2024+KDIGO临床实践指南：慢性肾脏病的评估和管理.pdf

KDIGO 2024 CLINICAL PRACTICE GUIDELINEFOR THE EVALUATION AND MANAGEMENTOF CHRONIC KIDNEY DISEASEKidney International(2024)105(Suppl 4S),S117S314S117KDIGO 2024 Clinical Practice Guideline for the Evaluation andManagement of Chronic Kidney DiseaseS118Tables,figures,and supplementary materialS124KDIGO Executive CommitteeS125Reference keysS126CKD nomenclatureS127Conversion factorsS128Abbreviations and acronymsS129NoticeS130ForewordS131Work Group membershipS133AbstractS134Patient forewordS135Introduction,qualifying statements,and key conceptsS141Special considerationsS144Summary of relative and absolute risks relevant to CKD from meta-analysis oflarge multinational population studies in the CKD Prognosis Consortium(CKD-PC)S149Summary of recommendation statements and practice pointsS169Chapter 1:Evaluation of CKDS196Chapter 2:Risk assessment in people with CKDS205Chapter 3:Delaying CKD progression and managing its complicationsS246Chapter 4:Medication management and drug stewardship in CKDS255Chapter 5:Optimal models of careS270Chapter 6:Research recommendationsS274Methods for guideline developmentS283Biographic and disclosure informationS294AcknowledgmentsS295ReferencesThis article is published as part of a supplement sponsored by Kidney Disease:Improving Global Outcomes(KDIGO).Theopinions or views expressed in this supplement are those of the authors and do not necessarily reflect the opinions or rec-ommendations of the International Society of Nephrology or Elsevier.Dosages,indications,and methods of use for productsthat are referred to in the supplement by the authors may reflect their clinical experience or may be derived from the pro-fessional literature or other clinical sources.Because of the differences between in vitro and in vivo systems and betweenlaboratory animal models and clinical data in humans,in vitro and animal data do not necessarily correlate with clinical results.contentswww.kidney-international.orgVOL 105|ISSUE 4S|APRIL 2024S118Kidney International(2024)105(Suppl 4S),S117S314TABLESS137Table 1.Criteria for chronic kidney diseaseS137Table 2.GFR categories in CKDS137Table 3.Albuminuria categories in chronic kidney disease(CKD)S169Table 4.Use of GFR and albuminuriaS171Table 5.Risk factors for CKDS174Table 6.Guidance for selection of additional tests for evaluation of causeS178Table 7.Description of initial and supportive tests for evaluation of GFRS179Table 8.Indications for use of cystatin CS180Table 9.Comparison of estimated GFR and measured GFRS181Table 10.Indications for measured GFRS184Table 11.Implementation standards to ensure accuracy and reliability of GFR assessments using creatinine andcystatin CS184Table 12.Reported examples of substances that may cause analytical interferences in creatinine assaysS187Table 13.Criteria for a validated GFR estimating equationS189Table 14.Validated GFR estimating equationsS190Table 15.Criteria for equation comparison for comparison of candidate equations to another(i.e.,how todetermine validity)S191Table 16.Factors causing biological variation in urine albumin or urine proteinS193Table 17.Implementation standards to ensure accuracy and reliability of urine samplesS198Table 18.Impact of albuminuria/proteinuria on CKD progression in pediatricsS199Table 19.Externally validated risk equations for predicting kidney failure in the general(CKD G3G5)populationS203Table 20.Externally validated risk equations for predicting a 40%decline in GFRS209Table 21.Impact of plant-based foods in people with CKDS212Table 22.Age-based sodium intake recommendationsS222Table 23.Variation of laboratory values in a large population database by age group,sex,and eGFR;bicarbonate,mmol/l,mean(SD),n 3,990,898S223Table 24.Variation of laboratory values in a large population database by age group,sex,and eGFR;potassium,mmol/l,mean(SD),n 4,278,600S225Table 25.Factors and mechanisms that impact on potassium measurementsS226Table 26.Medications associated with increased risk of hyperkalemiaS227Table 27.A comparison of potassium exchange agentsS227Table 28.Suggested action in the event of moderate and severe hyperkalemiaS229Table 29.Variation of laboratory values in a large population database by age group,sex,and eGFR;hemoglobin,g/dl,mean(SD),n 3,561,622S233Table 30.Randomized controlled trials in the treatment of asymptomatic hyperuricemia in people with CKDS247Table 31.Key examples of common medications with documented nephrotoxicity and,where available,selectednon-nephrotoxic alternativesS252Table 32.Medications that should be considered for temporary discontinuation before elective surgeries andpotential perioperative adverse events associated with their continued useS253Table 33.Potential risk factors for contrast-associated acute kidney injuryS256Table 34.Benefits and consequences of early versus late referralS257Table 35.Factors associated with late referral for kidney replacement therapy planningS257Table 36.Outcomes examined in a systematic review by Smart et al.S258Table 37.Recommended patient-reported outcome measurement tools for use in people with CKDwww.kidney-international.orgcontentsKidney International(2024)105(Suppl 4S),S117S314S119S259Table 38.Management strategies for common symptoms in CKDS261Table 39.List of validated assessment tools for malnutritionS262Table 40.Key features of existing CKD care modelsS266Table 41.Indications for the initiation of dialysisS267Table 42.Studies examining the timing of dialysis in people with CKDS268Table 43.People with kidney failure who receive comprehensive conservative careS275Table 44.Clinical questions and systematic review topics in PICOS formatS280Table 45.Classification for certainty of evidenceS280Table 46.GRADE system for grading the certainty of evidenceS281Table 47.KDIGO nomenclature and description for grading recommendationsS281Table 48.Determinants of the strength of recommendationFIGURESS136Figure 1.Associations of chronic kidney disease(CKD)staging by estimated glomerular filtration rate bycreatinine and cystatin C(eGFRcr-cys)and albumin-to-creatinine ratio(ACR)categories and risks for10 common complications by age in multivariable-adjusted analysesS138Figure 2.Age-standardized chronic kidney disease disability-adjusted life-year(DALY)rates for each location bysociodemographic index,both sexes combined,2019S139Figure 3.Screening algorithm for diagnosis and staging of chronic kidney disease(CKD)in adultsS141Figure 4.Special considerations for chronic kidney disease(CKD)care across the lifespanS145Figure 5.Associations of chronic kidney disease(CKD)staging by estimated glomerular filtration rate bycreatinine(eGFRcr)and albumin-to-creatinine ratio(ACR)categories and risks for 10 commoncomplications in multivariable-adjusted analysesS146Figure 6.Associations of chronic kidney disease(CKD)staging by estimated glomerular filtration rate bycreatinine and cystatin C(eGFRcr-cys)and albumin-to-creatinine ratio categories and risks for 10common complications in multivariable-adjusted analysesS147Figure 7.Hazard ratios for adverse outcomes using the continuous model of estimated glomerular filtration rate(eGFR),comparison of the shape of associations between creatinine-based eGFR(eGFRcr)andcreatinine and cystatin Cbased eGFR(eGFRcr-cys)in the population with cystatin C(eGFRcr-cyspopulation)S173Figure 8.Evaluation of cause of chronic kidney disease(CKD)S174Figure 9.Actionable genes in kidney diseaseS175Figure 10.Proposed organization for implementing genetics in nephrologyS177Figure 11.Approach to glomerular filtration rate(GFR)evaluation using initial and supportive testsS182Figure 12.Sources and magnitude of error around measured glomerular filtration rate(mGFR)and estimated GFR(eGFR)S197Figure 13.Frequency of monitoring glomerular filtration rate(GFR)and albuminuria in people with chronickidney disease(CKD)S199Figure 14.(a)Predicted risk of kidney failure and(b)40%decline in estimated glomerular filtration rate(eGFR)by chronic kidney disease(CKD)eGFR(G1G5)and albumin-to-creatinine ratio(ACR)(A1A3)categories in Optum Labs Data WarehouseS201Figure 15.Transition from an estimated glomerular filtration rate(eGFR)-based to a risk-based approach tochronic kidney disease careS202Figure 16.Comparison of risk of chronic kidney disease(CKD)progression(5-year probability of estimatedglomerular filtration rate eGFR 5.5 mmol/l)in chronic kidney diseaseS228Figure 33.Potassium absorption rates of plant-based,animal-based,and processed foodsS229Figure 34.Association between estimated glomerular filtration rate(eGFR)and hemoglobin concentration fromgeneral population and high-risk cohorts from the Chronic Kidney Disease Prognosis Consortium,bydiabetes statusS230Figure 35.Association between estimated glomerular filtration rate(eGFR)with serum concentrations ofparathyroid hormone,phosphate,and serum calcium in general population and high-risk cohortsfrom the Chronic Kidney Disease Prognosis Consortium,by level of albuminuria(A1A3)S233Figure 36.Risk of all-cause and cardiovascular mortality by estimated glomerular filtration rate(eGFR)and level ofalbuminuria from general population cohorts contributing to the Chronic Kidney Disease PrognosisConsortiumS235Figure 37.Effect of lowering low-density lipoprotein(LDL)cholesterol per 1.0 mmol/l on risk of major vascularevents by level of estimated glomerular filtration rate(eGFR)at recruitmentS237Figure 38.Predicted 5-year absolute benefits and harms of allocation to aspirin(A)versus control(C)using asecondary or primary prevention strategy,by different levels of risk(based on age and sex)S240Figure 39.Meta-analyzed adjusted prevalence of atrial fibrillation from cohorts contributing to the Chronic KidneyDisease Prognosis Consortium,by diabetes statusS241Figure 40.Strategies for the diagnosis and management of atrial fibrillationS242Figure 41.Pooled hazard ratio(HR)comparing nonvitamin K antagonist oral anticoagulants(NOACs)withwarfarin among people with chronic kidney disease in terms of strokeS243Figure 42.Pooled hazard ratio(HR)comparing nonvitamin K antagonist oral anticoagulants(NOACs)withwarfarin among people with chronic kidney disease in terms of bleedingS244Figure 43.Evidence from(a)randomized controlled trials(RCTs)regarding therapeutic anticoagulation dose byglomerular filtration rate(GFR)and(b)in areas where RCTs are lackingS245Figure 44.Advice on when to discontinue nonvitamin K antagonist oral anticoagulants(NOACs)beforeprocedures(low vs.high risk)www.kidney-international.orgcontentsKidney International(2024)105(Suppl 4S),S117S314S121S248Figure 45.Selected herbal remedies and dietary supplements with evidence of potential nephrotoxicity,groupedby the continent from where the reports first cameS250Figure 46.Suggested steps in the process of medication review and reconciliationS251Figure 47.Essential steps for appropriate sick day rule implementationS255Figure 48.Circumstances for referral to specialist kidney care services and goals of the referralS258Figure 49.Common symptoms,prevalence,and severity in people with chronic kidney diseaseS261Figure 50.Optimal care model by increasing severity of chronic kidney disease(CKD)S262Figure 51.The chronic care modelS262Figure 52.Specific components of the chronic kidney disease model of careS263Figure 53.Strategy for effective patient education programs for people with chronic kidney disease(CKD)S264Figure 54.Telehealth technologies for people with chronic kidney disease(CKD)S265Figure 55.The process of transition from pediatric to adult care in chronic kidney disease(CKD)S269Figure 56.Relationship between supportive care,comprehensive conservative care,and end-of-life careS279Figure 57.Search yield and study flow diagramSUPPLEMENTARY MATERIALSupplementary File(PDF)Appendix A.Search strategiesTable S1.Search strategies for systematic review topicsAppendix B.Concurrence with Institute of Medicine(IOM)standards for guideline developmentTable S2.Guideline development checklist IOM standards for development of trustworthy clinical practiceguidelinesAppendix C.Data supplement-Summary of findings(SoF)tables cited in the guideline textChapter 1.Evaluation of CKDTable S3.Adults and children with or without CKD,estimated GFR(eGFR)based on measurements of cystatin C(eGFRcys);creatinine(eGFRcr);cystatin C and creatinine(eGFRcr-cys)versus measured GFR(mGFR;using urinary or plasma clearance of exogenous filtration marker)Table S4.Adults and children with suspected or diagnosed CKD,native kidney biopsy versus clinical or standarddiagnosis or prognosis for studies evaluating diagnostic or prognostic benefit;no comparator forstudies evaluating safetyTable S5.Adults and children,machine-read quantitative or semiquantitative protein or albumin urine dipsticktests versus laboratory-based methods for measuring urinary protein or albumin(e.g.,24-hour urinarysample,spot urine protein-to-creatinine ratio PCR,or albumin-to-creatinine ratio ACR)Chapter 2.Risk assessment in people with CKDTable S6.Adults,children,and young people with CKD G1G5,C-statistics of kidney failure risk equations forpredicting progression(e.g.,Tangri equation KFRE)Table S7.Adults,children,and young people with CKD G1G5,Brier scores of kidney failure risk equations forpredicting progression(e.g.,Tangri equation KFRE)Table S8.Adults,children,and young people with CKD G1G5,R2statistics of kidney failure risk equations forpredicting progression(e.g.,Tangri equation KFRE)Table S9.Adults,children,and young people with CKD G1G5,sensitivity and specificity to start kidneyreplacement therapy(KRT)for kidney failure risk equations for predicting progression(e.g.,Tangriequation KFRE)Chapter 3.Delaying CKD progression and managing its complicationsTable S10.Adults and children with CKD,sodium-glucose cotransporter-2 inhibitors(SGLT2i)versus placebo orusual care;active comparator(e.g.,another glucose-lowering agent)Table S11.Adults and children with CKD and symptomatic hyperuricemia,uric acidlowering therapy(ULT;allopurinol,benzbromarone,febuxostat,oxipurinol,pegloticase,probenecid,topiroxostat,rasburicase,sulfinpyrazone,lesinurad)versus active comparator,placebo,or usual careTable S12.Adults and children with CKD and asymptomatic hyperuricemia,uric acidlowering therapy(ULT;allopurinol,benzbromarone,febuxostat,oxipurinol,pegloticase,probenecid,topiroxostat,rasburicase,sulfinpyrazone,lesinurad)versus active comparator,placebo,or usual careTable S13.Adults and children with CKD and ischemic heart disease,angiography or coronary revascularizationversus medical treatmentcontentswww.kidney-international.orgS122Kidney International(2024)105(Suppl 4S),S117S314Table S14.Adults and children with CKD and atrial fibrillation,nonvitamin K antagonist oral anticoagulant(NOAC)with warfarin or NOAC alone versus medical treatmentstroke outcomesTable S15.Adults and children with CKD and atrial fibrillation,nonvitamin K antagonist oral anticoagulant(NOAC)with warfarin or NOAC alone versus medical treatmentbleeding outcomesAppendix D