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Chronic kidney disease · Web view Chronic kidney disease includes chronic renal failure, but also includes predictors of chronic renal failure in people with normal kidney function

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Chronic kidney disease

Chronic kidney disease.

Position paper 2007

Mai Rosenberg 1, Ruth Kalda 1, Vytautas Kasiulevičius 2 , Aivars Petersons 3, Margus Lember 1

1 University of Tartu, Estonia

2 University of Vilnius, Lithania

3 Stradins Medical Academy, Riga, Latvia

Table of contents:


Chronic kidney disease (CKD) is a worldwide public health problem that is often under-diagnosed and under-treated.

Definitions and classification

Chronic kidney disease represents a progressive, irreversible decline in glomerular filtration rate (1). Most chronic nephropathies unfortunately lack a specific treatment and progress relentlessly to end stage renal disease. Progressive renal function loss is a common phenomenon in renal failure irrespectively of the underlying cause of the kidney disease (2).

In recent years the concept of chronic kidney disease has gained more attention instead of chronic renal failure which is used to describe the more advanced stages of CKD. This is especially important for primary health care where the role of primary care providers is very important in handling the early phases of CKD to prevent or postpone chronic renal failure. In the current literature the terms CKD, renal insufficiency and renal failure are sometimes used without precisely defining these conditions.

Chronic renal failure indicates to chronically (at least 3 months' duration) reduced kidney function (clearance, glomerular filtration rate [GFR]). Renal function declines normally with age, and exact level of decline at a given age that should be considered pathological is not known.The Kidney Disease Improving Global Outcomes (KDIGO) statement considers GFR less than 60 mL/minute pathological at all ages. However, many elderly people have values less than this (in the USA, about 7% of white people without diabetes who are aged in their 60s and 15% of those aged in their 70s), and the extent to which low kidney function in the range of 30–60 mL/minute/1.73 m2 is pathological or progressive in all people is a subject of some controversy. Though people with end stage renal disease, by definition, have chronic failure of their kidneys (which may have resulted from an acute or a chronic process) they are generally not included in the term chronic renal failure, which in most of the literature and in this chapter refers exclusively to those with low kidney function who are not treated with renal replacement therapy.

Chronic kidney disease defined by the Kidney Disease Improving Global Outcomes (KDIGO) statement as either the presence of abnormalities in urine or imaging that may lead to progressive disease or creatinine clearance (or glomerular filtration rate) less than 60 mL/minute/1.73 m2 . Chronic kidney disease includes chronic renal failure, but also includes predictors of chronic renal failure in people with normal kidney function (e.g. proteinuria), and end stage renal disease.

The National Kidney Foundation - Kidney Disease Outcomes Quality Initiative (NKF-K/DOQI) workgroup has defined CKD as the following (10) which have been accepted internationally with some clarifications (7,11):

· The presence of markers of kidney damage for


· The presence of GFR <60 mL/min/1.73 m2 for 3 months, with or without other signs of kidney damage as described above.

Based upon representative samples of the United States population (12), the studies have estimated the prevalence of CKD in the general population through measurement of markers of kidney damage, such as elevated serum creatinine concentration, decreased predicted GFR, and presence of albuminuria. The term “albuminuria” should be substituted for terms “microalbuminuria” and “macroalbuminuria”. Increased urinary albumin excretion of albumin is the earliest manifestation of CKD due to diabetes, other glomerular diseases and hypertensive nephrosclerosis. Albuminuria may also accompany tubulointerstitial diaseases, polycysistic kidney disease, and kidney disease in transplant recipients (11).

According to the KD:IGO position statement (11) the use of the term “disease” in CKD is consistent with: 1) the need for action to improve outcomes through prevention, detection, evaluation and treatment; 2) providing a message for public, physician and patient education programs; 3) common usage; and 4) its use in other conditions defined by findings and laboratory tests, such as hypertension, diabetes, and hyperlipidemia (11).

Classification of CKD.

CKD classified according to the severity, diagnosis, treatment and prognosis (11). Suffix “T” is used for all transplant recipients, at any level of GFR and, “D” for dialysis, for CKD stage 5 patients treated with dialysis. Clinical evaluation for CKD should include elucidation of the cause of disease. However, cause of the disease cannot be ascertained in all cases.




GFR (mL/min per 1.73 m2)

Related terms


Kidney damage with normal or ↑ GFR

≥ 90





Kidney damage with mild ↓ GFR





“T” if kidney transplant recipient


Moderate ↓ GFR


Chronic renal insufficiency Early renal insufficiency


Severe ↓ GFR


Chronic renal insufficiency Late renal insufficiency



Kidney failure

< 15

Renal failure


End-stage renal disease

“D” if dialysis (HD, PD)


1. Anderson, Brenner

2. Ots M, Pechter U, Tamm A: Characteristics of progressive renal disease. Clin Chim Acta 2000;2971-2:29-41.

3. Moeller S, Gioberge S, Brown G: ESRD patients in 2001: global overview of patients, treatment modalities and development trends. Nephrol Dial Transplant 2002;1712:2071-2076.

4. Jager KJ, van Dijk PC. Has the rise in the incidence of renal replacement therapy in developed countries come to an end? Nephrol Dial Transplant 2007;22:678-680

5. U.S. Renal Data System, USRDS 2006 Annual Data Report: Atlas of End-Stage Renal Disease in the United States, National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, MD, 2006. Am J Kidney Dis 2006; 47(Suppl 1):S1.

6. Locatelli F, D'Amico M, Cernevskis H, Dainys B, Miglinas M, Luman M, Ots M, Ritz E: The epidemiology of end-stage renal disease in the Baltic countries: an evolving picture. Nephrol Dial Transplant 2001;167:1338-1342.

7. Gregorio T Obrador, Brian JG Pereira. Epidemiology of chronic kidney disease and screening recommendations. UpToDate 2007; 15


9. K. Kõlvald,…. Renal replacement therapy trends in Estonia. Transplant Int 2007:

10. K/DOQI clinical practice guidelines for chronic kidney disease: evaluation, classification, and stratification. Am J Kidney Dis 2002; 39:S1.),

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

12. Baigent C, Burbury K, Wheeler D: Premature cardiovascular disease in chronic renal failure. Lancet 2000;3569224:147-152.

13. Coresh, J, Astor, BC, Greene, T, et al. Prevalence of chronic kidney disease and decreased kidney function in the adult US population: Third National Health and Nutrition Examination survey. Am J Kidney Dis 2003; 41:1.

14. Foley RN, Parfrey PS, Sarnak MJ: Clinical epidemiology of cardiovascular disease in chronic renal disease. Am J Kidney Dis 1998;325 Suppl 3:S112-119.

15. Pereira, BJG. Optimization of pre-ESRD care: The key to improved dialysis outcomes. Kidney Int 2000; 57:351.

16. Orth SR, Ritz E: The renal risks of smoking: an update. Curr Opin Nephrol Hypertens 2002;115:483-488.

17. Ritz E, Orth SR: Nephropathy in patients with type 2 diabetes mellitus. N Engl J Med 1999;34115:1127-1133.

18. Shlipak MG, Simon JA, Grady D, Lin F, Wenger NK, Furberg CD: Renal insufficiency and cardiovascular events in postmenopausal women with coronary heart disease. J Am Coll Cardiol 2001;383:705-711.

19. Amann K, Tornig J, Kugel B, Gross ML, Tyralla K, El-Shakmak A, Szabo A, Ritz E: Hyperphosphatemia aggravates cardiac fibrosis and microvascular disease in experimental uremia. Kidney Int 2003;634:1296-1301.

20. Eknoyan G, Levey AS, Levin NW, Keane WF: The national epidemic of chronic kidney disease. What we know and what we can do. Postgrad Med 2001;1103:23-29: quiz 28

21. Meyer KB, Levey AS: Controlling the epidemic of cardiovascular disease in chronic renal disease: report from the National Kidney Foundation Task Force on cardiovascular disease. J Am Soc Nephrol 1998;912 Suppl:S31-42.

22. Holley, JL, Nespor, SL. Nephrologist-directed primary health care in chronic dialysis patients. Am J Kidney Dis 1993; 21:628

23. Schwartz, JS, Lewis, CE, Clancy, C, et al. Internists' practice in health promotion and disease prevention: A survey. Ann Intern Med 1991; 114:46.

24. Zimmerman, DL, Selick, A, Singh, R, Mendelssohn, DC. Attitudes of Canadian nephrologists, family physicians and patients with kidney failure toward primary care delivery for chronic dialysis patients. Nephrol Dial Transplant 2003; 18:305.)

25. Jean L Holley. The nephrologist as primary care physician in patients with end-stage renal disease. UpToDate 2007; 15

26. Inglismaal tehtud töö NDT, 2007