Chronic Kidney Disease in Europe: The Missing Link in Cardiovascular Risk Assessment

Professor Charles Ferro, Chair of the European Renal Association’s ‘Strong Kidneys’ Taskforce, highlights the urgent need to integrate chronic kidney disease screening into cardiovascular risk assessments across Europe, addressing a critical gap that could save lives and reduce healthcare costs.

The Kidneys’ Hidden Anti-Aging Role in Cardiovascular Health

Chronic Kidney Disease (CKD) is currently a silent but escalating public health crisis that remains largely undetected until its advanced stages. Across Europe, an estimated 75 million people are affected, yet many are only diagnosed when the disease has significantly progressed, and they are on the brink of requiring dialysis or a kidney transplant.¹

The economic burden of CKD is equally alarming, with CKD-related healthcare costs exceeding €140 billion annually, not including productivity loss.² This places an increasingly unsustainable strain on healthcare systems and societies.  In Eastern and Central Europe, the median annual costs of in-centre haemodialysis and peritoneal dialysis is €18,169 and €20,906, respectively.³ In Western Europe, the cost is much more: €42,452 for haemodialysis and €25,136 for peritoneal dialysis.⁴ Costs are influenced by local reimbursement policies, the availability of expertise, salary costs, and the presence of manufacturers of peritoneal dialysis equipment.

Given the high costs of CKD treatment, early screening and intervention are critical to reducing long-term expenditures. Most studies support the cost-effectiveness of targeted CKD screening, particularly for high-risk populations such as diabetic patients.⁵

However, the primary burden of CKD is not just the need for dialysis or transplantation, but its role in accelerating biological aging and premature death. This is due to the loss of the kidneys’ anti-aging function, which is most visible in the cardiovascular system. For example, in 60-year-olds, the impact of CKD on aging and life expectancy is profound. Individuals with diabetes alone experience a 5.7–6.7-year reduction in life expectancy, but when CKD is also present, this increases to 11–14 years. The effect is even more severe for those with diabetes and cardiovascular disease (CVD), who face a 14.4–15.7-year reduction.⁶

Recently, a joint statement from the European Renal Association, the American Society of Nephrology, and the International Society of Nephrology called for the inclusion of CKD in the current World Health Organisation list of major non-communicable diseases causing premature mortality.⁷ CKD is expected to rise from the 18^th leading cause of death in 1990 to the 5^th by 2040.⁸ A large proportion of CKD associated deaths arise from premature CVD.

Despite its well-established link to CVD, CKD remains frequently overlooked in cardiovascular risk assessments. Patients with CKD face a significantly higher risk of heart attacks, strokes, arrhythmia, limb ischemia, heart failure, and premature death, yet kidney function and damage are not routinely evaluated as part of cardiovascular screening. This diagnostic gap delays interventions that could further improve outcomes and reduce healthcare costs.

The Case for Change: A Simple Addition to Risk Assessments

For many years, multiple national and international guidelines have recommended once-yearly blood and urine tests to screen for CKD in high-risk populations such as individuals with hypertension, diabetes, and established CVD. This targeted screening has been widely recognised to be cost-effective and is consistent with the emerging concept of cardiovascular-kidney-metabolic syndrome.⁹

Indeed, the 2021 European Society of Cardiology (ESC) Guidelines on CVD prevention provides a clear directive to recognise CKD as a novel actionable cardiovascular risk factor requiring specific intervention, on par with hypercholesterolemia, diabetes, and hypertension.¹⁰ However, the implementation of targeted CKD screening in at-risk populations has not been widely adopted in clinical practice, with many healthcare professionals and authorities unaware of how to incorporate CKD assessment into existing protocols.¹¹

The solution is simple and feasible: CKD assessment should include albuminuria testing (UACR) – to detect high levels of the protein albumin in urine – alongside routine blood glucose, cholesterol, and creatinine measurements.

Since albuminuria is an early marker of kidney damage, and a strong predictor of the future need of dialysis and CVD, its detection allows for better risk stratification and enables early intervention to slow CKD progression and reduce cardiovascular complications. The traditional approach to diagnose CKD implied waiting until 50% of the kidney mass has been lost before intervening; that is, it solely relied on kidney function tests (eGFR) to diagnose CKD. This time-honoured approach has resulted in the current large and future unsustainable burden of CKD, the need for KRT, and premature mortality. By contrast, assessing albuminuria allows for the detection of kidney damage before irreversible loss of kidney mass and function occurs. Early intervention at this reversible stage can prevent loss of kidney function and delay the need of dialysis by up to 10-fold.¹²

Implementing Albuminuria Screening

There is an increasing appreciation that population-wide CKD screening may be cost-effective when combined with optimal treatment to reduce cardiovascular risk, premature mortality, risk of CKD progression, and the need for dialysis. Some healthcare systems have already piloted or integrated albuminuria screening into cardiovascular risk assessments, offering practical, cost-effective models for implementation. For example, Madrid is leading the way by expanding its age-50 health screenings to include cardiovascular risk assessment, testing 500,000 people for diabetes, cholesterol, blood pressure, and body mass index. As part of this initiative, a pilot program is incorporating albuminuria screening to detect CKD, recognising its link to CVD.⁹ The Madrid experience is significant as a benchmark, as it represents the European region with the longest life expectancy.¹³

Many European guidelines already recommend targeted albuminuria testing for high-risk populations, such as patients with hypertension, CVD, diabetes, or who are older than 60 years.¹⁴ However, testing can often only be routinely performed for diabetes, and compliance with this is still generally poor. Additionally, reimbursement barriers can restrict access to albuminuria testing outside of diabetes care. This highlights the need for policy adjustments to expand testing access in high-risk groups.

Beyond structured screening programmes, opportunistic testing presents another pathway to expand albuminuria screening. In Spain, tests for cholesterol, blood sugar, and kidney function are routinely performed during visits to emergency rooms, hospitals, and primary care clinics, regardless of the reason for the visit. A pilot program in a catchment area of one million people is now integrating albuminuria testing into routine urine dipstick analysis. If the dipstick test shows a high albumin-to-creatinine ratio, a quantitative test is done.

Urgent Policy Changes Needed

CVD prevention cannot be truly effective without addressing kidney disease and vice versa. Adding albuminuria testing to existing cardiovascular risk assessments is a simple, cost-effective solution that could prevent thousands of deaths, reduce hospitalisations, and ease the financial burden on healthcare systems.

Policymakers must act now. By making CKD screening a standard part of cardiovascular risk assessment, Europe can take a major step toward reducing preventable deaths and improving public health outcomes.

At the national level, we urge policymakers to:

• Mandate albuminuria testing in cardiovascular risk assessments to align with the 2021 ESC Guidelines.
• Adapt screening approaches based on national healthcare systems, integrating albuminuria testing within routine blood panels, opportunistic screenings, or high-risk patient evaluations.
• Expand reimbursement policies for albuminuria testing beyond diabetes care to reach other at-risk populations.
• Reallocate existing healthcare resources to fund albuminuria testing without increasing overall expenditure, leveraging cost savings from early CKD detection and CVD risk reduction.

Since the new EU Commissioner for Health and Animal Welfare has committed to an EU plan against CVD, we urge the European Commission to:

• Include albuminuria screening as part of the recommendations to enhance CVD risk factor prevention.

We have the tools—now we need the commitment.

 

References

1. European Kidney Alliance (2021). Improving prevention, treatment and care of CKD in the aftermath of COVID-19. https://ekha.eu/wp-content/uploads/EKHA_call-to-action-to-tackle-CKD-at-EU-level-1.pdf
2. van Mil, D., Pouwels, X. G. L. V., Heerspink, H. J. L. et al. (2023). Cost-effectiveness of screening for chronic kidney disease: existing evidence and knowledge gaps. Clinical kidney journal, 17(1), sfad254. https://doi.org/10.1093/ckj/sfad254
3. Alparslan, C., Malyszko, J., Caskey, F. J., et al. (2024). Capacity for the management of kidney failure in the International Society of Nephrology Eastern and Central Europe region: report from the 2023 ISN Global Kidney Health Atlas (ISN-GKHA). Kidney international supplements, 13(1), 29–42. https://doi.org/10.1016/j.kisu.2024.01.006
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8. Global Burden of Disease Forecasting Collaborators. Burden of disease scenarios for 204 countries and territories, 2022-2050: a forecasting analysis for the Global Burden of Disease Study 2021. Lancet. 2024;403:2204-2256
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