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CME

Overview of Chronic Kidney Disease (CKD) in Adults

General Information

Description

  • CKD is characterized by abnormalities of kidney structure or function that are present for > 3 months and have implications for health of the patient4
  • Kidney Disease: Improving Global Outcomes (KDIGO) defines CKD as either of the following for > 3 months4
    • glomerular filtration rate (GFR) < 60 mL/minute/1.73 m2
    • kidney damage as evidenced by ≥ 1 of
      • albuminuria
      • urine sediment abnormalities
      • electrolyte or other abnormalities due to tubular disorders
      • abnormal histology
      • abnormal structure detected by imaging
    • history of kidney transplant
  • CKD staging based on cause, GFR category, and albuminuria category (KDIGO Level 1, Grade B)4
    • cause - assignment based on presence or absence of systemic disease and location in the kidney of observed or presumed pathologic-anatomic findings
    • GFR categories
      • G1 - GFR > 90 mL/minute/1.73 m2 (normal or high)
      • G2 - GFR 60-89 mL/minute/1.73 m2 (mildly decreased compared to young adult level)
      • G3a - GFR 45-59 mL/minute/1.73 m2 (mild-to-moderately decreased)
      • G3b - GFR 30-44 mL/minute/1.73 m2 (moderate-to-severely decreased)
      • G4 - GFR 15-29 mL/minute/1.73 m2 (severely decreased)
      • G5 - GFR < 15 mL/minute/1.73 m2 (kidney failure)
    • albuminuria categories
      • A1 - albumin excretion rate (AER) < 30 mg/24 hours, albumin to creatinine ratio (ACR) < 30 mg/g (3 mg/mmol) (normal to mildly increased)
      • A2 - AER 30-300 mg/24 hours, ACR 30-300 mg/g (3-30 mg/mmol) (moderately increased compared to young adult level)
      • A3 - AER > 300 mg/24 hours, ACR > 300 mg/g (30 mg/mmol) (severely increased [including nephrotic syndrome])
  • alternative classification system based on combination of estimated GFR and proteinuria
    • risk category 0 - if estimated GFR ≥ 60 mL/minute/1.73 m2 and normal proteinuria
    • risk category 1 - if either
      • estimated GFR 45-59.9 mL/minute/1.73 m2 and normal proteinuria
      • estimated GFR ≥ 60 mL/minute/1.73 m2 and mild proteinuria
    • risk category 2 - if either
      • estimated GFR 45-59.9 mL/minute/1.73 m2 and mild proteinuria present
      • estimated GFR 30-44.9 mL/minute/1.73 m2 and normal proteinuria
    • risk category 3 - if any of the following
      • estimated GFR ≥ 60 mL/minute/1.73 m2 and heavy proteinuria
      • estimated GFR 30-44.9 mL/minute/1.73 m2 and mild proteinuria
      • estimated GFR 15-29.9 mL/minute/1.73 m2 and normal proteinuria
    • risk category 4 - if either
      • estimated GFR 15-29.9 mL/minute/1.73 m2 and mild proteinuria
      • estimated GFR 15-59.9 mL/minute/1.73 m2 and heavy proteinuria
    • alternative staging system would reclassify some patients to lower stage compared to standard staging system using estimated GFR alone
    • Reference - mnh21200034pmdc21200034pAnn Intern Med 2011 Jan 4;154(1):12, editorial can be found in mnh21200043pmdc21200043pAnn Intern Med 2011 Jan 4;154(1):65

Definitions

  • progression of CKD4
    • defined as drop in category (based on glomerular filtration rate [GFR]) plus ≥ 25% decrease in estimated GFR from baseline
    • sustained decrease in estimated GFR ≥ 5 mL/min/1.73 m2/year is considered rapid progression
    • confidence in evaluating progression is increased with greater number of serum creatinine measurements and longer follow-up

Also called

  • CKD
  • chronic renal failure (CRF)
  • chronic renal insufficiency (CRI)
  • end-stage renal disease (ESRD) - if renal replacement therapy required

References

General References Used

  1. Webster AC, Nagler EV, Morton RL, Masson P. Chronic Kidney Disease. Lancet. 2017 Mar 25;389(10075):1238-1252
  2. Romagnani P, Remuzzi G, Glassock R, et al. Chronic kidney disease. Nat Rev Dis Primers. 2017 Nov 23;3:17088
  3. Meyer TW, Hostetter TH. Uremia. N Engl J Med. 2007 Sep 27;357(13):1316-25, commentary can be found in N Engl J Med 2008 Jan 3;358(1):95
  4. Kidney Disease: Improving Global Outcomes (KDIGO) CKD Work Group. KDIGO 2012 clinical practice guideline for the evaluation and management of chronic kidney disease. KDIGO 2013 Jan PDF

Recommendation grading systems used

  • American College of Cardiology/American Heart Association (ACC/AHA)
    • classifications of recommendations
      • Class I - procedure or treatment should be performed or administered
      • Class IIa - reasonable to perform procedure or administer treatment, but additional studies with focused objectives needed
      • Class IIb - procedure or treatment may be considered; additional studies with broad objectives needed, additional registry data would be useful
      • Class III - procedure or treatment should not be performed or administered because it is not helpful or may be harmful
        • Class III ratings may be subclassified as Class III No Benefit or Class III Harm
    • levels of evidence
      • Level A - data derived from multiple randomized clinical trials or meta-analyses
      • Level B - data derived from single randomized trial or nonrandomized studies
      • Level C - only expert opinion, case studies, or standard of care
    • Reference - 16549646Circulation 2006 Mar 21;113(11):e463PDF (focused update can be found in 21959305Circulation 2011 Nov 1;124(18):2020full-text)
  • American College of Cardiology/American Heart Association (ACC/AHA) grading system for recommendations
    • classes of recommendations
      • Class I (Strong) - should be performed or administered; indicated/useful/effective/beneficial
      • Class IIa (Moderate) - reasonable to perform or administer; can be useful/effective/beneficial
      • Class IIb (Weak) - may be considered; usefulness/effectiveness is unknown/unclear/uncertain or not well established
      • Class III: No Benefit (Moderate) - should not be performed or administered; not indicated/useful/effective/beneficial
      • Class III: Harm (Strong) - should not be performed or administered; potentially harmful, causes harm, or associated with excess morbidity/mortality
    • levels of evidence
      • Level A - high-quality evidence from > 1 randomized controlled trial (RCT), meta-analyses of high-quality RCTs, or ≥ 1 RCTs corroborated by high-quality registry studies
      • Level B-R - moderate-quality evidence from ≥ 1 RCTs or meta-analysis of moderate-quality RCTs
      • Level B-NR - moderate-quality evidence from ≥ 1 well-designed, well-executed nonrandomized studies, observational studies, or registry studies, or meta-analysis of such studies
      • Level C-LD - randomized or nonrandomized observational or registry studies with limitations of design or execution, meta-analyses of such studies, or physiological or mechanistic studies in human subjects
      • Level C-EO - consensus of expert opinion based on clinical experience
    • Reference - ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA guideline on prevention, detection, evaluation, and management of high blood pressure in adults (29133356Hypertension 2018 Jun;71(6):e13)
    • Reference - ACC/AHA guideline on primary prevention of cardiovascular disease (Circulation 2019 Mar 17. doi: 10.1161/CIR.0000000000000678 or J Am Coll Cardiol 2019 Mar 17. doi: 10.1016/j.jacc.2019.03.009
  • American College of Physicians (ACP) guideline grading system
    • strength of recommendation
      • Strong - benefits clearly outweigh risks and burden, or risks and burden clearly outweigh benefits
      • Weak - benefits closely balanced with risks and burden or uncertainty in estimates of benefits, risks, and burdens
      • Insufficient - balance of benefits and risks cannot be determined
    • quality of evidence
      • High - randomized trials without important limitations, or overwhelming evidence from observational studies
      • Moderate - randomized trials with important limitations (inconsistent results, methodologic flaws, indirect, or imprecise), or exceptionally strong evidence from observational studies
      • Low - observational studies or case series
      • Insufficient - evidence is conflicting, poor quality, or lacking
    • Reference - ACP methods for development of clinical practice guidelines and guidance statements (20679562Ann Intern Med 2010 Aug 3;153(3):194)
  • American College of Radiology (ACR) rating scale
    • Rating 1, 2, and 3 - usually not appropriate
    • Rating 4, 5, and 6 - may be appropriate
    • Rating 7, 8, and 9 - usually appropriate
    • Reference - ACR appropriateness criteria on renal failure (ACR 2013 PDF)
  • Canadian Society of Transplantation (CST) uses Canadian Task Force on Preventive Health Care (CTFPHC) grades of recommendation
    • Grade A - good evidence to support clinical preventive action
    • Grade B - fair evidence to support clinical preventive action
    • Grade C
      • existing evidence conflicts
      • other factors may influence decision making
    • Grade D - fair evidence to recommend against clinical preventive action
    • Grade E - good evidence to recommend against clinical preventive action
    • Reference - CST consensus guidelines on eligibility for kidney transplantation (16275969CMAJ 2005 Nov 8;173(10):1181full-text), supporting details can be found in 16275956CMAJ 2005 Nov 8;173(10):S1full-text
  • Eighth Joint National Committee (JNC 8) 2014 grades of recommendation
    • Strong recommendation - Grade A - high certainty based on evidence that net benefit is substantial
    • Moderate recommendation - Grade B - moderate certainty based on evidence that net benefit is moderate-to-substantial OR high certainty that net benefit is moderate
    • Weak recommendation - Grade C - at least moderate certainty based on evidence that there is small net benefit
    • Recommendation against - Grade D - at least moderate certainty based on evidence that no net benefit or that risks/harms outweigh benefits
    • Expert opinion - Grade E - "There is insufficient evidence or evidence is unclear or conflicting, but this is what the committee recommends", net benefit unclear
    • No recommendation for or against - Grade N - "There is insufficient evidence or evidence is unclear or conflicting", net benefit unclear
    • Reference - JNC8 2014 evidence-based guideline for the management of high blood pressure in adults (24352797JAMA 2014 Feb 5;311(5):507)
  • European Society of Cardiology/European Society of Hypertension (ESC/ESH) grading system
    • classifications of recommendations
      • Class I - evidence and/or general agreement that procedure or treatment is beneficial, useful, effective
      • Class II - conflicting evidence and/or divergence of opinion about usefulness/efficacy of given treatment of procedure
        • Class IIa - weight of evidence/opinion in favor of usefulness/efficacy
        • Class IIb - usefulness/efficacy less well established by evidence/opinion
      • Class III - evidence or general agreement that procedure or treatment is not useful/effective, and in some cases may be harmful
    • levels of evidence
      • Level A - data derived from multiple randomized clinical trials or meta-analyses
      • Level B - data derived from single randomized trial or large nonrandomized studies
      • Level C - consensus opinions of experts, and/or small studies, retrospective studies, or registries
    • Reference - ESC/ESH guideline on management of arterial hypertension (Eur Heart J 2018 Sep 1;39(33):3021)
    • PubMed28886620European heart journalEur Heart J20180301399763-816763ESC guideline on diagnosis and treatment of peripheral arterial disease (Eur Heart J 2018 Mar 1;39(9):763)
  • Hypertension Canada grades of recommendations
    • Grade A - recommendations based on randomized trials (or systematic reviews) with high levels of internal validity and statistical precision for which study results can be directly applied to patients because of similar clinical characteristics and clinical evidence of study outcomes
    • Grade B - recommendations based on randomized trials, systematic reviews, or prespecified subgroup analyses of randomized trials that have lower precision, or if there is a need to extrapolate from studies because of differing populations or reporting of validated intermediate/surrogate outcomes rather than clinically important outcomes
    • Grade C - recommendations from trials with lower levels of internal validity and/or precision, or that report unvalidated surrogate outcomes, or results from nonrandomized observational studies
    • Grade D - recommendations based on expert opinion alone
    • Reference - Hypertension Canada guideline on diagnosis, risk assessment, prevention, and treatment of hypertension in adults and children (Can J Cardiol 2018 May;34(5):506)
  • International Society for Peritoneal Dialysis (ISPD) recommendations based on Recommendation Assessment, Development and Evaluation (GRADE) system for classification level of evidence and grade of recommendations
    • strength of recommendation
      • Level 1 ("we recommend") - most patients should receive recommended course of action
      • Level 2 ("we suggest") - different choices will be appropriate for different patients, based on patient's values and preferences
      • Not Graded - topic does not allow adequate application of evidence, not meant to be interpreted as being stronger recommendations than Level 1 or 2
    • quality of evidence
      • Grade A - high-quality evidence, true effect lies close to that of estimate of effect
      • Grade B - moderate-quality evidence, true effect likely to be close to estimate of effect, but there is a possibility it is substantially different
      • Grade C - low-quality evidence, true effect may be substantially different from estimate of effect
      • Grade D - very low-quality evidence, estimate of effect very uncertain and often far from the truth
    • Reference - ISPD 2017 update for catheter-related infection recommendations (cxh122957243pmdc28360365pPerit Dial Int 2017 Mar-Apr;37(2):141)
  • Kidney Disease: Improving Global Outcomes (KDIGO)
    • strength of recommendation
      • Level 1 ("we recommend") - most patients should receive recommended course of action
      • Level 2 ("we suggest") - different choices appropriate for different patients, based on patient's values and preferences
      • Not Graded - topic does not allow adequate application of evidence, not meant to be interpreted as being stronger recommendations than Level 1 or 2
    • quality of evidence
      • Grade A - high-quality evidence, true effect lies close to that of estimate of effect
      • Grade B - moderate-quality evidence, true effect likely to be close to estimate of effect, but there is possibility it is substantially different
      • Grade C - low-quality evidence, true effect may be substantially different from estimate of effect
      • Grade D - very low-quality evidence, estimate of effect very uncertain and often far from truth
    • References -
  • National Kidney Foundation (NKF) strengths of recommendation
    • Grade A
      • strongly recommended that clinicians routinely follow guideline for eligible patients
      • strong evidence that practice improves health outcomes
    • Grade B
      • recommended that clinicians routinely follow guideline for eligible patients
      • moderately strong evidence that practice improves health outcomes
    • Clinical Practice Recommendations (Grade CPR)
      • consider following guideline for eligible patients
      • based on weak evidence or opinions of Work Group and reviewers that practice might improve health outcomes
    • PubMed26498416American journal of kidney diseases : the official journal of the National Kidney FoundationAm J Kidney Dis20151101665884-930884 Reference - NKF clinical practice guideline and recommendations on hemodialysis adequacy, 2015 update (Am J Kidney Dis 2015 Nov;66(5):884PDF)
  • UK Renal Association guideline recommendation grades
    • recommendation
      • Grade 1 - strong recommendation, benefits clearly outweigh risks
      • Grade 2 - weak recommendation, risks and benefits are more closely balanced or are more uncertain
    • level of evidence
      • Grade A - high-quality evidence from well-performed randomized controlled trials or overwhelming evidence of some other sort such as well-executed observational studies with very strong effects
      • Grade B - moderate-quality evidence from consistent results from well-performed randomized controlled trials or overwhelming evidence of some other sort such as well-executed observational studies with very strong effects
      • Grade C - low-quality evidence from observational studies or from controlled trials with several very serious limitations
      • Grade D - based on case studies or expert opinion
    • Reference - UK Renal Association clinical practice guideline on vascular access for hemodialysis (UK Renal Assoc 2019 Jun PDF)

Synthesized Recommendation Grading System for DynaMed Content

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  • We use the Grading of Recommendations Assessment, Development and Evaluation (GRADE) to classify synthesized recommendations as Strong or Weak.
    • Strong recommendations are used when, based on the available evidence, clinicians (without conflicts of interest) consistently have a high degree of confidence that the desirable consequences (health benefits, decreased costs and burdens) outweigh the undesirable consequences (harms, costs, burdens).
    • Weak recommendations are used when, based on the available evidence, clinicians believe that desirable and undesirable consequences are finely balanced, or appreciable uncertainty exists about the magnitude of expected consequences (benefits and harms). Weak recommendations are used when clinicians disagree in judgments of relative benefit and harm, or have limited confidence in their judgments. Weak recommendations are also used when the range of patient values and preferences suggests that informed patients are likely to make different choices.
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Special acknowledgements

On behalf of the American College of Physicians
  • Barbara Turner, MD, MSEd, MACP, ACP Deputy Editor, Clinical Decision Resource, as part of the ACP-EBSCO Health collaboration, managed the ACP peer review of the Overview and Recommendations section and related clinical content in this topic.
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How to cite

National Library of Medicine, or "Vancouver style" (International Committee of Medical Journal Editors):

  • DynaMed [Internet]. Ipswich (MA): EBSCO Information Services. 1995 - . Record No. T115336, Overview of Chronic Kidney Disease (CKD) in Adults ; [updated 2018 Nov 30, cited place cited date here]. Available from https://www.dynamed.com/topics/dmp~AN~T115336. Registration and login required.

Published by EBSCO Information Services. Copyright © 2020, EBSCO Information Services. All rights reserved. No part of this may be reproduced or utilized in any form or by any means, electronic or mechanical, including photocopying, recording, or by any information storage and retrieval system, without permission.

EBSCO Information Services accepts no liability for advice or information given herein or errors/omissions in the text. It is merely intended as a general informational overview of the subject for the healthcare professional.

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