Chronic kidney disease: Stemming the global tide
2005; Elsevier BV; Volume: 45; Issue: 1 Linguagem: Inglês
10.1053/j.ajkd.2004.09.005
ISSN1523-6838
AutoresEmeka Nwankwo, Aminu K. Bello, A. Meguid El Nahas,
Tópico(s)Renal Diseases and Glomerulopathies
ResumoCHRONIC KIDNEY DISEASE (CKD) is rapidly becoming a major public health problem globally, with more than 1 million patients on renal replacement therapy (RRT) worldwide and an expected 2 million patients by 2010.1Lysaght M.J. Maintenance dialysis population dynamics Current trends and long-term implications.J Am Soc Nephrol. 2002; 13: S37-S40PubMed Google Scholar, 2Xue J.L. Ma J.Z. Louis T.A. Collins A.J. Forecast of the number of patients with end-stage renal disease in United States to the year 2010.J Am Soc Nephrol. 2001; 12: 2753-2758PubMed Google Scholar To a large extent, this may be the result of the forthcoming global epidemic of diabetes mellitus (154 million patients with diabetes in 2000, increasing to 370 million in 2030), as well as the aging of the population, with a much greater prevalence of end-stage renal failure (ESRF) in those older than 65 years. There is a clear and direct relationship between a nation's gross national product and the availability of RRT.3Schena F.P. Epidemiology of end-stage renal disease; International comparisons.Kidney Int. 2000; 57: S39-S45Crossref Scopus (139) Google Scholar Approximately 90% of patients with ESRF come from developed nations.3Schena F.P. Epidemiology of end-stage renal disease; International comparisons.Kidney Int. 2000; 57: S39-S45Crossref Scopus (139) Google Scholar Conversely, there is limited access to RRT in developing countries, where the low gross national product is unable to meet the increasing demands of health care and the growing burden of ESRF.4De Vecchi A.F. Dratwa M. Wiedmann M.E. Healthcare systems and end-stage renal disease: An international review: Costs and reimbursement/funding of ESRD therapies.Nephrol Dial Transplant. 1999; 14: 31-41Crossref PubMed Scopus (200) Google Scholar This is reflected in the relatively low prevalence of ESRF in emerging countries compared with high-economy states (Table 1). However, during the next decade, even the most affluent of nations will struggle to meet the demands of expanding ESRF programs; in the United States, the annual expenditure on ESRF has been estimated to reach US $39 billion by 2010.2Xue J.L. Ma J.Z. Louis T.A. Collins A.J. Forecast of the number of patients with end-stage renal disease in United States to the year 2010.J Am Soc Nephrol. 2001; 12: 2753-2758PubMed Google Scholar, 5Trivedi H.S. Pang M.M. Campbell A. Saab P. Slowing the progression of chronic renal failure Economic benefits and patients' perspectives.Am J Kidney Dis. 2002; 39: 721-729Abstract Full Text Full Text PDF PubMed Scopus (120) Google Scholar It is therefore highly imperative to shift the emphasis of the global approach to CKD from provision of RRT to early detection and prevention.Table 1International Comparisons of the Incidence and Prevalence of ESRFCountryIncidence (pmp/y)Prevalence (pmp/y)United States (overall)3361,403 White2561,004 African American9824,432 American Indian5143,540United Kingdom101626Europe135–173600–800Australia Overall94658 Aboriginal population4201,895Russia1579China102UnknownIndia34–240UnknownNigeriaUnknown2.5NOTE. Most data are for 2000 to 2003. Open table in a new tab NOTE. Most data are for 2000 to 2003. Although the management of patients with ESRF consumes the totality of renal health care budgets, they represent less than 0.5% of the total number of patients with CKD. In the United States, the Third National Health and Nutrition Examination Survey (NHANES III) estimated that 11% of the adult American population (19 million persons) may have CKD, with only 345,000 patients reaching ESRF.6Coresh J. Astor B.C. Greene T. Eknoyan G. Levey A.S. Prevalence of chronic kidney disease and decreased kidney function in the adult US population Third National Health and Nutrition Examination Survey.Am J Kidney Dis. 2003; 41: 1-12Abstract Full Text Full Text PDF PubMed Scopus (2293) Google Scholar In the United Kingdom, a recent survey estimated the prevalence of CKD to be approximately 5,554 patients per million population (pmp), with only 626 patients pmp on RRT.7John R. Webb M. Young A. Stevens P.E. Unreferred chronic kidney disease A longitudinal study.Am J Kidney Dis. 2004; 43: 825-835Abstract Full Text Full Text PDF PubMed Scopus (209) Google Scholar Identification of individuals with early CKD and prevention of progression of their disease are likely to be key factors in alleviating the future burden of ESRF. In addition, such an approach may reduce the morbidity and mortality of such underlying conditions as hypertension and diabetes, related directly to either the presence of albuminuria or degree of renal function impairment.8Ritz E. McClellan W.M. Overview: Increased cardiovascular risk in patients with minor renal dysfunction: An emerging issue with far-reaching consequences.J Am Soc Nephrol. 2004; 15: 513-516Crossref PubMed Scopus (125) Google Scholar The HOORN study in The Netherlands showed that renal function was associated inversely with all-cause and cardiovascular mortality in the general population; the relative risk for cardiovascular death was 1.26 for each decrease in glomerular filtration rate (GFR) of 5 mL/min/1.73 m.9Henry R.M. Kostense P.J. Bos G. et al.Mild renal insufficiency is associated with increased cardiovascular mortality The HOORN Study.Kidney Int. 2002; 62: 1402-1407Crossref PubMed Scopus (0) Google Scholar This editorial examines some of the strategies applied worldwide for the early detection and prevention of CKD and their potential impact. To identify patients at risk for CKD, a number of screening strategies have been implemented. Some screening and early-detection programs focused on the entire population, whereas others targeted a specific at-risk group within the population (Table 2).Table 2Prevalence of Markers of CKD in Various Screening StudiesStudyDesignNo. of PatientsTarget GroupCKD Prevalence (%)Proteinuria/Albuminuria (%)Hematuria (%)GFR < 60 mL/min (%)ESRF (%)NHANES III6Coresh J. Astor B.C. Greene T. Eknoyan G. Levey A.S. Prevalence of chronic kidney disease and decreased kidney function in the adult US population Third National Health and Nutrition Examination Survey.Am J Kidney Dis. 2003; 41: 1-12Abstract Full Text Full Text PDF PubMed Scopus (2293) Google ScholarCS15,625GP116.34.30.20KEEP20Brown W.W. Peters R.M. Ohmit S.E. et al.Early detection of kidney disease in community settings. The Kidney Early Evaluation Program (KEEP).Am J Kidney Dis. 2003; 42: 22-35Abstract Full Text Full Text PDF PubMed Scopus (205) Google ScholarCS/L11,246HR47.4273160.30PREVEND10Hillege H.L. Fidler V. Diercks G.F. et al.Prevention of Renal and Vascular End Stage Disease (PREVEND) Study GroupUrinary albumin excretion predicts cardiovascular and non-cardiovascular mortality in general population.Circulation. 2002; 106: 1777-1782Crossref PubMed Scopus (1332) Google ScholarCS40,856GP—7.2———Iceland11Magnason R.L. Indridason O.S. Sigvaldason H. Sigfusson N. Palsson R. Prevalence and progression of CRF in Iceland A population-based study.Am J Kidney Dis. 2002; 40: 955-963Abstract Full Text Full Text PDF PubMed Scopus (41) Google ScholarR18,912GP———0.22Ausdiab12Chadban S.J. Briganti E.M. Kerr P.G. et al.Prevalence of kidney damage in Australian adults The AusDiab Kidney Study.J Am Soc Nephrol. 2003; 14: S131-S138Crossref PubMed Google ScholarCS11,247GP162.44.611.2Singapore16Ramirez S.P. Hsu S.I. McClellan W. Taking a public health approach to the prevention of end-stage renal disease The NKF Singapore Program.Kidney Int. 2003; 63: S61-S65Crossref Scopus (36) Google ScholarCS450,000GP0.89.1Chennai17Mani M.K. Prevention of chronic renal failure at the community level.Kidney Int. 2003; 63: S86-S89Crossref Scopus (80) Google ScholarCS25,000GPHT, 6; DM, 4Tiwi18McDonald S.P. Maguire G.P. Hoy W.E. Renal function and cardiovascular risk markers in a remote Australian Aboriginal community.Nephrol Dial Transplant. 2003; 18: 1555-1561Crossref PubMed Scopus (89) Google ScholarCS237HR5644—12—Zuni19Stidley C.A. Shah V.O. Narva A.S. et al.A population-based, cross-sectional survey of the Zuni Pueblo A collaborative approach to an epidemic of kidney disease.Am J Kidney Dis. 2002; 39: 358-368Abstract Full Text Full Text PDF PubMed Scopus (36) Google ScholarCS1,483HR37.519.717.8——Abbreviations: Ausdiab, Australian Diabetes, Obesity and Lifestyle study; PREVEND, Prevention of Renal and Vascular End-Stage Disease Study; Singapore, NKF Singapore Program; Chennai, Prevention of Renal Failure at the Community Level Program in India; Tiwi, Australian Aboriginal Community Study; Zuni, Zuni Pueblo Community Study; CS, cross-sectional analysis; R, retrospective evaluation; GP, general population; HR, high-risk individuals; HT, hypertension; DM, diabetes mellitus. Open table in a new tab Abbreviations: Ausdiab, Australian Diabetes, Obesity and Lifestyle study; PREVEND, Prevention of Renal and Vascular End-Stage Disease Study; Singapore, NKF Singapore Program; Chennai, Prevention of Renal Failure at the Community Level Program in India; Tiwi, Australian Aboriginal Community Study; Zuni, Zuni Pueblo Community Study; CS, cross-sectional analysis; R, retrospective evaluation; GP, general population; HR, high-risk individuals; HT, hypertension; DM, diabetes mellitus. The US-based NHANES III was a nationally based health survey carried out from 1988 to 1994, involving 15,626 adult participants, to ascertain the prevalence of various stages of CKD by using spot urine albumin and calibrated serum creatinine values.6Coresh J. Astor B.C. Greene T. Eknoyan G. Levey A.S. Prevalence of chronic kidney disease and decreased kidney function in the adult US population Third National Health and Nutrition Examination Survey.Am J Kidney Dis. 2003; 41: 1-12Abstract Full Text Full Text PDF PubMed Scopus (2293) Google Scholar The overall prevalence of CKD was 11% (∼19 million persons). The prevalence distribution pattern across the National Kidney Foundation (NKF)-Kidney Disease Outcomes Quality Initiative stages of CKD was stage 1, 3.3% (∼6 million persons); stage 2, 3.0% (∼5.3 million persons); stage 3, 4.3% (7.6 million persons); stage 4, 0.25% (400,000 persons); and stage 5/ESRF, 0.2% (∼345,000 persons). This study pointed to a very large number of cases of asymptomatic CKD in the presumably healthy general population. In Europe, the Prevention of Renal and Vascular End Stage Disease (PREVEND) study undertaken in the Dutch city of Groningen screened and followed up (∼3 years) almost half the population (∼40,000 persons) to assess the prevalence of microalbuminuria (increased urine albumin-creatinine ratio [ACR]) in the general population.10Hillege H.L. Fidler V. Diercks G.F. et al.Prevention of Renal and Vascular End Stage Disease (PREVEND) Study GroupUrinary albumin excretion predicts cardiovascular and non-cardiovascular mortality in general population.Circulation. 2002; 106: 1777-1782Crossref PubMed Scopus (1332) Google Scholar Approximately 7% of those screened had albuminuria. During follow-up, individuals with the greatest level of albuminuria were found to have the greatest incidence of cardiovascular death, thus confirming the association between albuminuria and cardiovascular morbidity and mortality. In Iceland, a study of 18,912 adults found the prevalence of increased serum creatinine levels to be very low (0.22%) compared with other studies.11Magnason R.L. Indridason O.S. Sigvaldason H. Sigfusson N. Palsson R. Prevalence and progression of CRF in Iceland A population-based study.Am J Kidney Dis. 2002; 40: 955-963Abstract Full Text Full Text PDF PubMed Scopus (41) Google Scholar This may reflect the use of serum creatinine as the sole measure of renal function, thus potentially overlooking a significant number of individuals with early stage 1 to 2 CKD (GFR > 60 mL/min). In the Far East, studies have been undertaken in Australia, Japan, Singapore, and India. The Australian Diabetes, Obesity and Lifestyle (AusDiab) study is a population-based cross-sectional survey to determine the prevalence of diabetes mellitus, obesity, cardiovascular risk factors, and indicators of kidney disease in Australian adults.12Chadban S.J. Briganti E.M. Kerr P.G. et al.Prevalence of kidney damage in Australian adults The AusDiab Kidney Study.J Am Soc Nephrol. 2003; 14: S131-S138Crossref PubMed Google Scholar A representative sample of the Australian adult population comprising 11,247 participants was studied from May 1999 to December 2000, showing 11.2% to have significant renal impairment (GFR < 60 mL/min) and 2.4% to have proteinuria.12Chadban S.J. Briganti E.M. Kerr P.G. et al.Prevalence of kidney damage in Australian adults The AusDiab Kidney Study.J Am Soc Nephrol. 2003; 14: S131-S138Crossref PubMed Google Scholar The Okinawa screening program evaluated approximately 106,000 adult Japanese individuals between 1983 and 1984 for early markers of kidney disease (proteinuria by dipstick urinalysis and blood pressure measurement) and followed them up for 17 years.13Iseki K. The Okinawa screening program.J Am Soc Nephrol. 2003; 14: S127-S130Crossref PubMed Google Scholar The study identified obesity, dyslipidemia, and smoking as significant risk factors for the development of albuminuria. It also identified proteinuria14Iseki K. Ikemiya Y. Iseki C. Takishita S. Proteinuria and the risk of developing end stage renal disease.Kidney Int. 2003; 63: 1468-1474Crossref PubMed Scopus (428) Google Scholar and obesity15Iseki K. Ikemiya Y. Kinjo K. Inoue T. Iseki C. Takishita S. Body mass index and the risk of development of end-stage renal disease in a screened cohort.Kidney Int. 2004; 65: 1870-1876Crossref PubMed Scopus (468) Google Scholar as major risk factors for the development of ESRF. NKF Singapore has set up a comprehensive program for CKD prevention, initiated in 2000, with more than 450,000 Singaporeans recruited to date.16Ramirez S.P. Hsu S.I. McClellan W. Taking a public health approach to the prevention of end-stage renal disease The NKF Singapore Program.Kidney Int. 2003; 63: S61-S65Crossref Scopus (36) Google Scholar The program detected significant urinary abnormalities (proteinuria, 0.8%; hematuria, 9.1%) in the general population.16Ramirez S.P. Hsu S.I. McClellan W. Taking a public health approach to the prevention of end-stage renal disease The NKF Singapore Program.Kidney Int. 2003; 63: S61-S65Crossref Scopus (36) Google Scholar In southern India, the Chennai community screening program, screened approximately 25,000 individuals and detected around 6% with previously undiagnosed hypertension and 4% with diabetes mellitus.17Mani M.K. Prevention of chronic renal failure at the community level.Kidney Int. 2003; 63: S86-S89Crossref Scopus (80) Google Scholar When applied to this community, intensive management of patients with hypertension and diabetes with readily available and inexpensive drugs achieved target values in the majority of patients.17Mani M.K. Prevention of chronic renal failure at the community level.Kidney Int. 2003; 63: S86-S89Crossref Scopus (80) Google Scholar Some screening programs targeted specific at-risk populations, such as the Australian aborigines18McDonald S.P. Maguire G.P. Hoy W.E. Renal function and cardiovascular risk markers in a remote Australian Aboriginal community.Nephrol Dial Transplant. 2003; 18: 1555-1561Crossref PubMed Scopus (89) Google Scholar and the Zuni Indians in the southwestern United States.19Stidley C.A. Shah V.O. Narva A.S. et al.A population-based, cross-sectional survey of the Zuni Pueblo A collaborative approach to an epidemic of kidney disease.Am J Kidney Dis. 2002; 39: 358-368Abstract Full Text Full Text PDF PubMed Scopus (36) Google Scholar The inhabitants of the Tiwi islands are Australian aborigines, for whom a quarter of all deaths are attributed to ESRF.18McDonald S.P. Maguire G.P. Hoy W.E. Renal function and cardiovascular risk markers in a remote Australian Aboriginal community.Nephrol Dial Transplant. 2003; 18: 1555-1561Crossref PubMed Scopus (89) Google Scholar They have an annual incidence of ESRF 5 times that of the Australian population (Table 1). This may explain their very high incidence of cardiovascular mortality; 5-fold that of the general population. In the Tiwi screening program, the overall prevalence of albuminuria was a staggering 44%, and when followed up longitudinally, it highlighted all future risks for renal and cardiovascular deaths. Of interest, intervention in this high-risk group with angiotensin-converting enzyme inhibition significantly reduced blood pressure, proteinuria, and overall mortality.18McDonald S.P. Maguire G.P. Hoy W.E. Renal function and cardiovascular risk markers in a remote Australian Aboriginal community.Nephrol Dial Transplant. 2003; 18: 1555-1561Crossref PubMed Scopus (89) Google Scholar The Zuni Indians also have a very high prevalence of ESRF (17,400 pmp; 2% of the population), mainly caused by chronic mesangioproliferative glomerulonephritis and diabetic nephropathy.19Stidley C.A. Shah V.O. Narva A.S. et al.A population-based, cross-sectional survey of the Zuni Pueblo A collaborative approach to an epidemic of kidney disease.Am J Kidney Dis. 2002; 39: 358-368Abstract Full Text Full Text PDF PubMed Scopus (36) Google Scholar The Zuni Pueblo community study showed a prevalence of albuminuria of approximately 20%.19Stidley C.A. Shah V.O. Narva A.S. et al.A population-based, cross-sectional survey of the Zuni Pueblo A collaborative approach to an epidemic of kidney disease.Am J Kidney Dis. 2002; 39: 358-368Abstract Full Text Full Text PDF PubMed Scopus (36) Google Scholar The Kidney Early Evaluation Program (KEEP) was piloted in 1997 to 1999 by the NKF to determine the prevalence of early stages of CKD in the at-risk US population.20Brown W.W. Peters R.M. Ohmit S.E. et al.Early detection of kidney disease in community settings. The Kidney Early Evaluation Program (KEEP).Am J Kidney Dis. 2003; 42: 22-35Abstract Full Text Full Text PDF PubMed Scopus (205) Google Scholar KEEP is ongoing, and by the end of 2003, it had recruited more than 22,000 participants. KEEP had a high yield, with an overall prevalence of the different stages of CKD of approximately 50%. Of these, 27% had albuminuria, approximately 16% had elevated serum creatinine concentrations, and 3% had other asymptomatic urinary abnormalities, including hematuria.20Brown W.W. Peters R.M. Ohmit S.E. et al.Early detection of kidney disease in community settings. The Kidney Early Evaluation Program (KEEP).Am J Kidney Dis. 2003; 42: 22-35Abstract Full Text Full Text PDF PubMed Scopus (205) Google Scholar As in the NHANES III, KEEP identified socioeconomic deprivation as an additional risk for the development of CKD. Different communities probably will have to adopt different methods for screening and detecting CKD that best suit their environment, taking into consideration such factors as health awareness and availability of human and material resources. Targeted population screening may best suit well-developed health systems with accurate medical records and databases. Conversely, whole-population surveys may increase health awareness in countries with less sophisticated health systems and could have good yields in the pick-up of first time diabetic and hypertensive individuals. The latter also may have the added advantage of improving the quality of care of those with diabetes and hypertension, thus hopefully minimizing their renal and cardiovascular complications. A range of common risk factors/markers have been identified that are associated with increased susceptibility to both renal and cardiovascular diseases. These include albuminuria/proteinuria, hypertension, dyslipidemia, and obesity (Table 2, Table 3).Table 3Major Risk Factors for CKD in CommunitiesStudyHypertensionObesityHyperlipidemiaSmokingOkinawa13Iseki K. The Okinawa screening program.J Am Soc Nephrol. 2003; 14: S127-S130Crossref PubMed Google Scholar−+++FOS21Fox C.S. Larson M.G. Leip E.P. Culleton B. Wilson P.W. Levy D. Predictors of new-onset kidney disease in a community-based population.JAMA. 2004; 291: 844-850Crossref PubMed Scopus (977) Google Scholar++NS+MRFIT22Klag M.J. Whelton P.K. Randall B.L. Neaton J.D. Brancati F.L. Stamler J. End-stage renal disease in African-Americans and white men 16-Year MRFIT findings.JAMA. 1997; 277: 1293-1298Crossref PubMed Google Scholar++++ARIC23Muntner P. Coresh J. Smith J.C. Eckfeldt J. Klag M.J. Plasma lipids and risk of developing renal dysfunction The Atherosclerosis Risk in Communities Study.Kidney Int. 2000; 58: 293-301Crossref PubMed Scopus (533) Google ScholarNSNS+NSWCS24Haroun M.K. Jaar B.G. Hoffman S.C. Comstock G.W. Klag M.J. Coresh J. Risk factors for chronic kidney disease A prospective study of 23,534 men and women in Washington County, Maryland.J Am Soc Nephrol. 2003; 14: 2934-2941Crossref PubMed Scopus (403) Google Scholar+NSNS+PHS25Schaeffner E.S. Kurth T. Curhan G.C. et al.Cholesterol and risk of renal dysfunction in apparently healthy men.J Am Soc Nephrol. 2003; 14: 2084-2091PubMed Google ScholarNSNS+NSAbbreviations: MRFIT, Multiple Risk Factor Intervention Trial; FOS, Framingham Offspring Study; ARIC, Atherosclerosis Risk in Communities Study; WCS, Washington County Survey in Maryland; PHS, Physicians' Health Study; Okinawa, Okinawa Screening Program; +, identified risk factor; −, not a risk factor; NS, not studied. Open table in a new tab Abbreviations: MRFIT, Multiple Risk Factor Intervention Trial; FOS, Framingham Offspring Study; ARIC, Atherosclerosis Risk in Communities Study; WCS, Washington County Survey in Maryland; PHS, Physicians' Health Study; Okinawa, Okinawa Screening Program; +, identified risk factor; −, not a risk factor; NS, not studied. In an attempt to identify predictors of new-onset kidney disease, 2,585 healthy participants of the Framingham Offspring Study attended a baseline examination in 1978 to 1982 and a follow-up examination 20 years later.21Fox C.S. Larson M.G. Leip E.P. Culleton B. Wilson P.W. Levy D. Predictors of new-onset kidney disease in a community-based population.JAMA. 2004; 291: 844-850Crossref PubMed Scopus (977) Google Scholar Of those, 244 persons (9.4%) developed CKD, for whom identifiable risk factors were increasing age (odds ratio [OR], 2.36/10-y increment), GFR less than 90 mL/min/1.73 m2 (OR, 3.01), increased body mass index (OR, 2.60), diabetes (OR, 2.38), smoking (OR, 1.42), and hypertension (OR, 1.57) (21). Similar observations were made in the Okinawa screening program, in which obesity, smoking, and hypertriglyceridemia predicted the onset of proteinuria.13Iseki K. The Okinawa screening program.J Am Soc Nephrol. 2003; 14: S127-S130Crossref PubMed Google Scholar Proteinuria,14Iseki K. Ikemiya Y. Iseki C. Takishita S. Proteinuria and the risk of developing end stage renal disease.Kidney Int. 2003; 63: 1468-1474Crossref PubMed Scopus (428) Google Scholar as well as obesity,15Iseki K. Ikemiya Y. Kinjo K. Inoue T. Iseki C. Takishita S. Body mass index and the risk of development of end-stage renal disease in a screened cohort.Kidney Int. 2004; 65: 1870-1876Crossref PubMed Scopus (468) Google Scholar also predicted the development of ESRF. The Multiple Risk Factors Intervention Study (MRFIT), studying more than 300,000 male US citizens, also showed that hypertension, obesity, and hyperlipidemia were associated with a greater risk for developing CKD.22Klag M.J. Whelton P.K. Randall B.L. Neaton J.D. Brancati F.L. Stamler J. End-stage renal disease in African-Americans and white men 16-Year MRFIT findings.JAMA. 1997; 277: 1293-1298Crossref PubMed Google Scholar The study also identified low socioeconomic status as a risk factor for the development of renal insufficiency. The Atherosclerosis Risk in Communities (ARIC) study investigated the relationship between plasma lipid levels and the development of renal dysfunction (0.4-mg/dL increase in serum creatinine level) in 12,728 participants with baseline serum creatinine values between 1.8 and 2 mg/dL (159 and 177 μmol/L).23Muntner P. Coresh J. Smith J.C. Eckfeldt J. Klag M.J. Plasma lipids and risk of developing renal dysfunction The Atherosclerosis Risk in Communities Study.Kidney Int. 2000; 58: 293-301Crossref PubMed Scopus (533) Google Scholar The study reported that high serum triglyceride levels and low high-density lipoprotein cholesterol levels predicted an increase in serum creatinine level during a 3-year period.23Muntner P. Coresh J. Smith J.C. Eckfeldt J. Klag M.J. Plasma lipids and risk of developing renal dysfunction The Atherosclerosis Risk in Communities Study.Kidney Int. 2000; 58: 293-301Crossref PubMed Scopus (533) Google Scholar The Washington County survey in Maryland prospectively followed up 23,534 men and women during a 20-year period.24Haroun M.K. Jaar B.G. Hoffman S.C. Comstock G.W. Klag M.J. Coresh J. Risk factors for chronic kidney disease A prospective study of 23,534 men and women in Washington County, Maryland.J Am Soc Nephrol. 2003; 14: 2934-2941Crossref PubMed Scopus (403) Google Scholar Baseline blood pressure, cigarette smoking (hazard ratios, 2.4 in men and 2.9 in women), and treated diabetes (hazard ratios, 5 in men and 10.7 in women) were risk factors for the development of CKD.24Haroun M.K. Jaar B.G. Hoffman S.C. Comstock G.W. Klag M.J. Coresh J. Risk factors for chronic kidney disease A prospective study of 23,534 men and women in Washington County, Maryland.J Am Soc Nephrol. 2003; 14: 2934-2941Crossref PubMed Scopus (403) Google Scholar The Physicians' Health Study followed up 4,483 initially healthy men for 14 years and observed that elevated total cholesterol and low high-density lipoprotein cholesterol levels were associated with an increased risk for developing renal dysfunction.25Schaeffner E.S. Kurth T. Curhan G.C. et al.Cholesterol and risk of renal dysfunction in apparently healthy men.J Am Soc Nephrol. 2003; 14: 2084-2091PubMed Google Scholar Common risk factors clearly appear to be associated with both renal and cardiovascular diseases in developed countries. Early detection and prevention may have an impact on the outcome of both renal and cardiovascular morbidity and mortality. In developing countries, the risk-factor profile for CKD may be determined by the extent of Westernization of the society. Westernized societies acquire a risk profile similar to that of the developed world, with diabetes and hypertension leading the risk factors for CKD. It is relevant in that respect to note that the prevalence of diabetes is due to increase significantly more in the developing world (3-fold between 2000 and 2030) compared with developed nations (50% increase). However, developing countries continue to experience the burden of infectious diseases and associated CKD; the global burden of human immunodeficiency virus infection, with 40 million infected individuals; hepatitis C (170 million); malaria (300 million cases/y); schistosomiasis (200 million); and tuberculosis (200 million) is compounded by the high incidence of CKD in affected individuals and the increased morbidity and mortality associated with renal involvement. Programs for the detection and prevention of CKD in the emerging world will have to keep the infectious disease burden in mind in any targeted screening of at-risk individuals. Many of these studies relied on the measurement of urinary albumin or protein for the detection of patients at risk of kidney diseases. However, some have questioned the value of mass screening of the population for proteinuria in isolation, reasoning that its yield of treatable diseases, especially in young adults, is too low to warrant the exercise.26Harwell T.S. Nelson R.G. Little R.R. McDowall J.M. Helgerson S.D. Gohdes D. Testing for microalbuminuria in 2002. Barriers to implementing current guidelines.Am J Kidney Dis. 2003; 42: 245-249Abstract Full Text Full Text PDF PubMed Scopus (15) Google Scholar Orthostatic proteinuria, diet, menstruation, transient fever, hydration status, and physical activity are all factors that may affect the level of proteinuria and undermine the outcome of an untargeted randomly selected mass proteinuria screening exercise. In addition, reliance on proteinuria as the sole marker of CKD can be confounded by its variation with time and the sensitivity of methods used to measure it. In the NHANES III, only 63% of positive results on initial testing for microalbuminuria could be confirmed on repeated testing.6Coresh J. Astor B.C. Greene T. Eknoyan G. Levey A.S. Prevalence of chronic kidney disease and decreased kidney function in the adult US population Third National Health and Nutrition Examination Survey.Am J Kidney Dis. 2003; 41: 1-12Abstract Full Text Full Text PDF PubMed Scopus (2293) Google Scholar NHANES III also showed variability in urinary albumin excretion rates with age, with abnormal albuminuria levels varying from 7% in the 20- to 39-year-year-olds group to approximately 30% in those older than 70 years.27Coresh J. Wei G.L. McQuillan G. Brancati F.L. Prevalence of high blood pressure and elevated serum creatinine level in the United States Findings from the Third National Health and Nutrition Examination Survey (1988–1994).Arch Intern Med. 2001; 161: 1207-1216Crossref PubMed Scopus (494) Google Scholar The Nord-Trondlerg Health study in Norway showed that 3 urine samples positive for an elevated ACR were superior to a lower number of samples in predicting proteinuria.28Romundstad S. Holmen J. Kvenild K. Hallan H. Ellekjaer H. Microalbuminuria and all cause mortality in 2,089 apparently healthy individuals. A 4.4-year follow up study. The Nord-Trondelag Health Study (HUNT) Norway.Am J Kidney Dis. 2003; 42: 466-473Abstract Full Text Full Text PDF PubMed Scopus (226) Google Scholar However, the Nord-Trondlerg He
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