Guidelines

NKF K/DQI GUIDELINES

on
Chronic Kidney Disease
National Kidney Foundation
Kidney / Dialysis Outcomes Quality Initiative

[ NKF K/DOQI ]
NKF K/DQI GUIDELINES

Background
 • The adverse outcomes of Chronic Kidney Disease, such as
kidney failure, cardiovascular disease, and premature death,
can be prevented or delayed
NKF K/DQI GUIDELINES

• Earlier stages of chronic kidney disease can be detected

through laboratory testing

• Treatment of earlier stages of chronic kidney disease is

effective in slowing the progression toward kidney failure

• Initiation of treatment for cardiovascular risk factors at earlier

stages of chronic kidney disease should be effective in
reducing cardiovascular disease events both before and after
the onset of kidney failure
 • Chronic kidney disease is “under – diagnosed” and “under –
treated” in United States, resulting in lost opportunities for
prevention
NKF K/DQI GUIDELINES

• One reason is the lack of agreement on a definition and

classification of stages in the progression of chronic kidney
disease

• A clinically applicable classification would be based on

laboratory evaluation of the severity of kidney disease,
association of level of kidney function with complications, and
stratification of risks for loss of kidney function and
development of cardiovascular disease
 A uniform terminology would permit :
1. More reliable estimates of the prevalence of earlier
stages of disease and of the population at increased risk
for development of chronic kidney disease
NKF K/DQI GUIDELINES

2. Recommendation for laboratory testing to detect earlier

stages and progression to later stages
3. Association of stages with clinical manifestations of
disease
4. Evaluation of factors associated with a high risk of
progression from one stage to the next or of the
development of other adverse outcomes
5. Evaluation of treatments to slow progression or prevent
other adverse outcomes
 Guideline 1
NKF K/DQI GUIDELINES

Definition and Stages of Chronic Kidney

Disease
 DEFINITION OF CHRONIC KIDNEY DISEASE

1. Kidney damage for > 3 months, as defined by

structural or functional abnormalities of the kidney,
NKF K/DQI GUIDELINES

with or without decreased GFR, manifested by either :

• Pathological abnormalities; or
• Markers of kidney damage, including
abnormalities in the composition of the blood or
urine, or abnormalities in imaging tests

2. GFR < 60 mL/min/1.73m2 for > 3 months, with or

without kidney damage
 STAGES OF CHRONIC KIDNEY DISEASE

GFR
Stage Description
(mL/min/1.73m2)
NKF K/DQI GUIDELINES

Kidney damage with normal

1 > 90
or  GFR
Kidney damage with mild 
2 60 – 89
GFR
3 Moderate  GFR 30 – 59

4 Severe  GFR 15 – 29
< 15
5 Kidney Failure
(or dialysis)
 Why develop a new classification ?
• Currently, there is no uniform classification of stages of chronic kidney
disease
• Uniform definitions of terms and stages would improve communication
between patients and providers, enhance public education, and promote
NKF K/DQI GUIDELINES

dissemination of research results, and perhaps would enhance conduct of

clinical research
Why base a clinical classification system on severity of disease ?
• Adverse outcomes of kidney disease are based on the level of kidney
function and risk of loss of function in the future. Chronic kidney disease
tends to worsen over time. Therefore, the risk of adverse outcomes
increases over time with disease severity.
Why classify severity as the level of GFR ?
• The level of GFR is widely accepted as the best overall measure of kidney
function in health and disease
Why include an action plan ?
• To improve outcomes
 DEFINITION AND STAGES OF CHRONIC KIDNEY DISEASE
[ The classification of individual based on the presence or absence of markers of kidney
disease and level of GFR, according to definition and staging of chronic disease proposed by
the guideline, with the addition of columns for the presence or absence of high blood
pressure due to complex relationship of high blood pressure and chronic kidney disease ]
NKF K/DQI GUIDELINES

With Kidney Damage* Without Kidney Damage*

GFR
(mL/min/1.73m2) With Without Without
With HBP**
HBP** HBP** HBP**
> 90 1 1 “High blood pressure” “Normal”

60 – 89 2 2 “High blood pressure “ GFR”a

with  GFR”
30 – 59 3 3 3 3
15 – 29 4 4 4 4
< 15 (or dialysis) 5 5 5 5
Shaded area represents chronic kidney disease; numbers designate stage of chronic kidney disease
* Kidney damage is defined as pathologic abnormalities or markers of damage, including abnormalities on
blood or urine tests or imaging studies
** High blood pressure is defined as > 140/90 in adults and > 90th percentile for height and gender in children
a
May be normal in infants and in the elderly
 Diabetes Kidney Disease
NKF K/DQI GUIDELINES
 Stages and Clinical Features of Diabetic kidney Disease

Stage Description Clinical Features

At increased risk Diabetes Mellitus, HBP, family
history
NKF K/DQI GUIDELINES

1–2 Kidney damage Microalbuminuria :

Diabetes duration 5 – 10
years, retinopathy, rising BP

Albuminuria :
Diabetes duration 10 – 15
years, retinopathy, HBP
3–4 Decreased GFR HBP, retinopathy, CVD, other
diabetic complications
5 Kidney Failure Retinopathy, CVD, other
diabetic complications, uremia
HBP = High Blood Pressure, CVD = Cardiovascular Disease
NKF K/DQI GUIDELINES

Clinical Action Plan

 CLASSIFICATION OF CHRONIC KIDNEY DISEASE
AND CLINICAL ACTION PLAN
GFR
Stage Description Action*
(mL/min/1.73m2)
> 90
Screening
NKF K/DQI GUIDELINES

At increased risk (with CKD risk

CKD risk reduction
factors)
Diagnosis & treatment
Kidney damage
Treatment of comorbid
1 with normal or  > 90
conditions, slowing progression,
GFR CVD risk reduction
Kidney damage
2 60 – 89 Estimating progression
with mild  GFR
Moderate  Evaluating & treating
3 30 – 59
GFR complications
Preparation for kidney
4 Severe  GFR 15 – 29
replacement therapy
< 15
5 Kidney Failure Replacement (if uremia present)
(or dialysis)
* Includes actions from preceding stages
 Evidence model of the course of chronic kidney disease

Complications
NKF K/DQI GUIDELINES

Increased Kidney CKD

Normal Damage  GFR
Risk failure death

Screening CKD risk Diagnosis & Estimate Replacement

for CKD risk reduction, treatment, progression, by dialysis &
factors Screening Treat Treat transplant
for CKD comorbid complications,
conditions, Prepare for
Slow replacement
progression
NKF K/DQI GUIDELINES

Estimation of GFR
 Estimates of GFR are the best overall indices of the level of
kidney fiunction
The level of GFR should be estimated from prediction equations that take
into account the serum creatinine concentration and some or all of the
following variables : age, gender, race, and body size. The following
NKF K/DQI GUIDELINES

equations provide useful estimates of GFR :

• In adults, the MDRD Study and Cockroft-Gault

equations
• In children, the Schwartz and Counahan-Barrat equations

• The serum creatinine concentration alone should not

be used to assess the level of kidney function
• Clinical laboratories should report an estimate of GFR using a prediction
equation, in addition to reporting the serum creatinine measurement
• Autoanalyzer manufacturers and clinical laboratories should calibrate
serum creatinine assays using an international standard
 Measurement of creatinine clearance using timed (for
example, 24 hour) urine collection does not improve
the estimate of GFR over that provided by prediction
NKF K/DQI GUIDELINES

equations.
A 24-hour urine sample provides useful information for :
• Estimation of GFR in individuals with excretory dietary
intake (vegetarian diet, creatine supplements) or muscle
mass (amputation, malnutrition, muscle wasting ;
• Assessment of diet and nutritional status ;
• Need to start dialysis
 Cockcroft-Gault Equation :

(140 – Age) x Weight

NKF K/DQI GUIDELINES

CCr (ml/min) = X (0.85 if female)

72 x SCr

Age in years
Weight in kg
 Abbreviated MDRD Study Equation
NKF K/DQI GUIDELINES

Estimated GFR (ml/min/1.73 m2) :

= 186 x (SCr)-1.154 x (Age)-0.203 x (0.742 if female) x (1.210

if African-American)

= exp ( 5.228 – 1.154 x ln (SCr) – 0.203 x ln (Age) –

(0.299 if female) + (0.192 if African-American) )
 Guideline 2. Evaluation and Treatment
NKF K/DQI GUIDELINES
 Stages of Chronic Kidney Disease : Clinical Action Plan

GFR
Stage Description Action*
(mL/min/1.73m2)
Diagnosis & treatment
NKF K/DQI GUIDELINES

Kidney damage
Treatment of comorbid
1 with normal or  > 90
conditions, slowing progression,
GFR CVD risk reduction
Kidney damage
2 60 – 89 Estimating progression
with mild  GFR
Moderate  Evaluating & treating
3 30 – 59
GFR complications
Preparation for kidney
4 Severe  GFR 15 – 29
replacement therapy
< 15
5 Kidney Failure Replacement (if uremia present)
(or dialysis)

* Includes actions from preceding stages

 Classification and Management of Comorbid Conditions
in Chronic Kidney Disease
Type of
Comorbid
Condition Examples Management Goals
NKF K/DQI GUIDELINES

Diseases Diabetes Improve CKD

causing CKD High blood pressure
Obstruction of the urinary tract
Diseases Chronic obstructive pulmonary
disease,
unrelated to
Gastroesophageal reflux disease,
CKD
Degenerative joint disease,
Alzheimer’s disease,
Malignancies
Cardiovascular Atherosclerotic CVD
Coronary heart disease
disease (CVD)
Cerebrovascular disease
Peripheral vascular disease
Left ventricular hypertrophy
Heart failure
Improve functioning and well-being
Integration of care with
management of CKD
Improve functioning and well-being
Integration of care with
management of CKD
Evaluation and management of
traditional and CKD-related CVD
risk factors
Possibly improve CKD
Improve functioning and well-being
Integration of care with
management of CKD
 Association of Stages of Chronic kidney Disease with
Complications
Complications
HBP or Lab
Stage Description GFR Abnormality Symptoms
NKF K/DQI GUIDELINES

Kidney damage with > 90 -* -*

1
normal or  GFR
Kidney damage with 60 – 89 + -
2
mild  GFR
3 Moderate  GFR 30 – 59 + +
4 Severe  GFR 15 – 29 ++ +
5 Kidney Failure < 15 +++ ++
(or dialysis)

* Manifestation of kidney damage may occur during this stage even though
GFR is not decreased (e.g. nephrotic syndrome, nephritic syndrome, urinary
tract symptoms, tubular syndromes)
- None , + possible , + mild , ++ moderate , +++ severe
 Factors Linked with noncompliance in Chronic Disease
Misunderstanding instruction Forgetfulness
High Stress Perception of negative side effects
Depression Perception of less benefit from
NKF K/DQI GUIDELINES

Coping by avoidance treatment

Belief that powerful others Lessening of symptoms

control health outcome Perception that illness affects work
Unemployment and life

Lower income Less confidence in care providers

Less social support Less time with physicians

Less family support Drug abuse history

Many chronic illnesses Male gender and medication

compliance
Need for many medications
Female gender and diet compliance
Limited medication access
Black race
 Traditional vs. Chronic Kidney Disease-Related Factors Potentially
Related to an Increased Risk for Cardiovascular Disease
CKD-Related (Nontraditional) CVD
Traditional CVD Risk Factors Risk Factors
Older age Type (diagnosis) of CKD
NKF K/DQI GUIDELINES

Male gender Decreased GFR

White race Proteinuria
Hypertension Renin-angiotensin system activity
Elevated LDL cholesterol Extra-cellular fluid volume overload
Decreased HDL cholesterol Abnormal calcium and phosphorous
Diabetes mellitus metabolism
Tobacco use Dyslipidemia
Physical inactivity Anemia
Menopause Malnutrition
Psychosocial stress Inflammation
Family history of CVD Infection
Thrombogenic factors
Oxidative stress
Elevated homocysteine
Uremic toxins
 Guideline 3. Individuals at Increased Risk of
NKF K/DQI GUIDELINES

Chronic Kidney Disease

 Types and Examples of risk Factors for Chronic
Kidney Disease

Definition Examples
Susceptibility Increase Older age, family history
NKF K/DQI GUIDELINES

factors susceptibility to
kidney damage
Initiation Directly initiate Diabetes, high blood pressure,
factors kidney damage autoimmune diseases, systemic
infections, urinary tract
infections, urinary stones, lower
urinary tract obstruction, drug
toxicity
Progression Cause worsening Higher level of proteinuria,
factors kidney damage higher blood pressure level, poor
and faster decline glycemic control in diabetes,
in kidney function smoking
after initiation of
kidney damage
 Potential Risk Factors for Susceptibility to and
Initiation of Chronic Kidney Disease

Sociodemographic
Clinical Factors Factors
NKF K/DQI GUIDELINES

Diabetes Older age

Hypertension US ethnic minority status:
Autoimmune disease African American, American
Systemic infection Indian, hispanic, Asian, or
Pacific Islander
Urinary tract infections
Exposure to certain
Urinary stones chemical and
Lower urinary tract obstruction environmental conditions
Neoplasia Low income / education
Family history of chronic kidney disease
Recovery from acute kidney failure
Reduction in kidney mass
Exposure to certain drugs
Low birth weight
 Relationship Between Types of Kidney Disease and
Risk Factors for Initiation and Susceptibility to
Chronic Kidney Disease
Types of Kidney
Disease CKD Risk Factors
NKF K/DQI GUIDELINES

Diabetes (Type 1 & Diabetes Mellitus, HBP, family history, US ethnic

type 2) minority
Glomerular Autoimmune diseases, systemic infections,
Diseases neoplasia, drug or chemical exposure, family
history
Vascular Diseases HBP, family history, US ethnic minority

Tubulointerstitial Urinary tract infections, stones, obstruction, toxic

Diseases drugs
Cystic Diseases Family history

Disease in the Prior acute rejection, greater HLA mismatches,

Kidney Transplant cyclosporine or tacrolimus, glomerular disease in
native kidneys
 Potentially modifiable risk factors for development
and progression of chronic kidney

• Lack of awareness • Oxidative stress

NKF K/DQI GUIDELINES

• Proteinuria • Elevated homocysteine

• Hypertension • Menopause
• Dyslipidemia • Smoking
• Hyperglycemia • Infection / inflammation
• Anemia • Other uremic toxins
• Nutritional factors • Depression / poor mental
health
• Thrombogenic factors
• Poor physical functioning
 NKF K/DQI GUIDELINES

