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Screening for, Monitoring, and Treatment of Chronic Kidney Disease Stages 1 to 3: A Systematic Review for the U.S. Preventive Services Task Force and for an American College of Physicians Clinical Practice Guideline

Howard A. Fink, MD, MPH; Areef Ishani, MD, MS; Brent C. Taylor, PhD, MPH; Nancy L. Greer, PhD; Roderick MacDonald, MS; Dominic Rossini, MD; Sameea Sadiq, MD; Srilakshmi Lankireddy, MD; Robert L. Kane, MD; and Timothy J. Wilt, MD, MPH
[+] Article and Author Information

From Geriatric Research, Education, and Clinical Center and Center for Chronic Disease Outcomes Research, Minneapolis Veterans Affairs Medical Center; Minnesota Evidence-based Practice Center; University of Minnesota; and University of Minnesota School of Public Health, Minneapolis, Minnesota.

Disclaimer: This report is based on research conducted by the Minnesota Evidence-based Practice Center under contract from the Agency for Healthcare Research and Quality, Rockville, Maryland (contract HHSA 290-2007-10064-I). The findings and conclusions in this document are those of the authors, who are responsible for its content, and do not necessarily represent the views of the Agency for Healthcare Research and Quality. No statement in this report should be construed as an official position of the Agency for Healthcare Research and Quality, the U.S. Department of Health and Human Services, or the U.S. Department of Veterans Affairs.

Acknowledgment: The authors thank Indulis Rutks for his expertise in searching literature, database management, extracting skills, and general support. They also thank Marilyn Eells and Maureen Carlyle for technical editing support and Jeannine Ouellette for her developmental editing. In addition, they thank Nino Alapishvili, MD; Milind Junghare, MD; and Wei Yen Kong, MD, for their assistance with abstract triaging and data extraction.

Grant Support: By a contract from the AHRQ to the Minnesota Evidence-based Practice Center (contract HHSA 290-2007-10064-I).

Potential Conflicts of Interest: Disclosures can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M11-2383.

Requests for Single Reprints: Howard A. Fink, MD, MPH, Minneapolis Veterans Affairs Medical Center (11-G), One Veterans Drive, Minneapolis, MN 55417; e-mail, mailto:howard.fink@va.gov.

Current Author Addresses: Dr. Fink: Minneapolis Veterans Affairs Medical Center (11-G), One Veterans Drive, Minneapolis, MN 55417.

Dr. Ishani: Minneapolis Veterans Affairs Medical Center (111-J), One Veterans Drive, Minneapolis, MN 55417.

Dr. Taylor: Minneapolis Veterans Affairs Medical Center (152/2E), One Veterans Drive, Minneapolis, MN 55417.

Drs. Greer and Wilt and Mr. MacDonald: Minneapolis Veterans Affairs Medical Center (111-O), One Veterans Drive, Minneapolis, MN 55417.

Drs. Rossini, Sadiq, and Lankireddy: Department of Medicine, University of Minnesota, 420 Delaware Street Southeast #806, Minneapolis, MN 55455.

Dr. Kane: Division of Health Policy and Management, University of Minnesota School of Public Health, D351 Mayo (MMC 197), 420 Delaware Street Southeast, Minneapolis, MN 55455.

Author Contributions: Conception and design: H.A. Fink, A. Ishani, R.L. Kane.

Analysis and interpretation of the data: H.A. Fink, A. Ishani, B.C. Taylor, N.L. Greer, R. MacDonald, D. Rossini, S. Sadiq, S. Lankireddy, R.L. Kane, T.J. Wilt.

Drafting of the article: H.A. Fink, A. Ishani, R. MacDonald, D. Rossini, S. Sadiq.

Critical revision of the article for important intellectual content: H.A. Fink, A. Ishani, B.C. Taylor, D. Rossini, R.L. Kane, T.J. Wilt.

Final approval of the article: H.A. Fink, A. Ishani, B.C. Taylor, R.L. Kane, T.J. Wilt.

Statistical expertise: H.A. Fink, A. Ishani, B.C. Taylor, R. MacDonald, T.J. Wilt.

Obtaining of funding: H.A. Fink, R.L. Kane, T.J. Wilt.

Administrative, technical, or logistic support: H.A. Fink, N.L. Greer, R.L. Kane, T.J. Wilt.

Collection and assembly of data: H.A. Fink, A. Ishani, B.C. Taylor, N.L. Greer, R. MacDonald, D. Rossini, S. Sadiq, S. Lankireddy.


Ann Intern Med. 2012;156(8):570-581. doi:10.7326/0003-4819-156-8-201204170-00008
Text Size: A A A

Background: Screening and monitoring for chronic kidney disease (CKD) could lead to earlier interventions that improve clinical outcomes.

Purpose: To summarize evidence about the benefits and harms of screening for and monitoring and treatment of CKD stages 1 to 3 in adults.

Data Sources: MEDLINE (1985 through November 2011), reference lists, and expert suggestions.

Study Selection: English-language, randomized, controlled trials that evaluated screening for or monitoring or treatment of CKD and that reported clinical outcomes.

Data Extraction: Two reviewers assessed study characteristics and rated quality and strength of evidence.

Data Synthesis: No trials evaluated screening or monitoring, and 110 evaluated treatments. Angiotensin-converting enzyme inhibitors (relative risk, 0.65 [95% CI, 0.49 to 0.88]) and angiotensin II–receptor blockers (relative risk, 0.77 [CI, 0.66 to 0.90]) reduced end-stage renal disease versus placebo, primarily in patients with diabetes who have macroalbuminuria. Angiotensin-converting enzyme inhibitors reduced mortality versus placebo (relative risk, 0.79 [CI, 0.66 to 0.96]) in patients with microalbuminuria and cardiovascular disease or high-risk diabetes. Statins and β-blockers reduced mortality and cardiovascular events versus placebo or control in patients with impaired estimated glomerular filtration rate and either hyperlipidemia or congestive heart failure, respectively. Risks for mortality, end-stage renal disease, or other clinical outcomes did not significantly differ between strict and usual blood pressure control. The strength of evidence was rated high for angiotensin II–receptor blockers and statins, moderate for angiotensin-converting enzyme inhibitors and β-blockers, and low for strict blood pressure control.

Limitations: Evidence about outcomes was sometimes scant and derived from post hoc analyses of subgroups of patients enrolled in trials. Few trials reported or systematically collected information about adverse events. Selective reporting and publication bias were possible.

Conclusion: The role of CKD screening or monitoring in improving clinical outcomes is uncertain. Evidence for CKD treatment benefit is strongest for angiotensin-converting enzyme inhibitors and angiotensin II–receptor blockers, and in patients with albuminuria combined with diabetes or cardiovascular disease.

Primary Funding Source: Agency for Healthcare Research and Quality.

Figures

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Figure 1.

Definition of CKD.

CKD = chronic kidney disease; GFR = glomerular filtration rate.

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Appendix Figure.

Analytic framework.

The patient population of interest is asymptomatic adults with or without CKD risk factors. The first and second key questions are related to benefits (KQ1) and harms (KQ2) of screening this population for the presence of CKD stages 1 to 3. The third and fourth key questions are related to benefits (KQ3) and harms (KQ4) associated with monitoring patients with early CKD. The fifth and sixth key questions are related to benefits (KQ5) and harms (KQ6) associated with treatment of patients with early CKD. The framework shows that monitoring may lead to treatment and that treatment may be monitored. The framework also includes intermediate outcomes of treatment that may be associated with the clinical outcomes of interest. ACEI = angiotensin-converting enzyme inhibitor; AKI = acute kidney injury; ARB = angiotensin II–receptor blocker; CHF = congestive heart failure; CKD = chronic kidney disease; CVA = cerebrovascular accident; CVD = cardiovascular disease; DM = diabetes mellitus; eGFR = estimated glomerular filtration rate; ESRD = end-stage renal disease; HTN = hypertension; KQ = key question; MI = myocardial infarction; QOL = quality of life.

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Figure 2.

Summary of evidence search and selection.

CKD = chronic kidney disease; RCT = randomized, controlled trial.

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