Elsevier

The Lancet

Volume 379, Issue 9811, 14–20 January 2012, Pages 165-180
The Lancet

Seminar
Chronic kidney disease

https://doi.org/10.1016/S0140-6736(11)60178-5Get rights and content

Summary

Chronic kidney disease is a general term for heterogeneous disorders affecting kidney structure and function. The 2002 guidelines for definition and classification of this disease represented an important shift towards its recognition as a worldwide public health problem that should be managed in its early stages by general internists. Disease and management are classified according to stages of disease severity, which are assessed from glomerular filtration rate (GFR) and albuminuria, and clinical diagnosis (cause and pathology). Chronic kidney disease can be detected with routine laboratory tests, and some treatments can prevent development and slow disease progression, reduce complications of decreased GFR and risk of cardiovascular disease, and improve survival and quality of life. In this Seminar we discuss disease burden, recommendations for assessment and management, and future challenges. We emphasise clinical practice guidelines, clinical trials, and areas of uncertainty.

Introduction

Chronic kidney disease is a general term for heterogeneous disorders affecting the structure and function of the kidney. The variation in disease expression is related partly to cause and pathology, severity, and rate of progression. Since the introduction of the conceptual model, definition, and staging of chronic kidney disease 10 years ago,1, 2, 3, 4 guidelines have recommended a shift from kidney disease being recognised as a life-threatening disorder affecting few people who need care by nephrologists, to a common disorder of varying severity that not only merits attention by general internists, but also needs a concerted public health approach for prevention, early detection, and management.4, 5, 6 Although guidelines have had an important effect on clinical practice, research, and public health, they have also generated controversy.4, 7 A Series8 in The Lancet emphasised early recognition and prevention of disease and described treatment recommendations. In this Seminar we review the framework and estimates of disease burden; present an overview of the assessment and management of disease; emphasise guidelines and clinical trials; and discuss the challenges that are met in the association of chronic kidney disease with ageing and vascular disease, management of clinical trials, development of guidelines, and public health. We focus on the latest data and indicate areas of uncertainty and future directions for research.9

Section snippets

Conceptual model, definitions, and outcomes

Figure 1 shows a conceptual model for the development, progression, and complications of chronic kidney disease.1, 4 The model includes antecedents associated with increased risk, disease stages, and complications including death. Risks can be categorised either as susceptibility to kidney disease because of sociodemographic and genetic factors, or as exposure to factors that can lead to disease. Early stages of disease are often asymptomatic, are detected during the assessment of comorbid

Causes

In developed countries, chronic kidney disease is generally associated with old age, diabetes, hypertension, obesity, and cardiovascular disease, with diabetic glomerulosclerosis and hypertensive nephrosclerosis as the presumed pathological entities; however, exact diagnosis is often difficult.25 Diabetic glomerulosclerosis is characterised by slowly worsening albuminuria, hypertension, and progressive decline in GFR, sometimes with nephrotic syndrome. Hypertensive nephrosclerosis has no

Prevalence

Many countries have surveillance programmes to monitor kidney failure treated by dialysis and transplantation (figure 3).26 Incidence and prevalence vary because of differences in underlying diseases rates and availability of government-sponsored treatment. Incidence is now as high as 200 cases per million per year in many countries. It is nearing 400 cases per million in the USA, Taiwan, and some regions in Mexico, and has risen fastest in older individuals. Dialysis is the main treatment

Detection and assessment

Panel 2 provides a five-step guide to the detection and assessment of chronic kidney disease, which can be accomplished by routine laboratory tests. Although GFR is difficult to measure, it can be estimated from serum creatinine. Creatinine assays are now traceable to reference methods, and estimated GFR (eGFR) is now routinely reported in more than 75% of clinical laboratories in the USA.31 Because serum creatinine is commonly measured, reporting of eGFR allows chronic kidney disease to be

Concepts

Treatments for chronic kidney disease can prevent development, slow progression, reduce complications of decreased GFR, reduce risk of cardiovascular disease, and improve survival and quality of life. Data from the US renal data system25 show a decreasing incidence of kidney failure in some high-risk groups—eg, in young people with diabetes—suggesting beneficial effects of these interventions. Despite these remarkable advances, the detection, assessment, and management of chronic disease are

Association with ageing and vascular disease

Ageing and vascular disease are associated with low GFR and high albuminuria, and whether the present definition leads to overdiagnosis of chronic kidney disease has been questioned, particularly for older individuals.116, 117 The magnitude and cause of these associations are not well understood and are important topics for research; however, some evidence suggests that low GFR and high albuminuria are not normal and that the term kidney disease is appropriate. First, the age-related decline in

Search strategy and selection criteria

We searched the database of clinical practice guidelines in adults, which are developed and maintained by Kidney Disease Improving Global Outcomes (KDIGO)9 in collaboration with the five main groups that develop English-speaking guidelines: Australian and New Zealand Society of Nephrology, Caring for Australians with Renal Impairment, Canadian Society of Nephrology, European Renal Association/European Dialysis and Transplant Association (ERA/EDTA) European Best Practice Guidelines (EBPG),

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