Kidney disease has been underappreciated globally for a long time. Although advances in medical technology have made it possible to detect kidney disease at an early stage with easy-to-use methods and effective prevention and treatment tools, they are not widely known and used. While more attention has been paid to the prevention and treatment of common chronic diseases such as hypertension and diabetes, an equally important and more widespread disease, chronic kidney disease, has been overlooked. Just to treat the end-stage of this disease, uremia, costs the world billions or even tens of billions of dollars each year, with a huge economic burden on both countries and individuals. Tang Rong, Department of Nephrology, Xiangya Hospital, Central South University
Pay attention to the danger of kidney disease
The kidney is one of the most important organs to maintain the basic activities of life. Chronic kidney disease is insidious and lacks or rarely has obvious clinical manifestations, therefore, the early diagnosis rate is very low, and many patients are already in the middle and late stages or uremic syndrome, often accompanied by serious complications, with high mortality and high treatment costs. Chronic kidney disease is like a “stealth killer”, accompanied by hypertension, diabetes, hyperlipidemia, gout, cardiovascular and cerebrovascular diseases and other common chronic diseases, which eventually cause serious kidney damage. The huge treatment cost and high mortality rate bring a heavy burden to the society, families and individuals. Due to our long-term neglect and underestimation of kidney disease, we ignore this “silent killer” around us and miss the early diagnosis and the best time for treatment.
With the increasing awareness and attention to kidney disease, the concept of chronic kidney disease was formally introduced in the “Guidelines for Detection and Prevention of Progression of Chronic Kidney Disease/Kidney Disease Patient Quality of Life Instruction (K/DOQI)” published by the American Kidney Foundation (NKF) in 1999. The definition of chronic kidney disease will rely on a combination of the presence or absence of evidence of kidney injury and glomerular filtration rate (GFR). The GFR, which is derived from a formula that takes into account an individual’s age, weight and blood creatinine value, is a better indicator of kidney damage than the traditionally used blood creatinine, thus further expanding the scope of kidney disease and benefiting more patients.
According to the new definition of chronic kidney disease, the third National Health and Nutrition Examination Survey in the United States showed that the prevalence of chronic kidney disease in the United States is as high as 11%, with the prevalence of chronic kidney disease in stages 1-5 reaching 3.3%, 3.0%, 4.3%, 0.2%, and 0.1%, respectively. This means that in the United States, there is one case of chronic kidney disease in every nine normal people, and many more people are under the risk factors of chronic kidney disease. Although there is no corresponding epidemiological data in China, it is a real problem that a large number of patients with chronic kidney disease are underdiagnosed and misdiagnosed.
In addition to the serious consequences of renal decompensation, the relationship between chronic kidney disease and cardiovascular disease is also quite close, with the incidence of cardiovascular complications and mortality rates at all stages of chronic kidney disease much higher than in the general population, and a significant number of patients with chronic kidney disease die from serious cardiovascular complications before reaching end-stage renal disease. Indicators of renal damage (such as blood creatinine, urinary albumin and uric acid) are independent risk factors for prognosis, and delaying the progression of chronic kidney disease or correcting the risk factors of chronic kidney disease can significantly reduce cardiovascular complications.
Therefore, chronic kidney disease itself is an independent risk factor for cardiovascular disease, and has the same importance as cardiovascular disease and diabetes mellitus. Delaying the progression of kidney disease is especially important to reduce cardiovascular complications and mortality.
Focus on early screening
Chronic kidney disease has a variety of causes, and people with risk factors for chronic kidney disease require special attention, including: diabetes, hypertension, autoimmune disease, systemic infection, >60 years of age, family history of kidney disease, and recovery from acute renal failure. Clinicians should perform regular urine protein and even urine microalbumin testing in these high-risk groups.
The early onset of chronic kidney disease is often insidious, and some patients may show swelling, foamy urine, hypertension, etc. Many young patients are already in advanced renal failure at the time of diagnosis, losing the opportunity to reverse the treatment. Therefore, it is important to pay attention to the early signs of kidney disease during routine physical examination for early detection of kidney disease.
The main manifestations of renal disease include hypertension, proteinuria, hematuria and renal insufficiency. For patients with hypertension, routine urine tests should be performed routinely to exclude renal hypertension, and thereafter, urine microalbumin should be reviewed regularly (annually) for early detection of hypertensive kidney damage.
Proteinuria is an important prognostic indicator of kidney disease. Clinical tests include urine routine, urine microalbumin, 24-hour urine protein quantification, and urine protein electrophoresis, etc. Different tests have different sensitivities and characteristics, and effective control of proteinuria can delay the progression of chronic kidney disease and reduce cardiovascular complications.
Blood creatinine has long been commonly used to assess renal function, but it lacks sufficient sensitivity. First, creatinine is influenced by age, race and gender, and young men and older women with the same creatinine level have completely different levels of renal function. Secondly, because of the strong compensatory function of the kidney, blood creatinine will rise only when renal function decreases by more than 50%, while most patients with stage 3 chronic kidney disease (glomerular filtration rate between 30-60 ml/min) have a normal high level of blood creatinine, which is often not taken seriously.
With the introduction of the definition of chronic kidney disease, we emphasize the correct assessment of renal function. The formula method of calculating glomerular filtration rate, isotope assay, endogenous creatinine clearance assay, Iohexol plasma clearance assay, and CystatinC assay can all be used for the early assessment of renal insufficiency. In general, two to three methods are recommended for comprehensive assessment. For some special groups of patients such as obese, children, elderly, and myopathy, attention should be paid to the selection of appropriate assessment tools.
The progression of chronic kidney disease to end-stage renal disease is a gradual process, but due to insidious clinical manifestations, it is often not easy to detect early and the best time to intervene for treatment is lost. Rapid advances in renal replacement therapy have made nephrology one of the most effective disciplines for the treatment of organ failure, and has also provided important support for the resuscitation of a large number of critically ill patients, including those from other disciplines. Although the mortality rate of end-stage renal disease has decreased significantly in recent years, the high cost of medical care, the severe complications and high mortality rate, the relatively low quality of life and the social return rate of end-stage renal disease patients compared to other populations are the focus of our attention. Therefore, as nephrologists, we emphasize early screening and diagnosis of chronic kidney disease and early intervention to minimize and delay the occurrence of end-stage renal disease and its complications, reduce patient suffering, improve quality of life, and save medical resources.
Emphasis on patient education
The diagnosis of chronic kidney disease is the prerequisite and foundation of prevention and treatment, and it is not only the work of medical personnel to improve the understanding of chronic kidney disease, but also for more patients with chronic kidney disease and people with risk factors for chronic kidney disease, it is important to fully understand the knowledge about chronic kidney disease for self-monitoring and management. Medical staff should also take responsibility for patient education.
First, patients with chronic kidney disease should be educated to have a correct understanding of the disease. Most patients with chronic kidney disease can maintain a normal work and life without excessive anxiety and worry, but they should pay attention to avoid factors that may aggravate kidney damage in daily life, such as infections and medications.
Secondly, not all patients need long-term medication, but regular annual checkups are very important to keep track of changes in the disease.
Thirdly, in addition to the treatment of the cause of chronic kidney disease, the academic community also emphasizes the active control of blood pressure, proteinuria and the establishment of a comprehensive treatment system. Some drugs, such as angiotensin-converting enzyme inhibitors and angiotensin II receptor 1 antagonists, have been widely used in kidney disease clinics because they have been proven to be effective in reducing proteinuria and slowing down the progression of renal failure in a large number of clinical trials.
In conclusion, with the rapid increase in the number of diabetes and hypertension and the accelerated aging of the population, chronic kidney disease has become a serious social public health problem and a heavy medical burden in China. The prevention and treatment of chronic kidney disease requires the attention of the whole society. Let’s take action to achieve the early detection and prevention of chronic kidney disease!