Chronic kidney disease: new clinical guidelines from the American College of Physicians

Recent data indicate that about 11% of U.S. adults have stage 1 to 3 chronic kidney disease (CKD). The condition is usually asymptomatic but associated with mortality, cardiovascular disease, fractures, bone loss, infections, cognitive impairment, and frailty.

A clinical practice guideline issued by the Clinical Guidelines Committee of the American College of Physicians in October 2013, provides evidence-based recommendations for screening, monitoring, and treatment of early-stage CKD.¹

The major risk factors for CKD are diabetes, hypertension, and cardiovascular disease. Older patients and those who are obese, have a positive family history, or belong to certain ethnic groups are also at increased risk.

Chronic kidney disease: evidence-based recommendationsThe recommendation against systematic screening of asymptomatic adults without risk factors was based on the absence of randomized, controlled trials evaluating its impact, the lack of evidence evaluating benefits of early treatment, and recognition of potential harms of screening, which include false positives, unnecessary treatment, and added healthcare system costs.

In its systematic literature review, the Clinical Guidelines committee also found insufficient evidence to evaluate the benefits and harms of routine screening for CKD in asymptomatic adults with risk factors.

The recommendation against monitoring proteinuria levels in patients taking Angiotensin-converting enzyme (ACE) inhibitors or Angiotensin II receptor blockers (ARBs) considered the absence of evidence showing any outcomes benefit or that reducing proteinuria in patients with CKD is beneficial.

In addition, the systematic review identified no randomized, controlled trials evaluating benefits and harms of routine monitoring of patients with early-stage CKD. However, the group concluded that individual monitoring of kidney function parameters, blood pressure, and medications could be helpful in some patients.

The recommendation on treatment with ACE inhibitors or ARBs in patients with early-stage CKD considered evidence (moderate-quality for ACE inhibitors, high-quality for ARBs) that these medications reduce the risk of end-stage renal disease (ESRD) and other adverse renal outcomes in this population, along with head-to-head trial results showing that outcomes were similar using these two categories of drugs. The review identified that combination therapy with an ACE inhibitor and an ARB increased the risk of adverse events compared with monotherapy without evidence of any benefit.

The recommendation on statin treatment considered high-quality evidence that treatment reduces all-cause mortality and cardiovascular event rates. Low-quality evidence showed no effect of statin treatment on risk of progression in ESRD.