1 : GFR > 90 (normal to increased) 2 : GFR 60-89 (mildly decreased) 3 : GFR 30-59 (moderately decreased) 4 : GFR 15-29 (severely decreased) 5 : GFR <15 (failure) 6 : DIALYSIS (source: National Kidney Foundation, KDOQI)
Often occur late (<6 months before eventual start of RRT) ~20-50% first referred <4 months (multiple studies) Due to both patient and physician biases Studies suggest increased all-cause mortality in patients referred late.
Suggested for women with SCr > 1.2 and men with SCr > 1.5, or anyone with CKD 3 Why so early? CKD can progress at different rates Reversible causes (vasculitis, etc) Access Management of comorbidities Anemia, Bone-Mineral Metabolism… Living Donor Allograft Dialysis discussions
Currently a topic of contention in the nephrology world Cockraft Gault Equation: Age, weight effects Loose guidelines now suggested by multiple entities: K/DOQI (2006): GFR < 15 (CKD 5) Europe Best Practices (2005): consider when GFR 8- 10, definitely start when GFR < 6
Why the uncertainty? No study to date has effectively proven a survival benefit with earlier initiation of RRT Proposed morbitity benefits: Liberal Nutrition HTN control IDEAL Trial Prospective study underway in Australia/NZ GFR 10 vs 14 when starting RRT
Current (2007) UpToDate National Kidney Foundation IDEAL San Diego Zoo