Who Should Be Targeted for CKD Screening? Impact of Diabetes, Hypertension, and Cardiovascular Disease

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To address the highly complex interrelated nature of chronic kidney disease (CKD) and diabetes, hypertension, and cardiovascular disease, we examined CKD prevalence by the predictive effect of demographic factors, comorbid conditions, and CKD risk factors by using National Health and Nutrition Examination Survey (NHANES) 1999-2004 data. NHANES is a nationally representative cross-sectional series of surveys with a complex stratified multistage sampling design. NHANES 1999-2004 participants (n = 15,332; age ≥ 20 years) were interviewed in their homes and asked to participate in standardized medical examinations in mobile centers and provide samples for laboratory tests. Weighted logistic regression modeling was used to assess the importance of individual CKD risk factors. Multiple logistic regressions were performed on patient cohorts, with increasing levels of CKD severity defined by means of estimated glomerular filtration rate. A branching diagram was constructed to address the distribution of CKD grouped by diabetes, hypertension, and cardiovascular disease status. CKD prevalence increases with age (39.2% for age ≥ 60 years). For ages 20 to 59 years, CKD prevalence was greater for participants with diabetes (33.8%) than for those without diabetes (8.2%) and for participants with both diabetes and hypertension (43%) than for diabetic participants without hypertension (25.5%) or nondiabetic participants with hypertension (15.2%). The prevalence was 6.8% for nondiabetic participants without hypertension. Effects of cardiovascular disease are less dramatic when hypertension and diabetes are considered. A CKD screening approach targeting individuals 60 years and older or those with diabetes or hypertension likely would be useful from a public health standpoint.

Section snippets

Methods

NHANES is conducted by the National Centers for Health Statistics of the Centers for Disease Control and Prevention (CDC). NHANES 1999-2004 consisted of nationally representative cross-sectional health examination surveys using a complex stratified multistage probability cluster sampling design.9 Participants were interviewed in their homes and asked to participate in standardized medical examinations in mobile centers and provide samples for laboratory tests. Details of NHANES methods and

Results

CKD prevalence increases with age, such that for patients 60 years and older, 39.2% had evidence of CKD stages 1 through 5 and 27.6% had an eGFR less than 60 mL/min/1.73 m2 (Table 1). Based on sex, percentages ranged between 6.5% and 13.6% of men with evidence of kidney disease and between 9.7% and 17.5% of women. Similar rates of disease were evident according to racial and ethnic groups. For example, CKD stages 1 through 5 were present in 16.0% of non-Hispanic whites; 9.5% had an eGFR less

Discussion

The increasing prominence of CKD as a major public health problem has led to better understanding of the complex interrelationship among CKD, diabetes, hypertension, and cardiovascular events.2, 4, 7 Strategies to identify at-risk populations may have a public health benefit. Because cardiovascular event rates are accelerating and death rates are increased in the CKD population, intervention programs targeted at the high-risk CKD population with diabetes and hypertension may yield more active

Acknowledgements

The authors thank Chronic Disease Research Group colleagues Dana Knopic and Nan Booth, MSW, MPH, for manuscript preparation and manuscript editing, respectively, and CDC staff, including Drs Desmond Williams and Nilka Burrows, for assistance with the public health approach in CKD and its relationship to diabetes and hypertension.

Support: This study was partially funded by CDC Grant 1 U18 DP000608-01. Dr Vassalotti reports having received grant support from the CDC.

Financial Disclosure: None.

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