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Kidney Int. 2018 Jun;93(6):1281-1292. doi: 10.1016/j.kint.2018.02.006. Epub 2018 Apr 12.

Improving the prognosis of patients with severely decreased glomerular filtration rate (CKD G4+): conclusions from a Kidney Disease: Improving Global Outcomes (KDIGO) Controversies Conference.

Author information

1
Department of Nephrology and Medical Intensive Care, Charité - Universitätsmedizin Berlin, Berlin, Germany. Electronic address: kai-uwe.eckardt@charite.de.
2
Kidney Research Institute, Division of Nephrology, University of Washington, Seattle, Washington, USA.
3
Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA.
4
Division of Renal Medicine, CLINTEC, Karolinska Institutet, Stockholm, Sweden; Swedish Renal Registry, Jönköping, Sweden.
5
Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA; Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA.
6
Chronic Disease Research Group, Minneapolis Medical Research Foundation, Minneapolis, Minnesota, USA; Division of Cardiology, Department of Medicine, Hennepin County Medical Center and University of Minnesota, Minneapolis, Minnesota, USA.
7
Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada; Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada.
8
Department of Clinical Pharmacy and Pharmacology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands.
9
Department of Renal Medicine, Royal North Shore Hospital, Sydney, New South Wales, Australia; Sydney Medical School, The University of Sydney, Sydney, New South Wales, Australia.
10
Kent Kidney Care Centre, East Kent Hospitals, University NHS Foundation Trust, Canterbury, Kent, UK.
11
VA Palo Alto Geriatric Research and Education Clinical Center, Palo Alto, California, USA; Division of Nephrology, Stanford University School of Medicine, Palo Alto, California, USA.
12
Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada.
13
University College London, London, UK.
14
Selzman Institute for Kidney Health, Section of Nephrology, Department of Medicine, Baylor College of Medicine, Houston, Texas, USA.
15
KDIGO, Brussels, Belgium.
16
Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada; Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada. Electronic address: brenda.hemmelgarn@ahs.ca.

Abstract

Patients with severely decreased glomerular filtration rate (GFR) (i.e., chronic kidney disease [CKD] G4+) are at increased risk for kidney failure, cardiovascular disease (CVD) events (including heart failure), and death. However, little is known about the variability of outcomes and optimal therapeutic strategies, including initiation of kidney replacement therapy (KRT). Kidney Disease: Improving Global Outcomes (KDIGO) organized a Controversies Conference with an international expert group in December 2016 to address this gap in knowledge. In collaboration with the CKD Prognosis Consortium (CKD-PC) a global meta-analysis of cohort studies (n = 264,515 individuals with CKD G4+) was conducted to better understand the timing of clinical outcomes in patients with CKD G4+ and risk factors for different outcomes. The results confirmed the prognostic value of traditional CVD risk factors in individuals with severely decreased GFR, although the risk estimates vary for kidney and CVD outcomes. A 2- and 4-year model of the probability and timing of kidney failure requiring KRT was also developed. The implications of these findings for patient management were discussed in the context of published evidence under 4 key themes: management of CKD G4+, diagnostic and therapeutic challenges of heart failure, shared decision-making, and optimization of clinical trials in CKD G4+ patients. Participants concluded that variable prognosis of patients with advanced CKD mandates individualized, risk-based management, factoring in competing risks and patient preferences.

KEYWORDS:

chronic kidney disease; kidney failure; prediction; prognosis; progression; supportive care

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