Many patients are horrified when they come to my office after learning for the first time that they have stage 3 or stage 4 chronic kidney disease (CKD). They are bewildered about why they never knew they had a diagnosable illness when they were in stages 1 and 2. Patients are more likely to present with symptomatic complaints like diabetes and heart disease, but identifying CKD at an early stage in these patients should be a priority as it can be both life-changing and life-saving.
The information needed to identify CKD is often available in routine laboratory testing, but often the diagnosis is not confirmed, and the stage 1 CKD box is not checked in the patient’s record. Sadly, as a transplant nephrologist, my first encounter with patients with CKD is usually in late or even end-stage, when catastrophic kidney failure is looming.
The US Centers for Disease Control and Prevention estimates that 15% of US adults — approximately 37 million people — have CKD, and an astounding 90% of them have no idea that they have it.1 In fact, half of people with very low kidney function who are not already on dialysis do not know that they have CKD.2 In 2016, the treatment cost for Medicare beneficiaries with CKD reached more than $79 billion, and the cost for end-stage kidney disease was an additional $35 billion.3
The 5 stages of kidney disease were identified in 2002 as part of clinical practice guidelines established by the National Kidney Foundation.4 This categorization enhances early detection, creating an opportunity to educate patients, slow the progress of CKD, and prevent serious complications. However, these can only occur if the disease is identified in its earliest stages.
The benefits of early diagnosis of CKD for patients and for society are tremendous. Patients who are diagnosed in the early stages of kidney disease have the chance to make lifestyle changes, learn how to manage their disease, and extend their lives while avoiding or postponing the need for dialysis or transplant. Society benefits because of the reduced cost of caring for patients with late-stage kidney disease.
Chronic kidney disease is particularly dangerous because the symptoms emerge slowly and silently, and are often detected only when it has reached stage 3 or later, when damage is already severe and irreversible. Patients can lose 30% to 40% of kidney function without showing symptoms.5 Although a simple test can detect protein in the urine, which is the first sign of trouble, these tests are not routinely ordered. When these tests are administered, protein in the urine frequently is not flagged as CKD, partly because patients without symptoms are not pressing for a diagnosis.
The National Kidney Foundation recommends routine screening for those at higher risk: people aged ≥60 years and those with hypertension, diabetes, coronary artery disease, family history of CKD, or morbid obesity.4 Individuals of African American, Asian, and Hispanic ethnicity are also at higher risk.4 A single positive urine test requires follow-up, and the detection of albuminuria on 3 consecutive monthly urine tests should trigger a diagnosis of stage 1 CKD, even if the blood test is normal. This early diagnosis should be followed by a clinical action plan for CKD, which can be co-managed with a nephrologist, and will hopefully slow or prevent progression to more advanced stages of the disease.
Those of us who treat late-stage CKD applaud this long-overdue attention to kidney health in Washington, and we hope that patients and physicians will recognize this wake-up call so that more people do not find themselves discussing options for late-stage CKD at their first visit.
1. Chronic kidney disease in the United States, 2019. Centers for Disease Control and Prevention. https://www.cdc.gov/kidneydisease/publications-resources/2019-national-facts.html. Reviewed March 11, 2019. Accessed September 17, 2019.
2. Kidney disease: the basics. National Kidney Foundation website. https://www.kidney.org/news/newsroom/factsheets/KidneyDiseaseBasics. Accessed September 17, 2019.
3. Healthcare expenditures for persons with CKD. United States Renal Data System website. https://www.usrds.org/2018/view/v1_07.aspx. Accessed September 17, 2019.
4. Clinical practice guidelines for chronic kidney disease: evaluation, classification and stratification. National Kidney Foundation website. https://www.kidney.org/sites/default/files/docs/ckd_evaluation_classification_stratification.pdf. Published 2002. Accessed September 17, 2019.
5. Kidney disease: chronic kidney disease. Cleveland Clinical website. https://my.clevelandclinic.org/health/diseases/15096-kidney-disease-chronic-kidney-disease. Reviewed September 22, 2015. Accessed September 17, 2019.