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Screening strategies for chronic kidney disease in the general population: follow-up of cross sectio

Setting Nord-Trøndelag County, Norway Participants 65 604 people (70.6% of all adults aged ≥ 20 in the county). Main outcome measures Incident end stage renal disease (ESRD) and cardiovascular mortality monitored by individual linkage to central registries. Results 3069/65 604 (4.7%) people had chronic kidney disease (estimated glomerular filtration rate < 60 ml/min/1.73 m2), so we would need to screen 20.6 people (95% confidence interval 20.0 to 21.2) to identify one case. Restriction of screening to those with hypertension, diabetes, or age > 55 would identify 93.2% (92.4% to 94.0%) of patients with chronic kidney disease, with a number needed to screen of 8.7 (8.5 to 9.0). Restriction of screening according to guidelines of the United States kidney disease outcomes quality initiative (US KDOQI) gave similar results, but restriction according to the United Kingdom’s chronic kidney disease guidelines detected only 51.6% (49.6% to 53.4%) of cases. Screening only people with previously known diabetes or hypertension detected 44.2% (42.7% to 45.7%) of all cases, with a number needed to screen of six. During the eight year follow-up only 38 of the 3069 people with chronic kidney disease progressed to end stage renal disease, and the risk was especially low in people without diabetes or hypertension, women, and those aged ≥ 70 or with a glomerular filtration rate 45-59 ml/min/1.73 m2 at screening. In contrast, there was a high cardiovascular mortality: 3.5, 7.4, and 10.1 deaths per 100 person years among people with a glomerular filtration rate 45-59, 30-44, and < 30 ml/min/1.73 m2, respectively. Conclusion Screening people with hypertension, diabetes mellitus, or age > 55 was the most effective strategy to detect patients with chronic kidney disease, but the risk of end stage renal disease among those detected was low. Introduction Currently, screening for chronic kidney disease is accepted practice only in patients with hypertension or diabetes.1 2 More widespread screening is increasingly proposed,3–6 including screening of all patients visiting general practitioners.7 Recommendations, however, are based mostly on consensus procedures,5 8 and the different screening strategies have not been compared for their ability to detect chronic kidney disease or their efficiency. It has also been assumed that most patients with advanced renal insufficiency (stages 3-5) will eventually require renal replacement therapy,9 but the natural course in those with newly detected disease (stages 3-5) is not well described. We compared strategies for detecting patients with chronic kidney disease and examined the occurrence of end stage renal disease or cardiovascular death in these patients.We used data from the population based Nord-Trøndelag health study (HUNT study), Norway, and assessed different screening models. We also report on progression to end stage renal disease or cardiovascular death over the next eight years. Material and methods Study sample and design During 1995-7, a large scale general health survey was conducted in Nord-Trøndelag County, Norway.10 The population is ethnically homogenous and fairly representative of Norway. Everyone aged ≥ 20 (n = 92 939) was invited to participate, and 70.6% did so. The survey comprised a questionnaire and clinical examination, including analysis of serum creatinine concentration. Three consecutive standardised blood pressure measurements were recorded. Participants were observed to 31 June 2004 or until advancement to end stage renal disease or death, by individual linkage to central registries with the unique identification number of every Norwegian citizen. See bmj.com for laboratory methods and estimation of glomerular filtration rate. Statistical analysis We assessed the established model of screening only people with previously known diabetes mellitus or treated hypertension. We evaluated models that included people with other risk factors like higher age groups, obesity, smoking, cardiovascular disease, or family history of hypertension or diabetes. Finally, we assessed screening models proposed by international authorities: a modification of the UK chronic kidney disease guidelines (screening people with diabetes/ hypertension/cardiovascular disease/moderate to severe lower urinary tract symptoms/autoimmune disease); a modification of the US kidney disease outcomes quality initiative guidelines (screening people with diabetes/hypertension/age > 60/ autoimmune disease); and the International Society of Nephrology (screening everybody). When appropriate, we used receiver operating characteristics curves This is the abridged version of an article that was posted on bmj.com on 6 November 2006: http://bmj.com/cgi/doi/ 10.1136/bmj.39001.657755.BE Research Editorial by Clase Department of Cancer Research and Molecular Biology, Faculty of Medicine, Norwegian University of Science and Technology, 7006 Trondheim, Norway Stein I Hallan associate professor Department of Medicine, Division of Nephrology, St Olav University Hospital, 7006 Trondheim, Norway Ketil Dahl consultant Cecilia M Oien consultant Department of Clinical Epidemiology, Leiden University Medical Center, 2300 Leiden, Netherlands Diana C Grootendorst postdoctoral fellow Friedo W Dekker associate professor Department of Clinical Biochemistry, St Olav University Hospital, 7006 Trondheim Arne Aasberg consultant HUNT Research Center, Faculty of Medicine, Norwegian University of Science and Technology, 7650 Verdal, Norway Jostein Holmen professor Correspondence to: S I Hallan Dit e-mailadres wordt beveiligd tegen spambots. JavaScript dient ingeschakeld te zijn om het te bekijken. BMJ 2006;333:1047–50 BMJIntroductionCurrently, screening for chronic kidney disease isaccepted practice only in patients with hypertension ordiabetes.1 2 More widespread screening is increasinglyproposed,3–6 including screening of all patients visitinggeneral practitioners.7 Recommendations, however,are based mostly on consensus procedures,5 8 and thedifferent screening strategies have not been comparedfor their ability to detect chronic kidney disease or theirefficiency. It has also been assumed that most patientswith advanced renal insufficiency (stages 3-5) willeventually require renal replacement therapy,9 but thenatural course in those with newly detected disease(stages 3-5) is not well described. Stein I Hallan, Ketil Dahl, Cecilia M Oien, Diana C Grootendorst, Arne Aasberg, Jostein Holmen, Friedo W Dekker Abstract Objective To find an effective screening strategy for detecting patients with chronic kidney disease and to describe the natural course of the disease. Design Eight year follow-up of a cross sectional health survey (the HUNT II study). Setting Nord-Trøndelag County, Norway Participants 65 604 people (70.6% of all adults aged ≥ 20 in the county). Main outcome measures Incident end stage renal disease (ESRD) and cardiovascular mortality monitored by individual linkage to central registries. Results 3069/65 604 (4.7%) people had chronic kidney disease (estimated glomerular filtration rate < 60 ml/min/1.73 m2), so we would need to screen 20.6 people (95% confidence interval 20.0 to 21.2) to identify one case. Restriction of screening to those with hypertension, diabetes, or age > 55 would identify 93.2% (92.4% to 94.0%) of patients with chronic kidney disease, with a number needed to screen of 8.7 (8.5 to 9.0). Restriction of screening according to guidelines of the United States kidney disease outcomes quality initiative (US KDOQI) gave similar results, but restriction according to the United Kingdom’s chronic kidney disease guidelines detected only 51.6% (49.6% to 53.4%) of cases. Screening only people with previously known diabetes or hypertension detected 44.2% (42.7% to 45.7%) of all cases, with a number needed to screen of six. During the eight year follow-up only 38 of the 3069 people with chronic kidney disease progressed to end stage renal disease, and the risk was especially low in people without diabetes or hypertension, women, and those aged ≥ 70 or with a glomerular filtration rate 45-59 ml/min/1.73 m2 at screening. In contrast, there was a high cardiovascular mortality: 3.5, 7.4, and 10.1 deaths per 100 person years among people with a glomerular filtration rate 45-59, 30-44, and < 30 ml/min/1.73 m2, respectively. Conclusion Screening people with hypertension, diabetes mellitus, or age > 55 was the most effective strategy to detect patients with chronic kidney disease, but the risk of end stage renal disease among those detected was low. Introduction Currently, screening for chronic kidney disease is accepted practice only in patients with hypertension or diabetes.1 2 More widespread screening is increasingly proposed,3–6 including screening of all patients visiting general practitioners.7 Recommendations, however, are based mostly on consensus procedures,5 8 and the different screening strategies have not been compared for their ability to detect chronic kidney disease or their efficiency. It has also been assumed that most patients with advanced renal insufficiency (stages 3-5) will eventually require renal replacement therapy,9 but the natural course in those with newly detected disease (stages 3-5) is not well described. We compared strategies for detecting patients with chronic kidney disease and examined the occurrence of end stage renal disease or cardiovascular death in these patients.We used data from the population based Nord-Trøndelag health study (HUNT study), Norway, and assessed different screening models. We also report on progression to end stage renal disease or cardiovascular death over the next eight years. Material and methods Study sample and design During 1995-7, a large scale general health survey was conducted in Nord-Trøndelag County, Norway.10 The population is ethnically homogenous and fairly representative of Norway. Everyone aged ≥ 20 (n = 92 939) was invited to participate, and 70.6% did so. The survey comprised a questionnaire and clinical examination, including analysis of serum creatinine concentration. Three consecutive standardised blood pressure measurements were recorded. Participants were observed to 31 June 2004 or until advancement to end stage renal disease or death, by individual linkage to central registries with the unique identification number of every Norwegian citizen. See bmj.com for laboratory methods and estimation of glomerular filtration rate. Statistical analysis We assessed the established model of screening only people with previously known diabetes mellitus or treated hypertension. We evaluated models that included people with other risk factors like higher age groups, obesity, smoking, cardiovascular disease, or family history of hypertension or diabetes. Finally, we assessed screening models proposed by international authorities: a modification of the UK chronic kidney disease guidelines (screening people with diabetes/ hypertension/cardiovascular disease/moderate to severe lower urinary tract symptoms/autoimmune disease); a modification of the US kidney disease outcomes quality initiative guidelines (screening people with diabetes/hypertension/age > 60/ autoimmune disease); and the International Society of Nephrology (screening everybody). When appropriate, we used receiver operating characteristics curves This is the abridged version of an article that was posted on bmj.com on 6 November 2006: http://bmj.com/cgi/doi/ 10.1136/bmj.39001.657755.BE Research Editorial by Clase Department of Cancer Research and Molecular Biology, Faculty of Medicine, Norwegian University of Science and Technology, 7006 Trondheim, Norway Stein I Hallan associate professor Department of Medicine, Division of Nephrology, St Olav University Hospital, 7006 Trondheim, Norway Ketil Dahl consultant Cecilia M Oien consultant Department of Clinical Epidemiology, Leiden University Medical Center, 2300 Leiden, Netherlands Diana C Grootendorst postdoctoral fellow Friedo W Dekker associate professor Department of Clinical Biochemistry, St Olav University Hospital, 7006 Trondheim Arne Aasberg consultant HUNT Research Center, Faculty of Medicine, Norwegian University of Science and Technology, 7650 Verdal, Norway Jostein Holmen professor Correspondence to: S I Hallan Dit e-mailadres wordt beveiligd tegen spambots. JavaScript dient ingeschakeld te zijn om het te bekijken. BMJ 2006;333:1047–50 BMJ

 

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