Summary of KDIGO 2012 CKD Guideline

Behind the Scenes, Need for Guidance, and a Framework for Moving Forward

Adeera Levin; Paul E Stevens

Disclosures

Kidney Int. 2014;85(1):49-61. 

In This Article

Abstract and Introduction

Abstract

The 2012 KDIGO Guideline for CKD evaluation, classification, and management has updated the original 2002 KDOQI Guidelines, using newer data and addressing issues raised over the last decade concerning definitions and assessment. This review highlights the key aspects of the CKD guideline, and describes the rationale for specific wording and the scope of the document. A précis of key concepts in each of the five sections of the guideline is presented. The guideline document is intended for general practitioners and nephrologists, and covers CKD evaluation, classification, and management for both adults and children. Throughout the guideline, we have attempted to overtly address areas of controversy or non-consensus, international relevance, and impact on practice and public policy.

Introduction

After a decade of focused research and clinical practice in chronic kidney disease (CKD), the 2012 Kidney Disease: Improving Global Outcomes (KDIGO) Clinical Practice Guideline for the Evaluation and Management of CKD[1] serves to update the original 2002 Kidney Disease Outcomes Quality Initiative (KDOQI) Clinical Practice Guidelines for CKD: Evaluation, Classification, and Stratification.[2] That decade has brought controversy, validation, and new ideas but has also highlighted CKD as global public health issue.[3] Through use of a common language and classification system, the original guidance stimulated new knowledge, resulting in the need for this new guideline.

It is beyond the scope of this document to review each statement and all the nuances and issues related to the guideline development, so the reader is encouraged to read the original document. This overview is intended to highlight the important concepts in the guideline, some old and some new. Moreover, we wish to ensure an understanding of the rationale for specific wording, and how and why specific topics were or were not addressed, and the depth to which they were addressed. Throughout the guideline, we have attempted to overtly address areas of controversy or non-consensus, international relevance, and impact on practice and public policy. The reader is encouraged to review those specific areas within each of the sections in addition to the scientific and evidence base for rationale, so as to gain further insights into the specific recommendation statement.

The guideline document[1] aims to provide state-of-the-art guidance on the evaluation, management, and treatment for both adult and pediatric populations with CKD. The intended audience is diverse and includes nephrologists, primary-care practitioners, and other specialists, as well as allied health-care professionals. We appreciate that different health-care systems exist around the world, and so attempt to provide best practice recommendations. It is recognized that there will be variation in the ability to implement some of the recommendations in different jurisdictions, but by identifying best practices and describing the evidence base, we hope to encourage advocacy for those best practices to improve the care of patients with CKD around the world. Individual country commentaries and implementation efforts are encouraged and should highlight major areas of controversy or relevance.

The development of this guideline followed an explicit process of evidence review and appraisal. Treatment approaches are addressed in each chapter and guideline recommendations are based on systematic reviews of relevant trials. Important statements that serve as educational or practical comments are ungraded and included for the readership. Appraisal of the quality of the evidence and the strength of recommendations followed the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach.[4]

We used the GRADE system to rate the strength of evidence and the strength of recommendations. In all, there were 12 (17.1%) recommendations in this guideline for which the overall quality of evidence was graded 'A,' whereas 36 (51.4%) were graded 'B,' 17 (24.3%) were graded 'C,' and 5 (7.1%) were graded 'D.' Although there are reasons other than quality of evidence to make a grade 1 or 2 recommendation, in general, there is a correlation between the quality of overall evidence and the strength of the recommendation. Thus, there were 43 (62.3%) recommendations graded '1' and 26 (37.7%) graded '2.' There were 9 (13.0%) recommendations graded '1A,' 23 (33.3%) were '1B,' 10 (14.5%) were '1C,' and 1 (1.4%) was '1D.' There were 2 (2.9%) recommendations graded '2A,' 13 (18.8%) were '2B,' 7 (10.1%) were '2C,' and 4 (5.8%) were '2D.' There were 41 (37.3%) statements that were not graded.

Some argue that recommendations should not be made when evidence is weak. However, clinicians still need to make clinical decisions in their daily practice, and they often ask, 'What do the experts do in this setting?' We opted to give guidance, rather than remain silent. These recommendations are often rated with a low strength of recommendation and a low quality of evidence, or were not graded. It is important for the users of this guideline to be cognizant of this. In every case, these recommendations are meant to be a place for clinicians to start, not stop, their inquiries into specific management questions pertinent to the patients they see in daily practice.

It is our hope that this document will serve several useful purposes. Our primary goal is to improve patient care. We hope to accomplish this, in the short term, by helping clinicians know and better understand the evidence (or lack of evidence) that determines current practice. The balance of few grade A evidence-based recommendations (17%; 12 statements) and many ungraded recommendations can help define areas where research is needed. Although many would state that this guideline should be much shorter given the paucity of evidence, we and the Work Group, as well as the public groups consulted, were committed to constructing a comprehensive guidance document that was transparent and useful. We would submit that defining the research agenda is an often neglected, but very important, function of clinical practice guideline development. We would suggest that the implementation of the more granular cause, glomerular filtration rate (GFR), and albuminuria (CGA) system, with refined subcategories within GFR level 3 into 3a and 3b, and albuminuria categories will help practitioners with risk assessment as well as management plans. Perhaps most importantly, it will also lead to improvements in clinical trial design and execution by ensuring recruitment of the specific patient populations.

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