 1)3.
Figure 1. Proportion of patients with diagnosed and undiagnosed chronic kidney disease across disease stages in adult patients with type 2 diabetes (Adapted4). aPercentage of study population at each indicated CKD stage. CKD, chronic kidney disease.
Approximately half of people with CKD remain undiagnosed by stage 4–5 when CKD symptoms begin to develop3
Late diagnosis drives up annual healthcare costs from nearly double at stage 2–3, to around four-fold with progression to stage 4–55. This is especially detrimental to people with a lower socioeconomic status who have limited access to appropriate treatment and consequently face poorer outcomes1. The adverse consequences of later treatment, such as the loss of employment due to the need for dialysis, also discourages patients from seeking treatment. This inevitably leads to preventable morbidity and death6.
Why is chronic kidney disease underdiagnosed?
Despite clear rationales and guidelines for early detection, risk stratification, treatment of CKD, and timely management with evidence-based strategies have not been universally adopted1.
Just over half of governments around the world recognise kidney failure (58%) and CKD (51%) as health priorities, and even fewer (43%) have national strategies for improving CKD care7
Even in countries where guidelines and interventions have been established, various obstructions can reduce the effective implementation of these strategies, including8–10:
- Inadequate delivery of kidney care
- Poor understanding of CKD and its risk factors among primary care physicians
- Low patient awareness
- Absence of locally appropriate or adapted guidelines
Moreover, unlike other chronic diseases, there is no consensus on early identification and intervention for CKD despite the potential beneficial impact on treatment outcomes1. This could be due to low policymaker awareness with few countries having policies or public programmes aimed at CKD prevention and control11.
How does early diagnosis impact chronic kidney disease treatment?
The early identification and management of patients can reverse, delay, or prevent progression of CKD and is a central aspect of international initiatives in kidney disease. The goals of early diagnosis and management include12:
- Provision of specific therapy based on diagnosis
- Slowing/arresting CKD progression
- Evaluation and management of comorbid conditions
- Prevention and management of cardiovascular disease
- Identification, prevention, and management of CKD-specific complications (such as malnutrition, anaemia, bone disease, acidosis)
- Planning and preparation for renal replacement therapy (such as the choice of modality, access-placement and care, pre-emptive transplantation)
- Psychosocial support and provision of conservative care and palliative care options where required
Early diagnosis is also needed for determining appropriate blood pressure targets and management. Notably, the presence of albuminuria can impact the choice of antihypertensive agent as angiotensin-converting enzyme inhibitors (ACEi) and angiotensin II receptor blockers (ARBs) are first-line agents for patients with albuminuria1.
Accurate diagnosis and staging of CKD are essential for the early and effective use of treatments1
An accurate estimated glomerular filtration rate (eGFR) is also crucial for determining safe and effective doses for patients with CKD1. For instance, gabapentinoids, a prevalent drug class in the treatment of CKD13, increase the risks of side-effects due to drug accumulation1.
Similarly, the risks of encephalopathy associated with the use of baclofen increase with higher stages of CKD14. Diagnosis and appropriate staging also impact the need for nephrotoxin avoidance, such as the minimisation of non-steroidal anti-inflammatory drugs (NSAIDs)1.
Why is early chronic kidney disease screening important?
CKD currently meets the World Health Organisation (WHO) principles of screening for disease (Table 1) as early CKD is asymptomatic, accurate and low-cost diagnostic tests are available, and effective treatments can be initiated in the early stages of the disease1.
Table 1. Chronic kidney disease screening meets the WHO’s principles of screening for disease (Adapted1). CKD, chronic kidney disease.
| WHO criteria | CKD screening |
| 1. The condition sought should be an important public health problem | CKD is highly prevalent, costly, and its worldwide disease burden is increasing |
| 2. There should be an accepted treatment for patients with recognised disease | Treatment during early stages are accepted, and are highly effective |
| 3. Facilities for diagnosis and treatment should be available | CKD screening can occur in primary care practices or community settings |
| 4. There should be a recognisable latent or early symptomatic stage |
CKD is asymptomatic until late stages |
| 5. There should be a suitable test or examination | There are low-cost and accurate tests for CKD |
| 6. The test should be acceptable to the population | Testing for CKD is accepted by the population |
| 7. The natural history of the condition, including development from latent to declared disease, should be adequately understood | The natural history of CKD is well-understood |
| 8. There should be an agreed policy on whom to treat as patients | There are clear guidelines for CKD treatment upon CKD detection |
| 9. The cost of case-finding (including diagnosis and treatment of patients diagnosed) should be economically balanced in relation to possible expenditure on medical care as a whole | CKD screening in high-risk groups is likely to be cost-effective |
| 10. Case-finding should be a continuing process and not a 'once and for all' project | Repeated screening is needed in people with an initial negative screen |
The development of a CKD screening programme is also considered to be essential for social equality. Currently, socially disadvantaged and vulnerable populations experience a disproportionate CKD burden, are less likely to receive effective treatments, and may face a greater risk of complications1.
However, while a population-wide CKD screening programme may be a more complete approach to reducing the global burden of CKD, its implementation may have potential challenges1:
- Higher costs
- Greater barriers than targeted high-risk CKD screening
- Lower identification of CKD cases attributable to less common or unrecognised risk factors
Narrowing focus towards the common and important CKD risk factors will prioritise the identification of high risk cases for CKD progression and may also beneficially impact expenditures by lowering the cost per case identified1. Various characteristics that elevate the possibility of having CKD have already been identified, including2,15:
- Age
- Race/ethnicity
- Systemic diseases (for example, systemic lupus erythematosus, HIV infection)
- Family history of kidney disease
- Genetic risk factors
- Poor access to health care or low socioeconomic status
- High-risk occupations and environmental exposures
- Prior acute kidney injury
- Preeclampsia
- Exposure to nephrotoxins
- Obesity
CKD screening for people with these risk factors should be guided by individualised clinical assessments and joint decision making1.
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