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Screening, Monitoring, and Treatment of Early Stage Chronic Kidney Disease: Recommendations From the American College of Physicians FREE

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The full report is titled “Screening, Monitoring, and Treatment of Stage 1 to 3 Chronic Kidney Disease: A Clinical Practice Guideline From the American College of Physicians.” It is in the 17 December 2013 issue of Annals of Internal Medicine (volume 159, pages 835-847). The authors are A. Qaseem, R.H. Hopkins Jr., D.E. Sweet, M. Starkey, and P. Shekelle, for the Clinical Guidelines Committee of the American College of Physicians.

This article was published online first at www.annals.org on 22 October 2013.

Summaries for Patients are a service provided by Annals to help patients better understand the complicated and often mystifying language of modern medicine.

Summaries for Patients are presented for informational purposes only. These summaries are not a substitute for advice from your own medical provider. If you have questions about this material, or need medical advice about your own health or situation, please contact your physician. The summaries may be reproduced for not-for-profit educational purposes only. Any other uses must be approved by the American College of Physicians.

Ann Intern Med. 2013;159(12):I-28. doi:10.7326/0003-4819-159-12-201312170-00728
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Who developed these recommendations?

The American College of Physicians (ACP) developed these recommendations. Members of the ACP are internists, specialists in the care of adults.

What is the problem and what is known about it so far?

The kidneys remove waste and water from the blood. In chronic kidney disease (CKD), the kidneys stop working as well over time and dialysis becomes necessary. Caring for CKD involves controlling diet and blood pressure and taking medications to delay heart complications and the need for dialysis. There are 5 stages of CKD; stages 1 to 3 are considered “early” disease, and it is important to manage it in early stages to keep it from getting worse. The ACP wanted to determine whether screening healthy adults for CKD or monitoring for worsening in adults known to have CKD improves patient outcomes, and what treatments improve outcomes in early CKD.

CKD is most common in people with high blood pressure or diabetes. However, it can also occur in apparently healthy people without these conditions, and many people do not know that they have CKD. Glomerular filtration rate (GFR) is a measure of kidney function that can be estimated from the amount of creatinine in the blood. It is also possible to look for CKD by measuring albumin and protein in urine. These tests can be used in healthy people to see whether they have CKD (screening) or to monitor for worsening of CKD after diagnosis.

How did the ACP develop these recommendations?

The ACP reviewed research on the benefits and harms of screening for CKD, monitoring after diagnosis, and treatment of early CKD.

What did the authors find?

Studies are lacking to show whether screening for CKD in healthy adults without diabetes, hypertension, or heart disease improves outcomes. Blood pressure–lowering drugs called angiotensin-converting enzyme (ACE) inhibitors and angiotensin II–receptor blockers (ARBs) can keep early CKD from worsening. However, there is no evidence that continuing to test for protein in the urine of people with early CKD who are already taking these medications improves outcomes.

Controlling blood pressure lowers the risk for worsening CKD, but there is no evidence that strict blood pressure control works better than standard blood pressure control. Standard blood pressure control aims for blood pressure of 134–141/81–87 mm Hg, and strict control aims for lower levels than this.

The cholesterol-lowering medications called statins have been shown to improve outcomes in patients with early CKD who also have unfavorable levels of low-density lipoprotein (LDL) cholesterol.

What does the ACP recommend that patients and doctors do?

Healthy adults with no risk factors for CKD should not be screened for CKD.

Adults with or without diabetes who are already taking an ACE inhibitor or ARB should not be tested for urine protein.

Treatment for patients with high blood pressure and early CKD should include either an ACE inhibitor or ARB.

Statins should be used in patients with early CKD and unfavorable LDL cholesterol levels.

What are the cautions related to these recommendations?

The screening recommendations do not apply to people with diabetes, high blood pressure, or symptoms that could be caused by CKD.





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