Screening for chronic kidney disease: where does Europe go?

Abstract

This review discusses various screening approaches for chronic kidney disease that are used in Europe. The criterion for defining chronic kidney disease in the various programs differs but is frequently limited to estimated glomerular filtration rate, thus offering only data on chronic kidney disease stages 3 and higher; however, screening should not be limited to measuring only estimated glomerular filtration rate but should also include a measure of microalbuminuria, because this will offer identification of chronic kidney disease stages 1 and 2. Defining these earlier stages is of importance because the risk for developing end-stage renal disease that is associated with stages 1 and 2 is nearly equal to the risk that is associated with stage 3. Moreover, the risk for cardiovascular events in stages 1 and 2 is equal to that in stage 3. Various reports argue that costs of screening programs in general practitioner or outpatient offices are high and that they are cost-effective only for preventing end-stage renal disease when they are limited to target groups, such as patients with diabetes or hypertension and elderly. The benefits of screening programs, however, should not be evaluated only with respect to the prevention of renal events but should also include the benefits of preventing cardiovascular events. The use of preselection based on either an impaired estimated glomerular filtration rate or on protein-dipstick positivity or elevated albuminuria in a morning urine void has been found effective in various European countries as an alternative for targeted screening.

Figure 1.

The uroscopist. Painting by David Teniers (1610 to 1690) in the Royal Museum for Art, Brussels, Belgium. Already long ago, screening of the urine could help the village physician to monitor his patient. Although medical history has resulted in many new discoveries since then, in 2007 we still can learn much from screening of the urine.

Figure 2.

Incidence of ESRD (Œ) and cardiovascular disease (CVD) events (f) according to baseline chronic kidney disease (CKD) stage. Data derived from the Prevention of Renal and Vascular Endstage Disease (PREVEND) study. Notice the log scale on the vertical axis.

Figure 3.

Various screening approaches for CKD applied in Europe. ACR, albumin-creatinine ratio; CV, cardiovascular; DM, diabetes; eGFR, estimated GFR; GP, general practitioner; HT, hypertension.

Figure 4.

Percentage of individuals who score negative or trace, 1, 2, or 3 positive on a dipstick protein test that with closer examination seemed to have microalbuminuria or macroalbuminuria. Microalbuminuria defined as ACR 30 and 300 mg/g and macroalbuminuria as ACR 300 mg/g (33).