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

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. 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. 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).1National Kidney FoundationK/DOQI clinical practice guidelines for chronic kidney disease: evaluation, classification, and stratification.Am J Kidney Dis. 2002; 39: S1-S266PubMed Google Scholar 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. But like much in medicine, new “discoveries”—medications, devices, or clinical practice guidelines—need a test of time to understand their risks, benefits, and overall place in the care of patients. As the KDOQI CKD guideline made its way into clinical practice, much changed; creatinine assays were standardized, laboratory reports changed, new International Classification of Diseases (ICD-9) codes were generated, new equations for the estimation of glomerular filtration rate (GFR) were developed, nephrologists and others began to speak a common language when it came to studying and taking care of those with CKD, and an explosion in CKD-related research occurred. However, there was also concern that patients who did not have clinically meaningful kidney dysfunction were being identified as having a “disease,” patients worried (stage 3 cancer is often life-threatening…stage 3 CKD cannot be much different), the inherent imprecision of formulas used to calculate estimated GFR (eGFR) for CKD classification was often underappreciated, and stage 5 CKD came to be interpreted by some as “time for dialysis.” New information also became available, notably that albuminuria, not part of the 2002 NKF-KDOQI guideline CKD classification schema, was itself an independent predictor of important clinical outcomes and that a more precise degree of risk prediction became available as the result of innovative international research collaborations.Thus, it became clear that a revision of the 2002 guideline was in order. The organization Kidney Disease: Improving Global Outcomes (KDIGO) convened a controversies conference in 2009 and subsequently organized an international work group to review and update the NKF-KDOQI CKD guideline. After the international KDIGO guideline was published in 2013,2Kidney Disease: Improving Global Outcomes (KDIGO) CKD Work GroupKDIGO 2012 clinical practice guideline for the evaluation and management of chronic kidney disease.Kidney Int Suppl. 2013; 3: 1-150Abstract Full Text Full Text PDF Scopus (1723) Google Scholar NKF-KDOQI organized its own work group to provide a US-focused commentary on the KDIGO guideline. The yeoman efforts of this work group, led expertly by Drs Harold Feldman and Lesley Inker, are now presented in this commentary. The work group included experts in clinical nephrology, clinical epidemiology, and primary care medicine, and their many countless hours of volunteer work are much appreciated.As has been stated many times, guidelines are guides to practice; they are not rules, they do not replace clinical judgment, they cannot anticipate patient preferences, and they are not able to speak to every conceivable clinical circumstance. They are also static, while medicine is not. Nonetheless, we believe that this NKF-KDOQI commentary will prove useful to physicians, nurses, and others involved in the care of patients with CKD.Michael V. Rocco, MD, MSCEKDOQI ChairJeffrey S. Berns, MDVice Chair, Guidelines and Commentary 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).1National Kidney FoundationK/DOQI clinical practice guidelines for chronic kidney disease: evaluation, classification, and stratification.Am J Kidney Dis. 2002; 39: S1-S266PubMed Google Scholar 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. But like much in medicine, new “discoveries”—medications, devices, or clinical practice guidelines—need a test of time to understand their risks, benefits, and overall place in the care of patients. As the KDOQI CKD guideline made its way into clinical practice, much changed; creatinine assays were standardized, laboratory reports changed, new International Classification of Diseases (ICD-9) codes were generated, new equations for the estimation of glomerular filtration rate (GFR) were developed, nephrologists and others began to speak a common language when it came to studying and taking care of those with CKD, and an explosion in CKD-related research occurred. However, there was also concern that patients who did not have clinically meaningful kidney dysfunction were being identified as having a “disease,” patients worried (stage 3 cancer is often life-threatening…stage 3 CKD cannot be much different), the inherent imprecision of formulas used to calculate estimated GFR (eGFR) for CKD classification was often underappreciated, and stage 5 CKD came to be interpreted by some as “time for dialysis.” New information also became available, notably that albuminuria, not part of the 2002 NKF-KDOQI guideline CKD classification schema, was itself an independent predictor of important clinical outcomes and that a more precise degree of risk prediction became available as the result of innovative international research collaborations. Thus, it became clear that a revision of the 2002 guideline was in order. The organization Kidney Disease: Improving Global Outcomes (KDIGO) convened a controversies conference in 2009 and subsequently organized an international work group to review and update the NKF-KDOQI CKD guideline. After the international KDIGO guideline was published in 2013,2Kidney Disease: Improving Global Outcomes (KDIGO) CKD Work GroupKDIGO 2012 clinical practice guideline for the evaluation and management of chronic kidney disease.Kidney Int Suppl. 2013; 3: 1-150Abstract Full Text Full Text PDF Scopus (1723) Google Scholar NKF-KDOQI organized its own work group to provide a US-focused commentary on the KDIGO guideline. The yeoman efforts of this work group, led expertly by Drs Harold Feldman and Lesley Inker, are now presented in this commentary. The work group included experts in clinical nephrology, clinical epidemiology, and primary care medicine, and their many countless hours of volunteer work are much appreciated. As has been stated many times, guidelines are guides to practice; they are not rules, they do not replace clinical judgment, they cannot anticipate patient preferences, and they are not able to speak to every conceivable clinical circumstance. They are also static, while medicine is not. Nonetheless, we believe that this NKF-KDOQI commentary will prove useful to physicians, nurses, and others involved in the care of patients with CKD. Michael V. Rocco, MD, MSCE KDOQI Chair Jeffrey S. Berns, MD Vice Chair, Guidelines and Commentary