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Too much nephrology? The CKD epidemic is real and concerning. A CON view
1Department of Nephrology-Dialysis-Transplantation, University of Liège (ULg CHU), CHU Sart Tilman, Liège, Belgium.
Insights
Chronic kidney disease (CKD) prevalence may be overestimated due to fixed glomerular filtration rate (GFR) thresholds and ignoring the chronicity criterion. Re-testing GFR is crucial for accurate CKD diagnosis.
Area of Science:
- Nephrology
- Epidemiology
- Public Health
Background:
- The 2012 Kidney Disease: Improving Global Outcomes (KDIGO) guidelines define chronic kidney disease (CKD) based on kidney structure or function abnormalities lasting over three months.
- Key markers include a glomerular filtration rate (GFR) below 60 mL/min/1.73 m² and albuminuria (albumin excretion rate >30 mg/24 h or albumin/creatinine ratio [ACR] >30 mg/g).
Purpose of the Study:
- To critically evaluate the current definition of CKD used in epidemiological studies.
- To investigate whether the fixed GFR threshold and the lack of confirmed chronicity lead to an overestimation of CKD prevalence.
Main Methods:
- Analysis of the KDIGO 2012 definition for CKD.
- Examination of the impact of age on normal GFR levels.
- Review of epidemiological study methodologies regarding the chronicity criterion for CKD.
Main Results:
- The fixed GFR threshold of 60 mL/min/1.73 m² is questionable as normal GFR declines with age.
- Many individuals initially diagnosed with low GFR show normal levels upon re-testing, indicating a lack of chronicity.
- These factors likely contribute to an overestimation of CKD prevalence in current studies.
Conclusions:
- The prevalence of CKD might be considerably lower than reported in many epidemiological studies.
- Re-evaluating the definition and diagnostic criteria, particularly emphasizing chronicity, is essential for accurate CKD prevalence assessment.
- Despite potential overestimation, CKD remains a significant health concern.
Abstract:
The prevalence of chronic kidney disease (CKD) clearly depends on its definition, and the definition used most often is the one proposed by the Kidney Disease: Improving Global Outcomes guidelines in 2012: 'CKD is defined as abnormalities of kidney structure or function, present for >3 months, with implications for health.' Abnormality of kidney function is a glomerular filtration rate (GFR) <60 mL/min/1.73 m2, and the most frequently used marker of kidney damage is the presence of albuminuria [albumin excretion rate >30 mg/24 h or albumin/creatinine ratio (ACR) >30 mg/g (or 3 mg/mmol)]. However, two major aspects of this definition could explain why CKD prevalence is, in our view, overstated in most epidemiological studies. First, the fixed threshold at 60 mL/min/1.73 m2 is questionable because normal GFR decreases with age. This and the profound consequence it has on CKD epidemiology will be illustrated. The second aspect of the definition is the criterion of chronicity, which is ignored by the vast majority of epidemiological studies. In other words, confirming CKD (low GFR and/or high ACR) is mandatory. Indeed, a large proportion of subjects with a low first GFR level has a normal GFR level when tested a second time. The prevalence of CKD may hence, in fact, be considerably lower although still neither negligible nor irrelevant.
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