#64 – KDIGO Guidelines



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What are KDIGO and KDOQI???

  • The 2 Organizations
    • Kidney Disease Outcomes Quality Initiative (KDOQI)
      • US Based
      • Developed in 1997 by National Kidney Foundation
    • Kidney Disease: Improving Global Outcomes (KDIGO)
      • Global organization developing and implementing evidence based clinical practice guidelines in kidney diseases
      • Developed in 2003 by NKF
    • Essentially individual entities, but both comment various aspects of kidney diseases
  • 2012 Guidelines
    • Published by KDIGO and commented by KDOQI
    • 5 chapters


Chapter 1: Definition and Classification of CKD

  • Definition
    • Abnormalities in kidney structure or function, present for > 3 months, with implications on health
  • Staging
    • Based on causes, GFR category, and albuminuria category
  • Predicting Prognosis of CKD
  • Evaluation of GFR
    • Recommend using serum creatinine and GFR estimating equation for initial assessment
    • Recommend only using cystatin C in adult patients with decreased GFR but without markers of kidney damage if diagnosis of CKD is required
  • Evaluation of Albuminuria
    • Initial testing for proteinuria should be an early morning urine sample(in descending order of preference):
      • Urine albumin-to-creatinine ratio (ACR)
      • Urine protein-to-creatinine ratio (PCR)
      • Reagent strip urinalysis for total protein with automated reading
      • Reagent strip urinalysis for total protein with manual reading
    • Microalbuminuria should no longer be used by laboratories
    • If ACR > 30mg/g, then proceed to confirm with a random untimed urine sample

Chapter 2: Definition, Identification, and Predication of CKD Progression

  • Assess albuminuria at least annually
  • CKD progression is based on the one of the following:
    • Decline in GFR category
    • Drop in eGFR by ≥ 25% of baseline
    • Sustained decline in eGFR by > 5mL/min/year
  • Identify known risk factors associated with CKD progression
    • Cause of CKD
    • Age
    • Gender
    • Hypertension
    • Hyperglycemia
    • Dyslipidemia
    • Smoking
    • Obesity
    • History of CVD
    • Ongoing exposure to nephrotoxic agents

Chapter 3: Management of Progression and Complication of CKD

  • Hypertension
    • BP ≤ 140/90 if urine albumin excretion < 30mg/d
    • BP ≤ 130/80 if urine albumin excretion > 30mg/d
    • Recommend ACEI or ARB
  • Protein Intake
    • Recommend protein intake 0.8g/kg/d
  • Glycemic Control
    • Recommend HbA1C AROUND 7.0%
    • ***newer ACE guidelines recommend < 6.5% with SGLT2i**
  • Recommend < 2g/day
    • Lifestyle
      • Recommend 30 min/day five times per week, smoking cessation, and healthy weight (BMI 20-25)
  • Complications Associated with CKD
    • Anemia
      • Diagnosed at < 13g/dL in men and < 12 g/dL in women
      • Screening in patients with CKD:
        • Stage G1-2 – when clinically indicated
        • Stage 3a-3b – at least annually
        • Stage 4-5 – at least twice per year
    • Metabolic Bone Disease
      • Obtained baseline calcium, phosphate, PTH, and ALP at least once in patients with GFR < 45 mL/min
      • Not recommended to screen with bone mineral density testing
      • Not recommended to supplement vitamin D of bisphophonates with deficiency or strong clinical rationale
    • Acidosis
      • Supplement oral bicarbonate in patients with serum bicarbonate < 22 mmol/L

Chapter 4: Other Complications of CKD

  • CVD
    • All CKD patients are at increased risk for CVD
    • Recommend same testing and treating as non-CKD patients
    • Use caution when interpreting NT-proBNP and troponins
  • PVD
    • Recommend regular podiatric assessment
  • Medication Management
    • Recommend using GFR for dosing adjustments
      • Example – Metformin
        • Stage G1-3a – continue
        • Stage G3b – monitored
        • Stage G4-5 – discontinued
  • Imaging studies and radiocontrast
    • Avoid if possible, but do not hold if needed
    • Following KDIGO Clinical Practice Guidelines for AKI
      • Avoid high osmolar agents
      • Use lowest contrast dose possible
      • Stop nephrotoxic agents before and after
      • Maintain adequate hydration
      • Measure GFR 48-96 hours after

Chapter 5: Referral to Specialist and Models of Care



Cottage Physician (1893)



References

  1. KDIGO. Clinical Practice Guideline for the Evaluation and Management of CKD. 2012.
  2. Inker LA, Astor BC, Fox CH, et al. KDOQI US commentary on the 2012 KDIGO clinical practice guideline for the evaluation and management of CKD. Am J Kidney Dis. 2014; 63(5):713-35. [pubmed]
  3. Stevens PE, Levin A. Evaluation and management of chronic kidney disease: synopsis of the kidney disease: improving global outcomes 2012 clinical practice guideline. Ann Intern Med. 2013; 158(11):825-30. [pubmed]
  4. Andrassy KM. Comments on ‘KDIGO 2012 Clinical Practice Guideline for the Evaluation and Management of Chronic Kidney Disease’. Kidney Int. 2013; 84(3):622-3. [pubmed]

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