LAS VEGAS – Many barriers to chronic kidney disease detection and screening exist in today’s health care landscape, according to Dr. Georges Saab.
For one thing, patient have a lack of knowledge about chronic kidney disease (CKD) and receive very little education about it, explained Dr. Saab of the department of medicine at Case Western Reserve University and MetroHealth Medical Center, Cleveland.
Patients lack education about CKD "because they don’t ask about it," Dr. Saab said at a meeting sponsored by the National Kidney Foundation. "They know about their hypertension, diabetes, and cholesterol, but they don’t know about kidney disease; they don’t take medications for kidney disease, so they fail to recognize it as a distinct entity."
Dr. Georges Saab
He noted that some primary care physicians feel they lack the knowledge and skills to educate patients on CKD. Thus, measures to enhance these skills are needed. Others are not familiar with published CKD screening guidelines, and among those that are, the recommendations are not consistent in whom to screen.
Dr. Saab called for ways to improve physician and patient education on risk factors for CKD and on the impact of the disease. Such information is available from the National Kidney Foundation and the National Kidney Disease Education Program. Recently, the National Kidney Foundation launched the CKD Primary Care Initiative to identify and overcome barriers to CKD testing, detection, and management in the primary care setting. The NKF’s CKD Primary Care Initiative will disseminate CKD guidelines to PCPs around the United States through education programs, symposia, and practical implementation tools.
Other strategies that could be used include implementing clinical reminders to screen for CKD in high-risk groups, routine reporting of estimated glomerular filtration rate (eGFR), incentivizing providers for higher-quality care, including screening for CKD, and providing patients with access to their laboratory data. He notes that patients themselves may initiate the process of referral to a nephrologist if given access to their results.
Community-based screening also has the potential to eliminate or mitigate some of the patient and physician barriers to screening. Dr. Saab cited the NKF’s Kidney Early Evaluation Program (KEEP) as an example. Between 2000 and 2013, KEEP reached more than 185,000 individuals at increased risk for developing CKD. The KEEP program "is free, it’s in a nonmedical location, such as a church or town hall, and it’s managed by a trained staff and nephrologists," Dr. Saab said of the program. "It’s also short in duration – it only takes about 45 minutes – and it’s focused on CKD and related issues."
Of KEEP data collected through 2010, roughly 20% of participants were found to have CKD (Am. J. Kidney Dis. 2012;60:692-3. At the time of screening, patients are asked if they’re aware if they have any kidney problems or not. Awareness increased from 8.8% in 2000-2002 to 16.6% in 2009-2011, "which means that the message is getting out there, and patients are getting screened a little more commonly than they were before," he said.
Community screening for CKD appears to increase patient awareness of chronic kidney disease, "and it may indirectly lead to increased screening in clinical encounters," Dr. Saab said. "For example, KEEP reports sent to PCPs may influence screening and detection, and friends and family members of those screened may also seek screening."
Another community-based initiative is the NKF’s KEEP Healthy program, designed to educate people about the kidneys and risk factors for kidney disease. A check-up for participants includes a risk survey, body mass index, blood pressure check, free educational materials, and an opportunity to speak with a health care professional.
"Awareness of CKD is low," Dr. Peter A. McCullough, chair of the NKF’s Kidney Early Evaluation Program Steering Committee, said during a separate presentation at the meeting. "We have to get to levels of awareness of diabetes, heart disease, and cancer. In kidney disease, we haven’t gotten there yet. I haven’t seen a single data set where [awareness] is more than 50%."
In his opinion, clinicians should screen for CKD with KEEP Healthy and other clinical and community approaches, "because it raises awareness for risk factors and CKD, it potentially triggers better risk factor control, it potentially helps avoid additional insults along the way, and it readies for the next steps."
Dr. Saab acknowledged limitations of community-based screening, including the fact that isolated measurements may lead to misclassification. "But that is usually the case in all screening processes," he added. "It also requires external funding, and it does attract patients who are motivated to be screened, so you may not necessarily be catching the people who aren’t aware of CKD."