ACP Guidelines: Do Not Screen Asymptomatic Adults for CKD

Laurie Barclay, MD

October 21, 2013

Adults without symptoms or risk factors should not be screened for chronic kidney disease (CKD), according to new guidelines from the American College of Physicians (ACP). The new evidence-based recommendations, published online October 21 in the Annals of Internal Medicine, address screening, monitoring, and treatment of adults with stage 1 to 3 CKD.

"There is no evidence that evaluated the benefits of screening for stage 1-3 chronic kidney disease," ACP President Molly Cooke, MD, FACP, said in a news release. "The potential harms of all the screening tests — false positives, disease labeling, and unnecessary treatment and associated adverse effects — outweigh the benefits," she said.

"Ordering lab tests is not going to have any impact on clinical outcomes of asymptomatic patients with CKD without risk factors but will add unnecessary costs to the health care system due to increased medical visits and unnecessary tests," she added.

Amir Qaseem, MD, PhD, MHA, and colleagues from the ACP Clinical Guidelines Committee based their recommendations on a systematic evidence review of pertinent studies identified by searching MEDLINE and the Cochrane Database of Systematic Reviews from 1985 through November 2011. They assessed outcomes including all-cause mortality, cardiovascular mortality, myocardial infarction, stroke, chronic heart failure, composite vascular outcomes, composite renal outcomes, end-stage renal disease, quality of life, physical function, and activities of daily living.

Specific Recommendations

  • Current evidence is insufficient to assess the benefits and harms of screening in asymptomatic adults, including those with major risk factors such as diabetes, hypertension, or cardiovascular disease.

  • Asymptomatic adults without risk factors should not be screened for CKD (weak recommendation, low-quality evidence).

  • Adults with or without diabetes who are currently taking an angiotensin-converting-enzyme (ACE) inhibitor or an angiotensin II receptor blocker (ARB) should not be tested for proteinuria (weak recommendation, low-quality evidence).

  • Patients with hypertension and stage 1-3 CKD should be treated with pharmacotherapy that includes either an ACE inhibitor (moderate-quality evidence) or an ARB (high-quality evidence; strong recommendation).

  • Patients with stage 1 to 3 CKD and elevated low-density lipoprotein levels should be treated with a statin (strong recommendation, moderate-quality evidence).

The committee also notes that treatment outcomes with ACE inhibitors or ARBs did not differ in head-to-head trials. However, combination therapy with ACE inhibitors and ARBs is associated with significantly increased risk for adverse effects, which may include cough, hyperkalemia, hypotension, and acute kidney failure necessitating dialysis.

In addition, the committee members found that the evidence is inconclusive regarding periodic laboratory monitoring of patients diagnosed with stage 1 to 3 CKD.

"Screening is recommended when it improves important clinical outcomes while limiting harms for screened individuals," the guidelines authors write. "Screening for CKD does not meet these generally accepted criteria for population-based screening. Although prevalence increases with age, CKD has a relatively low prevalence in the general population without risk factors."

In addition, the guidelines note uncertainty about the accuracy of available screening measures for CKD or its progression, a lack of available evidence regarding the sensitivity and specificity of various screening tests in the general population, and a very high risk for false-positive results of albuminuria and serum creatinine-derived estimated GFR.

"There was no evidence evaluating the benefits of early treatment in patients identified by screening," the guidelines authors conclude. "In contrast, harms, including false-positive results, disease labeling, and unnecessary testing and treatment, are associated with the screening. Given the potential harms of screening for stage 1 to 3 CKD and unknown benefits, current evidence does not support screening for stage 1 to 3 CKD in adults without risk factors."

The authors have disclosed no relevant financial relationships.

Ann Intern Med. Published online October 21, 2013.


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