Screening for Chronic Kidney Disease Preventing Harm or Harming the Healthy 英文参考文献.docVIP

Perspective ScreeningforChronicKidneyDisease:PreventingHarm orHarmingtheHealthy? MaartenW.Taal* DepartmentofRenalMedicine,RoyalDerbyHospital,UttoxeterRoad,Derby,Derbyshire,UnitedKingdom Advances in understanding the patho- genesis and natural history of diseases as well as developments in medical technol- ogy have made it possible to diagnose a large number of diseases at early stages, often in asymptomatic individuals. It is intuitivetobelievethatearlierdiagnosisis beneficial because it creates the opportu- nitytointerveneandpreventprogression. This simple paradigm may hold true for someconditions,e.g.,hypertension,but,it isincreasinglyclearthatforotherdiseases early diagnosis may not necessarily be beneficial—e.g., in prostate cancer, since not all cases identified will progress to causesymptomsorprematuredeath.Thus there are calls for health professionals to criticallyappraisetheevidencerelatingto screening policies, to prevent overdiagno- sis (‘‘harming the healthy’’) [1]. A new systematic review in this week’s PLOS MedicinebyJustinEchouffo-Tcheuguiand damage [9]. This equation is also not well validated in the elderly, leading some ne- phrologists to question the validity of diag- nosingCKDbasedoneGFRalone[10].A more accurate equation, CKD-EPI, that performs better at higher GFR values has beendevelopedandmayreplacetheMDRD equation, but performance in the elderly is alsouncertain[11].Recently,anewequation that estimates GFR from serum creatinine andcystatinChasbeenshowntocorrectly reclassifysomepatientsasnothavingCKD, thus reducing overdiagnosis [12]. Urinary ACRcorrelatescloselywithurinaryalbumin excretion, but mild albuminuria may be provokedbyfeverorexercise,andlongitudi- nal studies have shown that microalbumin- uriamayregressinpeoplewithdiabetic[13] and non-diabetic CKD [3]. Despite these limitations, studies utilising MDRD eGFR and urinary ACR have shown that these admittedly imperfect measures do serve as predictors of risk by identifying eGFR and al