medwireNews: As many as three-quarters of US adults with type 2 diabetes are not being routinely screened for indicators of chronic kidney disease (CKD), show data from a nationally representative cohort of more than 300,000 individuals.
This is despite CKD affecting more than 134 million people with type 2 diabetes globally and “consensus guidelines recommend[ing] annual CKD screening with estimated glomerular filtration rate (eGFR) and urinary albumin-to-creatinine ratio (UACR) in this population,” note the researchers.
Only one quarter of the 316,234 adults (aged a median 59 years) from 20 US healthcare systems with data confirming type 2 diabetes and no known CKD received such screening between 2015 and 2020, they report in JAMA Network Open, adding that only a fifth of those with known CKD received treatment.
“Understanding the patient-level risk factors associated with not receiving recommended primary CKD screening can inform implementation strategies to improve screening for people with [type 2 diabetes],” suggest Daniel Edmonston (Duke University School of Medicine, Durham, North Carolina, USA) and colleagues.
The team used data from the US National Patient-Centered Clinical Research Network to identify risk factors for both non-concordance with national guidelines for CKD screening (whole cohort) and treatment (n=4215 with confirmed CKD). Just over half of the cohort was female (52%) with 68% reporting White and 22% Black race, and 10% were of Hispanic ethnicity.
Full screening concordance comprised the measurement of serum creatinine levels and UACR, while measurement of either one of these was considered partial concordance. Similarly, full treatment consisted of an angiotensin-converting enzyme (ACE) inhibitor or angiotensin receptor blocker (ARB), plus a sodium-glucose cotransporter (SGLT) 2 inhibitor, with partial treatment including just one of these agents.
In all, 24.9% of the cohort were given care that was fully concordant with screening guidelines, with 56.5% partially so. Most (98.1%) of those who received partially concordant care received creatinine screening. A total of 18.6% of the cohort received no screening during the 15-month follow-up period.
Several demographic and clinical factors increased people’s risk for receiving non-condcordant screening, including race. Hispanic participants were 1.16-times more likely to receive non-concordant screening than their White counterparts.
Additionally, study participants who had experienced a prior stroke or who were already taking an ACE inhibitor or ARB were a significant 1.11- and 1.10-times more likely to have care non-concordant with screening guidelines, respectively, than their peers who had not experienced stroke and were not being treated with an ACE inhibitor or ARB.
Conversely, certain clinical factors reduced the likelihood of treatment non-concordance, report Edmonston et al, with heart failure, peripheral arterial disease, and hypertension reducing the risk by a significant 13%, 17%, and 14%, respectively.
Of note, the researchers found that individuals whose care was non-concordant with CKD screening guidelines had significantly reduced risks for all-cause mortality (34%) and hospitalization (53%). They suggest that “patients with better screening could have had more cumulative exposure to diabetes and other comorbidities that would increase the risk of adverse clinical events or the frequency of clinician visits (ie, screening opportunities).”
In the cohort with confirmed CKD and albuminuria, 78.0% received an ACE inhibitor or ARB, 4.6% received a SGLT2 inhibitor, and 21.0% received no treatment at all during follow-up.
Having peripheral arterial disease and a lower eGFR significantly increased the risk for receiving no CKD treatment, report Edmonston and colleagues, by a respective 1.23 times versus not having the disease, and by 1.66 times for an eGFR of 30–44 mL/min per 1.73 m2 versus 60–90 mL/min per 1.73m2.
“These limitations in CKD screening and treatment identify areas of focus for implementation strategies to improve concordance with guideline-recommended screening and therapies for CKD,” they conclude.
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