2 days ago
Is Albuminuria Screening the Answer to Tackling Unseen CKD?
VIENNA — Only 7%-20% of people with chronic kidney disease (CKD) in the US are aware of their condition; meanwhile, the disease is projected to become the fifth leading cause of death globally by 2050.
But what is the best way to change these statistics?
Facing off on opposite sides of a debate at 62nd European Renal Association (ERA) Congress 2025 on whether or not population screening of albuminuria is the answer were Ronald T. Gansevoort, MD, PhD, University Medical Center Groningen, Groningen, the Netherlands, and Joseph A. Vassalotti, MD, Icahn School of Medicine at Mount Sinai, New York City.
While the two speakers agreed on the importance of early detection of CKD and the limitations of current practice, they diverged on the best path forward.
The Case for Population Screening
'Albuminuria is by far the strongest predictor for kidney function decline,' said Gansevoort, who argued for broad screening.
'It can occur in an early stage of kidney disease, when kidney function is still normal,' he said, adding that it is often accompanied by as yet unknown — or poorly controlled — diabetes, hypertension, hyperlipidemia, and even cardiovascular disease.
He illustrated the gravity of the situation with a stark comparison: Patients on dialysis have 5-year survival rates similar to those of patients with colorectal cancer. Worse, survival is improving slightly in patients with cancer, whereas survival in patients on dialysis has not improved at all over the past few decades, he noted.
Gansevoort stressed the importance of identifying individuals at risk before a decline in the glomerular filtration rate begins, pointing to the increased availability of effective interventions, including SGLT2 inhibitors, GLP-1 receptor agonists, and mineralocorticoid receptor antagonists.
To demonstrate the feasibility of screening, he presented results from THOMAS, a Dutch prospective, randomized, open-label implementation study comparing two home-based screening methods.
Using a urine collection kit returned by post, the study achieved a 59% participation rate and identified confirmed high albuminuria in 3.3% of participants. Among those with albuminuria, 90% had newly diagnosed or poorly controlled comorbidities such as hypertension or high cholesterol.
Yet only 54% of referred patients actually visited their general practitioner. There's definitely room for improvement there, Gansevoort acknowledged.
Nonetheless, he argued that population screening was cost-effective when done at home. The researchers from THOMAS calculated a cost of €9225 per quality-adjusted life-year (QALY), far below typical European thresholds.
'It's already cost-effective,' he noted, adding that integrating albuminuria testing into existing national screening programs, such as those for colorectal cancer or cardiovascular disease, could further boost cost-effectiveness and increase participation.
He described the newly launched Check@Home study — a collaborative effort by the Dutch CardioVascular Alliance, the Dutch Heart Foundation, the Kidney Foundation, and the Diabetes Research Foundation — that combines screening for both CKD and cardiovascular disease.
He also highlighted the recently begun CASCADE CKD study, which uses a single at-home kit incorporating both urine and fecal collection to screen simultaneously for CKD and colorectal cancer.
'How easy would it be in the same package to have a second tube to collect some urine and to detect patients with chronic kidney disease?' he asked.
By sharing logistical infrastructure, 'It will definitely improve cost-effectiveness even further,' he noted.
The Case Against
Vassalotti, speaking against general population screening, began with a concession: 'I'm not against population screening for albuminuria,' he said. 'Rather, I think case finding among risk groups is more feasible, sustainable, and impactful.'
He emphasized the importance of context, asking the audience to consider 'the public, the patients, the primary care clinicians, and the policymakers. In the US, even among those diagnosed, only half receive urine albumin testing.'
'We're not even doing a good job managing people with CKD,' he said. 'We should implement better case finding or opportunistic screening to start with.'
Cost was another sticking point. Vassalotti cited a US study that used Markov models to assess population-wide CKD screening and put the cost at $86,300 per QALY for adults aged 55 years or older, a figure above commonly accepted thresholds.
'Implementation was assumed to be 100%,' he said, 'which in the US is quite a stretch.'
Vassalotti praised Gansevoort's THOMAS study but questioned its scalability. 'How can you screen the general population if only 59% participate?' he asked. He added that participation in the US might be even lower, given the lack of public awareness and fragmented health infrastructure.
He concluded by advocating for primary care engagement and better CKD education.
'Perceived risk will help us manage the risk condition,' he said. 'And that will result in more awareness, increased detection, and improved management.'
Agreement on Need for Action
In a rebuttal, Gansevoort reiterated that his model was already more cost-effective than those cited by Vassalotti. 'We do it in the home setting, making it far less costly,' he said. He also called for a more pragmatic view on participation. 'We are not going to save everybody,' he said. 'But should we not save many people because some do not like to be screened?'
Vassalotti, in turn, emphasized the need to work on education, for the public, patients, and clinicians alike, before expanding screening. 'How can you screen the public for kidney disease,' he asked, 'when they don't even know what it is?'
One key issue emerging from the closing discussion was how often screening should occur. 'It has not been decided yet,' Gansevoort admitted. 'We're looking into Markov models, perhaps a fixed interval or a patient-specific interval.'
Vassalotti argued for simplicity: 'Annual screening is something that we can disseminate easily,' he said. 'Less frequent screening is more difficult to socialize.'
Despite their differences, both speakers emphasized the need for action. 'We now have effective, sufficiently safe, and affordable treatments,' Gansevoort said. 'The present opportunistic screening approach has proven not to work.'
For Vassalotti, the path forward must be grounded in context. 'Every country should develop its own approach,' he said. 'Whether it be population screening or case finding.'
No funding was declared.
Gansevoort declared having relationships with AbbVie, AstraZeneca, Baxter, Bayer, Dutch Kidney Foundation, Galapagos, Happitech, Health~Holland, Ipsen, Mironid, Roche, Sanofi Genzyme, Sandoz, and Otsuka Pharmaceuticals.
Vassalotti declared having relationships with Novo Nordisk and Sanofi.
