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Clinical Practice Guidelines onic Kidney Disease: CLINICAL PRACTICE GUIDELINES Evaluation, Classification and Stratification For Chr K/DOQI CLINICAL PRACTICE GUIDELINES For Chronic Kidney Disease eet .org d Str ork, NY 10016 .kidney Phone 800 622-9010 www New Y 30 East 33r . and Bayer Diagnostics. ible through an educational grant from Amgen, der No. K/DOQI-156 Founding and Principal Sponsor of NKF-K/DOQI.™ Products, L.P Made poss Additional implementation support was received from Ortho Biotech K/DOQI Learning System (KLS)™ ISBN 1-931472-10-6 NKF Or Amgen Part No. P35181 Clinical Practice Guidelines For Chronic Kidney Disease: Evaluation, Classification and Stratification K/DOQI Disclaimer These guidelines are based upon the best information available at the time of publica- tion. They are designed to provide information and assist decision making. They are not intended to define a standard of care, and should not be construed as doing so. Neither should they be interpreted as prescribing an exclusive course of management. Variations in practice will inevitably and appropriately occur when clinicians take into account the needs of individual patients, available resources, and limitations unique to an institution or type of practice. Every healthcare professional making use of these guidelines is responsible for evaluating the appropriateness of applying them in the setting of any particular clinical situation. The recommendations for research contained within this document are general and not meant to imply a specific protocol. GENERAL ACKNOWLEDGEMENTS The NKF gratefully acknowledges the support of Amgen, Inc., Founding and Principal Sponsor of K/DOQI. We also thank Bayer Diagnostics and Ortho Biotech Products, L.P., K/DOQI Imple- mentation Partners. NKF-DOQI and K/DOQI are trademarks of the National Kidney Foundation, Inc. In citing this document, please refer to the original source as follows: National Kidney Foundation. K/DOQI Clinical Practice Guidelines for Chronic Kid- ney Disease: Evaluation, Classification and Stratification. Am J Kidney Dis 39:S1-S266, 2002 (suppl 1) These Guidelines, as well as all other K/DOQI guidelines, can be accessed on the Internet at: www.kdoqi.org ᭧ 2002 National Kidney Foundation, Inc. ISBN 1-931472-10-6 All Rights Reserved. No part of this publication may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopy, recording, or any information storage retrieval system, without permission in writing from the National Kidney Foundation, Inc. National Kidney Foundation, Inc. 30 E. 33rd Street New York, NY 10016 212-889-2210 ii National Kidney Foundation K/DOQI Chronic Kidney Disease Work Groupand Evidence Review Team Membership Andrew S. Levey, MD, Chair New England Medical Center Boston, MA Josef Coresh, MD, PhD, Vice Chair Johns Hopkins Medical Institutions Baltimore, MD Adult Work Group Members Kline Bolton, MD, FACP John Kusek, PhD University of Virginia Hospital National Institutes of Diabetes and Charlotesville, VA Digestive and Kidney Diseases Bethesda, MD Bruce Culleton, MD Foothills Hospital, University of Adeera Levin, MD, FRCP Calgary St. Paul’s Hospital Calgary, Alberta Vancouver, British Columbia Canada Canada Kathy Schiro Harvey, MS, RD, CSR Kenneth L. Minaker, MD Puget Sound Kidney Center Massachusetts General Hospital Mountlake Terrace, WA Boston, MA T. Alp Ikizler, MD Robert Nelson, MD, PhD Vanderbilt University Medical Center National Institutes of Diabetes and Nashville, TN Digestive and Kidney Diseases Phoenix, AZ Cynda Ann Johnson, MD, MBA University of Iowa Helmut Rennke, MD Iowa City, IA Brigham & Women’s Hospital Boston, MA Annamaria Kausz, MD, MS New England Medical Center Michael Steffes, MD, PhD Boston, MA University of Minnesota Minneapolis, MN Paul L. Kimmel, MD National Institutes of Diabetes and Beth Witten, MSW, ACSW, LSCSW Digestive and Kidney Diseases Witten and Associates, LLC Bethesda, MD Overland Park, KS K/DOQI National Kidney Foundation iii Pediatric Work Group Members Ronald J. Hogg, MD, Chair Medical City Hospital Dallas, TX Susan Furth, MD, PhD Ronald J. Portman, MD Johns Hopkins University University of Texas Health Sciences Baltimore, MD Center—Houston Houston, TX Kevin V. Lemley, MD, PhD Stanford University School of Medicine George Schwartz, MD Stanford, CT University of Rochester School of Medicine Rochester, NY Evidence Review Team Joseph Lau, MD, Director New England Medical Center Boston, MA Ethan Balk, MD, MPH, Assistant Director New England Medical Center Boston, MA Ronald D. Perrone, MD Priscilla Chew, MPH Tauqeer Karim, MD Brad C. Astor, PhD, MPH Lara Rayan, MD Deirdre DeVine, MLitt Inas Al-Massry, MD K/DOQI Support Group Garabed Eknoyan, MD, Co-Chair Baylor College of Medicine Houston, TX Nathan Levin, MD, FACP, Co-Chair Renal Research Institute New York, NY Sally Burrows-Hudson, RN Donna Mapes, DNSc, RN William Keane, MD Edith Oberley, MA Alan Kliger, MD Kerry Willis, PhD Derrick Latos, MD, FACP iv National Kidney Foundation K/DOQI K/DOQI Advisory Board Members Garabed Eknoyan, MD, Co-Chair Baylor College of Medicine Houston, TX Nathan Levin, MD, FACP, Co-Chair Renal Research Institute New York, NY George Bailie, PharmD, PhD Sally McCulloch, MSN, RN, CNN Gavin Becker, MD, MBBS Maureen Michael, BSN, MBA Jerrilynn Burrowes, MS, RD, CDN Joseph V. Nally, MD David Churchill, MD, FACP John M. Newmann, PhD, MPH Allan Collins, MD, FACP Allen Nissenson, MD William Couser, MD Keith Norris, MD Dick DeZeeuw, MD, PhD William Owen, Jr., MD Alan Garber, MD, PhD Thakor G. Patel, MD, MACP Thomas Golper, MD Glenda Payne, MS, RN, CNN Frank Gotch, MD Rosa A. Rivera-Mizzoni, MSW, Antonio Gotto, MD LCSW Joel W. Greer, PhD David Smith Richard Grimm, Jr., MD Robert Star, MD Ramon G. Hannah, MD, MS Michael Steffes, MD, PhD Jaime Herrera Acosta, MD Theodore Steinman, MD Ronald Hogg, MD Fernando Valderrabano, MD, PhD Lawrence Hunsicker, MD John Walls, MB, FRCP Cynda Ann Johnson, MD, MBA Jean-Pierre Wauters, MD Michael Klag, MD, MPH Nanette Wenger, MD Saulo Klahr, MD Caya Lewis, MPH Ex-Officio Edmund Lowrie, MD Josephine Briggs, MD Arthur Matas, MD K/DOQI National Kidney Foundation v K/DOQI CLINICAL PRACTICE GUIDELINES FOR CHRONIC KIDNEY DISEASE: EVALUATION CLASSIFICATIONAND STRATIFICATION Table of Contents Tables ...........................................................................................................................viii Figures ......................................................................................................................... xiii Acronyms and Abbreviations .................................................................................xvii Foreword .................................................................................................................. xxiii Part 1. Executive Summary ........................................................................................ 1 Part 2. Background .................................................................................................... 23 Part 3. Chronic Kidney Disease as a Public Health Problem ............................ 29 Part 4. Definition and Classification of Stages of Chronic Kidney Disease Guideline 1. Definition and Stages of Chronic Kidney Disease ............................... 43 Guideline 2. Evaluation and Treatment .................................................................... 66 Guideline 3. Individuals at Increased Risk of Chronic Kidney Disease ................... 75 Part 5. Evaluation of Laboratory Measurements for Clinical Assessment of Kidney Disease Guideline 4. Estimation of GFR ................................................................................ 81 Guideline 5. Assessment of Proteinuria .................................................................. 100 Guideline 6. Markers of Chronic Kidney Disease Other Than Proteinuria ........... 112 Part 6. Association of Level of GFR With Complications in Adults Guideline 7. Association of Level of GFR With Hypertension ............................... 124 Guideline 8. Association of Level of GFR With Anemia ........................................ 136 Guideline 9. Association of Level of GFR With Nutritional Status ........................ 145 Guideline 10. Association of Level of GFR With Bone Disease and Disorders of Calcium and Phosphorus Metabolism ............................................ 163 Guideline 11. Association of Level of GFR With Neuropathy ............................... 180 Guideline 12. Association of Level of GFR With Indices of Functioning and Well-Being ..................................................................................................... 186 Part 7. Stratification of Risk for Progression of Kidney Disease and Development of Cardiovascular Disease Guideline 13. Factors Associated With Loss of Kidney Function in Chronic Kidney Disease .................................................................................................... 197 Guideline 14. Association of Chronic Kidney Disease With Diabetic Complications ...................................................................................................... 230 Guideline 15. Association of Chronic Kidney Disease With Cardiovascular Disease ................................................................................................................. 238 K/DOQI National Kidney Foundation vii Part 8. Recommendations for Clinical Performance Measures ...................... 251 Part 9. Approach to Chronic Kidney Disease Using These Guidelines ......... 255
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