What Are The Highlights Of The 2023 KDIGO CKD Guidelines For Diagnosis And Assessment?

Kidney Disease: Improving Global Outcomes (KDIGO) is a not-for-profit organization dedicated to improving care and outcomes for people with kidney disease around the world. Its guidelines are important reference materials for nephrologists and nurses in many countries and regions.

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On June 16, 2023, at the 60th European Renal Association Congress (ERA), experts from KDIGO announced the upcoming news and some important contents of the 2023 KDIGO Chronic Kidney Disease (CKD) Guidelines.

The 2023 KDIGO CKD Guidelines make several important changes to the diagnosis and assessment of chronic kidney disease (CKD). These changes involve the definition and classification of CKD, diagnostic and evaluation criteria, point-of-care testing (POCT), estimated glomerular filtration rate (eGFR), and risk prediction. These updated guidelines will provide clinicians with a more accurate and comprehensive approach to the diagnosis and assessment of CKD, helping to improve patient care and management.

·Practice point 1: CKD should be differentiated from acute kidney injury (AKI). Some AKI patients have similar symptoms to CKD; if the patient is considered to have a high risk of renal disease progression or may develop CKD, CKD treatment can be performed at the initial diagnosis.

The focus of this practice point is that, for patients with CKD risk factors or at high risk for CKD, delayed diagnosis may delay treatment. If treatment is not initiated, many patients may not realize the importance of follow-up visits. Initiating treatment allows for early intervention, signaling to the patient the importance of the disease through action.

Etiological Evaluation of CKD

Clinical recommendation 1: All patients with CKD should be evaluated for etiology, taking into account the clinical background, personal and family history, social and environmental factors, drug therapy, physical examination, laboratory tests, imaging, and pathological diagnosis (1D).

Clinical Recommendation 2: Renal biopsy is an acceptable safe diagnostic test when appropriate and should be performed using standard methods to minimize complications (2D).

Point-of-care testing (POCT)

It is suggested that POCT can be used for the detection of serum creatinine and proteinuria, especially for the use of laboratories or limited medical resources. At the same time, POCT has two unique advantages, namely, the advantages of health economics and the ability to meet specific clinical analysis needs.

Practice point 1: When POCT equipment monitors urinary albumin-to-creatinine ratio (UACR), its sample collection and analysis process should meet relevant quality standards. In addition, quality assessment should also include external quality evaluation and result interpretation.

Practical point 2: When using a POCT device that can measure creatinine, it should generate eGFR using an eGFR formula consistent with that used in the facility/region.

Practical point 3: When a POCT device is used to detect albuminuria, it should also be able to analyze creatinine and generate UACR. When albuminuric patients receive POCT albuminuria testing, the positive rate should be above 95%.

Several studies have demonstrated acceptable accuracy of POCT for measuring creatinine or eGFR in patients who underwent contrast-enhanced CT scans and had an eGFR <30 ml/min/1.73 m2. At the same time, other studies have confirmed that POCT can reduce medical expenses.

Overall, point-of-care testing (POCT) has many advantages in the management of chronic kidney disease (CKD). First, it is convenient for patients to monitor at home, or visit a non-central/large medical institution to avoid the risk of hospital/clinic cross-infection and reduce the need for medical travel. Secondly, POCT is simple to operate (compared to venous blood collection). In addition, the samples used in POCT are whole blood/urine, which avoids the cumbersome process of sample transfer and processing. In addition, since the sample of POCT is usually finger blood, it may be more applicable to pediatric patients. In summary, POCT has many advantages in the management of CKD, which can improve the convenience of patients and the quality of medical care.

According to different recommendations, this summary is divided into recommendations and clinical points for clinicians and clinical laboratories.

01 For Clinicians

Practical point 1: Encourage physicians to clearly understand the relationship between one or two biomarkers (creatinine and cystatin C) and eGFR, clarify their value and limitations, understand the importance of standardization of the two detection methods, and understand When a more accurate assessment of glomerular filtration rate (GFR) is needed.

Practical point 2: Encourage physicians to understand the best way to measure GFR (mGFR) and how to reduce error; if accurate mGFR is not available and eGFR cys (based on cystatin C) is deemed inaccurate, timed urine collection may be considered.

In addition, KDIGO encourages physicians to understand the biological knowledge and laboratory assay variability of creatinine and cystatin C; physicians are encouraged to understand the errors and causes of eGFR, and the reasons for the differences between eGFR cr (based on creatinine) and eGFR cys.

It is worth noting that doctors or nurses should remind patients not to eat too much protein, such as eating too much meat or fish, 12 hours before receiving a cystatin C or creatinine test. When interpreting eGFR results, the causes of eGFR should be considered and communicated to the patient.

02 For clinical laboratories

Clinical Recommendation 1: When reporting serum concentrations of GFR-related biomarkers, eGFR levels should be reported using a valid formula;

Clinical recommendation 2: If eGFR<60ml/min/1.73㎡, it should be marked as "low level";

Clinical Recommendation 3: For serum creatinine testing, whole blood samples should be processed within 12 hours of the venipuncture (serum/plasma separation);

Clinical recommendation 4: Use a specific and accurate method to measure the concentration of GFR-related biomarkers, which can be compared with international standard reference substances, and try to minimize the deviation (1B);

· Clinical recommendation 5: Creatinine levels should be measured using an enzymatic method.

Practical point 1: When cystatin C is measured, serum creatinine levels should be measured at the same time in patients in the same state on the same day or within a reasonable time, so that eGFR cr and eGFR cys can be compared (related reading: Creatinine and cystatin C assessment There may be a significant difference in the GFR of patients, and it is closely related to heart failure);

Practical point 2: If sufficient resources are available, clinical laboratories should allow eGFR cr and eGFR cys as indicators for internal testing or referral testing;

Practice point 3: When the patient is a child, the eGFR formula for children should be used; if the child is >2 years old and the eGFR is <60ml/min/1.73㎡, "decrease" should be marked.

Risk prediction

The 2023 KDIGO CKD guidelines have made important changes in the risk prediction of disease progression in CKD patients. The new guidelines point out that it is difficult to accurately predict the risk of each adverse outcome event solely by eGFR and/or ACR indicators. Therefore, factors such as the patient's demographic characteristics, comorbidities, and lifestyle should be considered comprehensively when performing risk prediction. More importantly, accurate risk prediction models should be used for individualized risk assessment of patients, which is the basis for individualized treatment. Through accurate risk prediction, doctors can better understand the disease progression of patients and formulate more targeted treatment plans, thereby improving the management and treatment outcomes of CKD patients.

It is reported that this KDIGO guideline has revised the "Heat Map" related to CKD staging, and will no longer use the 2012 edition. The following figure is the risk prediction classification map/"heat map" for CKD patients recommended by this guideline. However, the specific definition of CKD stages in this figure needs to wait for the official release of the 2023 KDIGO CKD guidelines.

·Practice point 1: In addition to eGFR, urinary ACR, and other clinical features, referral to nephrology should also be based on whether the risk of renal failure within 5 years is ≥3-5%.

·Practice point 2: In addition to eGFR, urinary ACR, and other clinical characteristics, the timing of multidisciplinary treatment should also be determined according to whether the patient's 10-year renal failure risk is ≥10%.

·Practice point 3: In addition to eGFR, urinary ACR, and other clinical characteristics, the timing of vascular access should also be determined according to whether the patient's risk of renal failure within 2 years is ≥40%.

·Practice point 4: For the prediction of mortality risk in CKD patients, the all-cause mortality risk prediction model established in the CKD population should be used.

The above content is the tip of the iceberg of this guide, please wait for the official release of the 2023 KDIGO CKD guide for more content. It is reported that this guideline will be released in the next few weeks. Please continue to pay attention to the Yimaitong kidney channel to learn about the latest trends in this guideline!

References:

1. Rumeyza Kazancioglu. KDIGO 2023 CKD GL: Evaluation of CKD: What's changed? ERA 2023. Jun 16, 2023.