Battle brews over screening for asymptomatic kidney disease

Adults who don’t show symptoms of, or have risk factors for, early chronic kidney disease should not be screened for it, according to new guidelines from the American College of Physicians.

But the ACP’s recommendation prompted the American Society of Nephrology to counter with its own strong recommendation in favor of kidney disease screening regardless of a patient’s risk factors.

"There is no evidence that obtaining a ‘baseline creatinine’ level, or screening for renal dysfunction in asymptomatic individuals with no risk factors for kidney disease, improves outcomes for patients," said ACP President Molly Cooke in an interview.

The clinical practice guidelines are the first issued by the ACP for the screening, monitoring, and treatment of stage 1-3 chronic kidney disease in adults. Major risk factors for CKD in adults include diabetes, hypertension, and cardiovascular disease.

The ACP published the guidelines online in Annals of Internal Medicine 2013 Oct. 22 [doi:10.7326/0003-4819-159-12-201312170-00726]).

The college’s Clinical Guidelines Committee used Medline and Cochrane databases to systematically review all relevant data published between 1985 and November 2011. Outcomes assessed for the guidelines included all-cause mortality, cardiovascular events and disease, composite renal and vascular outcomes, end-stage renal disease, quality of life, physical function, and activities of daily living.

The investigators determined that there was not enough evidence to evaluate the benefits and harms of screening for early CKD, and so they recommended that clinicians not perform it.

The ACP specifically recommended against proteinuria testing in adults with or without diabetes and who are currently taking angiotensin-converting enzyme (ACE) inhibitors or angiotensin II receptor blockers (ARBs). That recommendation was a “reminder to physicians not to do tests that will not change patient management,” Dr. Cooke said. ACE inhibitors or ARBs are already the treatment for microalbuminuria, a form of low-grade proteinuria. “There is no evidence that monitoring proteinuria to assess the effects of pharmacological hypertension management produces better outcomes,” she added.

ASN: No screen? No way!

The ACP’s recommendations spurred an immediate rebuke from the American Society of Nephrology.

“Early detection is the key to preventing patients from progressing to relying on dialysis to stay alive,” Dr. Tod Ibrahim, the ASN’s executive director, said in a statement. “ASN and its nearly 15,000 members – all of whom are experts in kidney disease – are disappointed by ACP’s irresponsible recommendation.”

The lack of evidence on the benefits and harms of early CKD screening is precisely why physicians should test for early-stage CKD, according to ASN President Bruce Molitoris.

“One of the problems with CKD is we don’t have effective mechanisms to detect it early,” he said in an interview. “What we do have is screening for proteinuria, which is a very simple, extremely inexpensive test that can give great insight.”

As for proteinuria testing in adults taking ACE inhibitors or ARBs, there might be a more nuanced benefit, Dr. Molitoris explained. “It’s a little bit more incentive to increase compliance in a patient who is taking a medication for hypertension if you tell them they’re getting progressive kidney disease if they don’t control their blood pressure,” he said. “Not all patients with hypertension are started out on those first-line drugs,” he added.

The ACP endorses treating patients who have hypertension or stage 1-3 CKD with ACE inhibitors or ARBs, as well as giving patients with early CKD appropriate statin therapy to manage elevated levels of low-density lipoprotein. However, the college calls additional screening and treatment largely superfluous.

“For doctors who have been using a thiazide diuretic or a beta-blocker as their initial antihypertensive of choice, this guideline should change their practice,” said Dr. Cooke. However, because many practice “report cards” call for an annual urine microalbumin test in diabetic patients, many physicians perform the test on patients who are already on an ACE inhibitor or an ARB, she said.

“This guideline should prompt them to respond ‘test not indicated’ when it is requested,” Dr. Cooke said.

The ACP found no significant differences in outcomes between ACE inhibitors and ARBs, although it did note that the risk of adverse effects (cough, hyperkalemia, hypotension, and dialysis) significantly increased in combined ACE inhibitor and ARB therapy.

Meanwhile, the National Kidney Foundation recommends that anyone with diabetes, hypertension, cardiovascular disease, age over 60, or a family history of kidney failure have a blood test to estimate their glomerular filtration rate (GFR) and a urine test for proteinuria.

“The ACP guidelines looked at the clinical outcomes of CKD very differently than our guidelines did,” cautioned Sean Roach, spokesperson for the NKF, in an e-mail. The ACP put “CKD stages 1-3 together when they have markedly different risks of adverse outcomes, and [didn’t take] into account all of the patient safety issues that arise due to ignorance of a patient’s level of kidney function.

“We acknowledge that there have been no randomized trials of CKD screening,” Mr. Roach noted, “but our recommendations are based on extensive analysis of observational trials, clinical trials of diabetes and antihypertensive drugs, and clinical experience.”

Critics question CKD criteria

A recent U.S. Preventive Services Task Force (USPSTF) report took a position similar to the ACP’s, stating there is currently insufficient evidence to recommend general population-based screening. That report noted that although early screening could affect outcomes for people already diagnosed with conditions such as diabetes or hypertension, no evidence existed to show the benefits of early treatment in people without these risk factors.

The ASN swiftly responded. "We sent [the USPSTF] a letter asking them to reconsider," said Dr. Molitoris. "That was within the last 6 months. They came back with a ‘high recommendation’ for collecting more data to analyze the cost effectiveness of screening."

In 2002, the NFK-sponsored Kidney Disease: Improving Global Outcomes (KDIGO) released landmark guidelines on CKD. In a 2012 guidelines update, KDIGO kept the criteria it established in 2002 for CKD, including diagnostic thresholds of a GFR less than 60 mL/min per 1.73 m² and an albumin/creatinine ratio (ACR) of at least 30 mg/g. And it maintained its five-stage CKD classification system.

But it expanded the existing five-stage classification system to include two subcategories of grade 3 GFR categories – G3a, with a GFR of 45-59; and G3b, with a GFR of 30-44 – and three additional categories of albuminuria (Ann. Intern. Med. 2013;158:825-30).

Those CKD criteria raised eyebrows not just at the ACP, but also with some evidence-based medicine scholars. In an analysis published online earlier this year in BMJ, Dr. Roy Moynihan of the Centre for Research in Evidence-Based Practice, Robina, Australia, cited data that the GFR value used by KDIGO to determine early CKD falls within the normal range for men over age 60 and women over age 50.

By "labeling so many people at low risk of symptoms as having chronic kidney disease, the new definition axiomatically produces overdiagnosis," Dr. Moynihan and his colleagues cautioned (BMJ 2013;347:f4298).

Prior to the 2002 publication of the KDIGO criteria for CKD, according to Dr. Moynihan, the incidence rate for CKD in U.S. adults was estimated to be around 1.7%. After 2002, using the KDIGO criteria, it rose to 1 in 8 adults, or about 14% of the adult population.

"The controversial aspect around that is, at what point as your GFR decreases does it become abnormal?" cautioned Dr. Molitoris. "If you have a reduced GFR, and proteinuria, we know that’s abnormal. That’s why the screening for proteinuria is so important. If you just have a reduced GFR to a certain extent, it may be a normal aging process. That’s the European perspective, and I think they have a point there."

‘Different worldview’

While the ACP guidelines for CKD refer to the KDIGO criteria as their counterpoint, Dr. Cooke said she did not know what motivated KDIGO to expand the criteria. She suggested it might be the "different worldview" phenomenon that often occurs between subspecialists and generalists.

"It’s tempting to say, ‘Let’s just test everybody’s creatinine,’ " Dr. Cooke noted. "But it’s just like with prostate cancer screening: Once you start to factor in all the costs – and not just the money – of testing on that broad of a scale, it doesn’t [add up]."

But Dr. Molitoris countered that CKD screening is more akin to testing for cardiovascular disease.

"One could make the comparison to checking for cholesterol, only that’s invasive – that’s drawing blood," he said. "This is just taking urine, and yet, how many people do we screen for cholesterol? There is no risk in doing the proteinuria test. You collect the urine, put a stick into it, and read it. If it’s positive, then you will follow up with a more sophisticated chemical test." He also noted that false positives in proteinuria tests are rare.

The ACP guidelines offer physicians what it calls "high-value care advice": Skip early CKD screening, because in the absence of evidence that screening improves clinical outcomes, "testing will add costs, owing to both the screening test and additional follow-up tests (including those resulting from false-positive findings), increased medical visits, and costs of keeping or obtaining health insurance."

Dr. Molitoris disagreed, citing "the aggressive and silent nature" of kidney disease in all its stages.

"You have to think of the cost analysis as how many screenings you can do for the cost of one patient who goes on to need dialysis. That costs between $80,000 and $90,000 a year to maintain for every year [a patient is] on it," Dr. Molitoris explained. "You can do a lot of screening on that."

Dr. Cooke said the ACP was calling for a "middle ground" to bring the discussion back to what is best for the patient, not the practitioner.

"We are saying that unless the patient has a reason for you to be concerned, other than the fact that they are a human being, there is no reason to screen for CKD every year," she explained. "There is no evidence that diagnosing the average person on the street as stage 1 or 2 [CKD] does them any good if they don’t have any risk factors."

The American College of Physicians funded the guidelines. The guidelines’ authors had no relevant disclosures.

[email protected]

Adults who don’t show symptoms of, or have risk factors for, early chronic kidney disease should not be screened for it, according to new guidelines from the American College of Physicians.

But the ACP’s recommendation prompted the American Society of Nephrology to counter with its own strong recommendation in favor of kidney disease screening regardless of a patient’s risk factors.

"There is no evidence that obtaining a ‘baseline creatinine’ level, or screening for renal dysfunction in asymptomatic individuals with no risk factors for kidney disease, improves outcomes for patients," said ACP President Molly Cooke in an interview.

The clinical practice guidelines are the first issued by the ACP for the screening, monitoring, and treatment of stage 1-3 chronic kidney disease in adults. Major risk factors for CKD in adults include diabetes, hypertension, and cardiovascular disease.

The ACP published the guidelines online in Annals of Internal Medicine 2013 Oct. 22 [doi:10.7326/0003-4819-159-12-201312170-00726]).

The college’s Clinical Guidelines Committee used Medline and Cochrane databases to systematically review all relevant data published between 1985 and November 2011. Outcomes assessed for the guidelines included all-cause mortality, cardiovascular events and disease, composite renal and vascular outcomes, end-stage renal disease, quality of life, physical function, and activities of daily living.

The investigators determined that there was not enough evidence to evaluate the benefits and harms of screening for early CKD, and so they recommended that clinicians not perform it.

The ACP specifically recommended against proteinuria testing in adults with or without diabetes and who are currently taking angiotensin-converting enzyme (ACE) inhibitors or angiotensin II receptor blockers (ARBs). That recommendation was a “reminder to physicians not to do tests that will not change patient management,” Dr. Cooke said. ACE inhibitors or ARBs are already the treatment for microalbuminuria, a form of low-grade proteinuria. “There is no evidence that monitoring proteinuria to assess the effects of pharmacological hypertension management produces better outcomes,” she added.

ASN: No screen? No way!

The ACP’s recommendations spurred an immediate rebuke from the American Society of Nephrology.

“Early detection is the key to preventing patients from progressing to relying on dialysis to stay alive,” Dr. Tod Ibrahim, the ASN’s executive director, said in a statement. “ASN and its nearly 15,000 members – all of whom are experts in kidney disease – are disappointed by ACP’s irresponsible recommendation.”

The lack of evidence on the benefits and harms of early CKD screening is precisely why physicians should test for early-stage CKD, according to ASN President Bruce Molitoris.

“One of the problems with CKD is we don’t have effective mechanisms to detect it early,” he said in an interview. “What we do have is screening for proteinuria, which is a very simple, extremely inexpensive test that can give great insight.”

As for proteinuria testing in adults taking ACE inhibitors or ARBs, there might be a more nuanced benefit, Dr. Molitoris explained. “It’s a little bit more incentive to increase compliance in a patient who is taking a medication for hypertension if you tell them they’re getting progressive kidney disease if they don’t control their blood pressure,” he said. “Not all patients with hypertension are started out on those first-line drugs,” he added.

The ACP endorses treating patients who have hypertension or stage 1-3 CKD with ACE inhibitors or ARBs, as well as giving patients with early CKD appropriate statin therapy to manage elevated levels of low-density lipoprotein. However, the college calls additional screening and treatment largely superfluous.

“For doctors who have been using a thiazide diuretic or a beta-blocker as their initial antihypertensive of choice, this guideline should change their practice,” said Dr. Cooke. However, because many practice “report cards” call for an annual urine microalbumin test in diabetic patients, many physicians perform the test on patients who are already on an ACE inhibitor or an ARB, she said.

“This guideline should prompt them to respond ‘test not indicated’ when it is requested,” Dr. Cooke said.

The ACP found no significant differences in outcomes between ACE inhibitors and ARBs, although it did note that the risk of adverse effects (cough, hyperkalemia, hypotension, and dialysis) significantly increased in combined ACE inhibitor and ARB therapy.

Meanwhile, the National Kidney Foundation recommends that anyone with diabetes, hypertension, cardiovascular disease, age over 60, or a family history of kidney failure have a blood test to estimate their glomerular filtration rate (GFR) and a urine test for proteinuria.

“The ACP guidelines looked at the clinical outcomes of CKD very differently than our guidelines did,” cautioned Sean Roach, spokesperson for the NKF, in an e-mail. The ACP put “CKD stages 1-3 together when they have markedly different risks of adverse outcomes, and [didn’t take] into account all of the patient safety issues that arise due to ignorance of a patient’s level of kidney function.

“We acknowledge that there have been no randomized trials of CKD screening,” Mr. Roach noted, “but our recommendations are based on extensive analysis of observational trials, clinical trials of diabetes and antihypertensive drugs, and clinical experience.”

Critics question CKD criteria

A recent U.S. Preventive Services Task Force (USPSTF) report took a position similar to the ACP’s, stating there is currently insufficient evidence to recommend general population-based screening. That report noted that although early screening could affect outcomes for people already diagnosed with conditions such as diabetes or hypertension, no evidence existed to show the benefits of early treatment in people without these risk factors.

The ASN swiftly responded. "We sent [the USPSTF] a letter asking them to reconsider," said Dr. Molitoris. "That was within the last 6 months. They came back with a ‘high recommendation’ for collecting more data to analyze the cost effectiveness of screening."

In 2002, the NFK-sponsored Kidney Disease: Improving Global Outcomes (KDIGO) released landmark guidelines on CKD. In a 2012 guidelines update, KDIGO kept the criteria it established in 2002 for CKD, including diagnostic thresholds of a GFR less than 60 mL/min per 1.73 m² and an albumin/creatinine ratio (ACR) of at least 30 mg/g. And it maintained its five-stage CKD classification system.

But it expanded the existing five-stage classification system to include two subcategories of grade 3 GFR categories – G3a, with a GFR of 45-59; and G3b, with a GFR of 30-44 – and three additional categories of albuminuria (Ann. Intern. Med. 2013;158:825-30).

Those CKD criteria raised eyebrows not just at the ACP, but also with some evidence-based medicine scholars. In an analysis published online earlier this year in BMJ, Dr. Roy Moynihan of the Centre for Research in Evidence-Based Practice, Robina, Australia, cited data that the GFR value used by KDIGO to determine early CKD falls within the normal range for men over age 60 and women over age 50.

By "labeling so many people at low risk of symptoms as having chronic kidney disease, the new definition axiomatically produces overdiagnosis," Dr. Moynihan and his colleagues cautioned (BMJ 2013;347:f4298).

Prior to the 2002 publication of the KDIGO criteria for CKD, according to Dr. Moynihan, the incidence rate for CKD in U.S. adults was estimated to be around 1.7%. After 2002, using the KDIGO criteria, it rose to 1 in 8 adults, or about 14% of the adult population.

"The controversial aspect around that is, at what point as your GFR decreases does it become abnormal?" cautioned Dr. Molitoris. "If you have a reduced GFR, and proteinuria, we know that’s abnormal. That’s why the screening for proteinuria is so important. If you just have a reduced GFR to a certain extent, it may be a normal aging process. That’s the European perspective, and I think they have a point there."

‘Different worldview’

While the ACP guidelines for CKD refer to the KDIGO criteria as their counterpoint, Dr. Cooke said she did not know what motivated KDIGO to expand the criteria. She suggested it might be the "different worldview" phenomenon that often occurs between subspecialists and generalists.

"It’s tempting to say, ‘Let’s just test everybody’s creatinine,’ " Dr. Cooke noted. "But it’s just like with prostate cancer screening: Once you start to factor in all the costs – and not just the money – of testing on that broad of a scale, it doesn’t [add up]."

But Dr. Molitoris countered that CKD screening is more akin to testing for cardiovascular disease.

"One could make the comparison to checking for cholesterol, only that’s invasive – that’s drawing blood," he said. "This is just taking urine, and yet, how many people do we screen for cholesterol? There is no risk in doing the proteinuria test. You collect the urine, put a stick into it, and read it. If it’s positive, then you will follow up with a more sophisticated chemical test." He also noted that false positives in proteinuria tests are rare.

The ACP guidelines offer physicians what it calls "high-value care advice": Skip early CKD screening, because in the absence of evidence that screening improves clinical outcomes, "testing will add costs, owing to both the screening test and additional follow-up tests (including those resulting from false-positive findings), increased medical visits, and costs of keeping or obtaining health insurance."

Dr. Molitoris disagreed, citing "the aggressive and silent nature" of kidney disease in all its stages.

"You have to think of the cost analysis as how many screenings you can do for the cost of one patient who goes on to need dialysis. That costs between $80,000 and $90,000 a year to maintain for every year [a patient is] on it," Dr. Molitoris explained. "You can do a lot of screening on that."

Dr. Cooke said the ACP was calling for a "middle ground" to bring the discussion back to what is best for the patient, not the practitioner.

"We are saying that unless the patient has a reason for you to be concerned, other than the fact that they are a human being, there is no reason to screen for CKD every year," she explained. "There is no evidence that diagnosing the average person on the street as stage 1 or 2 [CKD] does them any good if they don’t have any risk factors."

The American College of Physicians funded the guidelines. The guidelines’ authors had no relevant disclosures.

[email protected]

Adults who don’t show symptoms of, or have risk factors for, early chronic kidney disease should not be screened for it, according to new guidelines from the American College of Physicians.

But the ACP’s recommendation prompted the American Society of Nephrology to counter with its own strong recommendation in favor of kidney disease screening regardless of a patient’s risk factors.

"There is no evidence that obtaining a ‘baseline creatinine’ level, or screening for renal dysfunction in asymptomatic individuals with no risk factors for kidney disease, improves outcomes for patients," said ACP President Molly Cooke in an interview.

The clinical practice guidelines are the first issued by the ACP for the screening, monitoring, and treatment of stage 1-3 chronic kidney disease in adults. Major risk factors for CKD in adults include diabetes, hypertension, and cardiovascular disease.

The ACP published the guidelines online in Annals of Internal Medicine 2013 Oct. 22 [doi:10.7326/0003-4819-159-12-201312170-00726]).

The college’s Clinical Guidelines Committee used Medline and Cochrane databases to systematically review all relevant data published between 1985 and November 2011. Outcomes assessed for the guidelines included all-cause mortality, cardiovascular events and disease, composite renal and vascular outcomes, end-stage renal disease, quality of life, physical function, and activities of daily living.

The investigators determined that there was not enough evidence to evaluate the benefits and harms of screening for early CKD, and so they recommended that clinicians not perform it.

The ACP specifically recommended against proteinuria testing in adults with or without diabetes and who are currently taking angiotensin-converting enzyme (ACE) inhibitors or angiotensin II receptor blockers (ARBs). That recommendation was a “reminder to physicians not to do tests that will not change patient management,” Dr. Cooke said. ACE inhibitors or ARBs are already the treatment for microalbuminuria, a form of low-grade proteinuria. “There is no evidence that monitoring proteinuria to assess the effects of pharmacological hypertension management produces better outcomes,” she added.

ASN: No screen? No way!

The ACP’s recommendations spurred an immediate rebuke from the American Society of Nephrology.

“Early detection is the key to preventing patients from progressing to relying on dialysis to stay alive,” Dr. Tod Ibrahim, the ASN’s executive director, said in a statement. “ASN and its nearly 15,000 members – all of whom are experts in kidney disease – are disappointed by ACP’s irresponsible recommendation.”

The lack of evidence on the benefits and harms of early CKD screening is precisely why physicians should test for early-stage CKD, according to ASN President Bruce Molitoris.

“One of the problems with CKD is we don’t have effective mechanisms to detect it early,” he said in an interview. “What we do have is screening for proteinuria, which is a very simple, extremely inexpensive test that can give great insight.”

As for proteinuria testing in adults taking ACE inhibitors or ARBs, there might be a more nuanced benefit, Dr. Molitoris explained. “It’s a little bit more incentive to increase compliance in a patient who is taking a medication for hypertension if you tell them they’re getting progressive kidney disease if they don’t control their blood pressure,” he said. “Not all patients with hypertension are started out on those first-line drugs,” he added.

The ACP endorses treating patients who have hypertension or stage 1-3 CKD with ACE inhibitors or ARBs, as well as giving patients with early CKD appropriate statin therapy to manage elevated levels of low-density lipoprotein. However, the college calls additional screening and treatment largely superfluous.

“For doctors who have been using a thiazide diuretic or a beta-blocker as their initial antihypertensive of choice, this guideline should change their practice,” said Dr. Cooke. However, because many practice “report cards” call for an annual urine microalbumin test in diabetic patients, many physicians perform the test on patients who are already on an ACE inhibitor or an ARB, she said.

“This guideline should prompt them to respond ‘test not indicated’ when it is requested,” Dr. Cooke said.

The ACP found no significant differences in outcomes between ACE inhibitors and ARBs, although it did note that the risk of adverse effects (cough, hyperkalemia, hypotension, and dialysis) significantly increased in combined ACE inhibitor and ARB therapy.

Meanwhile, the National Kidney Foundation recommends that anyone with diabetes, hypertension, cardiovascular disease, age over 60, or a family history of kidney failure have a blood test to estimate their glomerular filtration rate (GFR) and a urine test for proteinuria.

“The ACP guidelines looked at the clinical outcomes of CKD very differently than our guidelines did,” cautioned Sean Roach, spokesperson for the NKF, in an e-mail. The ACP put “CKD stages 1-3 together when they have markedly different risks of adverse outcomes, and [didn’t take] into account all of the patient safety issues that arise due to ignorance of a patient’s level of kidney function.

“We acknowledge that there have been no randomized trials of CKD screening,” Mr. Roach noted, “but our recommendations are based on extensive analysis of observational trials, clinical trials of diabetes and antihypertensive drugs, and clinical experience.”

Critics question CKD criteria

A recent U.S. Preventive Services Task Force (USPSTF) report took a position similar to the ACP’s, stating there is currently insufficient evidence to recommend general population-based screening. That report noted that although early screening could affect outcomes for people already diagnosed with conditions such as diabetes or hypertension, no evidence existed to show the benefits of early treatment in people without these risk factors.

The ASN swiftly responded. "We sent [the USPSTF] a letter asking them to reconsider," said Dr. Molitoris. "That was within the last 6 months. They came back with a ‘high recommendation’ for collecting more data to analyze the cost effectiveness of screening."

In 2002, the NFK-sponsored Kidney Disease: Improving Global Outcomes (KDIGO) released landmark guidelines on CKD. In a 2012 guidelines update, KDIGO kept the criteria it established in 2002 for CKD, including diagnostic thresholds of a GFR less than 60 mL/min per 1.73 m² and an albumin/creatinine ratio (ACR) of at least 30 mg/g. And it maintained its five-stage CKD classification system.

But it expanded the existing five-stage classification system to include two subcategories of grade 3 GFR categories – G3a, with a GFR of 45-59; and G3b, with a GFR of 30-44 – and three additional categories of albuminuria (Ann. Intern. Med. 2013;158:825-30).

Those CKD criteria raised eyebrows not just at the ACP, but also with some evidence-based medicine scholars. In an analysis published online earlier this year in BMJ, Dr. Roy Moynihan of the Centre for Research in Evidence-Based Practice, Robina, Australia, cited data that the GFR value used by KDIGO to determine early CKD falls within the normal range for men over age 60 and women over age 50.

By "labeling so many people at low risk of symptoms as having chronic kidney disease, the new definition axiomatically produces overdiagnosis," Dr. Moynihan and his colleagues cautioned (BMJ 2013;347:f4298).

Prior to the 2002 publication of the KDIGO criteria for CKD, according to Dr. Moynihan, the incidence rate for CKD in U.S. adults was estimated to be around 1.7%. After 2002, using the KDIGO criteria, it rose to 1 in 8 adults, or about 14% of the adult population.

"The controversial aspect around that is, at what point as your GFR decreases does it become abnormal?" cautioned Dr. Molitoris. "If you have a reduced GFR, and proteinuria, we know that’s abnormal. That’s why the screening for proteinuria is so important. If you just have a reduced GFR to a certain extent, it may be a normal aging process. That’s the European perspective, and I think they have a point there."

‘Different worldview’

While the ACP guidelines for CKD refer to the KDIGO criteria as their counterpoint, Dr. Cooke said she did not know what motivated KDIGO to expand the criteria. She suggested it might be the "different worldview" phenomenon that often occurs between subspecialists and generalists.

"It’s tempting to say, ‘Let’s just test everybody’s creatinine,’ " Dr. Cooke noted. "But it’s just like with prostate cancer screening: Once you start to factor in all the costs – and not just the money – of testing on that broad of a scale, it doesn’t [add up]."

But Dr. Molitoris countered that CKD screening is more akin to testing for cardiovascular disease.

"One could make the comparison to checking for cholesterol, only that’s invasive – that’s drawing blood," he said. "This is just taking urine, and yet, how many people do we screen for cholesterol? There is no risk in doing the proteinuria test. You collect the urine, put a stick into it, and read it. If it’s positive, then you will follow up with a more sophisticated chemical test." He also noted that false positives in proteinuria tests are rare.

The ACP guidelines offer physicians what it calls "high-value care advice": Skip early CKD screening, because in the absence of evidence that screening improves clinical outcomes, "testing will add costs, owing to both the screening test and additional follow-up tests (including those resulting from false-positive findings), increased medical visits, and costs of keeping or obtaining health insurance."

Dr. Molitoris disagreed, citing "the aggressive and silent nature" of kidney disease in all its stages.

"You have to think of the cost analysis as how many screenings you can do for the cost of one patient who goes on to need dialysis. That costs between $80,000 and $90,000 a year to maintain for every year [a patient is] on it," Dr. Molitoris explained. "You can do a lot of screening on that."

Dr. Cooke said the ACP was calling for a "middle ground" to bring the discussion back to what is best for the patient, not the practitioner.

"We are saying that unless the patient has a reason for you to be concerned, other than the fact that they are a human being, there is no reason to screen for CKD every year," she explained. "There is no evidence that diagnosing the average person on the street as stage 1 or 2 [CKD] does them any good if they don’t have any risk factors."

The American College of Physicians funded the guidelines. The guidelines’ authors had no relevant disclosures.

[email protected]