In early 2023, The United States Preventive Services Task Force (USPSTF) announced it would review the evidence regarding screening for chronic kidney disease (CKD). We discuss this important announcement along with the role of prevention, screening, and health equity with Dr. Carmen Peralta, Chief Clinical Officer for Interwell Health.
Q: The USPSTF has decided to research whether new screening guidelines are needed for CKD. Why is this important?
CP: I am very pleased that the USPSTF has decided to do an updated review of the literature on this topic. The Centers for Disease Control and Prevention (CDC) estimates that 37 million Americans are affected by kidney disease and the majority are unaware.1 When affected persons and their providers are unaware of the condition, the window for early education and preventive treatment to avoid complications closes.
Early identification of kidney disease is important so that therapies to slow progression and prevent complications can be instituted as early as possible. Early identification gives patients more time to learn about CKD and work with their providers to institute the right care plan. In addition, it supports earlier referral to nephrology care and allows for preparation in case the disease progresses to end-stage kidney disease (ESKD). Unfortunately, in the United States, many people begin dialysis to treat their ESKD having had little or no nephrology care, leading to worse outcomes. We must do better!
Q: How is kidney disease detected and can we make it easier?
CP: Simple tests in the blood and urine can determine the presence of CKD. It is important that both the blood and the urine are tested because having information on both allows practitioners to better discern risks for complications. New point of care digital tools for testing are being developed. In fact, a home urine test using a smart phone has already received FDA clearance. I hope that the process to determine kidney function can get faster and easier.
Q: Are there clear guidelines now for primary care physicians to follow when screening for CKD or is that part of the concern?
CP: That is indeed part of the concern. The USPSTF looked at the evidence back in 2012 and concluded that there was not enough evidence to make a recommendation on screening for CKD among persons without symptoms. This generated statements by different professional societies, but no national consensus emerged. Some disease specific guidelines recommend CKD screening. For example, the American Diabetes Association recommends CKD screening among persons with diabetes. A more recent review of the topic by the Kidney Disease: Improving Global Outcomes (KDIGO) controversies conference concluded that “persons with hypertension, diabetes, or cardiovascular disease should be screened for CKD,” as well as for “other high-risk individuals and populations based on comorbidities, environmental exposures, or genetic risk factors.”2
It is important that primary care providers are supported as they make decisions for screening, risk stratification, and treatment.
Q: What has changed since the USPSTF last looked at this question?
CP: Since 2012 when the USPSTF published its last statement, there have been several important advances. We know more about using multi-marker approaches to risk stratifying CKD such as combining serum creatinine and cystatin C with urine albumin. New drugs are available on the market that can slow the progression of kidney disease and prevent other complications including cardiovascular events. For example, drugs known as SGLT-2 inhibitors have been studied in several large clinical trials proving their efficacy to improve outcomes. Finally, the advent of value-based care is providing the resources needed to focus on earlier care, avoiding complications, improving quality of life, and reducing hospitalizations. I think it’s time to reconsider the guidelines given these new discoveries.
Q: What would these treatment developments mean if USPSTF updated its recommendations to increase screening?
CP: Because we have so many more effective ways to treat CKD, especially in its early stages, we can drastically slow the progression of the disease—even reverse it in some cases. This is tremendously exciting from a patient care perspective, and it also illuminates a path toward significant cost savings up and down the industry.
The treatments and the screenings have matured in parallel, and it appears to be a good time to bring them together to improve lives and reduce everyone’s costs.
Q: What have you found in your own research about the prevalence of kidney disease in populations with or without risk factors?
CP: In my own research, we have studied the use of a triple-marker approach using serum creatinine, cystatin C, and urine albumin-to-creatinine ratio to improve detection and risk stratification of CKD. We showed that this triple-marker approach improved the ability to detect persons whose CKD posed the highest risk for complications. We have highlighted the health disparities in kidney function decline by race/ethnicity, even at early stages of the disease. We also showed that undetected CKD is common among persons with hypertension. Even among persons with repeated laboratory tests showing a reduced estimated glomerular filtration rate (eGFR), they often remain undiagnosed by providers.
Q: How would updated screening guidelines potentially advance goals for health equity?
CP: I applaud the USPSTF for considering health equity in their draft research plan. I think it is critical that the USPSTF consider the value of screening in populations at higher risk for ESKD. A clear, evidence-based guideline has the potential to improve access for testing among the most vulnerable communities.
Q: What are the next steps for the USPSTF and how will the final guidance be issued?
CP: The USPSTF issued their draft research plan and allowed for comments from the community.3 I expect they will consider these when developing their final plan. The next step will be coming up with a draft recommendation which will hopefully be informed by all the new evidence from the past decade. That will be a time for stakeholders to once again offer their comments on any new proposal.
Q: How is Interwell Health contributing to the efforts of managing kidney disease earlier?
CP: When a patient first learns they have end-stage kidney disease in an emergency room and must start dialysis emergently this represents a failure of the system. This type of scenario robs a patient of the chance to make earlier decisions that best suit their life goals. Late identification closes the window for a pre-emptive transplant, not to mention the complications that ensue from such a traumatic start to ESKD treatment.
At Interwell Health, we are committed to making sure patients don’t have to start treatment in this way. Our goal is to support patients and providers with managing CKD so that patients have the best opportunity to receive treatments that could slow the progression of disease and reduce complications. If the disease progresses to end stage, we support them in transplant evaluations and choosing a modality for ESKD treatment that best aligns with their life goals.
Carmen A. Peralta, MD, MAS, FASN, is the Chief Clinical Officer at Interwell Health. She brings her deep clinical experience in treating persons with kidney diseases and hypertension, as well as expertise in epidemiology, use of healthcare data, predictive analytics, study design, and implementation sciences to deploy a patient-focused model of care that delivers real results and helps people living with kidney disease live their best lives. She has won several prestigious awards and was recognized as Fierce Healthcare’s Top 10 Most Influential Minority Healthcare Executives in 2020. Dr. Peralta co-founded and served as the inaugural Executive Director of the Kidney Health Research Collaborative (KHRC) at the University of California San Francisco, and her research has been published extensively. Dr. Peralta is a Health Innovators Fellow at the Aspen Institute. She earned her medical degree at The Johns Hopkins School of Medicine and completed her residency in internal medicine at the Brigham and Women’s Hospital. She completed her nephrology fellowship and earned a master’s degree in clinical research at UCSF.