Chronic Kidney Disease Stage 3a Research Articles

High Risk of Renal Failure in Stage 3B Chronic Kidney Disease is Under-recognized in Standard Medical Screening

The objective of this study was to determine the risk of renal failure in patients with under-recognized chronic kidney disease (CKD) in the self-pay standard medical screening program of health management centers. The abbreviated Modification of Diet in Renal Disease equation was used to calculate the estimated glomerular filtration rate (eGFR) of study subjects. Study subjects with eGFR less than 60 mL/min/1.73m(2) but with normal results of routine assessment, including serum creatinine, blood urea nitrogen, urinalysis and kidney ultrasound, were defined as having under-recognized CKD. Episodes of renal failure requiring dialysis within 2 years in subjects with stage 3 to stage 5 CKD were evaluated. A total of 15,817 subjects were recruited and 28.4% of subjects were identified by routine assessments as having a kidney problem. The prevalences of CKD 3A, 3B, 4 and 5 were 8.3%, 1.9%, 0.3% and 0.2%, respectively. All subjects with stages 4 and 5 CKD had abnormal serum creatinine levels, but 48.7% of 1,507 subjects with stage 3 CKD (stage 3A, n = 713; stage 3B, n = 21) had normal routine assessments. Subjects with under-recognized stage 3B CKD had the highest risk (20%) of developing renal failure compared to subjects with stages 3-5 CKD and abnormal results of routine assessments. Identifying subjects with CKD stage 3 by the eGFR equation, especially in stage 3B, is advantageous in detecting the risk of renal failure over the routine clinical assessment that is currently carried out by health management institutions in Taiwan.

Does stage-3 chronic kidney disease matter?: A systematic literature review

<h3>Background</h3> Stage-3 chronic kidney disease (CKD) is the first stage that is identifiable from a blood test alone. In the UK, it accounts for the majority of people on primary care CKD registers. It also represents a group of people who, in the past, would have gone unnoticed clinically. In order to support patients and plan services, the natural history of stage-3 CKD is important. <h3>Aim</h3> To systematically review the natural history of stage-3 CKD in order to describe all cause mortality, cardiovascular morbidity and mortality, and renal outcomes. <h3>Design of study</h3> Systematic review of the literature. <h3>Method</h3> MEDLINE and Embase databases were searched from 1998 to February 2009. Systematic reviews and cohort studies that included adults with stage-3 CKD were considered eligible. Studies were appraised and data extracted by one reviewer and checked by a second. <h3>Results</h3> Thirteen studies were identified including a total of 728 328 people. The all-cause mortality rate varied from 6% in 3 years to 51% in 10 years and was higher in stage-3B CKD (4.8 per 100 person-years) than stage-3A CKD (1.1 per 100 person-years). The relative risk of mortality (all-cause mortality or cardiovascular disease [CVD] mortality) was higher in stage-3 CKD compared with no CKD, but the increase was small for those with stage-3A CKD (hazard ratio [HR] 1.2–1.7) and greater in stage 3B (HR 1.8–3.3). End-stage renal disease was rare (4% in 10 years) and renal progression was evident in &lt;20% of patients after 5 years. <h3>Conclusions</h3> For patients with stage-3 CKD, risk of mortality was higher than for those without CKD, but the risk of progression was low. CKD registers provide an opportunity for GPs to assess the risk of patients developing CVD.

Early referral strategies for management of people with markers of renal disease: a systematic review of the evidence of clinical effectiveness, cost-effectiveness and economic analysis

Chronic kidney disease (CKD) is a long-term condition and has been described as the gradual loss of kidney function over time. Early in the disease process, people with CKD often experience no symptoms. For a long time, CKD has been an underdiagnosed condition. Even in the absence of symptoms, CKD appears to add significantly to the burden of cardiovascular disease and death and, for an important minority, can progress to kidney failure. To systematically review the evidence of the clinical effectiveness and cost-effectiveness of early referral strategies for management of people with markers of renal disease. Electronic searches of 12 major databases (such as MEDLINE, EMBASE, CINAHL, etc.) were conducted for the time period of 1990 to April 2008 to identify studies comparing early referral to other care options for people with CKD. Additional searching was performed in the NHS Economic Evaluation Database to support the cost-effectiveness literature review. Two authors reviewed all titles, abstracts and full papers to select relevant literature. A Markov model was constructed to represent the natural history of CKD. The model allowed cohorts to be tracked according to estimated glomerular filtration rate (eGFR) status and the presence of other complications known to influence CKD progression and the incidence of cardiovascular events. From 36 relevant natural history studies, CKD was found to be, despite marked heterogeneity between studies, a marker of increased risk of mortality, renal progression and end-stage renal disease. Mortality was generally high and increased with stage of CKD. After adjustment for comorbidities, the relative risk of mortality among those with CKD identified from the general population increased with stage. For clinical populations, the relative risk was higher. All three outcomes increased as eGFR fell. Only seven studies, and no randomised controlled trials, were identified as relevant to assessing the clinical effectiveness of early referral strategies for CKD. In the five retrospective studies constructed from cohorts starting on renal replacement therapy (RRT), mortality was reduced in the early referral group (more than 12 months prior to RRT) even as late as 5 years after initiation of RRT. Only two studies included predialysis participants. One study, in people screened for diabetic nephropathy, reported a reduction in the decline in renal function associated with early referral to nephrology specialists (eGFR decline 3.4 ml/min/1.73 m(2)) when compared with a similar group that had no access to nephrology services until dialysis was required (eGFR decline 12.0 ml/min/1.73 m(2)). The second study, among a group of veterans with two creatinine levels of at least 140 mg/dl, reported that a composite end point of death or progression was lower in the group receiving nephrology follow-up than in those receiving only primary care follow-up. The greatest effect was observed in those with stage 3 or worse disease after adjustment for comorbidities, age, race, smoking and proteinuria {stage 3: hazard ratio (HR) 0.8 [95% confidence interval (CI) 0.61 to 0.9)]; stage 4: HR 0.75 (95% CI 0.45 to 0.89)}. In the base-case analysis, all early referral strategies produced more quality-adjusted life-years (QALYs) than referral upon transit to stage 5 CKD (eGFR 15 ml/min/1.73 m(2)). Referral for everyone with an eGFR below 60 ml/min/1.73 m(2) (stage 3a CKD) generated the most QALYs and, compared with referral for stage 4 CKD (eGFR < 30 ml/min/1.73 m(2)), had an incremental cost-effectiveness ratio of approximately 3806 pounds per QALY. Because of a lack of data on the natural history of CKD in individuals without diabetes, and a lack of evidence on the costs and effects of early referral, the Markov model relied on many assumptions. The findings were particularly sensitive to changes in eGFR decline rates and the relative effect of early referral on CKD progression and cardiovascular events; the latter parameter being derived from a single non-randomised study. Despite substantial focus on the early identification and proactive management of CKD in the last few years, we have identified significant evidence gaps about how best to manage people with CKD. There was some evidence to suggest that the care of people with CKD could be improved and, because these people are at risk from both renal and cardiovascular outcomes, strategies to improve the management of people with CKD have the potential to offer an efficient use of health service resources. Given the number of people now being recognised as having markers of kidney impairment, there is an urgent need for further research to support service change.

Impact of late-stage CKD and aging on medical utilization in the elderly population: a closed-cohort study in Taiwan

Taiwan has the highest incidence and prevalence of end-stage renal disease globally, especially in the elderly population. The elderly with chronic kidney disease (CKD) also had high mortality. However, population-based research on how the elderly with CKD utilize medical services is still unexplored. We aimed to examine the effects of CKD severity and aging on medical utilizations in the elderly population. This retrospective closed cohort study analysed 7868 elderly residents of Kaohsiung City, who participated in the government-sponsored annual physical examination in 1997. The information of medical services and expenses were obtained from the claimed data of the National Health Insurance from 1996 to 1999. CKD was grouped into five stages according to the National Kidney Foundation Kidney Disease Outcomes Quality Initiative (NKF K-DOQI) criteria with modifications. Late-stage CKD was defined as CKD Stages 3 to 5 [estimated glomerular filtration rate (eGFR) below 60 ml/min/1.73 m(2)]. Those subjects with eGFR above 60 ml/min/1.73 m(2) were treated as the reference group. After adjusting all covariates, the odds ratios of hospitalization for elderly subjects with CKD stages 3a, 3b and 4/5 were 1.19 (95% CI = 1.08-1.32), 1.48 (95% CI = 1.26-1.73) and 1.68 (95% CI = 1.21-2.33) compared with the reference group, respectively (P < 0.001). The autoregressive generalized estimating equation analysis revealed that CKD stage had linear associations with medical expenditures during the study period, especially for those elderly subjects with later stage CKD. Increases in medical utilizations and expenses were demonstrated in elderly CKD subjects, especially those with late stage CKD. Early prevention of CKD is necessary to lessen the financial impact on medical health care.

Chronic kidney disease prevalence in a UK residential care home population

Chronic kidney disease (CKD) is common ( approximately 30%) in non-institutionalized older people but little is known about the prevalence of CKD amongst older people living in residential care. An observational study of older subjects [n = 250, median age 86 (range 67-100) years, 79% female, 100% Caucasian, 16% diabetic, 48% hypertensive, 5% known renal disease, mean number of medications 7] who were recruited over a 9-month period from 155 residential care homes in east Kent (total population 3811) using a randomization process. The estimated glomerular filtration rate (eGFR, ml/min/1.73 m(2)) was calculated using the Cockcroft and Gault equation corrected for the body surface area and the simplified Modification of Diet in Renal Disease (MDRD) Study equation. Serum cystatin C concentration was also measured. Using the MDRD equation 18% had eGFR >/=60, 39% stage 3A CKD (eGFR 45-59), 34% stage 3B CKD (eGFR 30-44) and 10% stage 4 CKD (eGFR 15-29). By the Cockcroft-Gault equation the equivalent figures were 3%, 18%, 48% and 31%, respectively. Agreement between the equations for staging of CKD was poor (kappa = 0.07). However, >80% of residents were categorized as having stage 3 CKD (>40% stage 3B) or worse whichever equation was used. Serum cystatin C concentration was increased in 92% of the population. Increasing age and higher body mass index were predictive of decreased renal function. Significant CKD is prevalent and unrecognized in this population. This may have important management implications particularly for treatment with renally excreted drugs, fracture prevention or managing cardiovascular risk.