Commentary
KDOQI US Commentary on the 2012 KDIGO Clinical Practice Guideline for the Evaluation and Management of CKD

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The National Kidney Foundation–Kidney Disease Outcomes Quality Initiative (NKF-KDOQI) guideline for evaluation, classification, and stratification of chronic kidney disease (CKD) was published in 2002. The KDOQI guideline was well accepted by the medical and public health communities, but concerns and criticisms arose as new evidence became available since the publication of the original guidelines. KDIGO (Kidney Disease: Improving Global Outcomes) recently published an updated guideline to clarify the definition and classification of CKD and to update recommendations for the evaluation and management of individuals with CKD based on new evidence published since 2002. The primary recommendations were to retain the current definition of CKD based on decreased glomerular filtration rate or markers of kidney damage for 3 months or more and to include the cause of kidney disease and level of albuminuria, as well as level of glomerular filtration rate, for CKD classification. NKF-KDOQI convened a work group to write a commentary on the KDIGO guideline in order to assist US practitioners in interpreting the KDIGO guideline and determining its applicability within their own practices. Overall, the commentary work group agreed with most of the recommendations contained in the KDIGO guidelines, particularly the recommendations regarding the definition and classification of CKD. However, there were some concerns about incorporating the cause of disease into CKD classification, in addition to certain recommendations for evaluation and management.

Section snippets

Foreword

It has been 12 years since the publication of the National Kidney Foundation–Kidney Disease Outcomes Quality Initiative (NKF-KDOQI) guideline for evaluation, classification, and stratification of chronic kidney disease (CKD).1 While not a new medication, a new device, or a landmark clinical trial, this guideline publication perhaps had a greater impact on the diagnosis and management of people with CKD than anything else that has happened in nephrology in the first decade of the 21st century.

Review and Approval Process for this Commentary

To assist US practitioners in interpreting the KDIGO guideline, the NKF-KDOQI convened a work group to write a commentary. The commentary addresses the full scope of the KDIGO guideline, focusing in particular on their relevance to and implementation in the United States. The NKF-KDOQI Steering Committee first selected Co-Chairs and then individual members based on their clinical and/or research expertise and interest in the guideline process. Individual sections focusing on each of the topic

Definition of CKD

  • 1.1.1:

    CKD is defined as abnormalities of kidney structure or function, present for >3 months, with implications for health. (Not Graded) [See table titled “Criteria for CKD (either of the following present for >3 months)”]

Criteria for CKD (either of the following present for >3 months)

Abbreviations: CKD, chronic kidney disease; GFR, glomerular filtration rate.

Definition and Identification of CKD Progression

  • 2.1.1:

    Assess GFR and albuminuria at least annually in people with CKD. Assess GFR and albuminuria more often for individuals at higher risk of progression, and/or where measurement will impact therapeutic decisions. (Not Graded)

  • 2.1.2:

    Recognize that small fluctuations in GFR are common and are not necessarily indicative of progression. (Not Graded)

  • 2.1.3:

    Define CKD progression based on one of more of the following (Not Graded):

    • Decline in GFR category (≥90 [G1], 60–89 [G2], 45–59 [G3a], 30–44 [G3b], 15–29 [G4], <15

Prevention of CKD Progression (Recommendations 3.1.1-3.1.11)

BP and RAAS interruption

  • 3.1.1:

    Individualize BP targets and agents according to age, coexistent cardiovascular disease and other comorbidities, risk of progression of CKD, presence or absence of retinopathy (in CKD patients with diabetes), and tolerance of treatment as described in the KDIGO 2012 Blood Pressure Guideline. (Not Graded)

  • 3.1.2:

    Inquire about postural dizziness and check for postural hypotension regularly when treating CKD patients with BP-lowering drugs. (Not Graded)

  • 3.1.3:

    Tailor BP treatment regimens

CKD and CVD

  • 4.1.1:

    We recommend that all people with CKD be considered at increased risk for cardiovascular disease. (1A)

  • 4.1.2:

    We recommend that the level of care for ischemic heart disease offered to people with CKD should not be prejudiced by their CKD. (1A)

  • 4.1.3:

    We suggest that adults with CKD at risk for atherosclerotic events be offered treatment with antiplatelet agents unless there is an increased bleeding risk that needs to be balanced against the possible cardiovascular benefits. (2B)

  • 4.1.4:

    We suggest that the level of

Referral to Specialist Services

  • 5.1.1:

    We recommend referral to specialist kidney care services for people with CKD in the following circumstances (1B):

    • AKI or abrupt sustained fall in GFR;

    • GFR < 30 ml/min/1.73 m2 (GFR categories G4-G5);

    • a consistent finding of significant albuminuria (ACR ≥ 300 mg/g [≥ 30 mg/mmol] or AER ≥ 300 mg/24 hours, approximately equivalent to PCR ≥ 500 mg/g [≥50 mg/mmol] or PER ≥ 500 mg/24 hours);

    • progression of CKD (see Recommendation 2.1.3 for definition);

    • urinary red cell casts, RBC >20 per high power field sustained and not

Conclusion

The KDIGO guideline recommendations on evaluation and management of CKD serve as an excellent summary of the state our knowledge and available evidence on CKD. Importantly, they provide an important and needed update to the staging system based on newly available data. They also highlight gaps in knowledge to guide future investigative efforts.

Acknowledgements

Guideline recommendations included in this article originally were published in Kidney International Supplements and were reproduced with permission from KDIGO.

We thank Drs Jeffrey Berns, Michael Choi, Holly Kramer, Michael Rocco, and Joseph Vassalotti for careful review of this manuscript; and Kerry Willis, Emily Howell, and James Papanikolaw from the NKF for help in coordinating the work of the group and preparing the manuscript.

Support: No financial support was required for the development

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