Chronic kidney disease

Management
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 system
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show a decreasing incidence of 
kidney failure in some high-risk groups—eg, in young 
people with diabetes—suggesting benefi cial eff ects of 
these interventions. Despite these remarkable advances, 
the detection, assessment, and management of chronic 
disease are not fully understood.
Disease management is based on clinical diagnosis 
and stage according to GFR and albuminuria. 
Identifi cation of clinical diagnosis allows for specifi c 
therapy that is directed at the cause and pathological 
processes. Thereafter, disease stage can be used to 
guide non-specifi c therapies to slow progression and 
reduce the risk of complications. Stage-based recom-
mendations are cumulative—ie, recom men dations for 
late stages include recommendations for early stages. 
Guidelines for stage-based recommen 
dations have 
simplifi ed the management of chronic kidney disease 
(table 1, webappendix pp 1–10); however because of an 
inadequate evidence base, thresholds for stage-based 
testing and treatment are uncertain. Despite many 
clinical trials, important clinical questions are 
unanswered (table 2, webappendix pp 11–19). Many 
trials have been underpowered or have relied on 
surrogate rather than clinical outcomes. Other trials 
have been diffi
cult to interpret because of fi ndings for 
both benefi ts and harms.
Practice models for the care of patients with chronic 
kidney disease will probably vary according to the 
availability of nephrologists and other specialists. Not all 
patients need referral to nephrologists; many common 
problems can be managed with existing guidelines by 
generalists and non-nephrology specialists. Referral is 
generally recommended for stage 4 disease, but early 
referral is recommended for patients with very high 
concentrations of albuminuria or with complications of 
decreased GFR that are diffi
cult to manage.
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