Andrew S. Levey, MD; Josef Coresh, MD, PhD; Ethan Balk, MD, MPH; Annamaria T. Kausz, MD, MS; Adeera Levin, MD; Michael W. Steffes, MD, PhD; Ronald J. Hogg, MD; Ronald D. Perrone, MD; Joseph Lau, MD; Garabed Eknoyan, MD
Chronic kidney disease is a worldwide public health problem with an increasing incidence and prevalence, poor outcomes, and high cost. Outcomes of chronic kidney disease include not only kidney failure but also complications of decreased kidney function and cardiovascular disease. Current evidence suggests that some of these adverse outcomes can be prevented or delayed by early detection and treatment. Unfortunately, chronic kidney disease is underdiagnosed and undertreated, in part as a result of lack of agreement on a definition and classification of its stages of progression.
Recent clinical practice guidelines by the National Kidney Foundation 1) define chronic kidney disease and classify its stages, regardless of underlying cause, 2) evaluate laboratory measurements for the clinical assessment of kidney disease, 3) associate the level of kidney function with complications of chronic kidney disease, and 4) stratify the risk for loss of kidney function and development of cardiovascular disease. The guidelines were developed by using an approach based on the procedure outlined by the Agency for Healthcare Research and Quality.
This paper presents the definition and five-stage classification system of chronic kidney disease and summarizes the major recommendations on early detection in adults. Recommendations include identifying persons at increased risk (those with diabetes, those with hypertension, those with a family history of chronic kidney disease, those older than 60 years of age, or those with U.S. racial or ethnic minority status), detecting kidney damage by measuring the albumincreatinine ratio in untimed (spot) urine specimens, and estimating the glomerular filtration rate from serum creatinine measurements by using prediction equations. Because of the high prevalence of early stages of chronic kidney disease in the general population (approximately 11% of adults), this information is particularly important for general internists and specialists.
Shaded ellipses represent stages of chronic kidney disease; unshaded ellipses represent potential antecedents or consequences of chronic kidney disease. Thick arrows between ellipses represent risk factors associated with the initiation and progression of disease that can be affected or detected by interventions: susceptibility factors ( ), initiation factors ( ), progression factors ( ), and end-stage factors ( ) (Table 3). Interventions for each stage are given beneath the stage. Persons who appear normal should be screened for chronic kidney disease risk factors. Persons known to be at increased risk for chronic kidney disease should be screened for chronic kidney disease. “Complications” refer to all complications of chronic kidney disease and its treatment, including complications of decreased glomerular filtration rate ( ) (hypertension, anemia, malnutrition, bone disease, neuropathy, and decreased quality of life) and cardiovascular disease. Reprinted with permission from reference .
The Work Group recommends a cutoff value for an albumin–creatinine ratio greater than 30 mg/g in men and women. Some studies suggest sex-specific cutoff values for an albumin–creatinine ratio of greater than 17 mg/g in men or greater than 25 mg/g in women . Reprinted with permission from reference .
Appendix Table 1.
Appendix Table 2.
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Levey AS, Coresh J, Balk E, Kausz AT, Levin A, Steffes MW, et al. National Kidney Foundation Practice Guidelines for Chronic Kidney Disease: Evaluation, Classification, and Stratification. Ann Intern Med. 2003;139:137-147. doi: 10.7326/0003-4819-139-2-200307150-00013
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Published: Ann Intern Med. 2003;139(2):137-147.
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