Kdigo 2012 ckd gl

Official Journal of the International Society of Nephrology KDIGO 2012 Clinical Practice Guideline for the Evaluation and Management of Chronic Kidney Disease volume | issue | JANUARY 2013 http://www.kidney-international.org KDIGO 2012 Clinical Practice Guideline for the Evaluation and Management of Chronic Kidney Disease KDIGO gratefully acknowledges the following consortium of sponsors that make our initiatives possible: Abbott, Amgen, Bayer Schering Pharma, Belo Foundation, Bristol-Myers Squibb, Chugai Pharmaceutical, Coca-Cola Company, Dole Food Company, Fresenius Medical Care, Genzyme, Hoffmann-LaRoche, JC Penney, Kyowa Hakko Kirin, NATCO—The Organization for Transplant Professionals, NKF-Board of Directors, Novartis, Pharmacosmos, PUMC Pharmaceutical, Robert and Jane Cizik Foundation, Shire, Takeda Pharmaceutical, Transwestern Commercial Services, Vifor Pharma, and Wyeth Sponsorship Statement: KDIGO is supported by a consortium of sponsors and no funding is accepted for the development of specific guidelines contents http://www.kidney-international.org & 2013 KDIGO VOL | ISSUE | JANUARY (1) 2013 KDIGO 2012 Clinical Practice Guideline for the Evaluation and Management of Chronic Kidney Disease v Tables and Figures vii KDIGO Board Members viii Reference Keys x CKD Nomenclature xi Conversion Factors & HbA1c Conversion xii Abbreviations and Acronyms Notice Foreword Work Group Membership Abstract Summary of Recommendation Statements 15 Introduction: 19 Chapter 1: Definition, and classification of CKD 63 Chapter 2: Definition, identification, and prediction of CKD progression 73 Chapter 3: Management of progression and complications of CKD 91 Chapter 4: Other complications of CKD: CVD, medication dosage, patient safety, infections, hospitalizations, and caveats for investigating complications of CKD 112 Chapter 5: Referral to specialists and models of care 120 Methods for Guideline Development 128 Biographic and Disclosure Information 134 Acknowledgments 136 References The case for updating and context This journal is a member of, and subscribes to the principles of, the Committee on Publication Ethics (COPE) www.publicationethics.org http://www.kidney-international.org contents & 2013 KDIGO TABLES 18 Table KDIGO nomenclature and description for grading recommendations 20 Table Criteria for CKD 20 Table Criteria for definition of CKD 27 Table Classification of CKD based on presence or absence of systemic disease and location within the kidney of pathologic-anatomic findings 27 Table GFR categories in CKD 28 Table Albuminuria categories in CKD 31 Table Relationship among categories for albuminuria and proteinuria 32 Table CGA staging of CKD: examples of nomenclature and comments 33 Table Prognosis of CKD: Relationship of outcomes and strength of relationship to Cause (C), GFR (G), Albuminuria (A) and other measures 35 Table 10 Annual percentage change in GFR across diagnosis categories 39 Table 11 Sources of error in GFR estimating using creatinine 41 Table 12 Equations based on serum creatinine assays in adults that are traceable to the standard reference material 44 Table 13 Performance comparison of creatinine-based GFR estimating equations in North America, Europe, and Australia 48 Table 14 Performance comparison of creatinine-based GFR estimating equations outside of North America, Europe, and Australia 50 Table 15 Sources of error in GFR estimating using cystatin C 52 Table 16 Equations based on IDMS traceable creatinine and IFCC traceable cystatin C assays 54 Table 17 Performance comparison of cystatin C-based estimating equations in North American and European populations 55 Table 18 Strengths and limitations of GFR measurement methods and markers 59 Table 19 Factors affecting urinary ACR 64 Table 20 Decline in kidney function in various populations (longitudinal studies only) 65 Table 21 Decline in kidney function in CKD populations 67 Table 22 Studies evaluating rapid progression (general population studies only) 68 Table 23 CKD progression and risk of all-cause mortality and ESRD using baseline (first) eGFR 68 Table 24 Association between absolute and percentage change in kidney function and risk of ESRD, based on adjustment for eGFR at the first and last measurement 77 Table 25 Intensive versus normal glycemic control and albuminuria outcome 78 Table 26 Recommended Daily Intake of sodium for healthy children 81 Table 27 Prevalence of CKD complications by GFR category derived from CKD cohorts 81 Table 28 Hemoglobin cutoffs for people living at sea level 87 Table 29 Phosphate binding agents in routine clinical practice and their ranked cost 89 Table 30 Summary data for bisphosphonates and CKD 100 Table 31 Peripheral arterial disease and CKD 103 Table 32 Cautionary notes for prescribing in people with CKD 107 Table 33 Risk factors for infection in people with CKD 110 Table 34 Components of community CKD management programs 114 Table 35 Early versus late referral: consequences and benefits 114 Table 36 Outcomes of early versus late referral 122 Table 37 Topics of interest for the management of CKD guideline 123 Table 38 Literature yield of primary articles for all topics 123 Table 39 Classification of study quality 124 Table 40 GRADE system for grading quality of evidence 124 Table 41 Final grade for overall quality of evidence 124 Table 42 Balance of benefits and harm 125 Table 43 KDIGO nomenclature and description for grading recommendations 125 Table 44 Determinants of strength of recommendation 125 Table 45 The Conference on Guideline Standardization checklist for reporting clinical practice guidelines Kidney International Supplements (2013) 3, v v contents http://www.kidney-international.org & 2013 KDIGO FIGURES 16 Figure Conceptual model of CKD 22 Figure Normal values for GFR by age 23 Figure Relationship of eGFR with mortality 23 Figure Relationship of albuminuria with mortality 28 Figure Age-standardized rates of death from any cause, cardiovascular events, and hospitalization, according to the eGFR among 1,120,295 ambulatory adults 29 Figure Summary of continuous meta-analysis for general population cohorts with ACR 30 Figure Summary of categorical meta-analysis for general population cohorts with ACR 31 Figure Prevalence of CKD in the USA by GFR and albuminuria 34 Figure Prognosis of CKD by GFR and albuminuria category 39 Figure 10 Determinants of the serum level of endogenous filtration markers 43 Figure 11 Performance of the CKD-EPI and MDRD Study equations in estimating measured GFR in the external validation data set 46 Figure 12 Comparison of distribution of GFR and CKD prevalence by age (NHANES 1999-2004) 47 Figure 13 Meta-analysis of NRI for all-cause mortality, CVD mortality, and ESRD 50 Figure 14 Association of CKD definitions with all-cause mortality and ESRD 53 Figure 15 Performance of three equations for estimating GFR 57 Figure 16 Suggested protocol for the further investigation of an individual demonstrating a positive reagent strip test for albuminuria/proteinuria or quantitative albuminuria/proteinuria test 63 Figure 17 GFR and albuminuria grid to reflect the risk of progression 69 Figure 18 Distribution of the probability of nonlinearity with three example trajectories demonstrating different probabilities of nonlinearity 86 Figure 19 Summary estimates for risks of all-cause mortality and cardiovascular mortality associated with levels of serum phosphorus, PTH, and calcium 88 Figure 20 Prevalence of deficiency of 1,25(OH)2D3, 25(OH)D3, and secondary hyperparathyroidism by GFR intervals 113 Figure 21 Referral decision making by GFR and albuminuria 116 Figure 22 The CKD chronic care model Additional information in the form of supplementary materials can be found online at http://www.kdigo.org/clinical_practice_guidelines/ckd.php vi Kidney International Supplements (2013) 3, vi http://www.kidney-international.org & 2013 KDIGO KDIGO Board Members Garabed Eknoyan, MD Norbert Lameire, MD, PhD Founding KDIGO Co-Chairs Kai-Uwe Eckardt, MD Immediate Past Co-Chair Bertram L Kasiske, MD KDIGO Co-Chair David C Wheeler, MD, FRCP KDIGO Co-Chair Omar I Abboud, MD, FRCP Sharon Adler, MD, FASN Rajiv Agarwal, MD Sharon P Andreoli, MD Gavin J Becker, MD, FRACP Fred Brown, MBA, FACHE Daniel C Cattran, MD, FRCPC Allan J Collins, MD, FACP Rosanna Coppo, MD Josef Coresh, MD, PhD Ricardo Correa-Rotter, MD Adrian Covic, MD, PhD Jonathan C Craig, MBChB, MM (Clin Epi), DCH, FRACP, PhD Angel LM de Francisco, MD Paul E de Jong, MD, PhD Ana Figueiredo, RN, MSc, PhD Mohammed Benghanem Gharbi, MD Gordon Guyatt, MD, MSc, BSc, FRCPC David Harris, MD Lai Seong Hooi, MD Enyu Imai, MD, PhD Lesley A Inker, MD, MS, FRCP Michel Jadoul, MD Simon Jenkins, MBE, FRCGP Suhnggwon Kim, MD, PhD Martin K Kuhlmann, MD Nathan W Levin, MD, FACP Philip K-T Li, MD, FRCP, FACP Zhi-Hong Liu, MD Pablo Massari, MD Peter A McCullough, MD, MPH, FACC, FACP Rafique Moosa, MD Miguel C Riella, MD Adibul Hasan Rizvi, MBBS, FRCP Bernardo Rodriquez-Iturbe, MD Robert Schrier, MD Justin Silver, MD, PhD Marcello Tonelli, MD, SM, FRCPC Yusuke Tsukamoto, MD Theodor Vogels, MSW Angela Yee-Moon Wang, MD, PhD, FRCP Christoph Wanner, MD Elena Zakharova, MD, PhD NKF-KDIGO GUIDELINE DEVELOPMENT STAFF Kerry Willis, PhD, Senior Vice-President for Scientific Activities Michael Cheung, MA, Guideline Development Director Sean Slifer, BA, Guideline Development Manager Kidney International Supplements (2013) 3, vii vii http://www.kidney-international.org & 2013 KDIGO Reference Keys NOMENCLATURE AND DESCRIPTION FOR RATING GUIDELINE RECOMMENDATIONS Within each recommendation, the strength of recommendation is indicated as Level 1, Level 2, or Not Graded, and the quality of the supporting evidence is shown as A, B, C, or D Implications Grade* Patients Clinicians Policy Level ‘We recommend’ Most people in your situation would want the recommended course of action and only a small proportion would not Most patients should receive the recommended course of action The recommendation can be evaluated as a candidate for developing a policy or a performance measure Level ‘We suggest’ The majority of people in your situation would want the recommended course of action, but many would not Different choices will be appropriate for different patients Each patient needs help to arrive at a management decision consistent with her or his values and preferences The recommendation is likely to require substantial debate and involvement of stakeholders before policy can be determined *The additional category ‘Not Graded’ was used, typically, to provide guidance based on common sense or where the topic does not allow adequate application of evidence The most common examples include recommendations regarding monitoring intervals, counseling, and referral to other clinical specialists The ungraded recommendations are generally written as simple declarative statements, but are not meant to be interpreted as being stronger recommendations than Level or recommendations Grade Quality of evidence Meaning A B C D High Moderate Low Very low We are confident that the true effect lies close to that of the estimate of the effect The true effect is likely to be close to the estimate of the effect, but there is a possibility that it is substantially different The true effect may be substantially different from the estimate of the effect The estimate of effect is very uncertain, and often will be far from the truth ADULT GFR ESTIMATING EQUATIONS 2009 CKD-EPI creatinine equation: 141  min(SCr/k, 1)a  max(SCr/k, 1) 1.209  0.993Age [  1.018 if female] [  1.159 if black], where SCr is serum creatinine (in mg/dl), k is 0.7 for females and 0.9 for males, a is 0.329 for females and 0.411 for males, is the minimum of SCr/k or 1, and max is the maximum of SCr/k or Equations expressed for specified sex and serum creatinine level Gender Serum creatinine Equation for estimating GFR Female Female Male Male p0.7 mg/dl 40.7 mg/dl p0.9 mg/dl 40.9 mg/dl 144  (SCr/0.7) 144  (SCr/0.7) 141  (SCr/0.9) 141  (SCr/0.9) (p62 mmol/l) (462 mmol/l) (p80 mmol/l) (480 mmol/l) 0.329  0.993Age  0.993Age 0.411  0.993Age 1.209  0.993Age 1.209 [  1.159 [  1.159 [  1.159 [  1.159 if if if if black] black] black] black] 2012 CKD-EPI cystatin C equation: 133  min(SCysC/0.8, 1) 0.499  max(SCysC/0.8, 1) 1.328  0.996Age [  0.932 if female], where SCysC is serum cystatin C (in mg/l), indicates the minimum of SCysC/0.8 or 1, and max indicates the maximum of SCysC/0.8 or Equations expressed for serum cystatin C level Female or male Female or male viii Serum cystatin C Equation for estimating GFR p0.8 mg/l 40.8 mg/l 133  (SCysC/0.8) 133  (SCysC/0.8) 0.499 1.328  0.996Age [  0.932 if female]  0.996Age [  0.932 if female] Kidney International Supplements (2013) 3, viii http://www.kidney-international.org & 2013 KDIGO 2012 CKD-EPI creatinine–cystatin C equation: 135  min(SCr/k, 1)a  max(SCr/k, 1) 0.601  min(SCysC/0.8, 1) 0.375  max(SCysC/ 0.8, 1) 0.711  0.995Age [  0.969 if female] [  1.08 if black], where SCr is serum creatinine (in mg/dl), SCysC is serum cystatin C (in mg/l), k is 0.7 for females and 0.9 for males, a is 0.248 for females and 0.207 for males, min(SCr/k, 1) indicates the minimum of SCr/k or 1, and max(SCr/k, 1) indicates the maximum of SCr/k or 1; min(SCysC/0.8, 1) indicates the minimum of SCysC/0.8 or and max(SCysC/ 0.8, 1) indicates the maximum of SCysC/0.8 or Equations expressed for specified sex, serum creatinine, and serum cystatin C level Gender Serum creatinine Serum cystatin C Equation for estimating GFR Female p0.7 mg/dl (p62 mmol/l) p0.8 mg/l 40.8 mg/l p0.8 mg/l 40.8 mg/l p0.8 mg/l 40.8 mg/l p0.8 mg/l 40.8 mg/l 130  (SCr/0.7) 130  (SCr/0.7) 130  (SCr/0.7) 130  (SCr/0.7) 135  (SCr/0.9) 135  (SCr/0.9) 135  (SCr/0.9) 135  (SCr/0.9) Female 40.7 mg/dl (462 mmol/l) Male p0.9 mg/dl (p80 mmol/l) Male 40.9 mg/dl (480 mmol/l) 0.248 0.375 0.248 0.711  (SCysC/0.8)  (SCysC/0.8) 0.601  (SCysC/0.8) 0.601  (SCysC/0.8) 0.207  (SCysC/0.8) 0.207  (SCysC/0.8) 0.601  (SCysC/0.8) 0.601  (SCysC/0.8)  0.995Age  0.995Age 0.375  0.995Age 0.711  0.995Age 0.375  0.995Age 0.711  0.995Age 0.375  0.995Age 0.711  0.995Age [  1.08 [  1.08 [  1.08 [  1.08 [  1.08 [  1.08 [  1.08 [  1.08 if if if if if if if if black] black] black] black] black] black] black] black] PEDIATRIC GFR ESTIMATING EQUATIONS Creatinine-based equations 41.3  (height/SCr) 40.7  (height/SCr)0.64  (30/BUN)0.202 BUN, blood urea nitrogen in mg/dl; height in meters; SCr, serum creatinine in mg/dl Cystatin C-based equations 70.69  (SCysC) 0.931 SCysC, serum cystatin C in mg/l Kidney International Supplements (2013) 3, ix ix http://www.kidney-international.org & 2013 KDIGO CURRENT CHRONIC KIDNEY DISEASE (CKD) NOMENCLATURE USED BY KDIGO CKD is defined as abnormalities of kidney structure or function, present for 43 months, with implications for health and CKD is classified based on cause, GFR category, and albuminuria category (CGA) Prognosis of CKD by GFR and albuminuria category Persistent albuminuria categories Description and range GFR categories (ml/min/ 1.73 m2) Description and range Prognosis of CKD by GFR and Albuminuria Categories: KDIGO 2012 A1 A2 A3 Normal to mildly increased Moderately increased Severely increased 30 mg/mmol ≥90 G1 Normal or high G2 Mildly decreased 60-89 G3a Mildly to moderately decreased 45-59 G3b Moderately to severely decreased 30-44 G4 Severely decreased 15-29 G5 Kidney failure