Kidney Disease Progression and Screening Cost-Effectiveness among African Americans

Abstract

Where is the wisdom we have lost in knowledge? Where is the knowledge we have lost in information?-T.S. EliotThe tragedy in the continuing disparities in the progression of CKD to ESRD and cardiovascular events for poor and disadvantaged (often minority) patients has not been so much that disparities exist, but the lack of will to prioritize and implement actions to address the problem. 1 This is not to insinuate that there are no initiatives to improve outcomes and reduce disparities, but the level of action pales compared with the magnitude of the problem. This is further complicated when population-level recommendations, such as the lack of sufficient evidence to support screening for CKD, 2 are applied to groups for whom the burden of disease is clearly greater. However, the absence of the will to take action on humanistic grounds and the inertia caused by the need for more evidence may be overcome by studies that demonstrate that addressing health disparities can also reduce overall health care costs, as well as uncover new knowledge at the basic, clinical, and community level that will translate to improved outcomes for all CKD patients. In this issue of JASN, Hoerger and colleagues 3 tackle the subject of kidney disease progression and screening costeffectiveness with a focus on African Americans, addressing the racial/ethnic group at the highest risk for developing ESRD in the nation. Building upon prior cost-effectiveness analyses and simulation models for CKD, 4-6 Hoerger et al. contribute to the rational argument for targeting racial and ethnic disparities as a priority in the battle against the larger burden of kidney disease by first calibrating a validated CKD health policy model to more specifically forecast the observed increased ESRD rates for African Americans and then describing the effect of ameliorating this disparate decline in renal function.For the model to predict the observed greater lifetime risk of ESRD for African Americans it was necessary to impute a 20% faster decline in estimated GFR (eGFR) at stage 3 and a 60% faster decline in eGFR at stage 4. Whether the assumptions made to account for this accelerated decline in eGFR are due to disparities in care, biologic factors, or other unmeasured conditions remains unclear. However, their results support the findings of disparate renal decline in African Americans seen in other analyses of decline in renal function, National Health and Nutrition Examination Survey 7 data, and observational studies of cohorts in real-world settings. 8 What Hoerger and colleagues attempt to do with this finding is to focus the debate on how we can address disparities, by demonstrating that, compared with usual care, targeted screening of African Americans for microalbuminuria at selected time intervals can be much more cost-effective per quality-adjusted life year than screening for non-African Americans, and that screening African Americans at intervals of 5 or 10 years is highly cost-effective.In addition to behavioral interventions aimed at prevention,...

Determining the effects and challenges of incorporating genetic testing into primary care management of hypertensive patients with African ancestry

“…While it remains critical to recognize the contribution of multiple factors, particularly social determinants, to chronic disease disparities [8–15], genomic contributors also warrant careful evaluation [16]. High-risk APOL1 variants are thought to explain approximately 70% of the excess prevalence of CKD in Blacks [4].…”

A Cost-Benefit and Accurate Method for Assessing Microalbuminuria: Single versus Frequent Urine Analysis

“…Early diagnosis and treatment of these disorders can slow progression to end-stage renal disease leading to lowering mortality and morbidity as well as reducing the overall costs [ 1 ]. Therefore, selection of cost-effective methods of diagnosing and screening for early chronic kidney diseases is needed to identify and manage subjects with this risky condition [ 2 ]. In this regard, following the presence of microalbuminuria as a sensitive marker especially in high-risk groups such as diabetics or hypertensive patients not only can provide valuable information on the stage of renal insufficiency but also can be cost-beneficial and prevent other diagnostic and therapeutic costs [ 3 ].…”