Patterns of Kidney Function and Risk Assessment in a Nationwide Laboratory Database: The Brazilian CHECK-CKD Study

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Réa, Viviane Calice-Silva, and 8 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-3380226/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 11 You are reading this latest preprint version Abstract Background Chronic kidney disease (CKD) is a global health problem with rising prevalence, morbidity, mortality, and associated costs. Early identification and risk stratification are key to preventing progression to kidney failure. However, there is a paucity of data on practice patterns of kidney function assessment to guide the development of improvement strategies, particularly in lower-income countries. Methods A retrospective observational analysis was conducted in a nationwide laboratory database in Brazil. We included all adult patients with at least one serum creatinine assessment between June 2018 and May 2021. Our primary objective was to determine the proportion of patients with estimated glomerular filtration rate (eGFR) evaluations accompanied by equivalents of urinary to creatinine ratio (eUCR) assessments within 12 months. Results Out of 4,5323,332 serum creatinine measurements, 42% lacked eUCR measurements within 12 months. Approximately 10.8% of tests suggested CKD, mostly at stage 3a. The proportion of serum creatinine exams paired with eUCR assessment varied according to the CKD stage. Internal Medicine, Cardiology, and Obstetrics/Gynecology were the specialties requesting most of the creatinine tests. Nephrology contributed with only 1.1% of serum creatinine requests for testing. Conclusion Our findings reveal that a significant proportion of individuals with a creatinine test lack an accompanying urinary eUCR in Brazil, contrary to the recommendations of the international guidelines. Non-Nephrologists perform most kidney function evaluations, even among patients with presumable advanced CKD. This highlights the urge to incorporate in clinical practice the early detection of CKD and to encourage more collaborative multidisciplinary care to improve CKD management. Figures Figure 1 Figure 2 Figure 3 Background Chronic kidney disease (CKD) is a common and often unrelenting condition that disproportionally affects individuals with multiple comorbidities and more limited access to healthcare services than the general population. The prevalence, incidence, and mortality rates of CKD have been rising staggeringly worldwide, and significant country variations reflect pervasive disparities on CKD care, from early disease identification to managing associated complications ( 1 ). The rise in CKD risk factors is expected to strain healthcare systems, particularly in non-high-income countries over the next decades ( 2 ). Unrestrained costs and persistent poor outcomes, consistent worldwide, illustrate the importance of preventing CKD progression into kidney failure. Early identification and risk stratification are the cornerstones of kidney failure prevention since they allow timely optimization of care ( 3 ). However, evidence-based recommendations for CKD screening and monitoring are not implemented uniformly across different healthcare areas and systems ( 4 ). The ensuing uncertainty results in differences in how countries develop and implement guidelines for CKD screening and monitoring, which may impact patient outcomes, particularly with the increasing availability of evidence-based safe and effective CKD-modifying therapies ( 5 , 6 ). Disparities in access to care and healthcare system fragmentation, particularly in countries where public and private healthcare systems coexist, complicate the process of CKD screening and management ( 7 ). In countries such as Brazil, the problem begins with inconsistent screening and stratification strategies and extends to poor care transition from primary to secondary networks, resulting in late referrals and inadequate preparation for kidney replacement therapies. The absence of nationwide implementation of a CKD care program exacerbates these issues. To date, no reports on national patterns of kidney function assessment across CKD stages and specialties in Brazil are available. Understanding patterns in CKD screening and risk stratification may guide the development of strategies to optimize this process. In the CHECK-CKD Study in Brazil, we describe a retrospective observational analysis using a nationwide laboratory database aiming to provide insights into practice patterns that can resemble screening or monitoring programs. In the study we use assume that serum creatinine is used to assess kidney function and structural kidney lesion is assessed by appropriate urine tests. Herein we illustrate the varying approaches of medical specialties to kidney disease assessment, focusing on serum creatinine to measure kidney function and tests that quantify proteins in the urine (converted to equivalents of urinary to albumin-creatinine ratio (eACR)) to assess kidney damage ( 8 ). Furthermore, we evaluate the adherence of practicing physicians in Brazil to guideline recommendations for kidney function assessment, including the frequency of concomitant eACR and creatine measurement and longitudinal creatinine-based eGFR evaluation among populations at risk for CKD. Methods Study Design and Database This is a descriptive, non-interventional, retrospective cohort study using real-world data from Diagnosticos da America (DASA) Datalake. DASA is a nationwide integrated healthcare network in Brazil that currently provides medical care to approximately 10 million individuals with health insurance coverage in Brazil. The database comprises a range of medical tests and biomarkers, including but not limited to complete blood cell count, basic and comprehensive metabolic panels, lipid panels, liver panels, cultures, imaging, and genetic biomarkers. These results are also linked to electronic medical records, which can be manipulated (i.e., filtered, extracted, and analyzed) to monitor laboratory parameters and, if relevant, link the results to specific diseases, conditions, and ICD codes for patients admitted to hospitals maintained by DASA. During clinical visits, patients voluntarily sign a privacy agreement, granting consent for generating analyses and studies that contribute to the improvement of Dasa´s activities in compliance with its Privacy Policy and the General Data Protection Law in Brazil. This protocol was also submitted to the appreciation of the local Research Ethics Committee. Due to the large number of patients and the retrospective nature of the study, a waiver of informed consent was obtained. This study was designed following the STROBE guidelines. Patient Population and Study Variables All adult patients who had at least one serum creatinine assessment from June 2018 and May 2021 were included in this study. For the present study, the extracted data included age, sex, the patient's residential zip code (if not available, the location of the unit where the test was collected will be used), numeric test results, the laboratory unit where the tests were collected, the date of the examination, and the prescribing physician's specialty. We only included laboratory tests ordered in outpatient settings. Urinary tests that quantify proteinuria were evaluated within 12 months of the index creatinine assessment. Results from semi-quantitative tests were converted into continuous albuminuria measured in mg/g creatinine using validated methods ( 8 ). Converted results are reported as eACR ( 8 ). Diabetes was defined as a single Hb1c > 6.5% or a serum glucose level above 200 mg/dL within 12 months from the index creatinine measurement. Objectives Our primary objective was to describe the proportion of patients who underwent eGFR evaluation and had at least one eACR measurement within 12 months. Our exploratory objectives were to (i) describe the frequency of medical specialties requesting laboratory tests for CKD diagnosis (reported in absolute counts), (ii) determine the proportion of patients with potential evidence of CKD based on single eGFR and eUCR measurements in the sample, and (iii) determine the proportion of patients who underwent a follow-up creatinine measurement after an initial eGFR lower than 60/ mL/min/1.73 m2. Statistical Analysis Descriptive statistics were calculated to summarize the demographic and clinical characteristics of the study population. Continuous variables were presented as means and standard deviations (SD) or medians and interquartile ranges (IQR), depending on the distribution of the data. Categorical variables were reported as frequencies and percentages. Results Figure 1 depicts the inclusion and exclusion process for the analysis sample. A total of 4,5323,332 serum patients with serum creatinine measurements were included. Approximately 41% of these patients did not have eACR measurements within 12 months, yielding 2,660,805 patients in the sample used for the estimation CKD frequency according to the KDIGO classification. Following the demographic distribution of the Brazilian population, most of the tests were performed in the states of São Paulo (47.6%), followed by Rio de Janeiro (22.6%), and Paraná (9.3%) ( Supplementary Fig. 1 ). Patients had a mean age of 45 years, were mostly female (60%), and up to 10% had diabetes. Overall, 10.8% of tests suggested CKD, mostly at stage 3a (57.8%), followed by 3b (22.0%), G4 (6.3%), G2 (6.3%), and G5 (2.4%) (Table 1 ). The proportion of serum creatinine exams paired with an eACR assessment varied according to CKD stage: G1 (54.9%), G2 (61.2%), G3a (66.7%), G3b (70.7%), G4 (70.2%) e G5 (46.7%). The proportion of laboratory results indicating A3-level albuminuria was 0.3%, 0.4%, 1.2%, 2.5%, 7.3%, and 28.4% from G1 to G5, respectively. Patients with CKD were older (mean age 69 ± 15.2 vs. 47.2 ± 15.4 years) and more likely to have diabetes (22% vs. 8%) than patients without CKD. The geographical distribution was similar between CKD and non-CKD patients. The medical specialty that requested most of the creatinine tests was Internal Medicine (17.7%), followed by Cardiology (16.05), Obstetrics/Gynecology (OBGYN) (16.0%), and Endocrinology (8.8%); Nephrology contributed with only 1.1% of the test requests (Fig. 2 ). OBGYN (20.7 and 13.0%), Internal Medicine (17.2 and 17.7%), and Cardiology (12.3 and 18.6%) ordered most of the creatinine tests with results suggesting no mild CKD (G1 and G2), respectively. At G3a, Cardiology (23.2%), Internal Medicine (18.8%), and Endocrinology (8.7%) led test orders, whereas at G3b, Nephrologists (12.5%) surpassed Endocrinologists in the third position (Fig. 2 ). Even at G4, Internal Medicine (14.9%) and Cardiology (13%) ordered more creatinine tests than Nephrology (third, 12.5%). Finally, at G5, most tests were requested by Nephrology (39%), followed by Internal Medicine (21.7%) and Cardiology (9.4%). eACR was more often assessed by Internal Medicine specialists (18.1%), Cardiologists (16.2%), OBGN (9.9%), and Nephrologists (5.9%). The one-year cumulative incidence functions for repeated creatinine measurement among patients with at least two serum creatinine tests in the sample are shown in Fig. 3 . Patients with lower eGFR have a greater probability of having a follow-up serum creatinine test. Most patients in CKD stage 3b to 5 have a new eGFR evaluation within 6 months of the first measurement available in this study. Almost all patients with a follow-up serum creatinine test had the second eGFR estimation within 12 months of the initial assessment. Discussion In this nationwide real-world study of practice patterns for kidney function assessment in Brazilians covered with medical insurance, we found that 41% of individuals undergoing creatinine testing lack an accompanying urinary test, a combination of tests that would comply with international guidelines. This incomplete CKD assessment is more common in patients with higher eGFR, who are often not followed by kidney specialists. Most laboratory evaluations of kidney function are performed by non-Nephrologists, namely internists, cardiologists and OBGYNs, even among patients with presumable advanced CKD. Finally, up to 80% of patients with at least two eGFR assessments have a follow-up creatinine test within 12 months of the first; the lower the eGFR, the more frequent the creatinine assessment. Although our study was not designed to evaluate the prevalence of CKD, our results suggest that approximately 11% of patients in Brazil have CKD, assuming no false positive results due to single eGFR and eUCR assessments. These results are consistent with the estimates of 10–12% worldwide CKD prevalence ( 9 ). They are also similar to two prior investigations of CKD prevalence in Brazil; one estimated an 8% prevalence in a cohort of civil servants ( 10 ), and the other reported an 11.4% prevalence in a convenience sample from a working setting ( 11 ). In Brazil, a country with universal public coverage of healthcare services, nearly 150,000 (640 per million population) patients are on kidney replacement therapy (KRT) as of 2020 ( 12 ). The number of patients on KRT in the country have steadily increased by 6% per year over the last two decades ( 13 ). In this period, mortality rates among patients on hemodialysis, the most frequent KRT modality in the country, increased from 17–20% ( 12 ). CKD and its associated conditions consume about 13% of all public health resources in Brazil ( 14 ). Our results imply that approximately 21 million persons living with CKD in Brazil, a country with roughly 4,000 registered Nephrologists. Thus, it is expected that non-Nephrologists will screen and assist most CKD patients in Brazil, even those with more advanced stages ( 13 ),a problem not exclusive to non-high-income countries ( 15 ).In fact, our analysis suggests that, in absolute numbers, Nephrologists rarely contribute to eGFR and eACR assessments in Brazil. In absolute numbers, Nephrologists ordered most eGFR assessments only among patients with single eGFR ≤ 15 mL/min/1.73 m 2 . In stages G3a and G3b, in which new therapies that prevent kidney failure can be implemented ( 5 , 6 ), Cardiologists and Internal Medicine specialists were the most frequent physicians to monitor or screen for CKD. Our analysis suggests that efforts to increase CKD awareness and promote screening should target non-Nephrologists in absolute terms. However, there are conflicting recommendations for CKD screening among distinct societies representing medical specialties. Diverse guidelines from cardiology, Internal Medicine, and Nephrology have shaped the varied implementation of CKD screening, mostly diverging on priorities. The American College of Physicians (ACP) advises against CKD screening in the general population due to a lack of evidence on its risks and benefits, warning it may lead to overdiagnosis and added costs ( 16 ). KDIGO highlights that using cystatin-C to measure eGFR can reduce misclassification and overdiagnosis risks, advocating for CKD screening in patients with a wide array of risk factors ( 4 ). Emphasizing early intervention's clinical advantages, KDIGO supports the prioritization of efforts to implement CKD screening( 4 ). Meanwhile, the 2021 European Society of Cardiology (ESC) Guidelines recognize CKD as a significant cardiovascular risk factor, suggesting its evaluation in broader cardiovascular screening ( 17 ). They underline the value of albuminuria and low GFR results, which can inform strategies, especially with new treatments that reduce cardiovascular events and preserve kidney function ( 17 ). Reflecting the ESC's stance, the European Renal Association now urges more proactive CKD screening in the wider population ( 18 ). However, barriers to broader CKD screening and monitoring prevail. Our analyses indicate that up to 41% of patients who had an eGFR evaluation did not undergo an eACR measure within 12 months. This pattern echoes findings from US and UK studies among CKD patients ( 19 , 20 ). The proportion of patients undergoing evaluations for eGFR and eACR grows with the severity of CKD stages, likely due to the increasing involvement of Nephrologists in advanced CKD care. In fact, a US survey found that non-nephrologists often underestimate the significance of albuminuria in early CKD stages ( 21 ). This uncertainty can hinder timely education, planning, and interventions critical for CKD progression and cardiovascular risk reduction ( 4 ). This study has several noteworthy limitations. First, we relied on secondary data extraction from an administrative database for our study. We did not have detailed clinical information on participating patients, nor were we able to assess the reasons for laboratory evaluation. Therefore, we were unable to evaluate whether creatinine or albuminuria were ordered for screening or monitoring purposes. Second, our evaluation of medical specialties is limited to the reported information on the laboratory requisition. In Brazil, Internal Medicine may broadly cover unspecialized physicians working on primary care, specialists in primary care (Family Medicine), or specialists in Internal Medicine. Third, our database covers primarily insured patients, not capturing users of the unified public healthcare system in Brazil. This can explain the lack of Family Medicine practitioners as a common medical specialty requesting laboratory tests in our sample, as these physicians are more often leading the care for patients in the public healthcare system. Finally, we used single assessments of creatinine and eACR to define CKD. Despite these limitations, our results have key strengths. Our large sample covers a wide geographic distribution in Brazil, which increases the external validity of our findings. Additionally, our results are very highly consistent with prior studies, which further reinforces the advantages of using large real-world databases for epidemiological research. Therefore, we believe our data can support action plans to reduce the growing burden of CKD and its complications in Brazil. In conclusion, in this real-world study evaluating practice patterns for laboratory evaluation of biomarkers of kidney damage and function in Brazil, we found that non-Nephrologists are the key drivers of CKD assessment in Brazil and that CKD assessment is largely non-compliant to current guideline recommendations, since more than one-third of patients with eGFR evaluation lack urinary tests. Our results suggest that a large proportion of patients with CKD remain undiagnosed in Brazil, particularly those with proteinuric CKD with eGFR above 60 mL/min/1.73 m2. Furthermore, most patients at risk of progressing to kidney failure and suffering poor outcomes are sub-optimally screened and risk-stratified in Brazil. Increasing the awareness of the importance of CKD diagnosis and coordinating multidisciplinary efforts for screening, risk stratification and referral strategies remain unmet goals in CKD care that require urgent attention. Table 1. Distribution of CKD Risk by KDIGO Stratification, N=2.600.805. eUACR (g/mg Creatinine) GFR category eGFR (CKD-EPI) (mL/min/1.73 m2) A1 A2 A3 < 30 30-299 ≥ 300 Total G1 ≥ 90 43,3% 0,8% 0,1% 44.2% G2 60-89 43,6% 1% 0.1% 44.7% G3a 45-59 6.7% 0.3% 0.1% 7.1% G3b 30-44 2.5% 0.3% 0.1% 2.9% G4 15-29 0.6% 0.1% 0.1% 0.8% G5 <15 0.1% 0.1% 0.1% 0.3% Total 96.8% 2.6% 0.6% 100% The proportion of serum creatinine exams paired with eUCR assessment varied according to CKD stage: G1 (54.9%), G2 (61.2%), G3a (66.7%), G3b (70.7%), G4 (70.2%) e G5 (46.7%). Declarations Ethics approval and consent to participate This protocol was submitted to the appreciation and approval was taken from the local Research Ethics Committee. Due to the large number of patients and the retrospective nature of the study, a waiver of informed consent was obtained (Ethical Review Board: Hospital Nove de Julho. Protocol number: 5.308.256) Availability of data and materials The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request. Competing interests MG and RP received research honoraria from AstraZeneca. CMT is an employee from AstraZeneca Brazil. The other authors have no relevant information to disclose. Funding This study was funded by AstraZeneca Brazil. Authors' contributions MG, RP, and CMT have made substantial contributions to the conception and design of the work, helped in the interpretation of data, and have drafted the work or substantively revised it. PLD made substantial contributions to data analysis and has drafted the work or substantively revised it. RRR, VCS, ML, AAB, ACB, AAS, PTMCAR, and BBR have made substantial contributions to data interpretation and have substantively revised the draft. All authors approved the submitted work and have agreed both to be personally accountable for the author's own contributions and to ensure that questions related to the accuracy or integrity of any part of the work. References Kovesdy CP. Epidemiology of chronic kidney disease: an update 2022. Kidney Int Suppl (2011). 2022;12(1):7-11. Stanifer JW, Muiru A, Jafar TH, Patel UD. Chronic kidney disease in low- and middle-income countries. Nephrol Dial Transplant. 2016;31(6):868-74. Chen TK, Knicely DH, Grams ME. Chronic Kidney Disease Diagnosis and Management: A Review. Jama. 2019;322(13):1294-304. Shlipak MG, Tummalapalli SL, Boulware LE, Grams ME, Ix JH, Jha V, et al. The case for early identification and intervention of chronic kidney disease: conclusions from a Kidney Disease: Improving Global Outcomes (KDIGO) Controversies Conference. Kidney Int. 2021;99(1):34-47. Bakris GL, Agarwal R, Anker SD, Pitt B, Ruilope LM, Rossing P, et al. Effect of Finerenone on Chronic Kidney Disease Outcomes in Type 2 Diabetes. New England Journal of Medicine. 2020;383(23):2219-29. Heerspink HJL, Stefánsson BV, Correa-Rotter R, Chertow GM, Greene T, Hou F-F, et al. Dapagliflozin in Patients with Chronic Kidney Disease. New England Journal of Medicine. 2020;383(15):1436-46. Bello AK, Johnson DW, Feehally J, Harris D, Jindal K, Lunney M, et al. Global Kidney Health Atlas (GKHA): design and methods. Kidney Int Suppl (2011). 2017;7(2):145-53. Sumida K, Nadkarni GN, Grams ME, Sang Y, Ballew SH, Coresh J, et al. Conversion of Urine Protein-Creatinine Ratio or Urine Dipstick Protein to Urine Albumin-Creatinine Ratio for Use in Chronic Kidney Disease Screening and Prognosis : An Individual Participant-Based Meta-analysis. Ann Intern Med. 2020;173(6):426-35. Jager KJ, Kovesdy C, Langham R, Rosenberg M, Jha V, Zoccali C. A single number for advocacy and communication-worldwide more than 850 million individuals have kidney diseases. Kidney Int. 2019;96(5):1048-50. Aquino EM, Barreto SM, Bensenor IM, Carvalho MS, Chor D, Duncan BB, et al. Brazilian Longitudinal Study of Adult Health (ELSA-Brasil): objectives and design. Am J Epidemiol. 2012;175(4):315-24. Piccolli AP, Nascimento MMD, Riella MC. Prevalence of chronic kidney disease in a population in southern Brazil (Pro-Renal Study). J Bras Nefrol. 2017;39(4):384-90. Neves P, Sesso RCC, Thomé FS, Lugon JR, Nasicmento MM. Brazilian Dialysis Census: analysis of data from the 2009-2018 decade. J Bras Nefrol. 2020;42(2):191-200. Sesso R, Lugon JR. Global Dialysis Perspective: Brazil. Kidney360. 2020;1(3). Alcalde PR, Kirsztajn GM. Expenses of the Brazilian Public Healthcare System with chronic kidney disease. J Bras Nefrol. 2018;40(2):122-9. Sozio SM, Pivert KA, Caskey FJ, Levin A. The state of the global nephrology workforce: a joint ASN-ERA-EDTA-ISN investigation. Kidney Int. 2021;100(5):995-1000. Qaseem A, Hopkins RH, Sweet DE, Starkey M, Shekelle P. Screening, Monitoring, and Treatment of Stage 1 to 3 Chronic Kidney Disease: A Clinical Practice Guideline From the American College of Physicians. Annals of Internal Medicine. 2013;159(12):835-47. Cebrian A, Escobar C, Aranda U, Palacios B, Capel M, Sicras A, et al. The 2021 European Society of Cardiology Cardiovascular Disease Prevention Guidelines: adding albuminuria to the SCORE scale increases the prevalence of very high/high cardiovascular risk among patients with chronic kidney disease. Clin Kidney J. 2022;15(6):1204-8. Ortiz A, Wanner C, Gansevoort R, Council ERA. Chronic kidney disease as cardiovascular risk factor in routine clinical practice: a position statement by the Council of the European Renal Association. European Journal of Preventive Cardiology. 2022;29(17):2211-5. Folkerts K, Petruski-Ivleva N, Comerford E, Blankenburg M, Evers T, Gay A, et al. Adherence to Chronic Kidney Disease Screening Guidelines Among Patients With Type 2 Diabetes in a US Administrative Claims Database. Mayo Clinic Proceedings. 2021;96(4):975-86. Jain V, Sinha S, Shaw C, Bramham K, Croucher C. Re-evaluating national screening for chronic kidney disease in the UK. BMJ. 2023;382:e074265. Abdel-Kader K, Greer RC, Boulware LE, Unruh ML. Primary care physicians’ familiarity, beliefs, and perceived barriers to practice guidelines in non-diabetic CKD: a survey study. BMC Nephrology. 2014;15(1):64. Additional Declarations Competing interest reported. MG and RP received research honoraria from AstraZeneca. CMT is an employee from AstraZeneca Brazil. The other authors have no relevant information to disclose. Supplementary Files CHECKCKDSupp.docx Cite Share Download PDF Status: Under Review Version 1 posted Editorial decision: Revision requested 26 Nov, 2023 Reviews received at journal 22 Nov, 2023 Reviews received at journal 06 Nov, 2023 Reviews received at journal 04 Nov, 2023 Reviewers agreed at journal 28 Oct, 2023 Reviewers agreed at journal 25 Oct, 2023 Reviewers invited by journal 23 Oct, 2023 Editor invited by journal 15 Oct, 2023 Editor assigned by journal 03 Oct, 2023 Submission checks completed at journal 03 Oct, 2023 First submitted to journal 23 Sep, 2023 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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18:14:08","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-3380226/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-3380226/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":44324188,"identity":"e47a1909-7e20-4bd2-a829-e69076a47bf9","added_by":"auto","created_at":"2023-10-09 22:03:44","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":61662,"visible":true,"origin":"","legend":"\u003cp\u003eFlow-Chart of Inclusion and Exclusion of Observations in the Sample.\u003c/p\u003e","description":"","filename":"floatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-3380226/v1/b431b04fea8724f527de7aa7.png"},{"id":44326327,"identity":"35f04ae7-91ed-4a05-9e0d-3bfe540e324e","added_by":"auto","created_at":"2023-10-09 22:11:44","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":23322,"visible":true,"origin":"","legend":"\u003cp\u003eDistribution of Medical Specialties Ordering Serum Creatinine Tests by CKD Stage\u003c/p\u003e","description":"","filename":"floatimage2.png","url":"https://assets-eu.researchsquare.com/files/rs-3380226/v1/d2c12b6328f89920a84288d9.png"},{"id":44324191,"identity":"aede0b86-2146-4180-8145-9b273ce12e52","added_by":"auto","created_at":"2023-10-09 22:03:44","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":56981,"visible":true,"origin":"","legend":"\u003cp\u003eCumulative Incidence of a New Measurement of Creatinine\u003cstrong\u003e \u003c/strong\u003eby CKD Stage\u003c/p\u003e","description":"","filename":"floatimage3.png","url":"https://assets-eu.researchsquare.com/files/rs-3380226/v1/b6f84ec36fb580d2f7fb6419.png"},{"id":44326667,"identity":"3f8e265d-5d98-42a4-8f28-6570f8eecd79","added_by":"auto","created_at":"2023-10-09 22:19:44","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":409540,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-3380226/v1/f78185f8-141e-46e9-89f5-d4b7ccb94dd1.pdf"},{"id":44324192,"identity":"2f842013-9508-45cd-a5fb-a658f252df78","added_by":"auto","created_at":"2023-10-09 22:03:44","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":136089,"visible":true,"origin":"","legend":"","description":"","filename":"CHECKCKDSupp.docx","url":"https://assets-eu.researchsquare.com/files/rs-3380226/v1/744fd40f0833b4e7ac1136db.docx"}],"financialInterests":"Competing interest reported. MG and RP received research honoraria from AstraZeneca. CMT is an employee from AstraZeneca Brazil. The other authors have no relevant information to disclose.","formattedTitle":"Patterns of Kidney Function and Risk Assessment in a Nationwide Laboratory Database: The Brazilian CHECK-CKD Study","fulltext":[{"header":"Background","content":"\u003cp\u003eChronic kidney disease (CKD) is a common and often unrelenting condition that disproportionally affects individuals with multiple comorbidities and more limited access to healthcare services than the general population. The prevalence, incidence, and mortality rates of CKD have been rising staggeringly worldwide, and significant country variations reflect pervasive disparities on CKD care, from early disease identification to managing associated complications (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e). The rise in CKD risk factors is expected to strain healthcare systems, particularly in non-high-income countries over the next decades (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eUnrestrained costs and persistent poor outcomes, consistent worldwide, illustrate the importance of preventing CKD progression into kidney failure. Early identification and risk stratification are the cornerstones of kidney failure prevention since they allow timely optimization of care (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e). However, evidence-based recommendations for CKD screening and monitoring are not implemented uniformly across different healthcare areas and systems (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e). The ensuing uncertainty results in differences in how countries develop and implement guidelines for CKD screening and monitoring, which may impact patient outcomes, particularly with the increasing availability of evidence-based safe and effective CKD-modifying therapies (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eDisparities in access to care and healthcare system fragmentation, particularly in countries where public and private healthcare systems coexist, complicate the process of CKD screening and management (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e). In countries such as Brazil, the problem begins with inconsistent screening and stratification strategies and extends to poor care transition from primary to secondary networks, resulting in late referrals and inadequate preparation for kidney replacement therapies. The absence of nationwide implementation of a CKD care program exacerbates these issues. To date, no reports on national patterns of kidney function assessment across CKD stages and specialties in Brazil are available. Understanding patterns in CKD screening and risk stratification may guide the development of strategies to optimize this process.\u003c/p\u003e \u003cp\u003eIn the CHECK-CKD Study in Brazil, we describe a retrospective observational analysis using a nationwide laboratory database aiming to provide insights into practice patterns that can resemble screening or monitoring programs. In the study we use assume that serum creatinine is used to assess kidney function and structural kidney lesion is assessed by appropriate urine tests. Herein we illustrate the varying approaches of medical specialties to kidney disease assessment, focusing on serum creatinine to measure kidney function and tests that quantify proteins in the urine (converted to equivalents of urinary to albumin-creatinine ratio (eACR)) to assess kidney damage (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e). Furthermore, we evaluate the adherence of practicing physicians in Brazil to guideline recommendations for kidney function assessment, including the frequency of concomitant eACR and creatine measurement and longitudinal creatinine-based eGFR evaluation among populations at risk for CKD.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStudy Design and Database\u003c/h2\u003e \u003cp\u003eThis is a descriptive, non-interventional, retrospective cohort study using real-world data from Diagnosticos da America (DASA) Datalake. DASA is a nationwide integrated healthcare network in Brazil that currently provides medical care to approximately 10\u0026nbsp;million individuals with health insurance coverage in Brazil. The database comprises a range of medical tests and biomarkers, including but not limited to complete blood cell count, basic and comprehensive metabolic panels, lipid panels, liver panels, cultures, imaging, and genetic biomarkers. These results are also linked to electronic medical records, which can be manipulated (i.e., filtered, extracted, and analyzed) to monitor laboratory parameters and, if relevant, link the results to specific diseases, conditions, and ICD codes for patients admitted to hospitals maintained by DASA.\u003c/p\u003e \u003cp\u003eDuring clinical visits, patients voluntarily sign a privacy agreement, granting consent for generating analyses and studies that contribute to the improvement of Dasa\u0026acute;s activities in compliance with its Privacy Policy and the General Data Protection Law in Brazil. This protocol was also submitted to the appreciation of the local Research Ethics Committee. Due to the large number of patients and the retrospective nature of the study, a waiver of informed consent was obtained. This study was designed following the STROBE guidelines.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003ePatient Population and Study Variables\u003c/h2\u003e \u003cp\u003eAll adult patients who had at least one serum creatinine assessment from June 2018 and May 2021 were included in this study. For the present study, the extracted data included age, sex, the patient's residential zip code (if not available, the location of the unit where the test was collected will be used), numeric test results, the laboratory unit where the tests were collected, the date of the examination, and the prescribing physician's specialty. We only included laboratory tests ordered in outpatient settings.\u003c/p\u003e \u003cp\u003eUrinary tests that quantify proteinuria were evaluated within 12 months of the index creatinine assessment. Results from semi-quantitative tests were converted into continuous albuminuria measured in mg/g creatinine using validated methods (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e). Converted results are reported as eACR (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e). Diabetes was defined as a single Hb1c\u0026thinsp;\u0026gt;\u0026thinsp;6.5% or a serum glucose level above 200 mg/dL within 12 months from the index creatinine measurement.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003eObjectives\u003c/h2\u003e \u003cp\u003eOur primary objective was to describe the proportion of patients who underwent eGFR evaluation and had at least one eACR measurement within 12 months. Our exploratory objectives were to (i) describe the frequency of medical specialties requesting laboratory tests for CKD diagnosis (reported in absolute counts), (ii) determine the proportion of patients with potential evidence of CKD based on single eGFR and eUCR measurements in the sample, and (iii) determine the proportion of patients who underwent a follow-up creatinine measurement after an initial eGFR lower than 60/ mL/min/1.73 m2.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003eStatistical Analysis\u003c/h2\u003e \u003cp\u003eDescriptive statistics were calculated to summarize the demographic and clinical characteristics of the study population. Continuous variables were presented as means and standard deviations (SD) or medians and interquartile ranges (IQR), depending on the distribution of the data. Categorical variables were reported as frequencies and percentages.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eFigure \u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e depicts the inclusion and exclusion process for the analysis sample. A total of 4,5323,332 serum patients with serum creatinine measurements were included. Approximately 41% of these patients did not have eACR measurements within 12 months, yielding 2,660,805 patients in the sample used for the estimation CKD frequency according to the KDIGO classification. Following the demographic distribution of the Brazilian population, most of the tests were performed in the states of S\u0026atilde;o Paulo (47.6%), followed by Rio de Janeiro (22.6%), and Paran\u0026aacute; (9.3%) (\u003cb\u003eSupplementary Fig.\u0026nbsp;1\u003c/b\u003e).\u003c/p\u003e \u003cp\u003ePatients had a mean age of 45 years, were mostly female (60%), and up to 10% had diabetes. Overall, 10.8% of tests suggested CKD, mostly at stage 3a (57.8%), followed by 3b (22.0%), G4 (6.3%), G2 (6.3%), and G5 (2.4%) (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). The proportion of serum creatinine exams paired with an eACR assessment varied according to CKD stage: G1 (54.9%), G2 (61.2%), G3a (66.7%), G3b (70.7%), G4 (70.2%) e G5 (46.7%). The proportion of laboratory results indicating A3-level albuminuria was 0.3%, 0.4%, 1.2%, 2.5%, 7.3%, and 28.4% from G1 to G5, respectively. Patients with CKD were older (mean age 69\u0026thinsp;\u0026plusmn;\u0026thinsp;15.2 vs. 47.2\u0026thinsp;\u0026plusmn;\u0026thinsp;15.4 years) and more likely to have diabetes (22% vs. 8%) than patients without CKD. The geographical distribution was similar between CKD and non-CKD patients.\u003c/p\u003e \u003cp\u003eThe medical specialty that requested most of the creatinine tests was Internal Medicine (17.7%), followed by Cardiology (16.05), Obstetrics/Gynecology (OBGYN) (16.0%), and Endocrinology (8.8%); Nephrology contributed with only 1.1% of the test requests (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). OBGYN (20.7 and 13.0%), Internal Medicine (17.2 and 17.7%), and Cardiology (12.3 and 18.6%) ordered most of the creatinine tests with results suggesting no mild CKD (G1 and G2), respectively. At G3a, Cardiology (23.2%), Internal Medicine (18.8%), and Endocrinology (8.7%) led test orders, whereas at G3b, Nephrologists (12.5%) surpassed Endocrinologists in the third position (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). Even at G4, Internal Medicine (14.9%) and Cardiology (13%) ordered more creatinine tests than Nephrology (third, 12.5%). Finally, at G5, most tests were requested by Nephrology (39%), followed by Internal Medicine (21.7%) and Cardiology (9.4%). eACR was more often assessed by Internal Medicine specialists (18.1%), Cardiologists (16.2%), OBGN (9.9%), and Nephrologists (5.9%).\u003c/p\u003e \u003cp\u003eThe one-year cumulative incidence functions for repeated creatinine measurement among patients with at least two serum creatinine tests in the sample are shown in Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e. Patients with lower eGFR have a greater probability of having a follow-up serum creatinine test. Most patients in CKD stage 3b to 5 have a new eGFR evaluation within 6 months of the first measurement available in this study. Almost all patients with a follow-up serum creatinine test had the second eGFR estimation within 12 months of the initial assessment.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003e In this nationwide real-world study of practice patterns for kidney function assessment in Brazilians covered with medical insurance, we found that 41% of individuals undergoing creatinine testing lack an accompanying urinary test, a combination of tests that would comply with international guidelines. This incomplete CKD assessment is more common in patients with higher eGFR, who are often not followed by kidney specialists. Most laboratory evaluations of kidney function are performed by non-Nephrologists, namely internists, cardiologists and OBGYNs, even among patients with presumable advanced CKD. Finally, up to 80% of patients with at least two eGFR assessments have a follow-up creatinine test within 12 months of the first; the lower the eGFR, the more frequent the creatinine assessment.\u003c/p\u003e \u003cp\u003eAlthough our study was not designed to evaluate the prevalence of CKD, our results suggest that approximately 11% of patients in Brazil have CKD, assuming no false positive results due to single eGFR and eUCR assessments. These results are consistent with the estimates of 10\u0026ndash;12% worldwide CKD prevalence (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e). They are also similar to two prior investigations of CKD prevalence in Brazil; one estimated an 8% prevalence in a cohort of civil servants (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e), and the other reported an 11.4% prevalence in a convenience sample from a working setting (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eIn Brazil, a country with universal public coverage of healthcare services, nearly 150,000 (640 per million population) patients are on kidney replacement therapy (KRT) as of 2020 (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e). The number of patients on KRT in the country have steadily increased by 6% per year over the last two decades (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e). In this period, mortality rates among patients on hemodialysis, the most frequent KRT modality in the country, increased from 17\u0026ndash;20% (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e). CKD and its associated conditions consume about 13% of all public health resources in Brazil (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eOur results imply that approximately 21\u0026nbsp;million persons living with CKD in Brazil, a country with roughly 4,000 registered Nephrologists. Thus, it is expected that non-Nephrologists will screen and assist most CKD patients in Brazil, even those with more advanced stages (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e),a problem not exclusive to non-high-income countries (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e).In fact, our analysis suggests that, in absolute numbers, Nephrologists rarely contribute to eGFR and eACR assessments in Brazil. In absolute numbers, Nephrologists ordered most eGFR assessments only among patients with single eGFR\u0026thinsp;\u0026le;\u0026thinsp;15 mL/min/1.73 m\u003csup\u003e2\u003c/sup\u003e. In stages G3a and G3b, in which new therapies that prevent kidney failure can be implemented (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e), Cardiologists and Internal Medicine specialists were the most frequent physicians to monitor or screen for CKD. Our analysis suggests that efforts to increase CKD awareness and promote screening should target non-Nephrologists in absolute terms. However, there are conflicting recommendations for CKD screening among distinct societies representing medical specialties.\u003c/p\u003e \u003cp\u003e Diverse guidelines from cardiology, Internal Medicine, and Nephrology have shaped the varied implementation of CKD screening, mostly diverging on priorities. The American College of Physicians (ACP) advises against CKD screening in the general population due to a lack of evidence on its risks and benefits, warning it may lead to overdiagnosis and added costs (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e). KDIGO highlights that using cystatin-C to measure eGFR can reduce misclassification and overdiagnosis risks, advocating for CKD screening in patients with a wide array of risk factors (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e). Emphasizing early intervention's clinical advantages, KDIGO supports the prioritization of efforts to implement CKD screening(\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e). Meanwhile, the 2021 European Society of Cardiology (ESC) Guidelines recognize CKD as a significant cardiovascular risk factor, suggesting its evaluation in broader cardiovascular screening (\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e). They underline the value of albuminuria and low GFR results, which can inform strategies, especially with new treatments that reduce cardiovascular events and preserve kidney function (\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e). Reflecting the ESC's stance, the European Renal Association now urges more proactive CKD screening in the wider population (\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eHowever, barriers to broader CKD screening and monitoring prevail. Our analyses indicate that up to 41% of patients who had an eGFR evaluation did not undergo an eACR measure within 12 months. This pattern echoes findings from US and UK studies among CKD patients (\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e). The proportion of patients undergoing evaluations for eGFR and eACR grows with the severity of CKD stages, likely due to the increasing involvement of Nephrologists in advanced CKD care. In fact, a US survey found that non-nephrologists often underestimate the significance of albuminuria in early CKD stages (\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e). This uncertainty can hinder timely education, planning, and interventions critical for CKD progression and cardiovascular risk reduction (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThis study has several noteworthy limitations. First, we relied on secondary data extraction from an administrative database for our study. We did not have detailed clinical information on participating patients, nor were we able to assess the reasons for laboratory evaluation. Therefore, we were unable to evaluate whether creatinine or albuminuria were ordered for screening or monitoring purposes. Second, our evaluation of medical specialties is limited to the reported information on the laboratory requisition. In Brazil, Internal Medicine may broadly cover unspecialized physicians working on primary care, specialists in primary care (Family Medicine), or specialists in Internal Medicine. Third, our database covers primarily insured patients, not capturing users of the unified public healthcare system in Brazil. This can explain the lack of Family Medicine practitioners as a common medical specialty requesting laboratory tests in our sample, as these physicians are more often leading the care for patients in the public healthcare system. Finally, we used single assessments of creatinine and eACR to define CKD. Despite these limitations, our results have key strengths. Our large sample covers a wide geographic distribution in Brazil, which increases the external validity of our findings. Additionally, our results are very highly consistent with prior studies, which further reinforces the advantages of using large real-world databases for epidemiological research. Therefore, we believe our data can support action plans to reduce the growing burden of CKD and its complications in Brazil.\u003c/p\u003e \u003cp\u003e In conclusion, in this real-world study evaluating practice patterns for laboratory evaluation of biomarkers of kidney damage and function in Brazil, we found that non-Nephrologists are the key drivers of CKD assessment in Brazil and that CKD assessment is largely non-compliant to current guideline recommendations, since more than one-third of patients with eGFR evaluation lack urinary tests. Our results suggest that a large proportion of patients with CKD remain undiagnosed in Brazil, particularly those with proteinuric CKD with eGFR above 60 mL/min/1.73 m2. Furthermore, most patients at risk of progressing to kidney failure and suffering poor outcomes are sub-optimally screened and risk-stratified in Brazil. Increasing the awareness of the importance of CKD diagnosis and coordinating multidisciplinary efforts for screening, risk stratification and referral strategies remain unmet goals in CKD care that require urgent attention.\u003c/p\u003e \u003cp style='margin:0in;font-size:16px;font-family:\"Times New Roman\",serif;'\u003e\u003cstrong\u003e\u003cspan style='font-size:15px;font-family:\"Calibri\",sans-serif;'\u003eTable 1.\u0026nbsp;\u003c/span\u003e\u003c/strong\u003e\u003cspan style='font-size:15px;font-family:\"Calibri\",sans-serif;'\u003eDistribution of CKD Risk by KDIGO Stratification, N=2.600.805.\u003c/span\u003e\u003c/p\u003e\n\u003cdiv style='margin:0in;font-size:16px;font-family:\"Times New Roman\",serif;'\u003e\n \u003ctable style=\"border: none;width:547.6pt;border-collapse:collapse;\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" rowspan=\"2\" style=\"width: 27.5862%; padding: 0in 5.4pt; height: 14.65pt; vertical-align: top;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd colspan=\"3\" rowspan=\"2\" style=\"width: 40.3273%; border-top: 1pt solid windowtext; border-left: 1pt solid windowtext; border-bottom: none; border-right: 1pt solid black; padding: 0in 5.4pt; height: 14.65pt; vertical-align: top;\"\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Times New Roman\",serif;text-align:center;'\u003e\u003cspan style='font-size:15px;font-family:\"Calibri\",sans-serif;color:black;'\u003eeUACR (g/mg Creatinine)\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" style=\"width: 13.2086%; border-top: 1pt solid windowtext; border-left: none; border-bottom: none; border-right: 1pt solid black; padding: 0in 5.4pt; height: 14.65pt; vertical-align: top;\"\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Times New Roman\",serif;text-align:center;'\u003e\u003cspan style='font-size:15px;font-family:\"Calibri\",sans-serif;color:black;'\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"height: 14.65pt; border: none; width: 0.9351%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"height: 9.35pt; border: none; width: 0.9351%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"3\" style=\"width: 11.6891%; border-top: 1pt solid windowtext; border-left: 1pt solid windowtext; border-bottom: none; border-right: 1pt solid black; padding: 0in 5.4pt; height: 9.35pt; vertical-align: top;\"\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Times New Roman\",serif;text-align:center;'\u003e\u003cspan style='font-size:15px;font-family:\"Calibri\",sans-serif;color:black;'\u003eGFR category\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"3\" style=\"width: 15.7802%; border-top: 1pt solid windowtext; border-left: none; border-bottom: none; border-right: 1pt solid black; padding: 0in 5.4pt; height: 9.35pt; vertical-align: top;\"\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Times New Roman\",serif;text-align:center;'\u003e\u003cspan style='font-size:15px;font-family:\"Calibri\",sans-serif;color:black;'\u003eeGFR (CKD-EPI) (mL/min/1.73 m2)\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" style=\"width: 14.3776%; border-top: 1pt solid windowtext; border-left: none; border-bottom: none; border-right: 1pt solid black; padding: 0in 5.4pt; height: 9.35pt; vertical-align: top;\"\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Times New Roman\",serif;text-align:center;'\u003e\u003cspan style='font-size:15px;font-family:\"Calibri\",sans-serif;color:black;'\u003eA1\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" style=\"width: 14.8451%; border-top: 1pt solid windowtext; border-left: none; border-bottom: none; border-right: 1pt solid black; padding: 0in 5.4pt; height: 9.35pt; vertical-align: top;\"\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Times New Roman\",serif;text-align:center;'\u003e\u003cspan style='font-size:15px;font-family:\"Calibri\",sans-serif;color:black;'\u003eA2\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" style=\"width: 11.1046%; border-top: 1pt solid windowtext; border-left: none; border-bottom: none; border-right: 1pt solid black; padding: 0in 5.4pt; height: 9.35pt; vertical-align: top;\"\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Times New Roman\",serif;text-align:center;'\u003e\u003cspan style='font-size:15px;font-family:\"Calibri\",sans-serif;color:black;'\u003eA3\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" style=\"width: 13.2086%; border-top: 1pt solid windowtext; border-left: none; border-bottom: none; border-right: 1pt solid black; padding: 0in 5.4pt; height: 9.35pt; vertical-align: top;\"\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Times New Roman\",serif;text-align:center;'\u003e\u003cspan style='font-size:15px;font-family:\"Calibri\",sans-serif;color:black;'\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"height: 9.35pt; border: none; width: 0.9351%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"height: 9.35pt; border: none; width: 0.9351%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 14.3776%; border-top: 1pt solid windowtext; border-left: none; border-bottom: 1pt solid windowtext; border-right: 1pt solid black; padding: 0in 5.4pt; height: 9.35pt; vertical-align: top;\"\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Times New Roman\",serif;text-align:center;'\u003e\u003cspan style='font-size:15px;font-family:\"Calibri\",sans-serif;color:black;'\u003e\u0026lt; 30\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 14.8451%; border-top: 1pt solid windowtext; border-left: none; border-bottom: 1pt solid windowtext; border-right: 1pt solid black; padding: 0in 5.4pt; height: 9.35pt; vertical-align: top;\"\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Times New Roman\",serif;text-align:center;'\u003e\u003cspan style='font-size:15px;font-family:\"Calibri\",sans-serif;color:black;'\u003e30-299\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 11.1046%; border-top: 1pt solid windowtext; border-left: none; border-bottom: 1pt solid windowtext; border-right: 1pt solid black; padding: 0in 5.4pt; height: 9.35pt; vertical-align: top;\"\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Times New Roman\",serif;text-align:center;'\u003e\u003cspan style='font-size:15px;font-family:\"Calibri\",sans-serif;color:black;'\u003e\u0026ge; 300\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 13.2086%; border-top: 1pt solid windowtext; border-left: none; border-bottom: 1pt solid windowtext; border-right: 1pt solid black; padding: 0in 5.4pt; height: 9.35pt; vertical-align: top;\"\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Times New Roman\",serif;text-align:center;'\u003e\u003cspan style='font-size:15px;font-family:\"Calibri\",sans-serif;color:black;'\u003eTotal\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"height: 9.35pt; border: none; width: 0.9351%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 11.6891%; border-top: 1pt solid windowtext; border-left: 1pt solid windowtext; border-bottom: none; border-right: 1pt solid black; padding: 0in 5.4pt; height: 9.35pt; vertical-align: top;\"\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Times New Roman\",serif;text-align:center;'\u003e\u003cspan style='font-size:15px;font-family:\"Calibri\",sans-serif;color:black;'\u003eG1\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 15.7802%; border-top: 1pt solid windowtext; border-left: none; border-bottom: none; border-right: 1pt solid black; padding: 0in 5.4pt; height: 9.35pt; vertical-align: top;\"\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Times New Roman\",serif;text-align:center;'\u003e\u003cspan style='font-size:15px;font-family:\"Calibri\",sans-serif;color:black;'\u003e\u0026ge; 90\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 14.3776%; background: rgb(112, 173, 71); padding: 0in 5.4pt; height: 9.35pt; vertical-align: top;\"\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Times New Roman\",serif;text-align:center;'\u003e\u003cstrong\u003e\u003cspan style='font-size:15px;font-family:\"Calibri\",sans-serif;color:black;'\u003e43,3%\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 14.8451%; background: yellow; padding: 0in 5.4pt; height: 9.35pt; vertical-align: top;\"\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Times New Roman\",serif;text-align:center;'\u003e\u003cstrong\u003e\u003cspan style='font-size:15px;font-family:\"Calibri\",sans-serif;color:black;'\u003e\u0026nbsp;0,8%\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 11.1046%; background: rgb(255, 192, 0); padding: 0in 5.4pt; height: 9.35pt; vertical-align: top;\"\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Times New Roman\",serif;text-align:center;'\u003e\u003cstrong\u003e\u003cspan style='font-size:15px;font-family:\"Calibri\",sans-serif;color:black;'\u003e\u0026nbsp;0,1%\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 13.2086%; border-top: none; border-left: 1pt solid windowtext; border-bottom: 1pt solid windowtext; border-right: 1pt solid black; padding: 0in 5.4pt; height: 9.35pt; vertical-align: top;\"\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Times New Roman\",serif;text-align:center;'\u003e\u003cspan style='font-size:15px;font-family:\"Calibri\",sans-serif;color:black;'\u003e44.2%\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"height: 9.35pt; border: none; width: 0.9351%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 11.6891%; border-top: none; border-left: 1pt solid windowtext; border-bottom: none; border-right: 1pt solid black; padding: 0in 5.4pt; height: 9.35pt; vertical-align: top;\"\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Times New Roman\",serif;text-align:center;'\u003e\u003cspan style='font-size:15px;font-family:\"Calibri\",sans-serif;color:black;'\u003eG2\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 15.7802%; border-top: none; border-bottom: none; border-left: none; border-image: initial; border-right: 1pt solid black; padding: 0in 5.4pt; height: 9.35pt; vertical-align: top;\"\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Times New Roman\",serif;text-align:center;'\u003e\u003cspan style='font-size:15px;font-family:\"Calibri\",sans-serif;color:black;'\u003e60-89\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 14.3776%; background: rgb(112, 173, 71); padding: 0in 5.4pt; height: 9.35pt; vertical-align: top;\"\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Times New Roman\",serif;text-align:center;'\u003e\u003cstrong\u003e\u003cspan style='font-size:15px;font-family:\"Calibri\",sans-serif;color:black;'\u003e43,6%\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 14.8451%; background: yellow; padding: 0in 5.4pt; height: 9.35pt; vertical-align: top;\"\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Times New Roman\",serif;text-align:center;'\u003e\u003cstrong\u003e\u003cspan style='font-size:15px;font-family:\"Calibri\",sans-serif;color:black;'\u003e1%\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 11.1046%; background: rgb(255, 192, 0); padding: 0in 5.4pt; height: 9.35pt; vertical-align: top;\"\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Times New Roman\",serif;text-align:center;'\u003e\u003cstrong\u003e\u003cspan style='font-size:15px;font-family:\"Calibri\",sans-serif;color:black;'\u003e0.1%\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 13.2086%; border-top: none; border-left: 1pt solid windowtext; border-bottom: 1pt solid windowtext; border-right: 1pt solid black; padding: 0in 5.4pt; height: 9.35pt; vertical-align: top;\"\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Times New Roman\",serif;text-align:center;'\u003e\u003cspan style='font-size:15px;font-family:\"Calibri\",sans-serif;color:black;'\u003e44.7%\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"height: 9.35pt; border: none; width: 0.9351%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 11.6891%; border-top: none; border-left: 1pt solid windowtext; border-bottom: none; border-right: 1pt solid black; padding: 0in 5.4pt; height: 9.35pt; vertical-align: top;\"\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Times New Roman\",serif;text-align:center;'\u003e\u003cspan style='font-size:15px;font-family:\"Calibri\",sans-serif;color:black;'\u003eG3a\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 15.7802%; border-top: none; border-bottom: none; border-left: none; border-image: initial; border-right: 1pt solid black; padding: 0in 5.4pt; height: 9.35pt; vertical-align: top;\"\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Times New Roman\",serif;text-align:center;'\u003e\u003cspan style='font-size:15px;font-family:\"Calibri\",sans-serif;color:black;'\u003e45-59\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 14.3776%; background: yellow; padding: 0in 5.4pt; height: 9.35pt; vertical-align: top;\"\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Times New Roman\",serif;text-align:center;'\u003e\u003cstrong\u003e\u003cspan style='font-size:15px;font-family:\"Calibri\",sans-serif;color:black;'\u003e6.7%\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 14.8451%; background: rgb(255, 192, 0); padding: 0in 5.4pt; height: 9.35pt; vertical-align: top;\"\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Times New Roman\",serif;text-align:center;'\u003e\u003cstrong\u003e\u003cspan style='font-size:15px;font-family:\"Calibri\",sans-serif;color:black;'\u003e0.3%\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 11.1046%; background: red; padding: 0in 5.4pt; height: 9.35pt; vertical-align: top;\"\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Times New Roman\",serif;text-align:center;'\u003e\u003cstrong\u003e\u003cspan style='font-size:15px;font-family:\"Calibri\",sans-serif;color:black;'\u003e0.1%\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 13.2086%; border-top: none; border-left: 1pt solid windowtext; border-bottom: 1pt solid windowtext; border-right: 1pt solid black; padding: 0in 5.4pt; height: 9.35pt; vertical-align: top;\"\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Times New Roman\",serif;text-align:center;'\u003e\u003cspan style='font-size:15px;font-family:\"Calibri\",sans-serif;color:black;'\u003e7.1%\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"height: 9.35pt; border: none; width: 0.9351%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 11.6891%; 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border-right: 1pt solid black; padding: 0in 5.4pt; height: 9.35pt; vertical-align: top;\"\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Times New Roman\",serif;text-align:center;'\u003e\u003cspan style='font-size:15px;font-family:\"Calibri\",sans-serif;color:black;'\u003e96.8%\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 14.8451%; border-top: 1pt solid windowtext; border-left: none; border-bottom: 1pt solid windowtext; border-right: 1pt solid black; padding: 0in 5.4pt; height: 9.35pt; vertical-align: top;\"\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Times New Roman\",serif;text-align:center;'\u003e\u003cspan style='font-size:15px;font-family:\"Calibri\",sans-serif;color:black;'\u003e2.6%\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 11.1046%; border-top: 1pt solid windowtext; border-left: none; border-bottom: 1pt solid windowtext; border-right: 1pt solid black; padding: 0in 5.4pt; height: 9.35pt; vertical-align: top;\"\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Times New Roman\",serif;text-align:center;'\u003e\u003cspan style='font-size:15px;font-family:\"Calibri\",sans-serif;color:black;'\u003e0.6%\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 13.2086%; border-top: none; border-left: none; border-bottom: 1pt solid windowtext; border-right: 1pt solid black; padding: 0in 5.4pt; height: 9.35pt; vertical-align: top;\"\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Times New Roman\",serif;text-align:center;'\u003e\u003cspan style='font-size:15px;font-family:\"Calibri\",sans-serif;color:black;'\u003e100%\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"height: 9.35pt; border: none; width: 0.9351%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cp style='margin:0in;font-size:16px;font-family:\"Times New Roman\",serif;'\u003e\u003cspan style='font-size:12px;font-family:\"Calibri\",sans-serif;'\u003eThe proportion of serum creatinine exams paired with eUCR assessment varied according to CKD stage: G1 (54.9%), G2 (61.2%), G3a (66.7%), G3b (70.7%), G4 (70.2%) e G5 (46.7%).\u003c/span\u003e\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003eEthics approval and consent to participate\u003c/p\u003e\n\u003cp\u003eThis protocol was submitted to the appreciation and approval was taken from the local Research Ethics Committee. Due to the large number of patients and the retrospective nature of the study, a waiver of informed consent was obtained (Ethical Review Board: Hospital Nove de Julho. Protocol number: 5.308.256)\u003c/p\u003e\n\u003cp\u003eAvailability of data and materials\u003c/p\u003e\n\u003cp\u003eThe datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003eCompeting interests\u003c/p\u003e\n\u003cp\u003eMG and RP received research honoraria from AstraZeneca. CMT is an employee from AstraZeneca Brazil. The other authors have no relevant information to disclose.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eFunding\u003c/p\u003e\n\u003cp\u003eThis study was funded by AstraZeneca Brazil.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAuthors\u0026apos; contributions\u003c/p\u003e\n\u003cp\u003eMG, RP, and CMT have made substantial contributions to the conception and design of the work, helped in the interpretation of data, and have drafted the work or substantively revised it. PLD made substantial contributions to data analysis and has drafted the work or substantively revised it. RRR, VCS, ML, AAB, ACB, AAS, PTMCAR, and BBR have made substantial contributions to data interpretation and have substantively revised the draft. All authors approved the submitted work and have agreed both to be personally accountable for the author\u0026apos;s own contributions and to ensure that questions related to the accuracy or integrity of any part of the work.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eKovesdy CP. Epidemiology of chronic kidney disease: an update 2022. Kidney Int Suppl (2011). 2022;12(1):7-11.\u003c/li\u003e\n\u003cli\u003eStanifer JW, Muiru A, Jafar TH, Patel UD. Chronic kidney disease in low- and middle-income countries. Nephrol Dial Transplant. 2016;31(6):868-74.\u003c/li\u003e\n\u003cli\u003eChen TK, Knicely DH, Grams ME. Chronic Kidney Disease Diagnosis and Management: A Review. Jama. 2019;322(13):1294-304.\u003c/li\u003e\n\u003cli\u003eShlipak MG, Tummalapalli SL, Boulware LE, Grams ME, Ix JH, Jha V, et al. The case for early identification and intervention of chronic kidney disease: conclusions from a Kidney Disease: Improving Global Outcomes (KDIGO) Controversies Conference. Kidney Int. 2021;99(1):34-47.\u003c/li\u003e\n\u003cli\u003eBakris GL, Agarwal R, Anker SD, Pitt B, Ruilope LM, Rossing P, et al. Effect of Finerenone on Chronic Kidney Disease Outcomes in Type 2 Diabetes. New England Journal of Medicine. 2020;383(23):2219-29.\u003c/li\u003e\n\u003cli\u003eHeerspink HJL, Stef\u0026aacute;nsson BV, Correa-Rotter R, Chertow GM, Greene T, Hou F-F, et al. Dapagliflozin in Patients with Chronic Kidney Disease. New England Journal of Medicine. 2020;383(15):1436-46.\u003c/li\u003e\n\u003cli\u003eBello AK, Johnson DW, Feehally J, Harris D, Jindal K, Lunney M, et al. Global Kidney Health Atlas (GKHA): design and methods. Kidney Int Suppl (2011). 2017;7(2):145-53.\u003c/li\u003e\n\u003cli\u003eSumida K, Nadkarni GN, Grams ME, Sang Y, Ballew SH, Coresh J, et al. Conversion of Urine Protein-Creatinine Ratio or Urine Dipstick Protein to Urine Albumin-Creatinine Ratio for Use in Chronic Kidney Disease Screening and Prognosis : An Individual Participant-Based Meta-analysis. Ann Intern Med. 2020;173(6):426-35.\u003c/li\u003e\n\u003cli\u003eJager KJ, Kovesdy C, Langham R, Rosenberg M, Jha V, Zoccali C. A single number for advocacy and communication-worldwide more than 850 million individuals have kidney diseases. Kidney Int. 2019;96(5):1048-50.\u003c/li\u003e\n\u003cli\u003eAquino EM, Barreto SM, Bensenor IM, Carvalho MS, Chor D, Duncan BB, et al. Brazilian Longitudinal Study of Adult Health (ELSA-Brasil): objectives and design. Am J Epidemiol. 2012;175(4):315-24.\u003c/li\u003e\n\u003cli\u003ePiccolli AP, Nascimento MMD, Riella MC. Prevalence of chronic kidney disease in a population in southern Brazil (Pro-Renal Study). J Bras Nefrol. 2017;39(4):384-90.\u003c/li\u003e\n\u003cli\u003eNeves P, Sesso RCC, Thom\u0026eacute; FS, Lugon JR, Nasicmento MM. Brazilian Dialysis Census: analysis of data from the 2009-2018 decade. J Bras Nefrol. 2020;42(2):191-200.\u003c/li\u003e\n\u003cli\u003eSesso R, Lugon JR. Global Dialysis Perspective: Brazil. Kidney360. 2020;1(3).\u003c/li\u003e\n\u003cli\u003eAlcalde PR, Kirsztajn GM. Expenses of the Brazilian Public Healthcare System with chronic kidney disease. J Bras Nefrol. 2018;40(2):122-9.\u003c/li\u003e\n\u003cli\u003eSozio SM, Pivert KA, Caskey FJ, Levin A. The state of the global nephrology workforce: a joint ASN-ERA-EDTA-ISN investigation. Kidney Int. 2021;100(5):995-1000.\u003c/li\u003e\n\u003cli\u003eQaseem A, Hopkins RH, Sweet DE, Starkey M, Shekelle P. Screening, Monitoring, and Treatment of Stage 1 to 3 Chronic Kidney Disease: A Clinical Practice Guideline From the American College of Physicians. Annals of Internal Medicine. 2013;159(12):835-47.\u003c/li\u003e\n\u003cli\u003eCebrian A, Escobar C, Aranda U, Palacios B, Capel M, Sicras A, et al. The 2021 European Society of Cardiology Cardiovascular Disease Prevention Guidelines: adding albuminuria to the SCORE scale increases the prevalence of very high/high cardiovascular risk among patients with chronic kidney disease. Clin Kidney J. 2022;15(6):1204-8.\u003c/li\u003e\n\u003cli\u003eOrtiz A, Wanner C, Gansevoort R, Council ERA. Chronic kidney disease as cardiovascular risk factor in routine clinical practice: a position statement by the Council of the European Renal Association. European Journal of Preventive Cardiology. 2022;29(17):2211-5.\u003c/li\u003e\n\u003cli\u003eFolkerts K, Petruski-Ivleva N, Comerford E, Blankenburg M, Evers T, Gay A, et al. Adherence to Chronic Kidney Disease Screening Guidelines Among Patients With Type 2 Diabetes in a US Administrative Claims Database. Mayo Clinic Proceedings. 2021;96(4):975-86.\u003c/li\u003e\n\u003cli\u003eJain V, Sinha S, Shaw C, Bramham K, Croucher C. Re-evaluating national screening for chronic kidney disease in the UK. BMJ. 2023;382:e074265.\u003c/li\u003e\n\u003cli\u003eAbdel-Kader K, Greer RC, Boulware LE, Unruh ML. Primary care physicians\u0026rsquo; familiarity, beliefs, and perceived barriers to practice guidelines in non-diabetic CKD: a survey study. BMC Nephrology. 2014;15(1):64.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-nephrology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bnep","sideBox":"Learn more about [BMC Nephrology](http://bmcnephrol.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bnep/default.aspx","title":"BMC Nephrology","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"","lastPublishedDoi":"10.21203/rs.3.rs-3380226/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-3380226/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eChronic kidney disease (CKD) is a global health problem with rising prevalence, morbidity, mortality, and associated costs. Early identification and risk stratification are key to preventing progression to kidney failure. However, there is a paucity of data on practice patterns of kidney function assessment to guide the development of improvement strategies, particularly in lower-income countries.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eA retrospective observational analysis was conducted in a nationwide laboratory database in Brazil. We included all adult patients with at least one serum creatinine assessment between June 2018 and May 2021. Our primary objective was to determine the proportion of patients with estimated glomerular filtration rate (eGFR) evaluations accompanied by equivalents of urinary to creatinine ratio (eUCR) assessments within 12 months.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eOut of 4,5323,332 serum creatinine measurements, 42% lacked eUCR measurements within 12 months. Approximately 10.8% of tests suggested CKD, mostly at stage 3a. The proportion of serum creatinine exams paired with eUCR assessment varied according to the CKD stage. Internal Medicine, Cardiology, and Obstetrics/Gynecology were the specialties requesting most of the creatinine tests. Nephrology contributed with only 1.1% of serum creatinine requests for testing.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003e Our findings reveal that a significant proportion of individuals with a creatinine test lack an accompanying urinary eUCR in Brazil, contrary to the recommendations of the international guidelines. Non-Nephrologists perform most kidney function evaluations, even among patients with presumable advanced CKD. This highlights the urge to incorporate in clinical practice the early detection of CKD and to encourage more collaborative multidisciplinary care to improve CKD management.\u003c/p\u003e","manuscriptTitle":"Patterns of Kidney Function and Risk Assessment in a Nationwide Laboratory Database: The Brazilian CHECK-CKD Study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2023-10-09 22:03:39","doi":"10.21203/rs.3.rs-3380226/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2023-11-26T10:25:51+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2023-11-22T18:50:40+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2023-11-06T16:17:39+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2023-11-04T10:31:39+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"80404f02-2d61-47e4-80d0-6d5c791e91cb","date":"2023-10-28T05:59:50+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"e5e0323f-70e3-47d4-8447-f3d300eceb48","date":"2023-10-25T09:07:05+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2023-10-23T10:43:50+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2023-10-15T11:29:39+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2023-10-03T19:02:10+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2023-10-03T19:02:10+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Nephrology","date":"2023-09-23T17:59:24+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-nephrology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bnep","sideBox":"Learn more about [BMC Nephrology](http://bmcnephrol.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bnep/default.aspx","title":"BMC Nephrology","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"57b04537-feb3-46bc-9743-36d493a4a65c","owner":[],"postedDate":"October 9th, 2023","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2024-04-24T15:37:37+00:00","versionOfRecord":[],"versionCreatedAt":"2023-10-09 22:03:39","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-3380226","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-3380226","identity":"rs-3380226","version":["v1"]},"buildId":"qQ7_6M8ijIrYJ9CiyUnPg","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}