Refining the Assessment of Chronic Kidney Disease

The Kidney Disease Improving Global Outcomes (Kdigo) organization has released updated recommendations for evaluating, managing, and treating chronic kidney disease (CKD) in adults and children not receiving renal replacement therapy. These guidelines, summarized in the journal Annals of Internal Medicine, emphasize a more precise estimation of kidney function and a shift toward risk-based management.

The updated guidelines stress the importance of assessing individuals at risk of CKD, such as those with hypertension, diabetes, multisystem disease, or exposure to perhaps nephrotoxic drugs. This assessment should include evaluating glomerular filtration rate (GFR) and urinary albumin-to-creatinine ratio (UACR).

Estimating Glomerular Filtration Rate (GFR)

• When possible,use the equation based on both creatinine and cystatin C values (GFR_CR-CYS) rather than creatinine alone (GFR_CR).
• GFR_CR-CYS is considered more precise and closer to measured GFR.

However, the authors caution that certain patient characteristics can affect creatinine and cystatin C values, thereby influencing GFR estimates.

• Creatinine is affected by:
  • Malnutrition
  • Very high or very low muscle mass
  • Food and drugs that inhibit tubular secretion of creatinine
• Cystatin C is influenced by:
  • Chronic inflammation
  • Adiposity
  • Cancer
  • Chemotherapy
  • Thyroid function
  • excess glucocorticoids

by understanding these limits, clinicians can choose the most suitable biomarker for each individual, in accordance with our objective of more personalized approaches.

The guidelines advocate for estimating the individual risk of renal failure using a validated tool, such as the Kidney Failure Risk equation (KFRE), which predicts the probability of progression at 2 and 5 years.

For the care of chronic kidney disease and advanced care planning, we propose to go from an approach based on DFG to a risk -based approach.

Expanding Treatment Options: SGLT2i and Statins

The new recommendations broaden the scope of patients who should be considered for treatment with sodium-glucose cotransporter-2 inhibitors (SGLT2i) to delay CKD progression and prevent complications.

• SGLT2i are recommended for adults, both diabetic and non-diabetic, with a GFR greater than 20 ml/min/1.73 m² and a UACR greater than 200 mg/g (> 20 mg/mmol).
• SGLT2i are also recommended for adults with heart failure, irrespective of albuminuria levels.

The authors suggest that it is reasonable to continue SGLT2i treatment even if the GFR falls below 20 ml/min/1.73 m², provided it is tolerated and renal replacement therapy is not yet established. However,SGLT2i should be stopped during prolonged fasting,surgical interventions,or serious illnesses when the risk of ketosis is higher.

Regarding statin use, the guidelines recommend:

• for patients older than 50 with CKD and a GFR less than 60 ml/min/1.73 m² who are not on chronic dialysis or transplant, treatment with a statin or a statin + ezetimibe is recommended.
• For patients with a GFR of 60 ml/min/1.73 m² or greater, treatment with a statin is recommended.
• Statins are also recommended for patients aged 18 to 49 with coronary artery disease,diabetes,prior ischemic stroke,or an estimated 10-year risk of cardiac death or non-fatal myocardial infarction greater than 10%.

Cost-effectiveness and Sustainability

The authors acknowledge the feasibility and sustainability of the recommended strategies, recognizing that many may only be applicable in high-resource settings.They address the higher costs associated with cystatin C measurement, arguing that these are offset by a reduction in diagnostic errors, improved drug dosing, and fewer adverse events.

The costs of the SGLT2i will probably be compensated by the delay or avoidance of the increase in the MRC and the profits beyond the renal results.

FAQ: Chronic Kidney Disease Management

What is chronic kidney disease (CKD)?

CKD is a condition in which the kidneys are damaged and cannot filter blood and also they should.

Who is at risk for CKD?

People with diabetes, high blood pressure, heart disease, or a family history of kidney disease are at higher risk.

how is CKD diagnosed?

CKD is diagnosed through blood and urine tests to measure kidney function.

What are SGLT2 inhibitors?

SGLT2 inhibitors are a class of drugs that help lower blood sugar and have been shown to protect the kidneys and heart.

What are statins?

Statins are drugs that help lower cholesterol levels and reduce the risk of heart disease.