Can early CKD detection improve outcomes?

With the advent of therapies that can preserve kidney function in chronic kidney disease (CKD), it is now possible to delay or prevent kidney failure.^1,2 However, many people with CKD are unaware of their CKD status, as symptoms may not appear until up to 90% of kidney function is lost.^3,4

CKD leads to premature mortality, disability, reduced quality of life, psychosocial harm, and an increased risk of cardiovascular disease (CVD).^5-7 The high costs of CKD treatment incurred by individuals and healthcare systems are exacerbated by lost productivity and an inability to work.^7,8

Globally, the prevalence of CKD is increasing.⁷ If CKD remains largely undetected – and therefore untreated – the number of people developing kidney failure and requiring kidney replacement therapy (KRT) will also increase. By 2030, an estimated 5.4 million people will receive KRT – more than double the number in 2010⁷.

Many people who require KRT in low-income and lower middle-income countries lack access to therapy and die prematurely. Of those who start dialysis, around 15 20% die within 12 months, even in high-income countries.⁷

By 2040, CKD is projected to become the fifth leading cause of years of lives lost globally⁹To mitigate the growing burden of CKD, early detection will be essential to maximize the benefits of kidney-preserving treatments.⁴

Targeted screening for CKD – who and when?

Up to 76% of people have at least one key risk factor for CKD, including diabetes, hypertension, and obesity^10-12

Although there is a lack of global consensus on screening for CKD, KDIGO strongly support targeted early detection of CKD in individuals at high risk, through estimated glomerular filtration rate (eGFR) and urine albumin/creatinine ratio (uACR) measurement.¹³ Blood pressure checks are also suggested.^4,6

Groups at high risk of CKD include those with:^4,6,13

• Diabetes, hypertension, obesity, or established CVD
• A family history of kidney failure
• A personal history of acute kidney injury
• A current or past history of smoking/vaping
• Medical conditions that impact kidney function (systemic lupus erythematosus, HIV, obesity, genetic risk factors)
• High-risk occupations and nephrotoxin exposure

Screening should be offered to those over 60 years without these factors, and yearly for those with diabetes or hypertension.⁴

KDIGO also recommends targeted screening for populations with low socioeconomic status and poor healthcare access, considering they are disproportionately affected by kidney disease.^6,7,13,14 For example, earlier and more frequent screening is recommended for First Nations Australians, starting from 18 years and continuing on a yearly basis.⁴

What are the benefits of early CKD detection?

Given the expanding range of therapies with cardiorenal benefits, targeted screening for kidney disease in individuals at high risk could provide an earlier opportunity to halt CKD progression,^4,15 and prevent kidney failure and associated adverse cardiovascular outcomes.¹³

In Australia, economic modeling indicates targeted early CKD detection in individuals at high risk could prevent 38,200 premature deaths and 237,324 CVD hospitalizations, and yield a net benefit of 10.2 billion AUD over 20 years.¹⁵

Results of a systematic review of 21 cost-effectiveness studies across various countries supported the cost-effectiveness of targeted screening for CKD in populations at high risk, including people with diabetes and specific ethnic groups.³

Early CKD detection remains a gap in practice

Screening for kidney disease is affordable and accessible but often incomplete.¹⁶ Albuminuria testing is essential for risk stratification and treatment selection in CKD, yet it often goes undetected, even in individuals at high risk of CKD.¹⁷

A US study of over 190,000 adults with hypertension or diabetes estimated the prevalence of albuminuria at 17.1%, but two-thirds of these individuals did not undergo urine albumin testing¹⁷

The underuse of uACR testing is a barrier to implementing effective treatments, and highlights a global healthcare practice gap.¹⁶

Kidney-preserving therapies

Besides conventional treatment with angiotensin-converting enzyme inhibitors (ACEi) and angiotensin II receptor blockers (ARB), treatments that can delay progression or preserve kidney function in CKD include:¹³

• Sodium-glucose cotransporter-2 inhibitors (SGLT2i)
• Finerenone, a non-steroidal mineralocorticoid receptor antagonist (ns-MRA), in those with type 2 diabetes (T2D)

Other kidney-preserving therapies under investigation for CKD and T2D include glucagon-like peptide 1 receptor agonists (GLP-1 RAs), such as semaglutide,^18,19 and ns-MRAs, such as esaxerenone and apararenone.^20,21

An evolving approach to CKD treatment

KDIGO guidelines have encouraged a shift to preserving kidney function,²² emphasizing the importance of reducing risk of kidney failure, cardiovascular mortality, and heart failure in people with CKD.¹³

CKD without diabetes

In addition to ACEi or ARB, the 2024 KDIGO guidelines now recommend SGLT2i as an option for CKD without diabetes.¹³ This was based on clinical trials showing reduced risks of kidney failure, acute kidney injury, hospitalization for heart failure, cardiovascular death, and myocardial infarction with SGLT2i in CKD, with or without diabetes.¹³

CKD with diabetes

A “four pillar” approach has been proposed for managing CKD in T2D.^1,16 The first three established pillars involve sequential layering of renin–angiotensin system inhibitors, SGLT2i, and finerenone, where indicated,^1,16 following the recommended treatment progression outlined in the 2024 KDIGO guidelines.¹³ A fourth emerging pillar involves use of GLP-1 RAs.^1,16 Although several GLP-1 RAs have been FDA- or EMA-approved for T2D, they are not yet approved for treatment of CKD in people with T2D.^23-26 However, recent findings from the phase 3 FLOW trial show that semaglutide benefits kidney function and cardiovascular outcomes in those with T2D and CKD.¹⁹

These four pillars rest on a foundation of healthy lifestyle and control of conventional risk factors, including hypertension, hyperglycemia, and dyslipidemia.¹⁶ This includes a diet with low glycemic index and low sodium¹⁶, physical activity including resistance exercise,^27,28 and smoking cessation.²⁹ Adequate dietary protein can help prevent frailty,³⁰ and KDIGO recommends the same protein intake for most people with CKD as for the general population (0.8 g/kg body weight per day in adults).¹³

While it remains to be seen how a pillar approach to CKD will be implemented in practice, an individualized approach remains key.^16,22,31

Early detection and timely treatment key to halting CKD progression

CKD is often silent, but kidney failure and dialysis are no longer inevitable for people with CKD – so we must be proactive about screening. Early detection and timely treatment will be crucial to mitigate the growing burden of CKD.

About Karen Dwyer

Professor Karen Dwyer is Director of Nephrology at the Royal Melbourne Hospital, Victoria, Australia. She is a kidney specialist with over 20 years of clinical experience across public and private sectors, in metro and regional settings. Her clinical passion is partnering with patients to support self-management practices through holistic models of care.

Read more about chronic kidney disease

References

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