Proteinuria among patients with chronic kidney disease: a performance measure for improving patient outcomes.
BACKGROUND
In an effort to improve identification and treatment of patients with chronic kidney disease (CKD), the National Kidney Foundation (NKF) developed the Kidney Disease Quality Outcomes Initiative (KDQOI) clinical practice guidelines, which include measurement of proteinuria among all patients with CKD who are not receiving chronic dialysis therapy. Encouraging dissemination and utilization of these guidelines may be enhanced by the development of performance measures. The question of whether adequate evidence exists to advocate for the measurement of proteinuria in CKD as a performance measure was explored.


METHODS
The US Preventive Services Task Force "chain of evidence" framework was used to guide evidence synthesis from the systematic review. Five questions were applied to specific links in the evidence chain: (1) Is there direct evidence that testing for proteinuria improves health outcomes? (2) What is the yield of testing, in terms of both accuracy and reliability of the test and the prevalence of undiagnosed proteinuria? (3) What adverse effects result from testing a person for proteinuria? (4) Does treatment of proteinuria as a result of testing provide an incremental benefit in health outcomes? and (5) What adverse effects result from treating a person for proteinuria? The systematic search specifically targeted meta-analyses and systematic reviews.


RESULTS
The systematic review revealed no direct evidence that testing for proteinuria among patients with CKD reduced incidence of end-stage renal disease (ESRD). However, the strong links between testing, treatment, and outcome suggest a correlation between proteinuria testing and ESRD.


CONCLUSIONS
Current evidence suggests that proteinuria testing (using the albumin-to-creatinine ratio [ACR]) among patients with CKD would be an appropriate health care quality performance measure for improving patient outcomes.
Kaiser Permanente Northwest, Portland, Oregon, USA.
Micah L
ML
Thorp
David H
DH
Smith
Eric S
ES
Johnson
Suma
S
Vupputuri
Jessica W
JW
Weiss
Amanda F
AF
Petrik
Xuihai
X
Yang
Andrew S
AS
Levey
Haimanot
H
Wasse
Rosemary
R
Muoneke
Susan R
SR
Snyder
D006801:Humans; D007676:Kidney Failure, Chronic / Q000150:complications* / Q000175:diagnosis / Q000503:physiopathology / Q000628:therapy; D010043:Outcome and Process Assessment, Health Care / Q000458:organization & administration; D017410:Practice Guidelines as Topic; D011507:Proteinuria / Q000175:diagnosis* / Q000209:etiology / Q000628:therapy; D058996:Quality Improvement / Q000458:organization & administration*; D019984:Quality Indicators, Health Care