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  • A critical link exists between awareness

    2019-06-01

    A critical link exists between awareness of risk, the presence of disease, and steps taken by the patient and clinician to change the natural history of disease. Chronic illnesses such as diabetes mellitus, dyslipidaemia, anaemia and a multitude of endocrinological and rheumatological diseases are relatively silent and rely on the clinical laboratory for diagnosis, particularly in their early stages. Probably no such illness permits such a large loss of organ function before symptoms become present as chronic kidney disease (CKD). Thus, the considerable dependence on the laboratory to establish the diagnosis of CKD is an issue for low-income and middle-income countries (LMIC), where access to in-vitro diagnostics on a screening basis might not be universally available. Even in high-income countries where routine laboratory tests are performed, CKD seems to lag considerably behind diabetes mellitus, hypertension, and cardiovascular disease in terms of patient and clinician awareness. This difference is partly due to the two-dimensional nature of CKD defined as a reduction in estimated glomerular lxr agonists rate (eGFR) and the presence of markers of chronic kidney damage (albuminuria or imaging evidence) over 3 months time. Thus, to have the eGFR and albumin:creatinine ratio at the same time and clearly inform the patient of the potential presence of CKD is complex. With these challenges as the backdrop, Ene-Iordache and colleagues report on 75 058 individuals screened for diabetes mellitus, hypertension, and CKD from LMICs. They found 44% of people with hypertension and 31% of those with diabetes were unaware of these conditions, suggesting public health screening efforts such as those described by the authors have a very high yield when there may not be access to primary care and routine screening. A total of 14·3% of the population was confirmed to have CKD by eGFR and or proteinuria (dipstick or albumin:creatinine ratio). Awareness of CKD was less than 10% in all risk groups in line with what has been found in the US Kidney Early Evaluation Program (KEEP). Importantly, less than half of those aware reported any treatment or clinical actions taken for CKD. Thus, these data seem to present a three-part challenge: (1) to screen and detect CKD, (2) to become aware of the condition, (3) to understand and act on the knowledge that controlling modifiable risk factors like blood pressure and glucose can attenuate progression of CKD. Importantly, the authors demonstrated a sharp linkage between risk of CKD and cardiovascular disease in young to middle-aged individuals from many regions in the world. Thus, the benefit of CKD screening and detection as conveyance of cardiovascular disease risk, and the opportunities to modulate this risk, is arguably a more optimistic treatment goal than attenuating the progression of CKD. With the advent of cardiovascular disease risk factor reduction there can be a dramatic reduction in the binary risks of myocardial infarction, stroke, and cardiovascular death. High-income countries are witnessing sharp declines in rates of cardiovascular disease events, which are probably attributable to population changes in global risk. Additionally, blood pressure control is tightly linked to reductions in incident heart failure and stroke. With half of those with hypertension and a third of those with diabetes from LMIC in this report taking no medications at all for these problems, there appears to be a considerable public health opportunity from strengthened community approaches that not only screen and detect disease but also provide some basic forms of pharmacological treatment and follow-up. Results from the present study and from over a decade of experience with KEEP suggest that hypertension, diabetes, smoking, concern for the presence of any of these risk factors, or a family history of CKD are proven high-yield criteria for individuals to undergo screening and measurement of eGFR and urine albumin. Confirmation of hypertension or diabetes mellitus is a mandatory call to treatment. Furthermore, identification of CKD in a middle-aged individual is a signal for cardiovascular disease risk, and additional steps can be taken to reduce the rates of myocardial infarction, stroke, heart failure, and cardiovascular death (). It all starts with screening and detection of a silent disease, which give years of opportunity for discovery and modification of its natural history.