The Primary Care Perspective on Routine Urine Dipstick Screening to Identify Patients with Albuminuria

Harvard University, Cambridge, Massachusetts, United States
Clinical Journal of the American Society of Nephrology (Impact Factor: 4.61). 08/2012; 8(1). DOI: 10.2215/CJN.12681211
Source: PubMed


Proponents of routine urine dipstick screening to identify patients at risk for ESRD in the primary care setting have argued that urine dipsticks are inexpensive, low risk, acceptable to patients, and now, more accurate. Proponents believe that urine dipstick screening has the potential to improve outcomes for people with early disease and increase awareness of CKD. Most primary care physicians agree that populations who are at high risk for CKD should be tested and appropriately treated to decrease complications of ESRD. However, proponents of mass screening may not appreciate the challenges, limitations, and potential harms of screening. Urine dipstick testing does not meet all of the criteria for a good screening test. Screening the general population with urine dipsticks will generate many false positives-between 50% and 90% of positive tests-that will require follow-up, increase costs, and cause patient anxiety. Routine screening with urine dipsticks is not cost-effective on the order of $200,000 per quality-adjusted life year. Most importantly, there is little evidence that early identification of microalbuminuria in unselected patients influences outcomes of CKD. Without proof of effectiveness, overdiagnosis, a problem for even well established screening tests, is risked. Finally, no specialty society or preventive services group currently recommends general screening. Instead of screening, primary care physicians and nephrologists should work together to identify patients at high risk for ESRD and optimize management to improve outcomes for patients with CKD.

8 Reads

  • BMJ (online) 07/2013; 347(jul29 3):f4298. DOI:10.1136/bmj.f4298 · 17.45 Impact Factor
  • Source
    [Show abstract] [Hide abstract]
    ABSTRACT: Objective: This study aims to investigate the influence of estimated glomerular filtration rate (eGFR) with two equations (and by one or two separate measurements), on the prevalence of chronic kidney disease (CKD) and its association with blood pressure, and cardiovascular and metabolic risk factors. Methods: Between January 2010 and October 2011, the Ibermutuamur CArdiovascular RIsk Assessment project included 128 588 workers (77.2% men, mean age 39.3 years, range 16-75), who underwent two consecutive yearly medical check-ups and had information for eGFR according to the MDRD-IDMS and CKD-EPI equations (serum creatinine was measured by a isotope-dilution mass spectrometry traceable method in a single central laboratory). CKD was defined by an eGFR less than 60 ml/min per 1.73 m. Subclinical (occult) renal disease was defined as an eGFR less than 60 ml/min per 1.73 m in patients with serum creatinine below 1.3 mg/dl and below 1.2 mg/dl in men and women, respectively. Results: In this working population, prevalence of CKD was very low, but two to six times lower when two separate eGFRs below 60 ml/min per 1.73 m were used. The prevalence of CKD was significantly lower with the CKD-EPI compared to the MDRD-IDMS equation. The same applies to occult CKD. In male workers, occult CKD was practically nonexistent.Multivariate analyses show that blood pressure, total serum cholesterol, and serum glucose (positively), and high-density lipoprotein and low-density lipoprotein (negatively) were associated with CKD, with both equations. Another metabolic factor (waist circumference) was only associated (positively) with CKD defined by the CKD-EPI equation, which appears to be associated with most components of the metabolic syndrome. Conclusions: The CKD-EPI formula, calculated on the basis of two reported blood samples, may provide the most specific definition of CKD.
    Journal of Hypertension 07/2014; 32(10). DOI:10.1097/HJH.0000000000000267 · 4.72 Impact Factor
  • [Show abstract] [Hide abstract]
    ABSTRACT: : With the recent massive scale-up of access to antiretroviral therapy (ART) in resource-limited countries, HIV has become a chronic disease with new challenges. There is mounting evidence of an increased burden of renal and genitourinary diseases among HIV-infected persons caused by direct HIV viral effects and/or indirectly through the development of opportunistic infections, ART medication-related toxicities, and other noncommunicable diseases (NCDs). We review the epidemiology of HIV-associated renal and urogenital diseases, including interactions with kidney-related NCDs such as hypertension, diabetes mellitus, and cardiovascular disease. We also examine the current evidence regarding the impact of HIV infection on the development of urogenital diseases. Highly advisable in sub-Saharan Africa are the establishment of renal disease registries, reviews of existing clinical practice including cost-effectiveness studies, and the adoption and use of HIV-related NCD management, with training for different cadres of health providers. Epidemiological research priorities include prospective studies to evaluate the true prevalence and spectrum of HIV-related renal disease and their progression. Simple diagnostics tools should be evaluated, including urinary dipsticks and point-of-care urea and creatinine tests to screen for kidney injury in primary care settings. Study of urological manifestations of HIV can help determine the extent of disease and outcomes. As patients live longer on ART, the burden of renal and genitourological complications of HIV and of ART can be expected to increase with a commensurate urgency in both discovery and evidence-based improvements in clinical management.
    JAIDS Journal of Acquired Immune Deficiency Syndromes 09/2014; 67 Suppl 1:S68-78. DOI:10.1097/QAI.0000000000000259 · 4.56 Impact Factor