Are there lost opportunities in chronic kidney disease? A region-wide cohort study.

Objectives: Identify the windows of opportunity for the diagnosis of chronic kidney disease (CKD) and the prevention of its adverse outcomes and quantify the potential population gains of such prevention.
Design and Setting: Observational, population-wide study of residents in the Stockholm and Skåne regions of Sweden between 1 January 2015 and 31 December 2020.
Participants: All patients who did not yet have a diagnosis of CKD in healthcare but had CKD according to laboratory measurements of CKD biomarkers available in electronic health records.
Outcome Measures: We assessed the proportions of the patient population that received a subsequent diagnosis of CKD in healthcare, that used guideline-directed pharmacological therapy (statins, renin-angiotensin aldosterone system inhibitors (RAASi) and/or sodium-glucose cotransporter-2 inhibitors (SGLT2i)) and that experienced adverse outcomes (all-cause mortality, cardiovascular mortality or major adverse cardiovascular events (MACE)). The potential to prevent adverse outcomes in CKD was assessed using simulations of guideline-directed pharmacological therapy in untreated subsets of the study population.
Results: We identified 99 382 patients with undiagnosed CKD during the study period. Only 33% of those received a subsequent diagnosis of CKD in healthcare after 5 years. The proportion that used statins or RAASi was of similar size to the proportion that didn't, regardless of how advanced their CKD was. The use of SGLT2i was negligible. In simulations of optimal treatment, 22% of the 21 870 deaths, 27% of the 14 310 cardiovascular deaths and 39% of the 22 224 MACE could have been avoided if every patient who did not use an indicated medication for their laboratory-confirmed CKD was treated with guideline-directed pharmacological therapy for CKD.
Conclusions: While we noted underdiagnosis and undertreatment of CKD in this large contemporary population, we also identified a substantial realisable potential to improve CKD outcomes and reduce its burden by treating patients early with guideline-directed pharmacological therapy.
Competing Interests: Competing interests: JS reports stock ownership in Anagram kommunikation AB and Symptoms Europe AB. AN has participated as a consultant on advisory board committees and educational activities with Astra Zeneca, Novo Nordisk, Boehringer Ingelhim and Eli Lilly. SK has participated as a consultant on advisory board committees and educational activities with AstraZeneca and Novo Nordisk. JB is an employee of AstraZeneca. TC is an employee and stockowner in Sence Research AB (an independent company in epidemiology and outcomes research) that received funding from AstraZeneca for statistical analysis within this research project. MKS has participated as a consultant on advisory board committees and educational activities with Amgen, AstraZeneca, Boehringer Ingelheim, GSK and NovoNordisk. JÄ has received payment/honoraria from AstraZeneca and Novartis; participated on a data safety monitoring/advisory board for AstraZeneca, Astella and Boehringer Ingelheim. The other authors report no competing interests.
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