Authors reply: "Global kidney health: Are we failing the silent pandemic?"

Abstract

Dear Editor,

Thank you for the opportunity to respond to the Letter to the Editor by Drs Vidal and Trevisanuto [1] regarding our article published in the Journal of Internal Medicine entitled “Global kidney health: Are we failing the silent pandemic?” [2]. We appreciate their thoughtful emphasis on the distinct challenges associated with screening for chronic kidney disease (CKD) in the pediatric population. While our article advocates for recognizing CKD as a major global public health priority and highlights the potential value of low-cost, accessible tools such as urine dipstick screening, we agree that the implementation of these strategies requires a context-specific and nuanced approach in the pediatric population.

We agree that an approach targeted toward children at higher risk, including those born preterm or with low birth weight, is of highest yield. We share the concern about false positive results causing healthcare costs and child and caregiver anxiety.

On the other hand, we are concerned about the asymptomatic individuals likely to be missed by a targeted approach. In the example we cited of a school urinary screening program in Iran, for example, there was demonstrated success in detecting kidney disease among otherwise asymptomatic children [3]. Successful programs have also been implemented in other regions [4].

The cost-effectiveness of large-scale screening certainly requires more investigation. In one of the studies cited in Drs Vidal and Trevisanuto's letter, for example, the incremental cost-effectiveness ratio of childhood proteinuria screening was reported as USD $2779.50 per CKD case diagnosed, but this does not consider potential lifetime benefits of early diagnosis [5]. As clinicians, we expect that early detection and management of kidney disease would confer lifetime health benefits and the potential to reduce future care costs, but the magnitude of these benefits in the pediatric population remains uncertain. Although their effectiveness and safety in the pediatric population remain to be established, newer emerging therapies for CKD management may substantially influence the evolving value of screening programs [5, 6].

While we believe that opportunistic testing at key timepoints or healthcare touchpoints, such as school entry, may remain a valuable strategy for increasing public awareness and facilitating the early identification of asymptomatic kidney disease in selected populations, we agree that a cautious approach is warranted, including further investigation of cost-effectiveness. In the interim, better implementing screening programs among those with established risk factors should be a priority.

The authors declare no conflicts of interest.

Tae Won Yi: writing - original draft, writing - review and editing. Daniel V. O'Hara: writing - original draft, writing - review and editing. Adeera Levin: writing - review and editing, supervision.