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Research

Prevalence estimates of chronic kidney disease in Canada: results of a nationally representative survey

Paul Arora, Priya Vasa, Darren Brenner, Karl Iglar, Phil McFarlane, Howard Morrison and Alaa Badawi
CMAJ June 11, 2013 185 (9) E417-E423; DOI: https://doi.org/10.1503/cmaj.120833
Paul Arora
From the Division of Science and Technology, Laboratory for Foodborne Zoonoses (Arora, Badawi), Public Health Agency of Canada, Toronto, Ont.; the Division of Epidemiology (Arora, Brenner), Dalla Lana School of Public Health, University of Toronto, Toronto, Ont.; the Department of Family and Community Medicine (Vasa), University of Toronto, Toronto, Ont.; the Departments of Family and Community Medicine (Vasa, Iglar) and Medicine (McFarlane), St. Michael’s Hospital, Toronto, Ont.; and the Science Integration Division, Social Determinants and Science Integration Directorate, Health Promotion and Chronic Disease Prevention Branch (Morrison), Public Health Agency of Canada, Ottawa, Ont.
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Priya Vasa
From the Division of Science and Technology, Laboratory for Foodborne Zoonoses (Arora, Badawi), Public Health Agency of Canada, Toronto, Ont.; the Division of Epidemiology (Arora, Brenner), Dalla Lana School of Public Health, University of Toronto, Toronto, Ont.; the Department of Family and Community Medicine (Vasa), University of Toronto, Toronto, Ont.; the Departments of Family and Community Medicine (Vasa, Iglar) and Medicine (McFarlane), St. Michael’s Hospital, Toronto, Ont.; and the Science Integration Division, Social Determinants and Science Integration Directorate, Health Promotion and Chronic Disease Prevention Branch (Morrison), Public Health Agency of Canada, Ottawa, Ont.
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Darren Brenner
From the Division of Science and Technology, Laboratory for Foodborne Zoonoses (Arora, Badawi), Public Health Agency of Canada, Toronto, Ont.; the Division of Epidemiology (Arora, Brenner), Dalla Lana School of Public Health, University of Toronto, Toronto, Ont.; the Department of Family and Community Medicine (Vasa), University of Toronto, Toronto, Ont.; the Departments of Family and Community Medicine (Vasa, Iglar) and Medicine (McFarlane), St. Michael’s Hospital, Toronto, Ont.; and the Science Integration Division, Social Determinants and Science Integration Directorate, Health Promotion and Chronic Disease Prevention Branch (Morrison), Public Health Agency of Canada, Ottawa, Ont.
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Karl Iglar
From the Division of Science and Technology, Laboratory for Foodborne Zoonoses (Arora, Badawi), Public Health Agency of Canada, Toronto, Ont.; the Division of Epidemiology (Arora, Brenner), Dalla Lana School of Public Health, University of Toronto, Toronto, Ont.; the Department of Family and Community Medicine (Vasa), University of Toronto, Toronto, Ont.; the Departments of Family and Community Medicine (Vasa, Iglar) and Medicine (McFarlane), St. Michael’s Hospital, Toronto, Ont.; and the Science Integration Division, Social Determinants and Science Integration Directorate, Health Promotion and Chronic Disease Prevention Branch (Morrison), Public Health Agency of Canada, Ottawa, Ont.
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Phil McFarlane
From the Division of Science and Technology, Laboratory for Foodborne Zoonoses (Arora, Badawi), Public Health Agency of Canada, Toronto, Ont.; the Division of Epidemiology (Arora, Brenner), Dalla Lana School of Public Health, University of Toronto, Toronto, Ont.; the Department of Family and Community Medicine (Vasa), University of Toronto, Toronto, Ont.; the Departments of Family and Community Medicine (Vasa, Iglar) and Medicine (McFarlane), St. Michael’s Hospital, Toronto, Ont.; and the Science Integration Division, Social Determinants and Science Integration Directorate, Health Promotion and Chronic Disease Prevention Branch (Morrison), Public Health Agency of Canada, Ottawa, Ont.
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Howard Morrison
From the Division of Science and Technology, Laboratory for Foodborne Zoonoses (Arora, Badawi), Public Health Agency of Canada, Toronto, Ont.; the Division of Epidemiology (Arora, Brenner), Dalla Lana School of Public Health, University of Toronto, Toronto, Ont.; the Department of Family and Community Medicine (Vasa), University of Toronto, Toronto, Ont.; the Departments of Family and Community Medicine (Vasa, Iglar) and Medicine (McFarlane), St. Michael’s Hospital, Toronto, Ont.; and the Science Integration Division, Social Determinants and Science Integration Directorate, Health Promotion and Chronic Disease Prevention Branch (Morrison), Public Health Agency of Canada, Ottawa, Ont.
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Alaa Badawi
From the Division of Science and Technology, Laboratory for Foodborne Zoonoses (Arora, Badawi), Public Health Agency of Canada, Toronto, Ont.; the Division of Epidemiology (Arora, Brenner), Dalla Lana School of Public Health, University of Toronto, Toronto, Ont.; the Department of Family and Community Medicine (Vasa), University of Toronto, Toronto, Ont.; the Departments of Family and Community Medicine (Vasa, Iglar) and Medicine (McFarlane), St. Michael’s Hospital, Toronto, Ont.; and the Science Integration Division, Social Determinants and Science Integration Directorate, Health Promotion and Chronic Disease Prevention Branch (Morrison), Public Health Agency of Canada, Ottawa, Ont.
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  • For correspondence: alaa.badawi@phac-aspc.gc.ca
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  • Prevalence of CKD in Canada
    Patrick Levallois
    Posted on: 20 June 2013
  • Prevalence of chronic kidney disease in Canada: is it reliable?
    Ningchang Huang
    Posted on: 22 May 2013
  • Posted on: (20 June 2013)
    Prevalence of CKD in Canada
    • Patrick Levallois, Medical Adviser
    • Other Contributors:

    Arora et al. (1) provided data on the prevalence of chronic kidney disease (CKD) in Canada through the analysis of the first cycle of the Canadian Health Measure Survey (CHMS). They acknowledged that their data had some limitations; more specifically that classification of the disease's status was based on a single measurement of serum creatinine and albuminuria. However, other limitations of the study that are not discu...

    Show More

    Arora et al. (1) provided data on the prevalence of chronic kidney disease (CKD) in Canada through the analysis of the first cycle of the Canadian Health Measure Survey (CHMS). They acknowledged that their data had some limitations; more specifically that classification of the disease's status was based on a single measurement of serum creatinine and albuminuria. However, other limitations of the study that are not discussed are worthwhile to mention. First, the filtration glomerular rate (GFR) was only estimated but not measured. It was based on serum creatinine and some personal characteristics of respondents (age, sex, and ethnic origin), which is the current procedure in clinical guidelines. However, the use of creatinine in the equation for GFR estimation leads to some imprecision, in particular for aged people and for those with low or high muscle mass(2). Adding serum cystatin C to assess GFR has been proposed recently to overcome these limitations, which may lead to more accurate GFR estimations(3). The lack of such parameter is therefore one the important limitation of the current CHMS. Second, despite that the CHMS sampling strategy was aimed to obtain a representative sample of Canadians aged 6-79 years. It did not include institutionalized patients that may have more chronic diseases (diabetes, hypertension, etc.), which are associated with higher prevalence of CKD. This may have lead to a slight underestimation of the real prevalence of CKD in the overall Canadian population. Moreover, despite the efforts to increase the participation rate, the CHMS only obtained an overall response rate of 51.7%. Did participants of CHMS have different characteristics than non-participants regarding risk factors for CKD? Data on these differences could clarify the magnitude of the potential selection bias that may be present in such a study, leading to under- or overestimation of the prevalence of CKD in Canadians.

    Patrick Levallois MD MSc Institut national de sante publique du Quebec Centre de recherche du CHU de Quebec

    Jean-Philippe Lafrance MD MSc Department of Medicine, University of Montreal Nephrology Division, Maisonneuve-Rosemont Hospital Research Center

    References (1) Arora P et al. Prevalence estimates of chronic kidney disease in Canada: results of a nationally representative survey. CMAJ 2013 (2) Levey AS et al. A new equation to estimate glomerular filtration rate. Ann Intern Med 2009;150:604-612. (3) Inker LA et al. Estimating glorerular filtration rate from serum creatinine and cystatin C. N Eng J Med 2012;367:20-29.

    Conflict of Interest:

    None declared

    Show Less
    Competing Interests: None declared.
  • Posted on: (22 May 2013)
    Prevalence of chronic kidney disease in Canada: is it reliable?
    • Ningchang Huang, doctor
    • Other Contributors:

    Chronic kidney disease (CKD) is a global public health problem, affecting 10-16% of the adult population worldwide.1 CKD is characterised by low estimated glomerular filtration rate (eGFR) and high albuminuria,1 present for more than three months,1 and is associated with adverse outcomes, irrespective of hypertension and diabetes.2 Arora and colleagues shed new light on this question in this issue of CMAJ.3 They report th...

    Show More

    Chronic kidney disease (CKD) is a global public health problem, affecting 10-16% of the adult population worldwide.1 CKD is characterised by low estimated glomerular filtration rate (eGFR) and high albuminuria,1 present for more than three months,1 and is associated with adverse outcomes, irrespective of hypertension and diabetes.2 Arora and colleagues shed new light on this question in this issue of CMAJ.3 They report that the overall prevalence of CKD was 12.5%; therefore the number of patients with CKD in Canada is estimated to be about 3 million. However, all the markers of CKD were obtained from single measurements; therefore the reported prevalence of CKD might be overestimated. Given the importance of excluding acute kidney disease (AKD, including AKI), it is recommended that any patient with a reduced GFR and no previous evidence of renal impairment should have a repeat eGFR within two weeks.4 For the diagnosis of microalbuminuria two abnormal results from three specimens are required.4

    eGFR was calculated with an equation by Arora and colleagues developed by Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) equation. On the basis of the 2000 population of 201 million people older than 20 years in the USA, the CKD-EPI equation demonstrates the prevalence of 11.5% in CKD and yields a prevalence of CKD of 23.2 million.4 They used repeated measurements, obtained approximately 2 weeks after the original examination. Both CKD-EPI equation and the combination of cystatin C and serum creatinine equation are useful for CKD patients.5 However, the combination of cystatin C and serum creatinine equation does better.5 According to the new KDIGO clinical practice guideline for evaluation and management of CKD,1 we suggest measuring cystatin C in adults with creatinine-based eGFR 45-59 who do not have other markers of kidney damage if confirmation of CKD is required. If cystatin C-based eGFR is >60 mL/min/1.73 m2, the diagnosis of CKD is not confirmed. 2012 CKD-EPI creatinine-cystatin C equations were recommended.1,6

    References 1. Kidney Disease: Improving Global Outcomes (KDIGO) CKD Work Group. KDIGO 2012 Clinical Practice Guideline for the Evaluation and Management of Chronic Kidney Disease. Kidney Int, Suppl. 2013; 3: 1-150. 2. Du X, Zhao Y, Huang W, et al. Association of chronic kidney disease with adverse outcomes. Lancet. 2013; 381(9866): 531-2. 3. Arora P, Vasa P, Brenner D, et al. Prevalence estimates of chronic kidney disease in Canada: results of a nationally representative survey. CMAJ. 2013 May 6. [Epub ahead of print] 4. Du X, Fan L. Prevalence of chronic kidney disease in China. Lancet. 2012; 380(9838): 213. 5. Du X, Liu L, Hu B, et al. Is the Chronic Kidney Disease Epidemiology Collaboration four-level race equation better than the cystatin C equation? Nephrology (Carlton). 2012,17(4):407-14. 6. Inker LA, Schmid CH, Tighiouart H, et al. Estimating glomerular filtration rate from serum creatinine and cystatin C. N Engl J Med. 2012;367:20-9.

    Conflict of Interest:

    None declared

    Show Less
    Competing Interests: None declared.
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Canadian Medical Association Journal: 185 (9)
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Vol. 185, Issue 9
11 Jun 2013
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Prevalence estimates of chronic kidney disease in Canada: results of a nationally representative survey
Paul Arora, Priya Vasa, Darren Brenner, Karl Iglar, Phil McFarlane, Howard Morrison, Alaa Badawi
CMAJ Jun 2013, 185 (9) E417-E423; DOI: 10.1503/cmaj.120833

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Prevalence estimates of chronic kidney disease in Canada: results of a nationally representative survey
Paul Arora, Priya Vasa, Darren Brenner, Karl Iglar, Phil McFarlane, Howard Morrison, Alaa Badawi
CMAJ Jun 2013, 185 (9) E417-E423; DOI: 10.1503/cmaj.120833
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