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Prevalence of Chronic Kidney Disease in an Adult Population
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Archives of Medical Research
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(2014)
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ORIGINAL ARTICLE
Prevalence of Chronic Kidney Disease in an Adult Population Alfonso M. Cueto-Manzano,a Laura Cortes-Sanabria,a Hector R. Martınez-Ramırez,a Enrique Rojas-Campos,a Benjamin G omez-Navarro,b and Marcelo Castillero-Manzanoc a
Unidad de Investigaci on Medica en Enfermedades Renales, bDepartamento de Nefrologıa, cDireccion General, Hospital de Especialidades, CMNO, IMSS, Guadalajara, Jalisco, Mexico Received for publication December 11, 2013; accepted June 19, 2014 (ARCMED-D-13-00704).
Background and Aims. One strategy to prevent and manage chronic kidney disease (CKD) is to offer screening programs. The aim of this study was to determine the percentage prevalence and risk factors of CKD in a screening program performed in an adult general population. Methods. This is a cross-sectional study. Six-hundred ten adults (73% women, age 51 14 years) without previously known chronic kidney disease (CKD) were evaluated. Participants were subjected to a questionnaire, blood pressure measurement and anthropometry. Glomerular filtration rate estimated by CKD-EPI formula and urine tested with albuminuria dipstick. Results. More than 50% of subjects reported family antecedents of diabetes mellitus (DM), hypertension and obesity, and 30% of CKD. DM was self-reported in 19% and hypertension in 29%. During screening, overweight/obesity was found in 75%; women had a higher frequency of obesity (41 vs. 34%) and high-risk abdominal waist circumference (87 vs. 75%) than men. Hypertension (both self-reported and diagnosed in screening) was more frequent in men (49%) than in women (38%). CKD was found in 14.7%: G1, 5.9%; G2, 4.5%; G3a, 2.6%; G3b, 1.1%, G4, 0.3%; and G5, 0.3%. Glomerular filtration rate was mildly/moderately reduced in 2.6%, moderately/severely reduced in 1.1%, and severely reduced in !1%. Abnormal albuminuria was found in 13%. CKD was predicted by DM, hypertension and male gender. Conclusions. A percentage CKD prevalence of 14.7% was found in this sample of an adult population, with most patients at early stages. Screening programs constitute excellent opportunities in the fight against kidney disease, particularly in populations at high risk. Ó 2014 IMSS. Published by Elsevier Inc. Key Words: Chronic kidney disease, Prevalence, General population, Screening.
Introduction Chronic kidney disease (CKD), and particularly its ultimate outcome end-stage renal disease (ESRD), is a severe worldwide health problem associated with increased morbidity and mortality, decreased quality of life and enormous economic costs (1). Therefore, it is of great importance to early diagnose and prevent CKD, whose obvious advantage is the
Address reprint requests to: Alfonso M. Cueto-Manzano, Unidad de Investigaci on Medica en Enfermedades Renales, Hospital de Especialidades, CMNO, IMSS, Belisario Domınguez No. 1000, Col. Independencia, Guadalajara, Jalisco, Mexico; Phone: (þ52) (33) 3809-7269; FAX: (þ52) (33) 3624-5050; E-mail: [email protected]
implementation of measures recognized to reduce the risk and/or slow progression of nephropathy (most effective when initiated early in the course of renal disease) (2,3). Notwithstanding, most individuals at earlier stages of kidney disease have been largely undiagnosed and/or undertreated (4,5). One strategy to prevent and manage CKD is to offer screening and prevention programs. The World Kidney Day (WKD) has become one of the most widely celebrated events to raise awareness among the general public and health professionals about the dangers of the kidney disease (6). The aim of the present study was to determine the percentage prevalence and risk factors of CKD in a screening program performed in general population.
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(2014)
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Subjects and Methods
Definitions
In March 10, 2011, the Hospital de Especialidades, Centro Medico Nacional de Occidente, Instituto Mexicano del Seguro Social (IMSS) in Guadalajara, Mexico organized a 1day public event celebrating WKD with educational and screening activities for CKD. Within the previous 2 weeks, the general public was informed by means of local media (press, TV and radio interviews), informative posters and pamphlets distributed in Family Medicine Units and strategic public areas of the city of Guadalajara. By all these means, persons aged 18 years and older were encouraged to attend this event. Patients with already known CKD, ESRD or self-reported potential transitory causes of proteinuria (i.e., urinary tract infections, menstruation or fever) were excluded. All personnel involved in the screening program (22 physicians, 19 nurses, six laboratory chemists/ technicians, 14 medical students, and 11 other profession) were trained in logistics and procedures (four sessions in 2 weeks). Participants stayed in a sitting area receiving lectures and pamphlets and watching videos and a theatrical performance about the importance of kidneys and CKD while waiting their turn to be evaluated. Subsequently, individuals were subjected to a questionnaire, blood pressure measurement, and anthropometry. A questionnaire specifically designed for this purpose contained questions about sociodemographic variables and risk factors and was applied by physicians. Blood pressure was measured by nurses on three separate occasions according to criteria of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (7). A mean of these readings was used for analysis. Weight, height and waist circumference were measured according to standardized methods. In a blood sample obtained after 8 h of fasting, serum creatinine was determined by the kinetic Jaffe-method with a Cobas c 111 Analyzer (Roche Diagnostics, Rostkreuz, Switzerland). This method has been standardized against isotope dilution mass spectrometry. With the serum creatinine result, glomerular filtration rate (GFR) was estimated by means of the Chronic Kidney Disease Epidemiology Collaboration creatinine equation (8). Additionally, a random urine sample was obtained for dipstick urinalysis (Multistix 10 SG; Bayer de Mexico, S.A. de C.V., Ecatepec, Mexico) and albuminuria-specific dipstick (Micral-Test; Roche Diagnostics GmbH, Mannheim, Germany). Results of urinalysis and albuminuria dipsticks were interpreted by trained and experienced personnel. The same day of the celebration, results were provided to participants. Those patients with CKD were advised to seek attention by primary health-care physicians or specialists (as appropriate) in order to confirm diagnosis and receive treatment.
CKD was classified according to the Kidney Disease Improving Global Outcomes (KDIGO) 2012 (9). We defined albuminuria as a value O50 mg/dL in the micraltest dipstick. In previous studies, we found this cut-off value as reliable, valid and rapid method for screening of albuminuria in diabetic and nondiabetic patients (10). Hypertension was defined as a self-reported history of high blood pressure, intake of antihypertensive medication or a mean blood pressure O140/90 mmHg during screening; adequate control was considered if mean blood pressure was !140/90 mmHg. Diabetes mellitus was defined as a self-report or treatment with antidiabetic drugs. A diagnosis of cardiovascular disease was considered if patients reported a history (or there was clinical evidence at examination) of heart failure, arrhythmias, or cerebrovascular accidents. A probable diagnosis of urinary tract infection or hematuria was considered when leukocytes and nitrites or blood, respectively, indicated a trace or greater in the urinalysis dipstick. Patients were classified as smokers if they reported to be smokers at the time of the questionnaire, and alcoholism was defined as at least one episode of alcohol intoxication during the previous month. Statistical Analysis Data are expressed as mean SD, median (percentiles 25% e75%), or percentages as appropriate. Comparisons between groups (according to gender, diabetes or hypertension) were made by independent samples Student t, Mann-Whitney U or chi-square tests, as appropriate. Multivariate analysis to identify factors predicting CKD was performed by Conditional Backward Logistic Regression; p value !0.05 was accepted as significant.
Results Six-hundred ten patients were evaluated; their main demographic and family antecedents are shown in Table 1. Most participants were women and mean age was 51.1 14.5 years (minimum 18, maximum 94). Age groups between 31 and 70 years were predominant. Three quarters of the population had social security health coverage and 25% had no coverage. Of those with social security affiliation, 92% were covered by the IMSS, 7% by Seguro Popular, and 1.5% by other institutions. Predominant marital status was married (64%) followed by single (18%), widow (9%), and other (9%). Ninety-six percent of the sample was from the state of Jalisco, 2% from the state of Michoacan, and 1% from other locations. More than a half of the sample had an educational level of high school or lower. Family history of chronic noncommunicable
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CKD Prevalence in the General Population
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Table 1. Sociodemographic characteristics and family antecedents of the studied population (n 5 610)
Table 2. Comparison of risk factors between the Mexican general population and patients of the present study
Variable
Variable
n (%)
Age group (years) #30 31e40 41e50 51e60 61e70 O70 Gender Male Female Social Security Yes No Years of education Illiteracy 1e6 7e9 9e12 O12 Family history of: Diabetes mellitus Hypertension Overweight/Obesity CVD CKD
56 98 134 140 126 56
(9) (16) (22) (23) (21) (9)
162 (27) 448 (73) 451 (74) 159 (26) 18 209 178 96 109
(3) (34) (29) (16) (18)
377 347 318 188 179
(62) (57) (52) (31) (30)
CVD, cardiovascular disease; CKD, chronic kidney disease.
diseases was frequent; one of three individuals had a family member with CKD. Risk Factors for CKD The frequency of risk factors for CKD in our patients were as follows: smoking 30%, alcoholism 30%, diabetes mellitus 19%, arterial hypertension 29%, use of nonsteroidal anti-inflammatory drugs 18% (in most cases they were self-prescribed), recurrent urinary tract infections 13%, cardiovascular disease 8%, and urinary lithiasis 6%. Comparison of risk factors for CKD between the Mexican general population and our patients is shown in Table 2.
Hypertension Overweight/obesity High-risk waist circumference Female/Male Illiteracy/Elementary school Smoking Alcoholism
Main clinical results according to gender are shown in Table 3. More than three quarters of the population had overweight or obesity. Women displayed a higher frequency of obesity and men a higher proportion of overweight. A high proportion of the evaluated subjects had a waist circumference at risk for cardiovascular disease, and this was especially significant in women. Hypertension was more frequent in male subjects, particularly the case of unknown hypertension detected during the screening. Proportion of patients with previously known high blood pressure and with adequate control was not different between genders; however, adequate control was not
a
Our study
33% 39%/33%
29% 40%/37%
83%/65%a 6%/37%b 22% 32%c
87%/75% 3%/34% 30% 30%
a
Encuesta Nacional de Salud y Nutricion 2006 (reference 16), and 2012 (reference 17). b Instituto Nacional de Estadıstica y Geografıa (reference 18); f Encuesta Nacional de Adicciones 2011. Tabaco (reference 19). c Encuesta Nacional de Adicciones 2011. Alcohol (reference 20).
frequently found in both groups (61% in women and 57% in men). Results of Renal Function Results of impaired renal function were more frequently observed in men compared to women, particularly in those aged 41e60 years (Table 4). Individuals O65 years old represented 6% of those with CKD stage 1, 43% with stage 2, 56% with stage 3, and 0% with stages 4 and 5 ( p !0.05 vs. subjects !65 years). In the urinalysis, data suggesting urinary tract infection were found in 4% of the population; however, there was no significant difference between genders (female 5 vs. male 2%) or between patients with or without CKD (6 vs. 4%, respectively). Prevalence of CKD Results of the estimated GFR and albuminuria are shown in Table 5. Estimated GFR was normal or high in almost 65% Table 3. Clinical results in the studied population by gender
Variable
Clinical Results
Official data
Women (n 5 448)
Men (n 5 162)
Weight (kg) 71.1 15.1 83.3 16.7 Height (m) 1.56 0.06 1.69 0.06 29.2 6.1 29.0 5.5 BMI (kg/m2) Normal, n (%) 115 (25) 32 (20) Overweight, n (%) 150 (34) 75 (46) Obesity, n (%) 183 (41) 55 (34) WC (cm) 94.8 13.4 101.3 12.8 At cardiovascular risk, n (%) 386 (87) 118 (75) SBP (mmHg) 124 19 128 15 DBP (mmHg) 81 10 84 10 Hypertension, n (%) 170 (38) 80 (49) Previously known, n (%) 124 (73) 51 (64) Detected during screening, n (%) 46 (27) 29 (36)
p !0.0001 !0.0001 0.74 0.02 !0.0001 !0.0001 0.16 0.08 0.02 0.30 0.007
BMI, body mass index; WC, waist circumference; SBP, systolic blood pressure; DBP, diastolic blood pressure.
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(2014)
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(56) (23) (12) (9)
39 9 2 11
(64) (15) (3) (18)
of population, 31% had mild reduction, 2.6% mild to moderate reduction, 1% moderate to severe reduction, and ! 1% had severe reduction. On the other hand, 78 (13%) subjects had a moderate or severe increase in the urinary excretion of albumin by dipstick. When combining both findings, the percentage prevalence of CKD was 14.7% (Figure 1), with most of these patients found in early stages of the disease. None of these patients were previously aware of their renal disease. No difference in CKD prevalence was found between patients with or without social coverage.
31 13 7 5 *p !0.05 vs. group O60 years of same gender; £ p !0.05 vs. groups 41e60 and O60 years of same gender; **p !0.05 vs same age group of women. GFR, glomerular filtration rate.
(65) (21) (9) (5) 28 9 4 2 (63) (12) (25) (0) 5 1 2 0 (67) (22) (4) (7) 81 26 5 9 (67) (23) (5) (5) 146 50 12 10 (66) (25) (5) (4) 67 26 5 4 (57) (29) (7) (7) 8 4 1 1
41e60 (n 5 56) 0.95 0.21** 96.5*,** (83e103) 21e40 (n 5 43) 0.90 0.13** 113.3£ (96e121)
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Risk Factors Associated with CKD
Age group (years) Serum creatinine (mg/dL) Estimated GFR (mL/min/1.73 m2) Albuminuria, n (%) 0 mg/dL 20 mg/dL 50 mg/dL 100 mg/dL
#20 (n 5 14) 0.64 0.11 126.0£ (98e132)
21e40 (n 5 102) 0.71 0.24 116.0£ (109e121)
41e60 (n 5 218) 0.70 0.14y 100.1y (91e107)
O60 (n 5 121) 0.83 0.62 85.0 (74e92)
#20 (n 5 8) 0.82 0.17** 100.0* (85e111)
Men (n 5 169) Women (n 5 455) Variable
Table 4. Results of renal function by gender and age group
345 346 347 348 349 350 351 352 353 354 355 356 357 358 359 360 361 362 363 364 365 366 367 368 369 370 371 372 373 374 375 376 377 378 379 380 381 382 383 384 385 386 387 388 389 390 391 392 393 394 395 396 397 398 399
Cueto-Manzano et al./ Archives of Medical Research O60 (n 5 61) 0.99 0.22** 79.2 (69e90)
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Factors independently predicting CKD in this population are shown in Table 6. Independent variables considered in the multivariate analysis were those which resulted significant in the univariate analysis or were clinically relevant: age, gender, years of education, family antecedents of diabetes, hypertension and CKD, use of nephrotoxic drugs, repeated urinary tract infections, social security coverage, and presence of diabetes or hypertension. The only significant predictive variables for CKD were the presence of diabetes mellitus, hypertension, and male gender; years of education were a marginal predictor. Figure 2 shows the higher CKD prevalence of patients with diabetes mellitus, hypertension and male gender compared with their counterparts.
Discussion Results obtained in this screening program are very interesting. Percentage prevalence of CKD in this sample was 14.7%, higher than reported in the general population of other countries, which is |10% (11e13). A recent systematic literature review reported a heterogeneous prevalence of impaired kidney function from 1.7% to 8.1% in community-screening samples (14); however, this review only included studies considering impaired kidney function as GFR (!60 mL/min/1.73 m2), creatinine clearance (!60 mL/min) or increased serum creatinine above predefined thresholds, but not proteinuria or other markers of kidney damage. The Mexican population displays many risk factors for CKD, which is probably related to its highest ESRD (15). Although subjects in the present study were a sample of volunteers, we consider that they may be representative of the adult general populations as our results were similar to those observed in the Mexican National Surveys in terms of prevalence of hypertension, overweight-obesity, highrisk waist circumference, educational level, smoking, and alcoholism (16e20). Interestingly, a high proportion of subjects had family antecedents of chronic noncommunicable diseases such as diabetes mellitus, hypertension, obesity, and particularly CKD. It cannot be ruled out that relatives of patients with CKD may have biased results by participating in this event in a higher proportion.
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CKD Prevalence in the General Population
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Q1 510 511 Albuminuria (%) 512 A1 A2 A3 513 514 Normal to mildly Moderately Severely 515 increased Increased Increased Total (%) 516 $90 58.8 3.8 2.1 64.7 517 60e89 26.4 1.9 2.6 30.9 518 45e59 1.3 0.3 1.0 2.6 519 30e44 0.5 0 0.6 1.1 520 15e29 0 0 0.3 0.3 !15 0 0 0.3 0.3 521 Total (%) 87 6 6.9 100 522 523 524 kind of measure is cost-effective only in patients with dia525 betes or hypertension (25) (however, this latter study was 526 based on a microsimulation model and included only health 527 care costs). On the other hand, a mass screening using 528 dipstick test and/or serum creatinine assay was found to 529 be cost-effective in a population with high CKD prevalence 530 such as the Japanese (26). Additionally, results of a large 531 cohort study from Taiwan (27) suggest that promotion of 532 CKD recognition through the general public knowing their 533 GFR and testing their urine is crucial to reduce premature 534 deaths from all causes (particularly cardiovascular causes) 535 and to attenuate this global epidemic because authors found 536 that CKD was highly prevalent and contributed to |10% of 537 all deaths. 538 Several reasons advocate screening for early-stage CKD: 539 the high incidence and prevalence of CKD, its known risk 540 factors, its numerous adverse consequences, its long asymp541 tomatic phase, the availability of simple screening tests for 542 CKD, and the availability of treatments that may alter the 543 course of early-stage CKD and reduce complications. We 544 have previously shown that an educational intervention to 545 primary physicians increased their clinical competence and 546 was associated with the preservation of renal function in pa547 tients with diabetes mellitus and early CKD (3). Moreover, a 548 multiple educational strategy guided by multidisciplinary 549 teams and supported by self-care groups significantly 550 improved the lifestyle and dietary habits of patients at high 551 risk of developing CKD (diabetes, hypertension, and obesity) 552 (28) and of diabetic patients with early CKD when compared 553 554 555 Table 6. Results of conditional backward logistic regression to identify 2 556 predictive factors for CKD (R 0.12, p !0.0001) 557 Variable OR p 558 559 Diabetes mellitus 2.62 !0.0001 560 Arterial hypertension 2.08 0.004 Male 1.99 0.007 561 Years of education 0.82 0.08 562 563 Diabetes mellitus: no 5 0, yes 5 1; Arterial hypertension: no 5 0, yes 5 1; Gender: female 5 0, male 5 1. 564
Table 5. Results of the estimated glomerular filtration rate and urinary excretion of albumin
Glomerular filtration rate categories (mL/min/1.73m2)
G1 G2 G3a G3b G4 G5
Normal or high Mildly decreased Mildly to moderately decreased Moderately to severely decreased Severely decreased Kidney failure
Other data related with CKD such as the self-prescribed use of nonsteroidal anti-inflammatory drugs, recurrent urinary tract infections and urinary lithiasis were present in a lower, but still important proportion. These data deserve further investigation. Diabetes mellitus, high blood pressure and male gender were predictive factors of CKD in the present study as has been extensively described. These findings are in concordance with the high CKD prevalence in patients at high risk (such as diabetic and hypertensive patients) observed in our setting (5,21). Ageing is also recognized as a risk factor for CKD; however, age did not predict CKD in this sample. In fact, even when eGFR decreased with older age, as a median value, eGFR was not lower than 60 mL/min/1.73 m2 in subjects O60 years old. It is possible that a slightly over-representative sample of individuals O60 years old may have influenced our results; additionally, a type II statistical error cannot be definitely excluded. The benefit of screening for early-stage CKD in general or high-risk populations is currently uncertain (22). Some organizations recommend CKD screening only in selected populations at risk (23,24) and one study suggested that this
14.8
85.5%
Normal Figure 1. Percentage prevalence and classification of CKD in the studied population.
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campaign had a positive impact on the awareness and control of risk factors in CKD subjects (30) but the frequency of CKD awareness remains undesirable and further emphasis to publicize the importance of early diagnosis and appropriate management of CKD is needed. One limitation of the present study, and this of kind screening programs is the cross-sectional nature. Diagnosis of CKD requires confirmation (9), which could reduce the number of diagnosed cases by screening programs (31). In addition, when screening is to be performed, several principles should be considered including the availability of facilities for diagnosis and treatment and the economic balance in the expenditure of medical care when cases are found. If a screening is performed but there is not comprehensive or adequate coverage for managing diagnosed cases, serious ethical problems may arise. In the case of the IMSS system there is no restriction for diagnosis and treatment of these kinds of patients and they were referered for medical management as appropriate. Patients without social security were advised to seek medical attention in other health-care systems. Further studies with larger sample sizes are needed to corroborate our results and their implications. In conclusion, a percentage CKD prevalence of 14.7% was found in this sample of the adult population with most patients at early stages. Screening programs constitute excellent opportunities in the fight against kidney disease, particularly in populations at high risk.
Acknowledgments
Figure 2. Comparisons of the presence of CKD by diabetes mellitus and hypertension status, and gender.
to conventional health-care models (29). In the present study, 15/100 subjects of our setting may have CKD. If neither physicians nor patients were aware, diagnostic and therapeutic measures against renal disease progression would not be implemented. If results of this screening are extrapolated to the total population of the state of Jalisco (7,350,682) (18), 1,080,550 of inhabitants may have some degree of renal damage, which is a disturbing piece of information. Most of these patients, however, would be in early stages during which, if adequate treatment is initiated, CKD progression could be delayed or stopped. Screening programs for CKD has several advantages including the increasing awareness and appropriate management of risk factors for kidney and cardiovascular disease, which has been shown to be very low even in patients at high risk for CKD (1,4e6,21,27,28). The WKD
Special thanks to alumni of the UIMER and residents/staff of Department of Nephrology, Hospital de Especialidades, CMNO, IMSS; alumni of the Post-Graduate Course of Nephrology Nursing, IMSS; alumni of the School of Medicine, University of Guadalajara; Dr. Diana J. Cerda Medina, Chemist Adolfo Cota Sanchez, and Dr. Blas Elizaldi, Central Laboratory, Hospital de Especialidades, CMNO, IMSS. This program was partially supported by the generosity of Impromed SA de CV, Roche Mexico, Laboratorios Pisa SA de CV, and Pfizer Mexico.
Disclosure Statement All authors declare no conflicts of interest.
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3. Cortes-Sanabria L, Cabrera-Pivaral CE, Cueto-Manzano AM, et al. Improving care of patients with diabetes and CKD: a pilot study for a cluster-randomized trial. Am J Kidney Dis 2008;51:777e788. 4. Collins AJ, Couser WG, Dirks JH, et al. World Kidney Day: an idea whose time has come. Kidney Int 2006;69:781e782. 5. Cueto-Manzano AM, Cortes-Sanabria L, Martınez-Ramırez HR, et al. Detection of early nephropathy in Mexican patients with type 2 diabetes mellitus. Kidney Int 2005;68(suppl 97):S40eS45. 6. The World Kidney Day. http://www.worldkidneyday.org (accessed December 10, 2013). 7. Chobanian AV, Bakris GL, Black HR, et al. The seventh report of Joint Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (The JNC 7 Report). JAMA 2003;289: 2560e2772. 8. Levey AS, Stevens LA, Schmid CH, et al, for the CKD-EPI (Chronic Kidney Disease Epidemiology Collaboration). A new equation to estimate glomerular filtration rate. Ann Intern Med 2009;150:604e612. 9. Kidney Disease Improving Global Outcomes (KDIGO) CKD Work Group. KDIGO 2012 Clinical Practice Guideline for the Evaluation and Management of Chronic Kidney Disease. Kidney Int Suppl 2013;3:1e150. 10. Cortes-Sanabria L, Martınez-Ramırez HR, Hernandez JL, et al. Utility of the dipstick micraltest IIÔ in the screening of microalbuminuria of diabetes mellitus type 2 and essential hypertension. Rev Invest Clin 2006;58:190e197. 11. Coresh J, Astor BC, Greene T, et al. 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;41:1e12. 12. Lameire N, Jager K, van Biesen W, et al. Chronic kidney disease: a European perspective. Kidney Int 2005;68(suppl 99):S30eS38. 13. Chen N, Wang W, Huang Y, et al. Community-based study on CKD subjects and the associated risk factors. Nephrol Dial Transplant 2009;24:2117e2123. 14. McCullough K, Sharma P, Ali T, et al. Measuring the population burden of chronic kidney disease: a systematic literature review of the estimated prevalence of impaired kidney function. Nephrol Dial Transplant 2012;27:1812e1821. 15. United States Renal Data System: http://www.usrds.org/2013/pdf/v2_ ch12_13.pdf (accessed December 11, 2013). 16. Olaiz-Fernandez G, Rivera-Dommarco J, Shamah-Levy T, et al. Encuesta Nacional de Salud y Nutricion 2006. Cuernavaca, Mexico: Instituto Nacional de Salud Publica; 2006. (accessed December 10, 2013). http://www.insp.mx/images/stories/Produccion/pdf/100722_ cp3.pdf. 17. Gutierrez JP, Rivera-Dommarco J, Shamah-Levy T, et al. Encuesta Nacional de Salud y Nutricion 2012. Resultados Nacionales. Cuernavaca, Mexico: Instituto Nacional de Salud P ublica (MX); 2012. (accessed December 10, 2013). http://ensanut.insp.mx/informes/ ENSANUT2012ResultadosNacionales.pdf.
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18. Instituto Nacional de Estadıstica y Geografıa: http://www.inegi.org.mx/ sistemas/mapatematico/Default.aspx (accessed December 11, 2013). 19. Reynales-Shigematsu LM, Guerrero-Lopez CM, Lazcano-Ponce E, et al. Encuesta Nacional de Adicciones 2011: Reporte de Tabaco. Mexico DF, Mexico: INPRFM; 2012. Available at: www.inprf.gob. mx www.conadic.gob.mx www.cenadic.salud.gob.mx www.insp.mx. 20. Medina-Mora ME, Villatoro-Velazquez JA, Fleiz-Bautista C, et al. Encuesta Nacional de Adicciones 2011: Reporte de Alcohol. Mexico DF, Mexico: INPRFM; 2012. Available at: www.inprf.gob.mx www. conadic.gob.mx www.cenadic.salud.gob.mx www.insp.mx. 21. Obrador GT, Garcıa-Garcıa G, Villa AR, et al. Prevalence of chronic kidney disease in the Kidney Early Evaluation Program (KEEP) Mexico and comparison with KEEP US. Kidney Int 2010;77(suppl 116):S2eS8. 22. Moyer VA. Screening for chronic kidney disease: U.S. Preventive Services Task Force recommendation statement. Ann Intern Med 2012; 157:567e570. 23. McCullough PA, Vassalotti JA, Collins AJ, et al. National Kidney Foundation’s Kidney Early Evaluation Program (KEEP) annual data report 2009: Executive summary. Am J Kidney Dis 2010;55(3 suppl 2):S1eS3. 24. Levey AS, Atkins R, Coresh J, et al. Chronic kidney disease as a global public health problem: Approaches and initiatives—A position statement from Kidney Disease Improving Global Outcomes. Kidney Int 2007;72:247e259. 25. Hoerger TJ, Wittenborn JS, Segel JE, et al. A health policy model of CKD: 2. The cost-effectiveness of microalbuminuria screening. Am J Kidney Dis 2010;55:463e473. 26. Kondo M, Yamagata K, Hoshi SL, et al. Cost-effectiveness of chronic kidney disease mass screening test in Japan. Clin Exp Nephrol 2012; 16:279e291. 27. Wen CP, Cheng TYD, Tsai MK, et al. All-cause mortality attributable to chronic kidney disease: a prospective cohort study based on 462 293 adults in Taiwan. Lancet 2008;371:2173e2182. 28. Cueto-Manzano AM, Martınez-Ramırez HR, Cortes-Sanabria L. Management of chronic kidney disease: primary health-care setting, selfcare and multidisciplinary approach. Clin Nephrol 2010;74(suppl 1): S99eS104. 29. Cueto-Manzano AM, Martınez-Ramırez HR, Cortes-Sanabria L. Comparison of primary health-care models in the management of chronic kidney disease. Kidney Int Suppl 2013;3:210e214. http://dx.doi.org/ 10.1038/kisup.2013.16. 30. Chin HJ, Ahn JM, Na KY, et al. The effect of the World Kidney Day campaign on the awareness of chronic kidney disease and the status of risk factors for cardiovascular disease and renal progression. Nephrol Dial Transplant 2010;25:413e419. 31. Bottomley MJ, Kalachik A, Mevada C, et al. Single estimated glomerular filtration rate and albuminuria measurement significantly overestimates the prevalence of chronic kidney disease. Nephron Clin Pract 2011;117:c348ec352.
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Archives of Medical Research
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(2014)
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ORIGINAL ARTICLE
Prevalence of Chronic Kidney Disease in an Adult Population Alfonso M. Cueto-Manzano,a Laura Cortes-Sanabria,a Hector R. Martınez-Ramırez,a Enrique Rojas-Campos,a Benjamin G omez-Navarro,b and Marcelo Castillero-Manzanoc a
Unidad de Investigaci on Medica en Enfermedades Renales, bDepartamento de Nefrologıa, cDireccion General, Hospital de Especialidades, CMNO, IMSS, Guadalajara, Jalisco, Mexico Received for publication December 11, 2013; accepted June 19, 2014 (ARCMED-D-13-00704).
Background and Aims. One strategy to prevent and manage chronic kidney disease (CKD) is to offer screening programs. The aim of this study was to determine the percentage prevalence and risk factors of CKD in a screening program performed in an adult general population. Methods. This is a cross-sectional study. Six-hundred ten adults (73% women, age 51 14 years) without previously known chronic kidney disease (CKD) were evaluated. Participants were subjected to a questionnaire, blood pressure measurement and anthropometry. Glomerular filtration rate estimated by CKD-EPI formula and urine tested with albuminuria dipstick. Results. More than 50% of subjects reported family antecedents of diabetes mellitus (DM), hypertension and obesity, and 30% of CKD. DM was self-reported in 19% and hypertension in 29%. During screening, overweight/obesity was found in 75%; women had a higher frequency of obesity (41 vs. 34%) and high-risk abdominal waist circumference (87 vs. 75%) than men. Hypertension (both self-reported and diagnosed in screening) was more frequent in men (49%) than in women (38%). CKD was found in 14.7%: G1, 5.9%; G2, 4.5%; G3a, 2.6%; G3b, 1.1%, G4, 0.3%; and G5, 0.3%. Glomerular filtration rate was mildly/moderately reduced in 2.6%, moderately/severely reduced in 1.1%, and severely reduced in !1%. Abnormal albuminuria was found in 13%. CKD was predicted by DM, hypertension and male gender. Conclusions. A percentage CKD prevalence of 14.7% was found in this sample of an adult population, with most patients at early stages. Screening programs constitute excellent opportunities in the fight against kidney disease, particularly in populations at high risk. Ó 2014 IMSS. Published by Elsevier Inc. Key Words: Chronic kidney disease, Prevalence, General population, Screening.
Introduction Chronic kidney disease (CKD), and particularly its ultimate outcome end-stage renal disease (ESRD), is a severe worldwide health problem associated with increased morbidity and mortality, decreased quality of life and enormous economic costs (1). Therefore, it is of great importance to early diagnose and prevent CKD, whose obvious advantage is the
Address reprint requests to: Alfonso M. Cueto-Manzano, Unidad de Investigaci on Medica en Enfermedades Renales, Hospital de Especialidades, CMNO, IMSS, Belisario Domınguez No. 1000, Col. Independencia, Guadalajara, Jalisco, Mexico; Phone: (þ52) (33) 3809-7269; FAX: (þ52) (33) 3624-5050; E-mail: [email protected]
implementation of measures recognized to reduce the risk and/or slow progression of nephropathy (most effective when initiated early in the course of renal disease) (2,3). Notwithstanding, most individuals at earlier stages of kidney disease have been largely undiagnosed and/or undertreated (4,5). One strategy to prevent and manage CKD is to offer screening and prevention programs. The World Kidney Day (WKD) has become one of the most widely celebrated events to raise awareness among the general public and health professionals about the dangers of the kidney disease (6). The aim of the present study was to determine the percentage prevalence and risk factors of CKD in a screening program performed in general population.
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Subjects and Methods
Definitions
In March 10, 2011, the Hospital de Especialidades, Centro Medico Nacional de Occidente, Instituto Mexicano del Seguro Social (IMSS) in Guadalajara, Mexico organized a 1day public event celebrating WKD with educational and screening activities for CKD. Within the previous 2 weeks, the general public was informed by means of local media (press, TV and radio interviews), informative posters and pamphlets distributed in Family Medicine Units and strategic public areas of the city of Guadalajara. By all these means, persons aged 18 years and older were encouraged to attend this event. Patients with already known CKD, ESRD or self-reported potential transitory causes of proteinuria (i.e., urinary tract infections, menstruation or fever) were excluded. All personnel involved in the screening program (22 physicians, 19 nurses, six laboratory chemists/ technicians, 14 medical students, and 11 other profession) were trained in logistics and procedures (four sessions in 2 weeks). Participants stayed in a sitting area receiving lectures and pamphlets and watching videos and a theatrical performance about the importance of kidneys and CKD while waiting their turn to be evaluated. Subsequently, individuals were subjected to a questionnaire, blood pressure measurement, and anthropometry. A questionnaire specifically designed for this purpose contained questions about sociodemographic variables and risk factors and was applied by physicians. Blood pressure was measured by nurses on three separate occasions according to criteria of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (7). A mean of these readings was used for analysis. Weight, height and waist circumference were measured according to standardized methods. In a blood sample obtained after 8 h of fasting, serum creatinine was determined by the kinetic Jaffe-method with a Cobas c 111 Analyzer (Roche Diagnostics, Rostkreuz, Switzerland). This method has been standardized against isotope dilution mass spectrometry. With the serum creatinine result, glomerular filtration rate (GFR) was estimated by means of the Chronic Kidney Disease Epidemiology Collaboration creatinine equation (8). Additionally, a random urine sample was obtained for dipstick urinalysis (Multistix 10 SG; Bayer de Mexico, S.A. de C.V., Ecatepec, Mexico) and albuminuria-specific dipstick (Micral-Test; Roche Diagnostics GmbH, Mannheim, Germany). Results of urinalysis and albuminuria dipsticks were interpreted by trained and experienced personnel. The same day of the celebration, results were provided to participants. Those patients with CKD were advised to seek attention by primary health-care physicians or specialists (as appropriate) in order to confirm diagnosis and receive treatment.
CKD was classified according to the Kidney Disease Improving Global Outcomes (KDIGO) 2012 (9). We defined albuminuria as a value O50 mg/dL in the micraltest dipstick. In previous studies, we found this cut-off value as reliable, valid and rapid method for screening of albuminuria in diabetic and nondiabetic patients (10). Hypertension was defined as a self-reported history of high blood pressure, intake of antihypertensive medication or a mean blood pressure O140/90 mmHg during screening; adequate control was considered if mean blood pressure was !140/90 mmHg. Diabetes mellitus was defined as a self-report or treatment with antidiabetic drugs. A diagnosis of cardiovascular disease was considered if patients reported a history (or there was clinical evidence at examination) of heart failure, arrhythmias, or cerebrovascular accidents. A probable diagnosis of urinary tract infection or hematuria was considered when leukocytes and nitrites or blood, respectively, indicated a trace or greater in the urinalysis dipstick. Patients were classified as smokers if they reported to be smokers at the time of the questionnaire, and alcoholism was defined as at least one episode of alcohol intoxication during the previous month. Statistical Analysis Data are expressed as mean SD, median (percentiles 25% e75%), or percentages as appropriate. Comparisons between groups (according to gender, diabetes or hypertension) were made by independent samples Student t, Mann-Whitney U or chi-square tests, as appropriate. Multivariate analysis to identify factors predicting CKD was performed by Conditional Backward Logistic Regression; p value !0.05 was accepted as significant.
Results Six-hundred ten patients were evaluated; their main demographic and family antecedents are shown in Table 1. Most participants were women and mean age was 51.1 14.5 years (minimum 18, maximum 94). Age groups between 31 and 70 years were predominant. Three quarters of the population had social security health coverage and 25% had no coverage. Of those with social security affiliation, 92% were covered by the IMSS, 7% by Seguro Popular, and 1.5% by other institutions. Predominant marital status was married (64%) followed by single (18%), widow (9%), and other (9%). Ninety-six percent of the sample was from the state of Jalisco, 2% from the state of Michoacan, and 1% from other locations. More than a half of the sample had an educational level of high school or lower. Family history of chronic noncommunicable
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CKD Prevalence in the General Population
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Table 1. Sociodemographic characteristics and family antecedents of the studied population (n 5 610)
Table 2. Comparison of risk factors between the Mexican general population and patients of the present study
Variable
Variable
n (%)
Age group (years) #30 31e40 41e50 51e60 61e70 O70 Gender Male Female Social Security Yes No Years of education Illiteracy 1e6 7e9 9e12 O12 Family history of: Diabetes mellitus Hypertension Overweight/Obesity CVD CKD
56 98 134 140 126 56
(9) (16) (22) (23) (21) (9)
162 (27) 448 (73) 451 (74) 159 (26) 18 209 178 96 109
(3) (34) (29) (16) (18)
377 347 318 188 179
(62) (57) (52) (31) (30)
CVD, cardiovascular disease; CKD, chronic kidney disease.
diseases was frequent; one of three individuals had a family member with CKD. Risk Factors for CKD The frequency of risk factors for CKD in our patients were as follows: smoking 30%, alcoholism 30%, diabetes mellitus 19%, arterial hypertension 29%, use of nonsteroidal anti-inflammatory drugs 18% (in most cases they were self-prescribed), recurrent urinary tract infections 13%, cardiovascular disease 8%, and urinary lithiasis 6%. Comparison of risk factors for CKD between the Mexican general population and our patients is shown in Table 2.
Hypertension Overweight/obesity High-risk waist circumference Female/Male Illiteracy/Elementary school Smoking Alcoholism
Main clinical results according to gender are shown in Table 3. More than three quarters of the population had overweight or obesity. Women displayed a higher frequency of obesity and men a higher proportion of overweight. A high proportion of the evaluated subjects had a waist circumference at risk for cardiovascular disease, and this was especially significant in women. Hypertension was more frequent in male subjects, particularly the case of unknown hypertension detected during the screening. Proportion of patients with previously known high blood pressure and with adequate control was not different between genders; however, adequate control was not
a
Our study
33% 39%/33%
29% 40%/37%
83%/65%a 6%/37%b 22% 32%c
87%/75% 3%/34% 30% 30%
a
Encuesta Nacional de Salud y Nutricion 2006 (reference 16), and 2012 (reference 17). b Instituto Nacional de Estadıstica y Geografıa (reference 18); f Encuesta Nacional de Adicciones 2011. Tabaco (reference 19). c Encuesta Nacional de Adicciones 2011. Alcohol (reference 20).
frequently found in both groups (61% in women and 57% in men). Results of Renal Function Results of impaired renal function were more frequently observed in men compared to women, particularly in those aged 41e60 years (Table 4). Individuals O65 years old represented 6% of those with CKD stage 1, 43% with stage 2, 56% with stage 3, and 0% with stages 4 and 5 ( p !0.05 vs. subjects !65 years). In the urinalysis, data suggesting urinary tract infection were found in 4% of the population; however, there was no significant difference between genders (female 5 vs. male 2%) or between patients with or without CKD (6 vs. 4%, respectively). Prevalence of CKD Results of the estimated GFR and albuminuria are shown in Table 5. Estimated GFR was normal or high in almost 65% Table 3. Clinical results in the studied population by gender
Variable
Clinical Results
Official data
Women (n 5 448)
Men (n 5 162)
Weight (kg) 71.1 15.1 83.3 16.7 Height (m) 1.56 0.06 1.69 0.06 29.2 6.1 29.0 5.5 BMI (kg/m2) Normal, n (%) 115 (25) 32 (20) Overweight, n (%) 150 (34) 75 (46) Obesity, n (%) 183 (41) 55 (34) WC (cm) 94.8 13.4 101.3 12.8 At cardiovascular risk, n (%) 386 (87) 118 (75) SBP (mmHg) 124 19 128 15 DBP (mmHg) 81 10 84 10 Hypertension, n (%) 170 (38) 80 (49) Previously known, n (%) 124 (73) 51 (64) Detected during screening, n (%) 46 (27) 29 (36)
p !0.0001 !0.0001 0.74 0.02 !0.0001 !0.0001 0.16 0.08 0.02 0.30 0.007
BMI, body mass index; WC, waist circumference; SBP, systolic blood pressure; DBP, diastolic blood pressure.
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(2014)
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(56) (23) (12) (9)
39 9 2 11
(64) (15) (3) (18)
of population, 31% had mild reduction, 2.6% mild to moderate reduction, 1% moderate to severe reduction, and ! 1% had severe reduction. On the other hand, 78 (13%) subjects had a moderate or severe increase in the urinary excretion of albumin by dipstick. When combining both findings, the percentage prevalence of CKD was 14.7% (Figure 1), with most of these patients found in early stages of the disease. None of these patients were previously aware of their renal disease. No difference in CKD prevalence was found between patients with or without social coverage.
31 13 7 5 *p !0.05 vs. group O60 years of same gender; £ p !0.05 vs. groups 41e60 and O60 years of same gender; **p !0.05 vs same age group of women. GFR, glomerular filtration rate.
(65) (21) (9) (5) 28 9 4 2 (63) (12) (25) (0) 5 1 2 0 (67) (22) (4) (7) 81 26 5 9 (67) (23) (5) (5) 146 50 12 10 (66) (25) (5) (4) 67 26 5 4 (57) (29) (7) (7) 8 4 1 1
41e60 (n 5 56) 0.95 0.21** 96.5*,** (83e103) 21e40 (n 5 43) 0.90 0.13** 113.3£ (96e121)
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Risk Factors Associated with CKD
Age group (years) Serum creatinine (mg/dL) Estimated GFR (mL/min/1.73 m2) Albuminuria, n (%) 0 mg/dL 20 mg/dL 50 mg/dL 100 mg/dL
#20 (n 5 14) 0.64 0.11 126.0£ (98e132)
21e40 (n 5 102) 0.71 0.24 116.0£ (109e121)
41e60 (n 5 218) 0.70 0.14y 100.1y (91e107)
O60 (n 5 121) 0.83 0.62 85.0 (74e92)
#20 (n 5 8) 0.82 0.17** 100.0* (85e111)
Men (n 5 169) Women (n 5 455) Variable
Table 4. Results of renal function by gender and age group
345 346 347 348 349 350 351 352 353 354 355 356 357 358 359 360 361 362 363 364 365 366 367 368 369 370 371 372 373 374 375 376 377 378 379 380 381 382 383 384 385 386 387 388 389 390 391 392 393 394 395 396 397 398 399
Cueto-Manzano et al./ Archives of Medical Research O60 (n 5 61) 0.99 0.22** 79.2 (69e90)
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Factors independently predicting CKD in this population are shown in Table 6. Independent variables considered in the multivariate analysis were those which resulted significant in the univariate analysis or were clinically relevant: age, gender, years of education, family antecedents of diabetes, hypertension and CKD, use of nephrotoxic drugs, repeated urinary tract infections, social security coverage, and presence of diabetes or hypertension. The only significant predictive variables for CKD were the presence of diabetes mellitus, hypertension, and male gender; years of education were a marginal predictor. Figure 2 shows the higher CKD prevalence of patients with diabetes mellitus, hypertension and male gender compared with their counterparts.
Discussion Results obtained in this screening program are very interesting. Percentage prevalence of CKD in this sample was 14.7%, higher than reported in the general population of other countries, which is |10% (11e13). A recent systematic literature review reported a heterogeneous prevalence of impaired kidney function from 1.7% to 8.1% in community-screening samples (14); however, this review only included studies considering impaired kidney function as GFR (!60 mL/min/1.73 m2), creatinine clearance (!60 mL/min) or increased serum creatinine above predefined thresholds, but not proteinuria or other markers of kidney damage. The Mexican population displays many risk factors for CKD, which is probably related to its highest ESRD (15). Although subjects in the present study were a sample of volunteers, we consider that they may be representative of the adult general populations as our results were similar to those observed in the Mexican National Surveys in terms of prevalence of hypertension, overweight-obesity, highrisk waist circumference, educational level, smoking, and alcoholism (16e20). Interestingly, a high proportion of subjects had family antecedents of chronic noncommunicable diseases such as diabetes mellitus, hypertension, obesity, and particularly CKD. It cannot be ruled out that relatives of patients with CKD may have biased results by participating in this event in a higher proportion.
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CKD Prevalence in the General Population
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Q1 510 511 Albuminuria (%) 512 A1 A2 A3 513 514 Normal to mildly Moderately Severely 515 increased Increased Increased Total (%) 516 $90 58.8 3.8 2.1 64.7 517 60e89 26.4 1.9 2.6 30.9 518 45e59 1.3 0.3 1.0 2.6 519 30e44 0.5 0 0.6 1.1 520 15e29 0 0 0.3 0.3 !15 0 0 0.3 0.3 521 Total (%) 87 6 6.9 100 522 523 524 kind of measure is cost-effective only in patients with dia525 betes or hypertension (25) (however, this latter study was 526 based on a microsimulation model and included only health 527 care costs). On the other hand, a mass screening using 528 dipstick test and/or serum creatinine assay was found to 529 be cost-effective in a population with high CKD prevalence 530 such as the Japanese (26). Additionally, results of a large 531 cohort study from Taiwan (27) suggest that promotion of 532 CKD recognition through the general public knowing their 533 GFR and testing their urine is crucial to reduce premature 534 deaths from all causes (particularly cardiovascular causes) 535 and to attenuate this global epidemic because authors found 536 that CKD was highly prevalent and contributed to |10% of 537 all deaths. 538 Several reasons advocate screening for early-stage CKD: 539 the high incidence and prevalence of CKD, its known risk 540 factors, its numerous adverse consequences, its long asymp541 tomatic phase, the availability of simple screening tests for 542 CKD, and the availability of treatments that may alter the 543 course of early-stage CKD and reduce complications. We 544 have previously shown that an educational intervention to 545 primary physicians increased their clinical competence and 546 was associated with the preservation of renal function in pa547 tients with diabetes mellitus and early CKD (3). Moreover, a 548 multiple educational strategy guided by multidisciplinary 549 teams and supported by self-care groups significantly 550 improved the lifestyle and dietary habits of patients at high 551 risk of developing CKD (diabetes, hypertension, and obesity) 552 (28) and of diabetic patients with early CKD when compared 553 554 555 Table 6. Results of conditional backward logistic regression to identify 2 556 predictive factors for CKD (R 0.12, p !0.0001) 557 Variable OR p 558 559 Diabetes mellitus 2.62 !0.0001 560 Arterial hypertension 2.08 0.004 Male 1.99 0.007 561 Years of education 0.82 0.08 562 563 Diabetes mellitus: no 5 0, yes 5 1; Arterial hypertension: no 5 0, yes 5 1; Gender: female 5 0, male 5 1. 564
Table 5. Results of the estimated glomerular filtration rate and urinary excretion of albumin
Glomerular filtration rate categories (mL/min/1.73m2)
G1 G2 G3a G3b G4 G5
Normal or high Mildly decreased Mildly to moderately decreased Moderately to severely decreased Severely decreased Kidney failure
Other data related with CKD such as the self-prescribed use of nonsteroidal anti-inflammatory drugs, recurrent urinary tract infections and urinary lithiasis were present in a lower, but still important proportion. These data deserve further investigation. Diabetes mellitus, high blood pressure and male gender were predictive factors of CKD in the present study as has been extensively described. These findings are in concordance with the high CKD prevalence in patients at high risk (such as diabetic and hypertensive patients) observed in our setting (5,21). Ageing is also recognized as a risk factor for CKD; however, age did not predict CKD in this sample. In fact, even when eGFR decreased with older age, as a median value, eGFR was not lower than 60 mL/min/1.73 m2 in subjects O60 years old. It is possible that a slightly over-representative sample of individuals O60 years old may have influenced our results; additionally, a type II statistical error cannot be definitely excluded. The benefit of screening for early-stage CKD in general or high-risk populations is currently uncertain (22). Some organizations recommend CKD screening only in selected populations at risk (23,24) and one study suggested that this
14.8
85.5%
Normal Figure 1. Percentage prevalence and classification of CKD in the studied population.
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campaign had a positive impact on the awareness and control of risk factors in CKD subjects (30) but the frequency of CKD awareness remains undesirable and further emphasis to publicize the importance of early diagnosis and appropriate management of CKD is needed. One limitation of the present study, and this of kind screening programs is the cross-sectional nature. Diagnosis of CKD requires confirmation (9), which could reduce the number of diagnosed cases by screening programs (31). In addition, when screening is to be performed, several principles should be considered including the availability of facilities for diagnosis and treatment and the economic balance in the expenditure of medical care when cases are found. If a screening is performed but there is not comprehensive or adequate coverage for managing diagnosed cases, serious ethical problems may arise. In the case of the IMSS system there is no restriction for diagnosis and treatment of these kinds of patients and they were referered for medical management as appropriate. Patients without social security were advised to seek medical attention in other health-care systems. Further studies with larger sample sizes are needed to corroborate our results and their implications. In conclusion, a percentage CKD prevalence of 14.7% was found in this sample of the adult population with most patients at early stages. Screening programs constitute excellent opportunities in the fight against kidney disease, particularly in populations at high risk.
Acknowledgments
Figure 2. Comparisons of the presence of CKD by diabetes mellitus and hypertension status, and gender.
to conventional health-care models (29). In the present study, 15/100 subjects of our setting may have CKD. If neither physicians nor patients were aware, diagnostic and therapeutic measures against renal disease progression would not be implemented. If results of this screening are extrapolated to the total population of the state of Jalisco (7,350,682) (18), 1,080,550 of inhabitants may have some degree of renal damage, which is a disturbing piece of information. Most of these patients, however, would be in early stages during which, if adequate treatment is initiated, CKD progression could be delayed or stopped. Screening programs for CKD has several advantages including the increasing awareness and appropriate management of risk factors for kidney and cardiovascular disease, which has been shown to be very low even in patients at high risk for CKD (1,4e6,21,27,28). The WKD
Special thanks to alumni of the UIMER and residents/staff of Department of Nephrology, Hospital de Especialidades, CMNO, IMSS; alumni of the Post-Graduate Course of Nephrology Nursing, IMSS; alumni of the School of Medicine, University of Guadalajara; Dr. Diana J. Cerda Medina, Chemist Adolfo Cota Sanchez, and Dr. Blas Elizaldi, Central Laboratory, Hospital de Especialidades, CMNO, IMSS. This program was partially supported by the generosity of Impromed SA de CV, Roche Mexico, Laboratorios Pisa SA de CV, and Pfizer Mexico.
Disclosure Statement All authors declare no conflicts of interest.
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