Early diagnosis of CKD is important as it can help lower the risk of morbidity, mortality and associated healthcare costs. In 2009/10, the NHS spent £1.45 billion on CKD alone, with more than half of this going towards renal replacement therapy for the 2 per cent of people with CKD which progresses to kidney failure.
As the disease carries no symptoms it can often be hard to recognise, leading to late presentation. In addition, the way CKD has been previously classified has raised concerns that it may have been overdiagnosed in the past.
NICE now recommends that CKD should be classified using a combination of glomerular filtration rate (GFR) and albumin:creatinine ratios (ACR) categories.
GPs should be aware that increased ACR or decreased GFR are associated with increased risk of adverse outcomes. In addition, increased ACR and decreased GFR in combination multiply the risk of adverse outcomes.
Elsewhere, the guideline recommends that testing for CKD using eGFRcreatinine and ACR should be offered to people with certain risk factors, which include AKI, diabetes, hypertension, heart disease.
NICE also recommends that patients who have had acute kidney injury should be warned that they are at increased risk of developing CKD and should be monitored for at least 2-3 years after the AKI, even if serum creatinine has returned to normal levels.
Professor Mark Baker, Director of the Centre for Clinical Practice at NICE, said: “Chronic kidney disease often has no symptoms so can go undetected, potentially leading to serious health problems. Late presentation of people with kidney failure increases sickness and death and costs the NHS more. Figures suggest chronic kidney disease costs the NHS in England between £1.44 and £1.45 billion every year.
“These updated recommendations seek to address the issues surrounding the correct diagnosis of CKD, and make sure that the right people get the right treatment for their condition.”
A series of algorithms have been produced that summarise the guideline and focus on classification and treatment.
Visit the NICE pathway on CKD for fast access to all that NICE recommends on the topic.
As a matter of urgency, the potential for overdiagnosis and related overtreatment should be routinely considered for inclusion in the introduction and discussion sections of reports of studies of therapies, studies of diagnostic test accuracy, systematic reviews of those studies, clinical guidelines, and changes to disease definitions (Box 1). Second, there is a clear need for more research—both original studies and reviews of studies—into the nature and extent of overdiagnosis and related overtreatment within specific conditions—as, for example, has occurred with studies on the risks associated with mammography . Third, the potential harms associated with new treatments and tests, or expanded disease definitions, demand much greater attention in primary studies and reviews.
Box 1. Summary of Suggestions for Improving the Evidence Base to Combat Overdiagnosis and Related Overtreatment
Routine consideration of overdiagnosis and related overtreatment in the introduction and discussion sections of primary studies and systematic review articles about tests and treatments
More condition-specific studies and reviews on the risk of overdiagnosis and related overtreatment—e.g., diagnosis of pulmonary embolism
More rigorous routine evaluation of potential harms of treatments, tests, and changes to disease definitions
In studies and reviews of studies of therapies, clearer stratification by baseline risk, to better identify treatment thresholds where benefits are likely to outweigh harms
In studies and reviews of studies of test accuracy, more clarity about which target condition or spectrum of a disease is being considered, with a shift from a dichotomous “disease/no disease” frame to a “spectrum of disease severity” frame, and a linking of test accuracy to consequences for treatment and patient outcomes
Panels that review and change disease definitions that are free of conflicts, and routinely consider evidence for potential harms as well as potential benefits of the changes they propose
For evaluation of treatments, more clarity is required about the specific definitions of diseases being treated in primary treatment studies and subsequent systematic reviews. As per the recommendations of Kent and colleagues , clearer stratification of groups at varying degrees of baseline risk or disease stage is needed, to better identify treatment thresholds at which the harms of treatment start to outweigh benefits. Sometimes this will require re-analysis of large (e.g., pooled individual participant) datasets, underscoring the need for access to raw data from trials.
For primary studies and reviews of studies of diagnostic test accuracy, there is a need to make explicit exactly which stages or spectrum of a target disease is being considered—also referred to as the “target condition” . Where possible, it may be desirable to shift the paradigm from a dichotomous frame—disease presence versus absence—to thinking about a spectrum of disease severity. Moreover, when diagnostic studies show improved detection (or exclusion) of specific disease stages, researchers should try to link the consequences of such improved diagnostic accuracy to subsequent treatment decisions. Ideally, the consequences of such changed treatment decisions for patient outcomes might also be addressed . Such elaborations to conventional diagnostic test accuracy studies would help identify at what diagnostic disease spectrum thresholds subsequent treatments will do more good than harm.
And, finally, the need to improve the process of disease definition—with awareness of the dangers of overdiagnosis and overtreatment—is being increasingly accepted, with international organisations, including the Guidelines International Network, currently looking to develop new guidance. While a detailed debate will ensue in coming years, we believe several key principles might underpin the reform of how disease definitions are changed: panel members should be free of financial and reputational conflicts of interest; strong evidence, ideally from randomised trial data, should demonstrate that the use of new criteria will meaningfully reduce mortality and/or morbidity; and potential benefits and potential harms of labelling and treatment using the new criteria should be explicitly investigated and reported.
We offer these suggestions as part of the wider scientific debate underway on how to safely and fairly wind back the harms of too much medicine . We are hopeful that a heightened attention to the dangers of overdiagnosis and related overtreatment may lead to an enhanced evidence base on these topics. This, in turn, will help produce fairer, more rational, and less wasteful health care systems, built on a reformed process of disease definition that offers diagnostic labels and medical interventions only to those likely to benefit from them.