What do Kidney Disease Outcomes Quality Initiative (KDOQI) and Kidney Disease: Improving Global Outcomes (KDIGO) guidelines recommend for managing patients with kidney disease?

KDOQI and KDIGO Guidelines for Managing Kidney Disease

Both KDOQI (Kidney Disease Outcomes Quality Initiative) and KDIGO (Kidney Disease: Improving Global Outcomes) provide comprehensive, evidence-based guidelines for the evaluation and management of chronic kidney disease (CKD), with KDIGO serving as the international standard and KDOQI often providing US-specific commentary and implementation guidance.

Definition and Classification of CKD

Current Definition

• CKD is defined as abnormalities of kidney structure or function present for >3 months with implications for health 1
• Diagnosis requires either:
  • GFR <60 mL/min/1.73 m² for ≥3 months
  • Evidence of kidney damage (albuminuria, urine sediment abnormalities, electrolyte disorders, histological abnormalities, structural abnormalities, or history of kidney transplantation) 1

Classification System

• GFR Categories:

  • G1: ≥90 mL/min/1.73 m² (normal or high)
  • G2: 60-89 mL/min/1.73 m² (mildly decreased)
  • G3a: 45-59 mL/min/1.73 m² (mildly to moderately decreased)
  • G3b: 30-44 mL/min/1.73 m² (moderately to severely decreased)
  • G4: 15-29 mL/min/1.73 m² (severely decreased)
  • G5: <15 mL/min/1.73 m² (kidney failure) 1

• Albuminuria Categories:

  • A1: <30 mg/g (normal to mildly increased)
  • A2: 30-300 mg/g (moderately increased)
  • A3: >300 mg/g (severely increased) 1

Key Evaluation Recommendations

1. GFR Assessment:

   • In adults at risk for CKD, use creatinine-based eGFR (eGFRcr)
   • If cystatin C is available, use combined creatinine and cystatin C (eGFRcr-cys) for more accurate estimation 1

2. Albuminuria Testing:

   • Test people at risk for CKD using both urine albumin measurement and GFR assessment 1
   • Confirm abnormal findings with repeat testing 1

3. Establishing Chronicity:

   • Confirm CKD with evidence of at least 3 months duration through past measurements, imaging findings, or pathological findings 1
   • Do not assume chronicity based on a single abnormal test 1

Management of CKD

Glycemic Control in Diabetic Kidney Disease

• KDOQI recommends individualized HbA1c targets based on risk of hypoglycemia and comorbidities
• Target HbA1c of approximately 7% to reduce risk of microvascular complications 1
• Avoid intensive glycemic control in patients at high risk for hypoglycemia 1

Lipid Management

• Statin therapy is recommended for all adults with diabetes and CKD 1
• No specific lipid targets are recommended; instead, focus on overall cardiovascular risk reduction 1

Blood Pressure Control

• Target blood pressure goals should be lower in patients with proteinuria 1
• KDIGO recommends:
  • BP target ≤140/90 mmHg in CKD without albuminuria
  • BP target ≤130/80 mmHg in CKD with albuminuria (>30 mg/g) 1

Albuminuria Management

• Use of ACE inhibitors or ARBs is recommended for patients with:
  • Diabetes and albuminuria >30 mg/g
  • Non-diabetic CKD with albuminuria >300 mg/g 1

Glomerulonephritis Management

• KDIGO provides specific treatment recommendations for various forms of glomerulonephritis based on pathological diagnosis 1
• Treatment approaches vary by specific glomerular disease and may include:
  • Immunosuppressive therapy
  • Corticosteroids
  • Cytotoxic agents
  • Targeted biologics 1

Monitoring and Progression

Monitoring Recommendations

• Frequency of monitoring should be based on CKD stage and risk of progression
• Monitor eGFR and albuminuria at least annually in stable patients, more frequently in those at higher risk 1
• Assess for complications (anemia, bone disorders, acidosis) based on CKD stage 1

CKD-Mineral Bone Disorder (CKD-MBD)

• Monitor serum calcium, phosphorus, PTH, and alkaline phosphatase based on CKD stage
• Manage phosphate binders, vitamin D analogs, and calcimimetics based on laboratory parameters 2, 3

Implementation Considerations

Multidisciplinary Care

• Team-based care including nephrologists, primary care physicians, pharmacists, dietitians, and other specialists improves outcomes 1
• Early nephrology referral is recommended for:
  • GFR <30 mL/min/1.73 m²
  • Significant albuminuria (>300 mg/g)
  • Rapid progression of kidney disease
  • Persistent hypertension despite optimal therapy
  • Recurrent or extensive nephrolithiasis 1

Common Pitfalls to Avoid

1. Relying solely on serum creatinine without calculating eGFR
2. Failing to test for albuminuria in high-risk patients
3. Not confirming abnormal findings with repeat testing
4. Overlooking non-albuminuric CKD presentations
5. Delaying nephrology referral until advanced CKD stages

Evolution of Guidelines

Both KDOQI and KDIGO guidelines have evolved over time, with KDIGO now serving as the primary international guideline developer for kidney disease, while KDOQI provides US-specific commentary and implementation guidance 1. The most recent updates have incorporated race-free eGFR equations and emphasized the importance of albuminuria in risk stratification 1.