Clinical practice guidelines for chronic kidney disease in adults: Part I. Definition, disease stages, evaluation, treatment, and risk factors.

hronic kidney disease is a major public health problem throughout the world. In the United States, kidney failure is becoming increasingly common and is associated with poor health outcomes and high medical expenditures. In this country, the number of patients treated with dialysis or transplantation is projected to increase from 340,000 in 1999 to 651,000 in 2010.1 The major outcomes of chronic kidney disease, regardless of the specific diagnosis (i.e., type of kidney disease), include progression to kidney failure, complications from decreased kidney function, and development of cardiovascular disease. Increasing evidence shows that early detection and treatment often can prevent or delay some of these adverse outcomes.2 However, opportunities for prevention may be lost because chronic kidney disease is not diagnosed or is treated insufficiently.3-6 One reason is lack of agreement about the definition of chronic kidney disease, as well as the classification of its stages. Another reason is lack of uniform application of simple tests for the detection and evaluation of the disease. In February 2002, the Kidney Disease In February 2002, the Kidney Disease Outcome Quality Initiative of the National Kidney Foundation published clinical practice guidelines on chronic kidney disease. The first six of the 15 guidelines are of the greatest relevance to family physicians. Part I of this two-part article reviews guidelines 1, 2, and 3. Chronic kidney disease is defined by the presence of a marker of kidney damage, such as proteinuria (ratio of greater than 30 mg of albumin to 1 g of creatinine on untimed [spot] urine testing), or a decreased glomerular filtration rate for three or more months. Disease staging is based on the glomerular filtration rate. Evaluation should be directed at determining the type and severity of chronic kidney disease. Treatment goals include preventing disease progression and complications. The guidelines place special emphasis on the prevention and treatment of cardiovascular disease in patients with chronic kidney disease. Risk factors for chronic kidney disease include diabetes mellitus, hypertension, family history of chronic kidney disease, age older than 60 years, and U.S. racial or ethnic minority status. The guidelines recommend testing for proteinuria and estimating the glomerular filtration rate in patients at risk for chronic kidney disease. Family physicians should weigh the value of the National Kidney Foundation guidelines for their clinical practice based on the strength of evidence and perceived cost-effectiveness until additional evidence becomes available on the usefulness of the recommended quality indicators. (Am Fam Physician 2004;70:86976. Copyright© 2004 American Academy of Family Physicians.) Clinical Practice Guidelines for Chronic Kidney Disease in Adults: Part I. Definition, Disease Stages, Evaluation, Treatment, and Risk Factors