Practical classification of chronic kidney disease (2016): A proposal

Clasificación práctica de la enfermedad renal crónica 2016: una propuesta

The classification of chronic kidney disease (CKD), made in 2002 by the Kidney Disease Outcome Quality Initiative group, includes 5 stages based upon the glomerular filtration rate. This has led to the standardisation of diagnostic parameters, and has been of great use in clinical practice, carrying out multiple research studies, as well as developing public health policies at a world level. Later publications have proposed differentiating the presence of kidney disease in a native kidney or in a transplanted one, and subdividing stage 3 of CKD into A and B, since there is a wide range of disease in which very important events occur, especially at a cardiovascular level. Furthermore, the Kidney Disease Improving Global Outcomes clinical practice guidelines support proteinuria-albuminuria as an undebatable prognostic risk factor of CKD. At the same time, and regarding chronic high blood pressure, while it does not have significant statistical value as an independent risk factor for the progression of CKD, the majority of analyses suggest that adequate control of blood pressure is beneficial and delays the progression of CKD in patients with proteinuria, so much so that it is considered the second cause of CKD after diabetes mellitus and above glomerulonephritis. Based upon what has been mentioned, and taking into account that a multifactor disease like CKD cannot be evaluated with only one of 3 principal risk factors that most determine its outcome, a new, practical, and easy method for the classification of CKD is proposed, taking into account all the 3 aforementioned variables, thereby achieving a more integral concept of the disease. This diagnostic method to identify the disease may also be useful for determining the severity as well as predict the risk of progression. At the same way, having quantifiable parameters can be very useful as a prospective follow-up tool for therapeutic interventions.

1. National Kidney Foundation. K/DOQI clinical practice guidelines for chronic kidney disease: Evaluation, classification, and stratification. Am J Kidney Dis. 2002;39 2 Suppl 1:S1–266.

2. Andrassy KM. Comments on ‘KDIGO 2012 Clinical Practice Guideline for the Evaluation and Management of Chronic Kidney Disease’. Kidney Int. 2013;84:622–3.

3. Bauer C, Melamed ML, Hostetter TH. Staging of chronic kidney disease: Time for a course correction. J Am Soc Nephrol. 2008;19:844–6.

4. Cockcroft DW, Gault MH. Prediction of creatinine clearance from serum creatinine. Nephron. 1976;16:31–41.

5. Levey AS, Bosch JP, Lewis JB, Greene T, Rogers N, Roth D. A more accurate method to estimate glomerular filtration rate from serum creatinine: A new prediction equation. Modification of Diet in Renal Disease Study Group. Ann Intern Med. 1999;130:461–70.

6. Levey AS, Stevens LA, Schmid CH, Zhang YL, Castro AF 3rd, Feldman HI, et al. A new equation to estimate glomerular filtration rate. Ann Intern Med. 2009;150:604–12.

7. Stevens LA, Coresh J, Feldman HI, Greene T, Lash JP, Nelson RG, et al. Evaluation of the modification of diet in renal disease study equation in a large diverse population. J Am Soc Nephrol. 2007;18:2749–57.

8. Michels WM, Grootendorst DC, Verduijn M, Elliott EG, Dekker FW, Krediet RT. Performance of the Cockcroft-Gault, MDRD, and new CKD-EPI formulas in relation to GFR, age, and body size. Clin J Am Soc Nephrol. 2010;5:1003–9.

9. Shlipak MG, Katz R, Sarnak MJ, Fried LF, Newman AB, Stehman-Breen C, et al. Cystatin C and prognosis for cardiovascular and kidney outcomes in elderly persons without chronic kidney disease. Ann Intern Med. 2006;145:237–46.

10. Brantsma AH, Bakker SJ, Hillege HL, de Zeeuw D, de Jong PE, Gansevoort RT. Cardiovascular and renal outcome in subjects with K/DOQI stage 1-3 chronic kidney disease: The importance of urinary albumin excretion. Nephrol Dial Transplant. 2008;23:3851–8.

11. Hallan SI, Ritz E, Lydersen S, Romundstad S, Kvenild K, Orth SR. Combining GFR and albuminuria to classify CKD improves prediction of ESRD. J Am Soc Nephrol. 2009;20:1069–77.

12. Warnock DG, Muntner P, McCullough PA, Zhang X, McClure LA, Zakai N, et al. Kidney function, albuminuria, and all-cause mortality in the REGARDS (Reasons for Geographic and Racial Differences in Stroke) study. Am J Kidney Dis. 2010;56:861–71.

13. Burgos-Calderon R, Depine S. Systematic approach for the management of chronic kidney disease: Moving beyond chronic kidney disease classification. Curr Opin Nephrol Hypertens. 2010;19:208–13.

14. Hemmelgarn BR, Manns BJ, Lloyd A, James MT, Klarenbach S, Quinn RR, et al. Relation between kidney function, proteinuria, and adverse outcomes. JAMA. 2010;303:423–9.

15. Gu Q, Dillon CF, Burt VL, Gillum RF. Association of hypertension treatment and control with all-cause and cardiovascular disease mortality among US adults with hypertension. Am J Hypertens. 2010;23:38–45.

16. Chen J. Epidemiology of hypertension and chronic kidney disease in China. Curr Opin Nephrol Hypertens. 2010;19:278–82.

17. Appel LJ, Wright JT Jr, Greene T, Agodoa LY, Astor BC, Bakris GL, et al. Intensive blood-pressure control in hypertensive chronic kidney disease. N Engl J Med. 2010;363:918–29.

18. James PA, Oparil S, Carter BL, Cushman WC, Dennison-Himmelfarb C, Handler J, et al. 2014 evidence-based guideline for the management of high blood pressure in adults: Report from the panel members appointed to the Eighth Joint National Committee (JNC 8). JAMA. 2014;311:507–20.

19. Comments on the ESC/ESH guidelines for the management of arterial hypertension 2013. A report of the Task Force of the Clinical Practice Guidelines Committee of the Spanish Society of Cardiology. Rev Esp Cardiol (Engl Ed). 2013;66:842–7.

20. Wen CP, Cheng TY, Tsai MK, Chang YC, Chan HT, Tsai SP, et al. All-cause mortality attributable to chronic kidney disease: A prospective cohort study based on 462 293 adults in Taiwan. Lancet. 2008;371:2173–82.

21. Gansevoort RT, de Jong PE. Challenges for the present CKD classification system. Curr Opin Nephrol Hypertens. 2010;19:308–14.

22. Levey AS, Eckardt KU, Tsukamoto Y, Levin A, Coresh J, Rossert J, et al. Definition and classification of chronic kidney disease: A position statement from Kidney Disease: Improving Global Outcomes (KDIGO). Kidney Int. 2005;67:2089–100.

23. Hogan M. KDIGO conference proposes changes to CKD classification, but not to the definition. Nephrology Times. 2009;2:9–10.

24. Levey AS, Stevens LA, Coresh J. Conceptual model of CKD: Applications and implications. Am J Kidney Dis. 2009;53 3 Suppl 3:S4–16.

25. Hallan SI, Stevens P. Screening for chronic kidney disease: Which strategy? J Nephrol. 2010;23:147–55.