Updated Chronic Kidney Disease Guideline Will Enable Physicians to Predict Prognosis More Accurately

An updated, global version of the groundbreaking National Kidney Foundation Kidney Disease Outcomes Quality Initiative (NKF-KDOQI) guideline Chronic Kidney Disease: Evaluation, Classification, Stratification, has been released by the Kidney Disease: Improving Global Outcomes (KDIGO).  The new guideline, published in Kidney International Supplements,  retains the current chronic kidney disease (CKD) definition but augments the classification system to include albuminuria, or protein in the urine, and cause of disease, as well as GFR stage.

“The original guideline provided a common language for communication among providers, patients and their families, investigators, and policy-makers and a framework for developing a public health approach to affect care and improve outcomes of CKD.  The definition of CKD remains the same so the prevalence in the US using that definition is still 26 million,” said Andrew S. Levey, MD, cochair of the NKF KDOQI workgroup that developed the 2002 CKD Guideline and Dr. Gerald J. and Dorothy R. Professor of Medicine at Tufts Medical Center in Boston.

“That guideline led to a paradigm change in the approach to CKD, shifting from an uncommon disease often culminating in kidney failure and treatment by nephrologists to a common condition leading to death from cardiovascular disease. As a result, CKD is now accepted as a worldwide public health problem and the global guideline was developed to address this issue,” continued Levey.

The updated guideline enables more accurate risk prediction and management by subdividing the GFR stages based on the level of albuminuria, providing a more precise picture of each patient’s condition.  The albuminuria level helps physicians stratify risk and evaluate likely outcomes which ultimately make a difference for management and treatment.

“The new staging predicts meaningful outcomes for patients more accurately based on both blood and urine tests instead of one or the other test alone,” said Joseph Vassalotti, MD, National Kidney Foundation chief medical officer. “When you put together a patient’s level of kidney function as assessed by the blood test to estimate glomerular filtration rate (eGFR) and the extent of kidney damage based on urine albumin level, you improve prediction of risk for future chronic kidney failure and subsequent cardiovascular events. The updated guideline also guides doctors on the appropriate frequency of monitoring based on GFR and albuminuria categories.”

Implementation plans from the National Kidney Foundation include educational tools that will help disseminate the updated guideline to  primary care physicians and nephrologists. A speakers guide will be prepared and distributed and a special digital app is being created that will help doctors estimate relative risk for kidney failure and other adverse health outcomes, based on the guideline.

“Recent studies on current practice indicate that primary care physicians could more routinely use inexpensive readily available testing for albumin in the urine, for people at risk for kidney disease. The new guideline points out what a powerful predictor of risk and outcomes  albuminuria is and so our goal is to encourage primary care physicians to screen those with diabetes, high blood pressure and a family history of kidney disease,” said Vassalotti .

Additional  recommendations in the new guideline include the following:

• CKD definition should remain the same but classification should now be based on cause (if it is known), lGFR category and albuminuria category. GFR stage 3 is now subdivided into GFR categories 3a and 3b.

• Estimated GFR should be determined using creatinine, but cystatin C can also be used to estimate GFR, and updated equations are provided as well as an explanation regarding how they can be used to confirm the presence of CKD.

• Risk should be defined through the relationship between two variables (eGFR and albuminuria) for various outcomes—risk for overall mortality, cardiovascular disease, end stage kidney failure, acute kidney injury and CKD progression.

• Patients with very low GFR (<15) or very high albuminuria (>300) should be referred to a kidney specialist in a timely manner.

• Patients with progressive CKD should be managed in a multidisciplinary care setting, including physicians as well as nurses, dietitians, and social workers.

Source: National Kidney Foundation