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Chronic Kidney Disease (CKD)
The forgotten illness
Prof. Raymond Vanholder (University Hospital Ghent, Belgium), President of the European Renal Association – European Dialysis and Transplant Association (ERA-EDTA)
Paris, France (May 25, 2012) – At least 70 million Europeans (> 10%) have lost more than half of their kidney function, a condition named chronic kidney disease (CKD). Below this threshold, CKD causes a dramatic increase of general and cardiovascular mortality. Survival chances at the start of dialysis, one of the treatment modalities for replacement of severely damaged kidneys, is currently worse than when colon carcinoma are diagnosed. Risk calculations demonstrate that CKD is a negative cardiovascular prognostic factor as such, irrespective of the traditional mortality risks such as cholesterol or blood pressure. CKD should thus be considered a crucial health issue, necessitating specific preventive and therapeutic approaches.
CKD is still frequently neglected as a health hazard, despite being epidemiologically and economically at least as important as diabetes. One reason might well be that the alarm signs for CKD are few, unless it has progressed to an advanced stage, when preventive measures have no further impact. An even more important problem is the lack of awareness among the general population and even among the medical community of the risks of kidney disease. A frequent misconception is that the CKD population is identical to those on dialysis. However, dialysis patients represent only 1 to 2% of the population with CKD. This also means that almost all affected patients will die, especially of cardiovascular causes, before they ever reach the dialysis stage. This underscores again the dramatic impact of CKD on public health and the importance of preventing this condition and its complications.
The scope of treatment and prevention of CKD extends far beyond the domain of kidney specialists due to its frequent association with other chronic conditions, where it worsens the complication profile and hinders adequate treatment. While diabetes and CKD are both equivalent cardiovascular risk factors per se, vascular damage is exponentially increased if both conditions are combined. Hypertension is not only the cause but also a consequence of CKD, thus resulting in a vicious circle. Many CKD patients have cancer and vice versa; however, CKD will prohibit adequate doses of oncologic therapy. The CKD population also suffers to a much greater extent than the general population from infections, malnutrition, gastrointestinal problems, neurological disorders including dementia and coagulation disturbances, which in turn are more difficult to treat when CKD is present.
Lack of awareness leads to insufficient screening and inadequate or belated response to warning signs. Greater educational efforts should be directed not only at the general population, but also at all medical and paramedical professionals who are not specialised in kidney disease. Several conditions are linked to an increased incidence of CKD: diabetes mellitus, hypertension, smoking, ageing, protein in the urine (albuminuria), overweight, contact with nephrotoxic substances including drugs, family history of kidney disease, chronic inflammation, certain infectious diseases and cancer. All subjects having these characteristics should not only be adequately treated for their primary condition, but should also be regularly screened and treated specifically for their kidney disease from the moment that the first signs develop.
Screening can be achieved by performing a simple blood and urine test. Creatinine is easy to determine and is essentially removed by the kidneys. A rise in serum creatinine is therefore a measure of decreasing renal function. Creatinine is often included in equations for calculating how much blood is cleaned by the kidneys. Another easily obtainable marker is albuminuria.
European kidney research is often clinically oriented, even if it is fundamental. Especially strong areas are hereditary and/or rare diseases, epidemiology, pathophysiology of CKD progression, and the link between CKD and cardiovascular disease. European nephrology units participate in a large number of clinical studies and research networks, both European and transcontinental. The European Renal Association – European Dialysis and Transplantation Association (ERA-EDTA) , the European society for nephrologists, supports several initiatives for European networking, including large research projects, fellowship exchanges, continuing medical education initiatives and workgroups. European nephrology researchers are well appreciated at international meetings, also outside Europe. Perhaps more than their colleagues from overseas, European nephrologists tend to publish not only in their own European journals but also in the USA. ERA-EDTA currently makes special efforts to collaborate with the other large nephrology societies (International Society of Nephrology and American Society of Nephrology) and with several other large national societies.
Nevertheless, research should be further stimulated or implemented, especially research focusing on early detection and prevention of chronic and acute kidney disease, their progression and their main complications, on unravelling the pathophysiologic mechanisms of specific kidney diseases, on the pharmacokinetics of common drugs in CKD and socioeconomic and pharmacoeconomic aspects linked to epidemiology. Specific attention should be paid to children, rare diseases and ageing. CKD is a specific problem of old age; as a consequence, its prevalence will continue to increase in the years ahead, while CKD in itself is a prototype of accelerated ageing. The development of strategies for coping with this predicted overwhelming influx of older kidney patients should be a priority.
There is certainly a need for further educational activities in respect of CKD. More efforts should be made and more opportunities created to increase the awareness of the general public and also of the medical community, especially of generalists and of specialists whose patients often suffer from CKD: cardiologists, diabetologists, urologists, oncologists, cardiac surgeons, vascular surgeons, rheumatologists, geriatricians, neurologists, intensivists, and transplant physicians. This should result in better screening, detection, mapping and prevention. Full support by regulatory bodies should also imply that CKD be considered a separate niche with its own specific pathophysiology and therapy. Only such a targeted approach can decrease the frequency, morbidity, mortality, and societal costs of CKD. For the time being, only diabetes, cancer and cardiovascular diseases have received such a privileged individual status. Initiatives should also propagate less expensive renal replacement strategies for end stage CKD (self-care haemodialysis, home haemodialysis, peritoneal dialysis and transplantation). Among transplantation options, living donation in particular should be propagated. All these measures impact not only health condition but also health economy.
Finally, more uniform European statistical data about CKD are needed, not only for the medical community, but also for regulators. The ERA-EDTA has invested for many years in a European nephrology register containing a host of data from many countries; however, not all European countries avail of the register as yet, even though they all collect the same data. There should be a uniform approach to CKD registration that should be compulsory for all countries, with financial incentives for ensuring consistency. Likewise, a European project aiming at producing, disseminating and implementing nephrological guidelines, especially for non-nephrologists, is urgently needed. Finally, efforts should also be made to create a more uniform policy on the reimbursement of nephrological prevention and therapies, including renal replacement.
In conclusion, the strengths of European nephrology are in its research, knowledge of pathophysiological pathways, prevention, and treatment of people at risk. Its weaknesses are in the insufficient dissemination about the occurrence and importance of this problem among the general population and the non-nephrological medical community, the ensuing lack of screening and prevention, and the consideration of CKD as ancillary to other health problems, rather than as a separate entity necessitating specific research, planning, and funding. Regulators, politicians, patients and the medical community should join and act together to correct these weaknesses and enhance these strengths.
ERA-EDTA Congress 2012, 25.05.2012 (tB)