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Staging of CKD: Is a New Stage Needed

2008; Elsevier BV; Volume: 51; Issue: 2 Linguagem: Inglês

10.1053/j.ajkd.2007.11.016

1523-6838

Suresh C. Tiwari, Dipankar Bhowmik,

Pharmacological Effects and Toxicity Studies

According to the current Kidney Disease Outcomes Quality Initiative (KDOQI) guidelines, all chronic kidney disease (CKD) patients with glomerular filtration rate (GFR) less than 15 mL/min/1.73 m2 (0.25 mL/s/1.73 m2) are classified as stage 5 CKD.1National Kidney FoundationK/DOQI clinical practice guidelines for chronic kidney disease: evaluation, classification, and stratification.Am J Kidney Dis. 2002; 39: S1-S266Abstract Full Text Full Text PDF PubMed Scopus (232) Google Scholar Renal replacement therapy (RRT) is recommended for this group of patients. The subscript D or T is appended to the stage if the patient is on dialysis or has been transplanted, respectively. According to the European Best Practice Guidelines,2European Best Practice Guidelines Expert Group on Hemodialysis, European Renal AssociationMeasurement of renal function, when to refer and when to start dialysis.Nephrol Dial Transplant. 2002; 17: 7-15Google Scholar in the presence of any uremic symptom, dialysis should be started when GFR is less than 15 mL/min/1.73 m2. Even if there are no symptoms, physicians should aim to start dialysis at a GFR of 8 to 10 mL/min/1.73 m2 (0.13-0.17 mL/s/1.73 m2) so that dialysis is definitely started before GFR drops below 6 mL/min/1.73 m2 (0.10 mL/s/1.73 m2). In developing countries where finances are a problem, large numbers of CKD patients continue on (often suboptimal) conservative therapy late into the disease when GFR is even as low as 2 to 3 mL/min/1.73 m2 (0.03-0.05 mL/s/1.73 m2). Although we advise initiation of RRT to these patients, they are unable to do so because of lack of resources. Subsequently, these patients develop severe anemia, malnutrition, cardiomyopathy, bone disease, infections, and other complications of uremia, which are uncommonly seen nowadays in the developed world. There is another group of patients who present directly to the tertiary care center with advanced azotemia. They are stabilized with a few sessions of dialysis and advised to continue RRT with their own resources, which they are unable to do. Once the acute emergency has settled, they continue on conservative therapy for as long as possible. Presently, both these groups with very low GFR on conservative therapy are also classified as stage 5 CKD. The clinical presentation of stage 5 CKD is very heterogeneous. At one end of the spectrum, a patient having a GFR of 14 mL/min/1.73 m2 (0.23 mL/s/1.73 m2) may be quite fit, and at the other end, a patient having a GFR of 4 mL/min/1.73 m2 (0.07 mL/s/1.73 m2) with complications of uremia may be on the brink of survival. Hence, we propose that a new stage, namely, stage 6 CKD, may be added for proper classification of this group of patients. Ideally this situation should not arise, but in reality this situation is likely to persist for the near future in developing countries. One of the main aims of staging CKD is to help the general public easily understand the increasing number and severity of complications associated with progressive fall in GFR. Adding stage 6 CKD will help in emphasizing the seriousness of the situation to patients. Moreover, it will also help in maintaining a proper database for subsequent analysis and for planning prospective interventional studies. Letters to the Editor may be in response to an article in AJKD or may concern a topic of interest to currentnephrology. For responses to AJKD articles, the Letter must be received no more than 6 weeks after the article's date of print publication. The body of the letter should be as concise as possible and in general should not exceed 250 words. Up to 10 references and 1 figure or table may be included. There is no guarantee that letters will be published. Letters are subject to editing and abridgment without notice.Letters should be submitted via AJKD's online manuscript handling site, http://www.editorialmanager.com/ajkd. More information, including details about how to contact the editorial staff for assistance, is available in the journal's Information for Authors. Letters to the Editor may be in response to an article in AJKD or may concern a topic of interest to currentnephrology. For responses to AJKD articles, the Letter must be received no more than 6 weeks after the article's date of print publication. The body of the letter should be as concise as possible and in general should not exceed 250 words. Up to 10 references and 1 figure or table may be included. There is no guarantee that letters will be published. Letters are subject to editing and abridgment without notice. Letters should be submitted via AJKD's online manuscript handling site, http://www.editorialmanager.com/ajkd. More information, including details about how to contact the editorial staff for assistance, is available in the journal's Information for Authors. Support: None. Financial Disclosure: None.