Published January 2, 2007
Chronic Kidney Disease (CKD) is a public health problem in the United States, affecting 20 million Americans. The most important adverse outcomes of CKD include increased risk for cardiovascular disease, complications of decreased kidney function, and progression to kidney failure, eventually requiring dialysis or kidney transplantation to survive. Early identification of individuals with CKD, combined with appropriate intervention, can delay the progression of kidney disease and its complications.1 However, since CKD is a silent disease, most individuals with CKD are not aware that they have this condition. Furthermore, primary care physicians may be overlooking CKD.2
The National Kidney Foundation (NKF) and the College of American Pathologists (CAP) share a strong commitment to advocate for, and support, public policy initiatives on CKD that are based on medical consensus, recognize the paramount importance of medical judgment in patient care, and facilitate early detection and treatment of patients with chronic kidney disease.
CKD can be detected in many patients by reporting estimated Glomerular Filtration Rate (eGFR) from a simple blood test for creatinine. Studies in the general population show that a reduced eGFR (less than 60 ml per minute per 1.73 m2) is associated with an increased risk of adverse outcomes of CKD.3 Recent advocacy efforts have been undertaken in various states to require mandatory clinical laboratory reporting of the (eGFR) for the patient whenever a serum creatinine test is ordered by a physician. Optimally, the physician education should also be coupled with an education program for patients and laboratory professionals. Studies by the National Kidney Foundation (NKF) and others have clearly demonstrated that physician education is necessary for successful implementation of an eGFR reporting system. Without appropriate education, physicians may resist receiving or using the eGFR reports. With a quality education effort, however, such resistance can be eliminated. In addition, not all patients with CKD can be identified by reduced eGFR. Measurement of the the urine albumin-to-creatinine ratio can detect CKD in individuals with CKD in whom eGFR is greater than 60 ml per minute per 1.73 m2, allowing earlier intervention.1,4
Given these concerns, both the National Kidney Foundation and the College of American Pathologists urge State Legislatures to not consider legislation mandating performance of eGFR calculations and instead consider a preferable form of legislation to establish CKD Task Forces at the state level. These Task Forces would promote the early detection and treatment of CKD. Such legislation should include a provision for education efforts as well as an evaluation of all available diagnostic strategies for identifying individuals with CKD.
Another benefit of legislation creating state CKD Task Forces is that these groups will be able to consider imminent advances in laboratory medicine that should facilitate identification of CKD, including standardization of the creatinine assay and validation of the formula for calculation of estimated GFR in additional populations.
Thus, both the CAP and NKF agree that optimally laboratory systems should be capable of performing an eGFR calculation when requested by a physician, or such calculations should be generated without a request when medically appropriate and feasible. The determination of when it is appropriate to perform a eGFR calculation is a part of the practice of medicine, for both the treating physician and the medical director of the clinical laboratory, and should be exclusively based on medical science.
Therefore, the National Kidney Foundation and the College of American Pathologists (CAP) support the estimated Glomerular Filtration Rate Calculation (eGFR), when appropriate and feasible, as a clinically useful calculation that should be promoted in the medical community in a scientific manner that does NOT require state legislation or state law that would create an inflexible, politically based mandate for the practice of medicine that, in general, may not advance patient care.
- National Kidney Foundation. K/DOQI clinical practice guidelines for chronic kidney disease: Evaluation, classification, and stratification. Kidney Disease Outcome Quality Initiative. Am J Kidney Dis 39(2 Suppl 1):S1-266, 2002.
- Boulware LE, Troll MU, Jaar BG, et al. Identification and referral of patients with progressive CKD: a national study. Am J Kidney Dis 48:192-204, 2006.
- Stevens LA, Coresh J, Greene T, et al. Assessing kidney function - measured and estimated Glomerular Filtration Rate. N Engl J Med 354: 2473-2483, 2006.
- G. Eknoyan, Hostetter T, Bakris G, et al. Proteinuria and Other Markers of Chronic Kidney Disease. A Position Statement of the National Kidney Foundation and the National Institute of Diabetes Digestive and Kidney Diseases. Am J Kidney Dis 42:617-622, 2003.