Evolving strategies for early diagnosis, proactive prevention and treatment of CKD

Abstract

Chronic kidney disease (CKD) is among the fastest growing global causes of death, forecasted to become the third leading cause of death in Western Europe and Japan by 2050. In contrast, mortality from cardiovascular disease is decreasing. Cardiovascular medicine is focused on identifying people at high risk and intervening to prevent cardiovascular events. The focus of kidney medicine has evolved over time. Last century the focus was on treating kidney failure by kidney replacement therapy (KRT). However, KRT outcomes are suboptimal. Life expectancy is up to 44 (women on dialysis) to 22 years (women with functioning kidney grafts) shorter on KRT than in the general population. The 21st century has witnessed an explosion of highly effective kidney-protective drugs that may both prevent and slow the progression of CKD while addressing the full cardiovascular–kidney–metabolic (CKM) syndrome spectrum, i.e. also improving cardiovascular and metabolic outcomes. However, these advances have met a barrier: 20th century concepts on whom to test for CKD, which focus on assessing albuminuria just in people with diabetes mellitus. This outdated concept limits early diagnosis and treatment in up to 80% of people who eventually develop kidney failure. Clinical trials suggest that starting kidney protective therapy because CKD was diagnosed based on albuminuria, when glomerular filtration rate is normal, may delay the need for KRT for up to nearly 3 decades, meaning that many older subjects would not require KRT. To improve outcomes, the next two steps in kidney medicine should involve the widespread adoption of the ABCDE (albuminuria, blood pressure, cholesterol, diabetes and estimated glomerular filtration rate) approach for early detection and treatment of CKM risk, followed by developing the concept of pre-CKD that may guide pharmacologic interventions targeted to prevent CKD, on top of healthy lifestyle measures for the entire population, not just for those at risk.