Chronic kidney disease prediction is an inexact science: The concept of “progressors” and “nonprogressors”

Abstract

In 2002, the National Kidney Foundation Kidney Disease Outcomes Quality Initiative (NKF KDOQI) instituted new guidelines that established a novel chronic kidney disease (CKD) staging paradigm. This set of guidelines, since updated, is now very widely accepted around the world. Nevertheless, the authoritative United States Preventative Task Force had in August 2012 acknowledged that we know surprisingly little about whether screening adults with no signs or symptoms of CKD improve health outcomes and that we deserve better information on CKD. More recently, the American Society of Nephrology and the American College of Physicians, two very well respected United States professional physician organizations were strongly at odds coming out with exactly opposite recommendations regarding the need or otherwise for ”CKD screening” among the asymptomatic population. In this review, we revisit the various angles and perspectives of these conflicting arguments, raise unanswered questions regarding the validity and veracity of the NKF KDOQI CKD staging model, and raise even more questions about the soundness of its evidence-base. We show clinical evidence, from a Mayo Clinic Health System Renal Unit in Northwestern Wisconsin, United States, of the pitfalls of the current CKD staging model, show the inexactitude and unpredictable vagaries of current CKD prediction models and call for a more cautious and guarded application of CKD staging paradigms in clinical practice. The impacts of acute kidney injury on CKD initiation and CKD propagation and progression, the effects of such phenomenon as the syndrome of late onset renal failure from angiotensin blockade and the syndrome of rapid onset end stage renal disease on CKD initiation, CKD propagation and CKD progression to end stage renal disease all demand further study and analysis. Yet more research on CKD staging, CKD prognostication and CKD predictions is warranted. Finally and most importantly, cognizant of the very serious limitations and drawbacks of the NKF K/DOQI CKD staging model, the need to individualize CKD care, both in terms of patient care and prognostication, cannot be overemphasized.

Keywords: Acute kidney injury, Chronic kidney disease, Chronic kidney disease staging, Estimated glomerular filtration rate, End stage renal disease, National Kidney Foundation Kidney Disease Outcomes Quality Initiative, Renal replacement therapy, Serum creatinine, Syndrome of late onset renal failure from angiotensin blockade, Syndrome of rapid onset end stage renal disease

Core tip: In 2002, the National Kidney Foundation established a novel chronic kidney disease (CKD) staging paradigm. In 2012, the authoritative United States Preventative Task Force questioned the validity of asymptomatic CKD screening. The American Society of Nephrology and the American College of Physicians have opposite recommendations regarding this controversy. We examined the evidence-base and limitations of CKD staging. Furthermore, we show clinical evidence of pitfalls of the current CKD staging model and the failings of current CKD prediction models. We called for more research into CKD to end stage renal disease translations including the impact of acute kidney injury on this continuum. CKD care and prognostication must be individualized.