Among women, chronic kidney disease (CKD) is less likely to be diagnosed and adequately managed in comparison with men with CKD, a Swedish observational cohort study indicates.
In an analysis of data from the Stockholm Creatinine Measurements (SCREAM) project, women were 53% less likely to receive a diagnosis of CKD compared with men across all subgroups evaluated, Juan Jesus Carrero, Pharm PhD, Karolinska Institute, Stockholm, Sweden, and colleagues report.
"Just getting the disease diagnosed is important for several reasons, including getting referral to a kidney specialist and to make other clinicians aware of the condition so they can avoid prescribing common medications that can further damage the kidneys," Carrero told Medscape Medical News in an email.
"Overall, our study shows that in absolute numbers, only a small proportion of people with 'probable' CKD — both men and women — have their disease recognized, monitored, and managed as per guideline recommendations, so there is an urgent need to increase awareness of CKD and its management among both patients and healthcare professionals," he added.
The study was published recently in the Journal of the American Society of Nephrology.
SCREAM Data Used to Analyze Sex Differences in CKD Detection, Management
Data from SCREAM was used to analyze sex differences in the recognition, detection, monitoring, and management of CKD between men and women in routine healthcare in Stockholm, Sweden. All serum or plasma creatinine measurements made between 2009 and 2018 were used to calculate the estimated glomerular filtration rate (eGFR). "We identified all individuals who had at least one eGFR measurement <60 mL/min/l.73m2, denoting probable CKD category G3a or worse," the investigators note.
They evaluated key steps in CKD care, including diagnosis; measurement of creatinine and albuminuria levels; whether or not referral was made to a nephrologist; and whether guideline-recommended therapies were provided, including a renin-angiotensin (RAS) inhibitor and a statin. Between 2009 and 2017, 227,847 patients underwent at least one outpatient measurement in which eGFR was <60 mL/min/1.732; of those patients, 55% were women.
The mean eGFR was similar for men and women. Most of the cohort had CKD of category G3a. Despite being slightly older than men, women generally had fewer comorbidities and had less diabetes and cardiovascular (CV) and peripheral arterial disease than men. Rates of hypertension were almost identical between the two sexes, at slightly over 60%.
Besides being less likely to be diagnosed, women were also 54% less likely than men to visit a nephrologist over the ensuing 18 months, the authors note (unadjusted hazard ratio [HR], 0.46). The findings were only slightly attenuated after multivariable adjustments.
"There have been modest improvements in referral patterns over time but women were persistently at lower risk of referral compared to men," the authors write. Albuminuria was measured for only about 28% of women, compared to about 34% for men. For a high proportion of patients of both sexes, creatinine was measured at least once over the following 18 months.
Fewer women received either an RAS inhibitor or a statin than men. The differences in the use of both drugs persisted over time. "These differences were...observed among high-risk groups, among people with evidence-based indications for medications and among people with confirmed CKD at re-testing," the investigators observe.
Guidelines recommend monitoring of eGFR and albuminuria in at-risk patients because therapies can be offered that slow kidney damage and reduce CV risk. For example, RAS inhibitors reduce albuminuria and the rate of eGFR decline.
RAS inhibitors also reduce the risk for end-stage kidney disease for patients with albuminuria as well as the risk for CV outcomes. Statins also reduce the risk of CV events. "All these indicators and medications scored worse for women, through all albuminuria categories and among people with indications for treatment, monitoring, and diagnosis," Carrero and colleagues point out.
Late referral to a nephrologist has been associated with more rapid disease progression and worse outcomes. "We believe that efforts to improve this and ensure equitable care between sexes could have important implications for justice and could reduce the burden of CKD," the investigators conclude.
The study was supported by the Swedish Research Council. Carrero has received payment for lectures, for participation on advisory boards, or as study grants from Astella, AstraZeneca, Bayer, Fresenius Medical Care, Fresenius Kabi, Abbott, Baxter, and Vifor Pharma.
J Am Soc Nephrol. Published online May 3, 2022. Full text
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