“Kidney disease is the most common chronic disease in the United States and the world, and the incidence is on the rise,” said Kim Zuber, PA-C, executive director of the American Academy of Nephrology PAs and outreach chair for the National Kidney Foundation in St. Petersburg, Fla.
Kim Zuber
Kidney disease also is an expensive problem that accounts for approximately 20% of the Medicare budget in the United States, she said in a virtual presentation at the Metabolic & Endocrine Disease Summit by Global Academy for Medical Education.
“It’s important that we know how to identify it and how to slow the progression if possible, and what to do when we can no longer control the disease,” she said.
Notably, the rate of growth for kidney disease is highest among adults aged 20-45 years, said Ms. Zuber. “That is the group who will live for many years with kidney disease,” but should be in their peak years of working and earning. “That is the group we do not want to develop chronic diseases.”
“Look for kidney disease. It’s not always on the chart; it is often missed because people don’t think of it,” Ms. Zuber said. Anyone over 60 years has likely lost some kidney function. Other risk factors include minority/ethnicity, hypertension or cardiovascular disease, diabetes, and a family history of kidney disease.
Women are more likely to develop chronic kidney disease (CKD), but less likely to go on dialysis, said Ms. Zuber. “What I find fascinating is that a history of oophorectomy” increases risk. Other less obvious risk factors in a medical history that should prompt a kidney disease screening include mothers who drank during pregnancy, individuals with a history of acute kidney disease, lupus, sarcoid, amyloid, gout, or other autoimmune conditions, as well as a history of kidney stones of cancer. Kidney donors or transplant recipients are at increased risk, as are smokers, soda drinkers, and heavy salt users.
CKD is missed by many health care providers, Ms. Zuber said. For example, she cited data from more than 270,000 veterans treated at a Veterans Affairs hospital in Texas, which suggested that the likelihood of adding CKD to a patient’s diagnosis was 43.7% even if lab results confirmed CKD.
Find the patients
There are many formulas for defining kidney function, Ms. Zuber said. The estimation of creatinine clearance (eCrCl) and estimated glomerular filtration rate (eGFR) are among them. The most common definition is to calculate eGFR using the CKD-EPI formula. Cystatin C is more exact, but it is not standardized, so a lab in one state does not use the same formula as one in another state.
Overall, all these formulas are plus or minus 30%. “It is an estimate,” she said. Within the stages of CKD, “what we know is that, if you have a high GFR, that’s good, but patients who are losing albumin are at increased risk for CKD.” The albumin is more of a risk factor for CKD than GFR, so the GFR test used doesn’t make much difference, whereas, “if you have a lot of albumin in your urine, you are going downhill,” she said.
Normally, everyone loses kidney function with age, Ms. Zuber said. Starting at age 30, individuals lose about 1 mL/min per year in measures of GFR, however, this progression is more rapid among those with CKD, so “we need to find those people who are progressing more quickly than normal.”
The way to identify the high-risk patients is albumin, Ms. Zuber said. Health care providers need to test the urine and check albumin for high levels of albumin loss through urine, and many providers simply don’t routinely conduct urine tests for patients with other CKD risk factors such as diabetes or hypertension.
Albuminuria levels of 2,000 mg/g are the most concerning, and a urine-albumin-to-creatinine ratio (UACR) test is the most effective tool to monitor kidney function, Ms. Zuber said.
She recommends ordering a UACR test at least once a year to monitor kidney loss in all patients with hypertension, diabetes, lupus, and other risk factors including race and a history of acute kidney injury.