http://www.kidney-international.

org review
& 2013 International Society of Nephrology

Summary of KDIGO 2012 CKD Guideline: behind
the scenes, need for guidance, and a framework
for moving forward
Adeera Levin1 and Paul E. Stevens2
1
Division of Nephrology, University of British Columbia, Vancouver, British Columbia, Canada and 2East Kent Hospitals University NHS
Foundation Trust, Canterbury, UK

The 2012 KDIGO Guideline for CKD evaluation, classification, After a decade of focused research and clinical practice in
and management has updated the original 2002 KDOQI chronic kidney disease (CKD), the 2012 Kidney Disease:
Guidelines, using newer data and addressing issues raised Improving Global Outcomes (KDIGO) Clinical Practice
over the last decade concerning definitions and assessment. Guideline for the Evaluation and Management of CKD1
This review highlights the key aspects of the CKD guideline, serves to update the original 2002 Kidney Disease Outcomes
and describes the rationale for specific wording and the Quality Initiative (KDOQI) Clinical Practice Guidelines for
scope of the document. A pre´cis of key concepts in each of CKD: Evaluation, Classification, and Stratification.2 That
the five sections of the guideline is presented. The guideline decade has brought controversy, validation, and new ideas
document is intended for general practitioners and but has also highlighted CKD as global public health issue.3
nephrologists, and covers CKD evaluation, classification, and Through use of a common language and classification
management for both adults and children. Throughout the system, the original guidance stimulated new knowledge,
guideline, we have attempted to overtly address areas of resulting in the need for this new guideline.
controversy or non-consensus, international relevance, and It is beyond the scope of this document to review each
impact on practice and public policy. statement and all the nuances and issues related to the
Kidney International (2013) 85, 49–61; doi:10.1038/ki.2013.444; guideline development, so the reader is encouraged to read
published online 27 November 2013
the original document. This overview is intended to highlight
KEYWORDS: chronic kidney disease (CKD); classification; complications; the important concepts in the guideline, some old and some
guidelines; KDIGO; management; progression
new. Moreover, we wish to ensure an understanding of the
rationale for specific wording, and how and why specific
topics were or were not addressed, and the depth to which
they were addressed. Throughout the guideline, we have
attempted to overtly address areas of controversy or non-
consensus, international relevance, and impact on practice
and public policy. The reader is encouraged to review those
specific areas within each of the sections in addition to the
scientific and evidence base for rationale, so as to gain further
insights into the specific recommendation statement.
The guideline document1 aims to provide state-of-the-art
guidance on the evaluation, management, and treatment for
both adult and pediatric populations with CKD. The
intended audience is diverse and includes nephrologists,
primary-care practitioners, and other specialists, as well as
allied health-care professionals. We appreciate that different
health-care systems exist around the world, and so attempt to
provide best practice recommendations. It is recognized that
there will be variation in the ability to implement some of the
Correspondence: Adeera Levin, Division of Nephrology, University of British recommendations in different jurisdictions, but by
Columbia, 1081 Burrard Street, Room 6010A, Vancouver, British Columbia identifying best practices and describing the evidence base,
V6Z1Y6, Canada. E-mail: alevin@providencehealth.bc.ca we hope to encourage advocacy for those best practices to
Received 12 August 2013; revised 27 September 2013; accepted 10 improve the care of patients with CKD around the world.
October 2013; published online 27 November 2013 Individual country commentaries and implementation

Kidney International (2014) 85, 49–61 49

These recommendations importance of albuminuria as a key dimension in risk are often rated with a low strength of recommendation and a assessment.. based on substantial data that Some argue that recommendations should not be made there are differences in outcomes and risk for those who have when evidence is weak.5%) were ‘1C. comprehensive guidance document that was transparent and Some have argued that there will be problems in removing useful. we have added a statement that emphasizes than quality of evidence to make a grade 1 or 2 the need to include cause and albuminuria categories in recommendation. public groups consulted.’ 13 (18. the reader is also educated about the guidance. and controversy or relevance. measures.’ There were 9 that CKD is not a diagnosis but rather a condition or (13. but again we offer purposes. and albuminuria (CGA) system. It is recognized that in many parts of the world. as well as the increased risk at all levels of urine albumin excretion. in general. For practical hope to accomplish this. or were not graded. ‘What do the experts do in this setting?’ We opted to give In this section. Treatment ap. so that appropriate treatment of underlying (2.4%) were graded ‘B. It is important for between protein-to-creatinine ratio to dipsticks and urine the users of this guideline to be cognizant of this.’ and 4 (5. The recommendation. 49–61 . In particular and in accordance with contem- few grade A evidence-based recommendations (17%. Although many would description of albuminuria by category or by specific value is state that this guideline should be much shorter given the encouraged. clinicians still need to make GFR values between 45 and 60 versus 30 and 45 ml/min per clinical decisions in their daily practice. we give direct instructions for the laboratories as to clinicians know and better understand the evidence (or lack how best to report both estimated GFR (eGFR) values and of evidence) that determines current practice.’ There were 2 within reason. As it is now clear that GFR is only 36 (51. small simple cysts). 10 (14.’ Although there are reasons other kidney disease. category 3. However.8%) were ‘2B. A practical table describing the relationships low quality of evidence. We would submit that defining the research agenda is ‘microalbuminuria’ from general usage. their inquiries into specific management clinicians as to the current potential problems with these questions pertinent to the patients they see in daily practice. The balance of albuminuria. and have avoided the word ‘stages’ which the overall quality of evidence was graded ‘A. Our primary goal is to improve patient care. 50 Kidney International (2014) 85. by helping purposes. into 3a and 3b.0%) recommendations graded ‘1A. (10. trials.’ and 1 (1.’ 17 (24.’ 23 (33.’ There were 41 Other changes include the further refinement of GFR (37. there CKD. Development and Evaluation that some abnormalities of structure or function may not (GRADE) approach. A classification based on the quality of overall evidence and the strength of the these three dimensions (CGA) is recommended. and that causes of CKD should be sought.’ whereas throughout the document. which includes additional dimensions to previous were 12 (17.7%) graded ‘2.73 m2.3%) recommen.3%) were graded ‘C. but very important. importantly. 12 porary international laboratory initiatives.1%) were graded ‘D. We the table for equivalences as a rough guide.’ 7 cause can be initiated. Thus. there is a correlation between addition to the GFR categories.8%) were ‘2D. We would suggest that the hope to change that practice. We used the GRADE system to rate the strength of We present an enhanced classification framework for evidence and the strength of recommendations. but by advocating an often neglected. albuminuria categories will help practitioners with risk The development of this guideline followed an explicit assessment as well as management plans. In every case.4 have any clinical significance (e. rather than remain silent. glomerular previous body of literature using the term. as it maps to levels filtration rate (GFR). Appraisal of the quality of the evidence and the We retained the original definition of CKD.’ and one important dimension in the assessment of those with 5 (7. function of clinical an alternative in this guideline. and added a short strength of recommendations followed the Grading of qualifier phrase (with implications for health) to emphasize Recommendations Assessment.review A Levin and PE Stevens: Summary of KDIGO 2012 CKD Guideline efforts are encouraged and should highlight major areas of refined subcategories within GFR level 3 into 3a and 3b. This is predicated on the data suggesting paucity of evidence. albumin-to-creatinine ratio (ACR) is provided here.9%) recommendations graded ‘2A. with of A2 (30–300 mg/g (3–30 mg/mmol)) in the new system. were committed to constructing a the laboratory physicians support this change in terminology. we practice guideline development.’ abnormal state. the use of the term statements) and many ungraded recommendations can help ‘microalbuminuria’ is discouraged and more quantitative define areas where research is needed.3%) statements that were not graded. Issues these recommendations are meant to be a place for clinicians related to assays and measurements serve to enlighten to start. there were 43 (62.4%) was ‘1D. It is our hope that this document will serve several useful urine ACR is not available in general use.3%) were ‘1B. and the rationale for it. rationale for this includes the need to remind practitioners dations graded ‘1’ and 26 (37. and they often ask. we and the Work Group. Perhaps most process of evidence review and appraisal.1%) were ‘2C. 1. Of note.g. it will also lead to improvements in clinical trial proaches are addressed in each chapter and guideline design and execution by ensuring recruitment of the specific recommendations are based on systematic reviews of relevant patient populations. in the short term.1%) recommendations in this guideline for simple GFRs categories. Important statements that serve as educational or practical comments are ungraded and included for the SECTION 1: DEFINITION AND CLASSIFICATION OF CKD readership. This does not negate the implementation of the more granular cause. In all. not stop.

we highlight for as modifiers of risk (of progression and of death).. and offers suggestions as to events like infection. and use CAVEATS FOR INVESTIGATING COMPLICATIONS OF CKD that grid throughout the guideline to highlight risks and This section is included as a reminder that it is important to actions. After these data are available. we discuss the management of progression In this section of the guideline.A Levin and PE Stevens: Summary of KDIGO 2012 CKD Guideline review We would envision the use of this CGA system. a fact not validation in clinical practice and studies. of CKD care: timing of specialist referral. The fundamental message more comprehensive and directive. high risk. acute kidney injury. including guidelines (blood pressure. Also we highlight potential misunderstandings regarding defined as a change in GFR over a set time period. and levels of GFR and albuminuria. CARDIOVASCULAR DISEASE. The definition of rapid progression. troponin have not been evaluated and validated in CKD Additional studies are needed to help further refine these populations. and anemia).3) as generated by the dimensions of GFR and PATIENT SAFETY. some evidence base. and used This section elaborates on the prognosis of CKD and the this section to remind the practitioner to identify important identification of its progression. and of (e. without necessarily heralding irrever. Overall. MEDICATION DOSAGE. and those needing dose involved in clinical trial design to clarify the concept using reduction or cessation. statements detailing the use of specific clearly state this. only estimates of true GFR. we would encourage well-designed trials to be advocate regular direct measurement in usual clinical conducted. prognosis and treatment intended to help practitioners to identify those at higher risk. A3’. G4. we sought to and caveats of creatinine. ongoing manage- and leveraging the statements from other recent KDIGO ment of people with progressive CKD. terms of diagnosis. with comprehensive guidance for common clinical scenarios. which may contribute to as having diabetic nephrosclerosis. This section was necessarily appreciated by many. is common tests. rigorous data methodology.3. section 1. and treatment options. with CKD and other conditions. HOSPITALIZATIONS. using the best evidence to date.. INFECTIONS. some of which are highlights the complexity of care associated with CKD in due to be published after the guideline. acute kidney injury. and as practitioners that some minor variations in kidney function related to patient safety. we advocate the use of the ‘heat map’ (see SECTION 4: OTHER COMPLICATIONS OF CKD: graphical representation at the end of this review.and cystatin-C-based estimating highlight the key issues so that practitioners would gain a equations are also discussed. to help with nephritis. We wanted to provide the reader may occur over time. but do remind the readers that all equations provide the need for updated guidance on many of these issues.g. The question has generated a We hope that the tables and issues identified in this series of novel papers examining this issue in different section will be useful tools for practitioners. with eGFR of 21 ml/min progression. For example. and CKD). we would anticipate practice. and ACRs of 40 mg/mmol (to be very specific) or statements to those relevant to clinical practice and with could be abbreviated using the terminology ‘diabetes. Where there remains little data. Many would have liked this section to be equations are developed in detail. timing the initiation of Kidney International (2014) 85.5–8 This section is comprehensive in individual patient descriptions in clinical practice.73 m2. diagnostic studies or/and medications should be offered). and the existence of other more detailed equation validated in the population of interest. We emphasize that those with CKD and concepts. This is the first attempt in a guideline to address the The value of hemoglobin A1c in patients with diabetes with difficult issue of ‘true progression’ and will need further more advanced CKD remains problematic. In addition. monitoring. We envision that implementation tools based on the appreciate the complexity of evaluating and treating patients heat map will be developed. However. glomerulo- cause. given the scope is to obtain the best estimate of GFR through use of the best of the guideline. appropriate some of the definitions. we Also in section 1. AND albuminuria to guide clinicians in risk assessment. As extensive research remains to be conducted to importance to be precise with respect to clinical decisions optimize treatment of complications of CKD. algorithms for elevations of B-type natriuretic peptide and and those in whom increased vigilance is warranted. Patients could be identified specific complications of CKD. and also itemizing the different treatments for progression and the for enrollment into clinical trials. We provide guidance into when sense of the breadth and depth of complications related to to directly measure GFR. Chapter 1. and imaging studies how to define rapid progression. we expand on the continuum and complications of CKD. We do not progression. sible progression. when there is an overwhelming CKD. The utility documents describing the management issues. We have listed in a table included because of requests from practitioners and those the commonly used drugs in CKD. 49–61 51 . SECTION 3: MANAGEMENT OF PROGRESSION OF CKD AND SECTION 5: REFERRAL TO SPECIALISTS AND MODELS OF COMPLICATIONS OF CKD CARE In this section.e. we limited the discussion and per 1. This section populations (general. and ideally information systems in laboratories will evidence of cardiac disease be treated in accordance with help to simplify the more difficult calculations required for best practices for those without CKD (i. however. nephrectomy or use of highly toxic drugs). We identified issues of patient safety and areas of evaluation of CKD patients for SECTION 2: PROGRESSION OF CKD common conditions (heart disease and diabetes).

In so doing. ment that should foster an extended collaborative and so many remain ungraded. It is clear that Markers of kidney Albuminuria (AER X30 mg/24 h. In the absence of evidence of kidney damage. Decisions about dialysis timing should reflect a composite of clinical symptoms and laboratory parameters. it highlights what G4 15–29 Severely decreased remains as known and unknown areas of care. (Not graded) me’). many of these specific suggestions will be individualized to damage (one or more) ACR X30 mg/g (X3 mg/mmol)) specific regional contexts. chronic kidney disease.1: We recommend that CKD is classified based on cause. glomerular filtration rate. (1B) severity. and serves to G5 o15 Kidney failure inform the research agenda for the next decade. including end-of-life care. is applicable worldwide. and finally the implementation of a treatment The goal of this guideline is to facilitate appropriate program that includes comprehensive conservative guidance as to the management and care of people with management.1: Definition of CKD continuum of care for patients living with CKD evolves over 1. with implications for making at multiple points (‘no decision about me without health. function on the health of individuals across a wide range of GFR category. We have recognized CKD. The utility of the concept is that recognition of CKD 1.73 m2) Terms The KDIGO 2012 CKD guideline re-emphasizes the value of the classification system.2: Staging of CKD of the contribution of disordered kidney structure and 1.2. (Not graded) A decade of systematic evaluation and research using 1. disorders affecting kidney structure and function with variable clinical presentation. albumin excretion rate. that we have learned much since 2002. Most importantly.3: Assign GFR categories as follows (not graded): common definitions. present for 43 months. Electrolyte and other abnormalities due to tubular disorders Abnormalities detected by histology Structural abnormalities detected by imaging SUMMARY History of kidney transplantation Kidney disease is defined as an abnormality of kidney Decreased GFR GFR o60 ml/min per 1. but the principles on which they Urine sediment abnormalities are founded are universal. they serve to remind practitioners at all levels about in the future.2.73 m2 (GFR categories structure or function with implications for the health of an G3a–G5) individual.1: CKD is defined as abnormalities of kidney structure or time and incorporates both patient and care team decision function. We stress that the 1. neither ment of robust equations has allowed us to move forward. and develop. G2 60–89 Mildly decreased* G3a 45–59 Mildly to moderately decreased and the need for an integrated approach to care of this G3b 30–44 Moderately to severely decreased chronic condition. systemic disease and the location within the kidney of This guideline serves to remind us. which can occur abruptly.1. the treatment of complications of CKD. As practical tips or key research agenda over the next decade and inform guidelines points. The concept of CKD evolved after the recognition 1. Criteria for CKD (either of the following present for All patients with CKD should be offered conservative 43 months) treatment options with supportive services. standardization of assays.2: Assign cause of CKD based on presence or absence of will have implications for individuals and their care. glomerular filtration rate. GFR. We have Abbreviations: CKD. and attempts to highlight GFR categories in CKD areas of misconceptions so that we can move forward together as a medical community. GFR (ml/min GFR category per 1. confusion have been resolved with well-conducted We highlight the importance of multidisciplinary care clinical trials. We appreciate that referral to specialists may vary of evidence. as a nephrology and observed or presumed pathologic-anatomic findings. The challenge for the renal community the multiple dimensions required in the care of patients with will be to ensure that important areas of controversy or CKD. fulfill the criteria for CKD. but we In the absence of evidence of kidney damage. and may either resolve Abbreviations: ACR.review A Levin and PE Stevens: Summary of KDIGO 2012 CKD Guideline dialysis. the need for robust definitions of G1 X90 Normal or high progression of CKD. CKD. progressed in our understanding and knowledge base. the next update of the KDIGO teams to enhance care and outcomes of this complex CKD 2012 guideline will be based on a growing foundation condition. GFR. or become chronic. which is present for 43 months. 49–61 . AER. CKD is a general term for heterogeneous chronic kidney disease. *Relative to young adult level. We present a framework for evaluation and assess- the paucity of data for many of these recommendations.2. This KDIGO guideline addresses important areas of con- troversy. by country or region. and albuminuria category (CGA). albumin-to-creatinine ratio. 52 Kidney International (2014) 85. GFR category G1 nor G2 fulfill the criteria for CKD. medical community. neither GFR category G1 nor G2 remain in need of robust large trials to inform clinical care. but underscore that the rationale for that referral should be to access specialist knowledge or CHAPTER 1: DEFINITION AND CLASSIFICATION OF CKD services so that care is optimized.

1: In predicting risk for outcome of CKD.73 m2 A1 o30 o3 o30 Normal to mildly increased (GFR categories G3a–G5) or markers of kidney A2 30–300 3–30 30–300 Moderately increased* damage. 4220 mg/mmol)).3.3. *Relative to young adult level. AER. very high risk. (3) albuminuria category. (Not factors. **Including nephrotic syndrome (albumin excretion usually 42200 mg/24 h (ACR Follow recommendations for CKD. use estimated risk of concurrent 1.4. group GFR and albuminuria *Note that where albuminuria measurement is not categories with similar relative risk for CKD outcomes available. Kidney International (2014) 85.1. social and environmental for testing and treatment for CKD complications. category. into risk categories. physical examination. (2) GFR repeated accordingly.4: Assign albuminuria* categories as follows (not graded): 1. red. Patients may have CKD or 1.  If duration is 43 months.4.90 GFR categories (ml/min per 1. (Not graded) chronic kidney disease. urine reagent strip results can be substituted. yellow: moderately increased risk. no CKD).2. and pathologic Persistent albuminuria categories Description and range A1 A2 A3 Prognosis of CKD by GFR and albuminuria categories: Normal to Moderately Severely mildly KDIGO 2012 increased increased increased <30 mg/g 30 – 300 mg/g >300 mg/g <3 mg/mmol 3 – 30 mg/mmol >30 mg/mmol G1 Normal or high . CKD.  If duration is not 43 months or unclear. 42220 mg/g.2: In people with CKD. imaging.1: Evaluation of chronicity Category (mg/24 h) (mg/mmol) (mg/g) Terms 1.2. CKD is confirmed. graded) laboratory measures. identify the injury (AKI)) or both and tests should be following variables: (1) cause of CKD. albumin excretion rate. review past history and previous mea- A3 4300 430 4300 Severely increased** surements to determine duration of kidney Abbreviations: ACR.3.4.4: Evaluation of CKD AER equivalent) 1. disease.73 m2) G2 Mildly decreased 60 – 89 Description and range Mildly to moderately G3a 45 – 59 decreased Moderately to G3b 30 – 44 severely decreased G4 Severely decreased 15 – 29 G5 Kidney failure <15 Green: low risk (if no other markers of kidney disease. 49–61 53 . (Not graded) 1. (Not graded) (see grid below) Albuminuria categories in CKD ACR (approximate 1. orange: high risk.3: Predicting prognosis of CKD acute kidney diseases (including acute kidney 1. medications. including personal complications and future outcomes to guide decisions and family history.2: Evaluation of cause 1. albumin-to-creatinine ratio. CKD is not confirmed.A Levin and PE Stevens: Summary of KDIGO 2012 CKD Guideline review 1.1: Evaluate the clinical context.4. (4) other risk factors and comorbid conditions.1: In people with GFR o60 ml/min per 1.3: In populations with CKD.

the 2012 CKD-EPI cystatin C and 2012 CKD- metry reference methodology. CKD is required. (2C) (2) Urine protein-to-creatinine ratio. respec-  Report eGFRcreat in addition to the serum tively. (2B)  We recommend eGFRcreat levels o60 ml/min per 1. An alternative creatinine-based GFR estimating equation is acceptable if it has When reporting serum cystatin C:  We recommend reporting serum cystatin C concentra- been shown to improve accuracy of GFR estimates compared to the 2009 CKD-EPI tion rounded to the nearest 100th of a whole number creatinine equation.4. when expressed as conventional units (mg/l).3.2: We suggest using additional tests (such as cystatin the serum cystatin C concentration alone.4.’ When reporting eGFRcreat:  We recommend that eGFRcreat should be reported and 1.73 m2.4: We recommend that clinical laboratories should (1B): to the serum cystatin C concentration in adults  Measure serum creatinine using a specific assay and specify the equation used whenever report- with calibration traceable to the international ing eGFRcys and eGFRcreat-cys. treatment decisions. to improve accuracy of GFR estimates compared  Report eGFRcreat in adults using the 2009 CKD- to the 2012 CKD-EPI cystatin C and 2012 Epidemiology Collaboration (CKD-EPI) creati.3.73 m2. o60 ml/min per 1.3: Evaluation of GFR professionals (2C): 1. in all cases an early morning urine eGFRcreat 45–59 ml/min per 1.4.  Report eGFRcys and eGFRcreat-cys in adults using standard reference materials and minimal bias compared with isotope-dilution mass spectro.5: We suggest measuring cystatin C in adults with preference.3. nine equation. 49–61 . 1.  Understand clinical settings in which eGFRcreat  Report eGFR from serum cystatin C in addition is less accurate. automated reading.73 m2 in adults (mmol/l) and rounded to the nearest 100th of a using the units ml/min per 1.73 m 2 1.3: We recommend that clinicians (1B): 1. the diagnosis of CKD is confirmed. 54 Kidney International (2014) 85. the diagnosis of CKD is not confirmed.  If eGFRcys/eGFRcreat-cys is also o60 ml/min per (3) Reagent strip urinalysis for total protein with 1.4. (1A) from serum cystatin C rather than relying on 1. on serum creatinine is less accurate.review A Levin and PE Stevens: Summary of KDIGO 2012 CKD Guideline diagnosis to determine the causes of kidney  If eGFRcys/eGFRcreat-cys is X60 ml/min per disease.  We recommend eGFRcys and eGFRcreat-cys levels whole number when expressed as conventional units (mg/dl).4. we suggest that health 1.3.7: We recommend that clinical laboratories that  Use a GFR estimating equation to derive GFR measure cystatin C should (1B): from serum creatinine (eGFRcreat) rather than  Measure serum cystatin C using an assay with relying on the serum creatinine concentration calibration traceable to the international stan- alone.3. C or a clearance measurement) for confirmatory  Understand clinical settings in which eGFRcys testing in specific circumstances when eGFR based and eGFRcreat-cys are less accurate.4. When reporting serum creatinine: When reporting eGFRcys and eGFRcreat-cys:  We recommend that eGFRcys and eGFRcreat-cys be  We recommend that serum creatinine concentration be reported and rounded to the nearest whole reported and rounded to the nearest whole number number when expressed as standard international units and relative to a body surface area of 1.3.73 m2 in adults using the units accurate ascertainment of GFR will impact on ml/min per 1.4.3.4: Evaluation of albuminuria should be reported as ‘decreased.8: We suggest measuring GFR using an exogenous rounded to the nearest whole number and relative to a filtration marker under circumstances where more body surface area of 1.4.4.’ 1. or alternative cystatin C-based GFR creatinine concentration in adults and specify estimating equations if they have been shown the equation used whenever reporting eGFRcreat.73 m2.4.6: If cystatin C is measured.73 m2. EPI creatinine-cystatin C equations.3.73 m2 who do not sample is preferred) (2B): have markers of kidney damage if confirmation of (1) Urine ACR. (Not graded) 1.73 m2 should be reported as ‘decreased. dard reference material.1: We suggest using the following measurements for initial testing of proteinuria (in descending order 1. (2B) 1.4.1: We recommend using serum creatinine and a GFR  Use a GFR estimating equation to derive GFR estimating equation for initial assessment.4. CKD-EPI creatinine-cystatin C equations. 1.

1: The term microalbuminuria should no longer be pressure (BP).3. AND PREDICTION rioration in kidney function.4. acute dete- CHAPTER 2: DEFINITION. 15–29 (G4).1. (Not graded) 1.1. BP and renin–angiotensin–aldosterone system interruption. (Not graded) affect interpretation of measurements of albuminuria and order confirmatory tests as indicated (not graded): CHAPTER 3: MANAGEMENT OF PROGRESSION AND  Confirm reagent strip positive albuminuria and COMPLICATIONS OF CKD proteinuria by quantitative laboratory measurement 3.73 m2).73 m2/year. (1B) 3.1: Individualize BP targets and agents according to age. (Not graded) Kidney International (2014) 85.1: Definition and identification of CKD progression 3. (1B) and are not necessarily indicative of progression.g. 3. diabetic and non-diabetic adults with CKD and urine ments and duration of follow-up. and others. including electrolyte disorders. history of cardiovascular disease. comorbidities. CKD by carefully considering age. inform prognosis. o15 (G5) tain a BP that is consistently p130 mm Hg systolic and ml/min per 1.1.2: We recommend that clinical laboratories report ACR and protein-to-creatinine ratio in untimed urine 2.2: Recognize that small fluctuations in GFR are common p90 mm Hg diastolic. 60–89 (G2). and proteinuria is required. 30–44 (G3b). excretion 30–300 mg/24 h (or equivalent*). (Not graded) a BP that is consistently p140 mm Hg systolic and 2.3: Define CKD progression based on one or more of the X30 mg/24 h (or equivalent*) whose office BP is following (not graded): consistently 4130 mm Hg systolic or 480 mm Hg  Decline in GFR category (X90 (G1). CKD. a1. as defined in ing an ACE-I with ARBs to prevent progression of Recommendation 2. (1B) level of albuminuria. trations alone. review current management.3: Clinicians need to understand settings that may nephrotoxic agents.1. IDENTIFICATION.1. other therapies.1. (Not graded) use assays for specific urine proteins (e.4: In people with CKD progression. obe- used by laboratories. BP-lowering drugs.7: We recommend that an ARB or ACE-I be used in both with increasing number of serum creatinine measure.1: Identify factors associated with CKD progression to proteinuria concentrations rather than the concen. and/or consistently 4140 mm Hg systolic or 490 mm Hg where measurement will impact therapeutic decisions diastolic be treated with BP-lowering drugs to maintain (see grid on next page).5: We suggest that in both diabetic and non-diabetic graded) adults with CKD and with urine albumin excretion of 2.1. monoclonal heavy or light chains.1: Assess GFR and albuminuria at least annually in people adults with CKD and urine albumin excretion with CKD.  Confirm ACR X30 mg/g (X3 mg/mmol) on a 3.4: If significant non-albumin proteinuria is suspected. albumin excretion 4300 mg/24 h (or equivalent*). age. and (known in some countries as ‘Bence Jones’ pro. These include cause of CKD. level of GFR. hyperglycemia. or angiotensin-converting enzyme inhibitor (ACE-I) be  Rapid progression is defined as a sustained decline in used in diabetic adults with CKD and urine albumin eGFR of 45 ml/min per 1. ongoing exposure to 1.1. diastolic be treated with BP-lowering drugs to main- 45–59 (G3a).1.3: Tailor BP treatment regimens in elderly patients with microglobulin. smoking.6: We suggest that an angiotensin receptor blocker (ARB) 25% or greater drop in eGFR from baseline.4.4.4.1. 3. consider referral to a specialist. (Not 3. (Not graded) sample.4.. elevated blood 1.4. measure albumin excretion tolerance of treatment as described in the KDIGO 2012 rate or total protein excretion rate in a timed urine Blood Pressure Guideline.2. Assess GFR and albuminuria more often for o30 mg/24 h (or equivalent*) whose office BP is individuals at higher risk of progression. OF CKD PROGRESSION and drug side effects. (Not graded) and close attention to adverse events related to BP treatment. 49–61 55 .4: We recommend that in both diabetic and non-diabetic 2. presence or absence  If a more accurate estimate of albuminuria or total of retinopathy (in CKD patients with diabetes). race/ethnicity. sex. (Not graded) 2.8: There is insufficient evidence to recommend combin- 2. (2D)  The confidence in assessing progression is increased 3.1. dyslipidemia.4.2.1. risk of progression of CKD.2: Predictors of progression samples in addition to albumin concentration or 2. and manual reading. (2D) defined as a drop in GFR category accompanied by a 3. orthostatic hypotension. random untimed urine with a subsequent early coexistent cardiovascular disease and other comorbid- morning urine sample.A Levin and PE Stevens: Summary of KDIGO 2012 CKD Guideline review (4) Reagent strip urinalysis for total protein with examine for reversible causes of progression. ities. (Not graded) sity.1.4. A certain drop in eGFR is p80 mm Hg diastolic.1: Prevention of CKD progression and express as a ratio to creatinine wherever possible.2: Inquire about postural dizziness and check for postural hypotension regularly when treating CKD patients with 1. with gradual escalation of treatment teins)).

17: We suggest that target hemoglobin A1c be extended considered to be at increased risk of AKI. the recommendations comorbidities or limited life expectancy and risk of detailed in the KDIGO AKI Guideline hypoglycemia.0% (53 mmol/mol) in individuals with 3. target of o7.10: We suggest that in children with CKD (particularly and GFR o30 ml/min per 1. strategy addressing BP control and cardiovascular dures that are likely to increase the risk of AKI. The numbers in the boxes are a guide to the frequency of monitoring (number of times per year). and protein reagent strip 3. (1A) protein-to-creatinine ratio. (2D) (53 mmol/mol) to prevent or delay progression of the *Approximate equivalents for albumin excretion rate per microvascular complications of diabetes. risk.73 m2) G2 Mildly decreased 60 – 89 1 if CKD 1 2 Description and range Mildly to moderately G3a 45 – 59 1 2 3 decreased Moderately to G3b 30 – 44 2 3 3 severely decreased G4 Severely decreased 15 – 29 3 3 4+ G5 Kidney failure <15 4+ 4+ 4+ GFR and albuminuria grid to reflect the risk of progression by intensity of coloring (green.1. 3.11: We suggest that an ARB or ACE-I be used in children Glycemic control.16: We recommend not treating to an hemoglobin A1c results—are given in Guideline Table 7. and height.1.1.8 g/kg/day in 90th percentile for age. (2C) symptoms of hypotension.18: In people with CKD and diabetes.3 g/kg/day) in adults with CKD at risk of unless achieving these targets is limited by signs or progression. (41. sex. (1C) adults with diabetes (2C) or without diabetes (2B) 3. (2C) should be followed for management of those 3. BP is lowered to consistently G4–G5). deep red). yellow.13: We suggest lowering protein intake to 0.73 m2 (GFR categories those with proteinuria).review A Levin and PE Stevens: Summary of KDIGO 2012 CKD Guideline Persistent albuminuria categories Description and range A1 A2 A3 Guide to frequency of monitoring (number of times Normal to Moderately Severely per year) by GFR and mildly increased increased albuminuria category increased <30 mg/g 30 – 300 mg/g >300 mg/g <3 mg/mmol 3 – 30 mg/mmol >30 mg/mmol G1 Normal or high . with CKD in whom treatment with BP-lowering drugs 3. (1B) 3. 49–61 .1.1.0% is indicated. diabetic kidney disease.1. achieve systolic and diastolic readings less than or 3. BP-lowering Protein intake. should be part of a multifactorial intervention or when undergoing investigation and proce. with appropriate education.1. (2D) 3. ACR.1.1. treatment is started when BP is consistently above the 3. (1A) above 7. sex. promoting the use of angiotensin-converting (Not graded) enzyme inhibition or angiotensin receptor 56 Kidney International (2014) 85.1. irrespective of the level of proteinuria.9: We recommend that in children with CKD. red. glycemic control at risk of AKI during intercurrent illness.1: In people with CKD. of hypoglycemia.12: We recommend that all people with CKD are 3.12. orange.1.14: We suggest avoiding high protein intake equal to the 50th percentile for age. and height.90 1 if CKD 1 2 GFR categories (ml/min per 1.15: We recommend a target hemoglobin A1c of B7.0% (o53 mmol/mol) in patients at risk CKD and risk of AKI. including 24 h—expressed as protein excretion rate per 24 h.

and 3. (1C) abnormalities 3.3.21: We recommend that people with CKD be encouraged hyperphosphatemia. suspected or documented deficiency. we suggest maintaining serum Hyperuricemia. (o2 g) per day of sodium (corresponding to 5 g of sodium chloride) in adults. CKD. o11. (1C) mended Daily Intake.6: We suggest not to prescribe bisphosphonate treat- the need to intervene on salt.73 m2 (GFR growth. (1B) (GFR categories G4–G5) without a strong clinical rationale. and alkaline phos- sion (systolic and/or diastolic BP 495th phatase activity at least once in adults with GFR percentile) or prehypertension (systolic and/ o45 ml/min per 1.73 m2 and protein intake where indicated. (2B) 3.3: In people with GFR o45 ml/min per 1. potassium. HOSPITALIZATIONS. INFECTIONS.0 g/dl (o110 g/l) in children unless contraindicated.3. unless contraindicated 3.4: In people with GFR o45 ml/min per 1.A Levin and PE Stevens: Summary of KDIGO 2012 CKD Guideline review blockade. 49–61 57 .1.73 m2 (GFR categories G3b–G5).2: Complications associated with loss of kidney function Definition and identification of anemia in CKD. (1D) supplements or vitamin D analogs. following the age-based Recom- prediction equations if used.19. (2B) 0. We suggest that people with levels progression of CKD.73 m2 (GFR in people with CKD and either symptomatic or categories G3b–G5).4. (Not graded) with oral bicarbonate supplementation be given to 3.19.0 g/dl (120 g/l) in children 12–15 CHAPTER 4: OTHER COMPLICATIONS OF CKD: years.1.22: We recommend that individuals with CKD receive elevated parathyroid hormone concentrations in expert dietary advice and information in the context of people with CKD not on dialysis. parathyroid hormone. (1C) 3.2: Diagnose anemia in children with CKD if Hb maintain serum bicarbonate within the normal range. in the absence of Additional dietary advice.3. phosphate concentrations in the normal range accord- 3.19: We recommend lowering salt intake to o90 mmol min per 1. achieve a Vitamin D supplementation and bisphosphonates in people with healthy weight (body mass index 20–25 kg/m2.2: We recommend supplemental free water and testing routinely in those with eGFR o45 ml/min per sodium supplements for children with CKD 1.0 g/dl 3. (2C) cardiovascular health and tolerance (aiming for at least 30 min five times per week). (2C) use of agents to lower serum uric acid concentrations 3.3: CKD metabolic bone disease including laboratory (see rationale).1: We recommend that all people with CKD be considered X60 ml/min per 1.1. (2B) an education program.2. 3.1.1: We recommend restriction of sodium intake 3. PATIENT SAFETY.5: We suggest not to routinely prescribe vitamin D stop smoking. tailored to severity of CKD and 3. as information and polyuria to avoid chronic intravas- may be misleading or unhelpful. (1C) categories G3b–G5).1: Diagnose anemia in adults and children 415 years 3. for children with CKD who have hyperten- phosphate. AND 3. (Not graded) per 1. at increased risk for cardiovascular disease.1: CKD and cardiovascular disease  When clinically indicated in people with GFR 4. normal limit of the assay are first evaluated for 3.  At least twice per year in people with GFRo30 ml/ 3. (Not graded) of intact parathyroid hormone above the upper Lifestyle. Salt intake.73 m2 (GFR categories G3b–G5) in or diastolic BP 490th percentile and o95th order to determine baseline values and inform percentile). according to country-specific demographics).73 m2 (GFR categories G3a–G3b).4: Acidosis with CKD when the Hb concentration is o13.2: We suggest not to perform bone mineral density 3. hypocalcemia.5–5 years. (1A) Kidney International (2014) 85. (Not graded) CARDIOVASCULAR DISEASE.2. and o12.1. and antiplatelet therapy where  At least annually in people with GFR 30–59 ml/min clinically indicated.1.0 g/dl (o120 g/l) in bicarbonate concentrations o22 mmol/l treatment females. the optimal parathyroid hormone asymptomatic hyperuricemia in order to delay level is not known. to suppress 3.2. Evaluation of anemia in people with CKD.73 m2 (GFR categories G1–G2). phosphate.1: We suggest that in people with CKD and serum (o130 g/l) in males and o12.1: We recommend measuring serum levels of calcium.5 g/dl (115 g/l) in children 5–12 years. (2B) cular depletion and to promote optimal 3. MEDICATION DOSAGE.3.3.73 m2 (GFR categories G4–G5). and vitamin D to undertake physical activity compatible with deficiency.1. statins.3: To identify anemia in people with CKD measure Hb CAVEATS FOR INVESTIGATING COMPLICATIONS OF CKD concentration (Not graded): 4. ment in people with GFR o30 ml/min per 1.3. concentration is o11.20: There is insufficient evidence to support or refute the ing to local laboratory reference values.

1: Balance the risk of acute impairment in kidney subsequent treatment should be initiated similarly). (Not graded) limitations of non-invasive cardiac tests (e. exercise Radiocontrast.2.3.1: We recommend that prescribers should take GFR into  Measurement of GFR 48–96 h after the procedure (1C). etc) in adults with CKD and interpret the results per 1.1.5: Imaging studies same local practice for people without CKD (and 4.73 m2 (GFR those with GFR 30–44 ml/min per 1.3: We recommend temporary discontinuation of potentially 4.2. and 4. (1B) tion. 4.g. and digoxin. during. These agents include.4. 4. its use should be reviewed in 4.3. considered for usual approaches to therapy.1.. direct renin to people with CKD should be the same as is offered to inhibitors).73 m2 (GFR drug levels regularly monitored. due to low muscle mass). (1A) 4. (2A) drug.1: In people with GFR o60 ml/min per 1.6: We recommend that metformin be continued in disease in people with CKD people with GFR X45 ml/min per 1.4. (1C) prejudiced by their CKD. and it should be discontinued in centrations of B-type natriuretic peptide/NT-proBNP be people with GFR o30 ml/min per 1. (Not graded) 4. (1B) nephrotoxic agents such as lithium and calcineurin Troponins.73 m2 (GFR categories G3a–G5) antiplatelet agents unless there is an increased who have serious intercurrent illness that increases the bleeding risk that needs to be balanced against the risk of AKI. medicines or nutritional protein supplements..g. we recommend that serum con.73 m2 (GFR B-type natriuretic peptide/N-terminal-proBNP (NT-proBNP).4.3: We recommend not using gadolinium-containing unreliable (e.7: We recommend that all people taking potentially volume status. any escalation in 4.4.  Adequate hydration with saline before.73 m2 (GFR interpreted with caution and in relation to GFR with categories G4–G5).1: We recommend that adults with CKD be regularly Guideline for AKI including: examined for signs of peripheral arterial disease and be  Avoidance of high osmolar agents (1B).1.5: We recommend not using herbal remedies in people with CKD.2: Where precision is required for dosing (due to narrow Gadolinium-based contrast media.2: Caveats when interpreting tests for cardiovascular 4. (2B) elective investigation involving the intravascular ad- ministration of iodinated radiocontrast media should 4. lithium. 4. category G3b).review A Levin and PE Stevens: Summary of KDIGO 2012 CKD Guideline 4. (1A) categories G3a–G5). electrocardiography.1.4. (1B) appropriate dose adjustment of cytotoxic drugs Non-invasive testing. electrolytes.4: Medication management and patient safety in CKD after the procedure (1A). aldosterone inhibitors. and 4.4: We suggest that the level of care for heart failure offered ing ACE-Is. nonsteriodal anti-inflammatory those without CKD.73 m2 (GFR categories G3a–G5) undergoing accordingly.3: We suggest that adults with CKD at risk for nephrotoxic and renally excreted drugs in people with a atherosclerotic events be offered treatment with GFR o60 ml/min per 1.5: In people with CKD and heart failure. (1C) respect to diagnosis of heart failure and assessment of 4. (2B) renin–angiotensin–aldosterone system blockers (includ- 4. we recommend that serum con.2: In people with GFR o60 ml/min per 1.4. inhibitors should have their GFR. but are not limited to: possible cardiovascular benefits. (1C) 4. (2A) and after the procedure (1C). 49–61 .73 m2 (GFR categories G3a–G5).8: People with CKD should not be denied therapies for centrations of troponin be interpreted with caution with other conditions such as cancer but there should be respect to diagnosis of acute coronary syndrome.4: We recommend that adults with CKD seek medical or therapy and/or clinical deterioration should prompt pharmacist advice before using over-the-counter monitoring of eGFR and serum potassium concentra. (1B) 4.4. (1A) 4. we contrast media in people with GFR o15 ml/min per 58 Kidney International (2014) 85.2. categories G1–G3a). metformin.3: We recommend that people with CKD presenting with chest pain should be investigated for underlying cardiac disease and other disorders according to the 4. according to knowledge of GFR. (Not graded) 4.5.2: We suggest that adults with CKD and diabetes are  Withdrawal of potentially nephrotoxic agents before offered regular podiatric assessment.5. diuretics.4: We suggest that clinicians are familiar with the investigation.2. (1B)  Use of lowest possible radiocontrast dose (not graded).2: We recommend that the level of care for ischemic heart recommend methods based upon cystatin C or direct disease offered to people with CKD should not be measurement of GFR.5.4. therapeutic or toxic range) and/or estimates may be 4. nuclear imaging. 4.2: We recommend that all people with GFR o60 ml/min phy. ARBs. function due to contrast agent use against the (1B) diagnostic value and therapeutic implications of the 4. account when drug dosing. echocardiogra.3: CKD and peripheral arterial disease be managed according to the KDIGO Clinical Practice 4.

high risk of pneumococcal infection (e. (1B) w CKD and risk of AKI.73 m2 (GFR categories G3a–G5) or in those 5.73 m2 (GFR categories G4–G5) and those at (X50 mg/mmol) or PER X500 mg/24 h).6: Pediatric immunization schedules should be 5.1. cination within 5 years. 1. nephrotic  Progression of CKD (see Recommendation 2. (1A) 5.2: The multidisciplinary team should include or have access to dietary counseling. AKI. social care.73 m2 (GFR categories G4–G5) who require gadoli. (2B) increase the risk of AKI.2: Care of the patient with progressive CKD followed for management of those at risk of AKI 5. or when undergoing should be managed in a multidisciplinary care investigation and procedures that are likely to setting. 4.4: We suggest that people with a GFR o30 ml/min per 4.73 m mortality 2 (GFR categories CKD and risk of infections. approximately equi- 4.2.3 for syndrome. as determined by validated risk prediction tools. CKD in whom the risk of kidney failure within 1 year (Not graded) is 10–20% or higherw.6. formal referral (i. (Not graded) 4. 4.7.1: We recommend that all adults with CKD are offered  A consistent finding of significant albuminuria annual vaccination with influenza vaccine.1: Referral to specialist services known to be at risk of phosphate nephropathy.5. (1B) field sustained and not readily explained. diabetes. transplant options.2.  GFR o30 ml/min per 1.1: In people with CKD. or those receiving immunosup.6. definition). 4 or more antihypertensive agents.1. RBC 420 per high-power coccal vaccine unless contraindicated. the recommendations detailed in the KDIGO AKI Guideline should be 5. psychological. education. (Not graded) Bowel preparation. (Not graded) 5.8: CKD disease management programs should be devel.g. defined here as referral to 4. (Not graded) Kidney International (2014) 85. (1B)  Persistent abnormalities of serum potassium.6. pression) receive vaccination with polyvalent pneumo..9: Interventions to reduce hospitalization and mortality 1. 4.5. for people with CKD should pay close attention to the nium-containing contrast media are preferentially management of associated comorbid conditions and offered a macrocyclic chelate preparation.5: We recommend not to use oral phosphate-containing CHAPTER 5: REFERRAL TO SPECIALISTS AND MODELS OF bowel preparations in people with a GFR o60 ml/min CARE per 1. The aim is to avoid late referral.6.6. and  AKI or abrupt sustained fall in GFR.73 m2 (GFR categories G4–G5) be immunized against hepatitis B and the response confirmed by appropriate *If this is a stable isolated finding. considered to be at increased risk of AKI. and oped in order to optimize the community manage.2: We recommend that all adults with eGFR o30 ml/min valent to protein-to-creatinine ratio X500 mg/g per 1. This should be in line with recommendations from official will be health-care system dependent.6.1: We recommend referral to specialist kidney care services for people with CKD in the following circumstances (1B): 4.6: CKD and risks for infections. progression of CKD and have GFR o30 ml/min per  Hereditary kidney disease.7: We recommend that all people with CKD are specialist services o1 year before start of RRT.1.5: Consideration of live vaccine should include an be necessary and advice from specialist services may be all appreciation of the patient’s immune status and that is required to facilitate best care for the patients. unless (ACR X300 mg/g (X30 mg/mmol) or albumin contraindicated.. (1B) hospital admission.2: We recommend timely referral for planning renal followed according to official international and replacement therapy (RRT) in people with progressive regional recommendations for children with CKD. or governmental bodies. and counseling CKD and risk of hospitalization and mortality. vascular access surgery. hospitalizations.73 m2 (GFR category G5) unless there is no ment of people with CKD and reduce the risk of alternative appropriate test. and ethical. serological testing. about different RRT modalities. 49–61 59 .4: We recommend that all adults who are at high risk of  Recurrent or extensive nephrolithiasis. (1B) excretion rate X300 mg/24 h.A Levin and PE Stevens: Summary of KDIGO 2012 CKD Guideline review 1.e.  Urinary red cell casts.6.1: We suggest that people with progressive CKD during intercurrent illness. (1A) 4. 4. G4–G5)*.6. (2B) cardiovascular disease in particular. (1B) formal consultation and ongoing care management) may not 4. (Not graded) 4. 4.6.3: We recommend that all adults with CKD who have  CKD and hypertension refractory to treatment with received pneumococcal vaccination are offered revac.6.

73 m2) G2 Mildly decreased 60 – 89 Monitor Refer* Description and range Mildly to moderately G3a 45 – 59 Monitor Monitor Refer decreased Moderately to G3b 30 – 44 Monitor Monitor Refer severely decreased G4 Severely decreased 15 – 29 Refer* Refer* Refer G5 Kidney failure <15 Refer Refer Refer Referral decision making by GFR and albuminuria. adults should be considered when the GFR is o20 ml/ (Not graded) min per 1. and culturally occurs in the GFR range between 5 and 10 ml/min per sensitive care for the dying patient and their family (whether 1. de Jong. and there is evidence of progressive and irreversible CKD over the preceding 6–12 months. Amgen.2: Living donor pre-emptive renal transplantation in provision of culturally appropriate bereavement support.73 m2. This often but not invariably ment.4: Structure and process of comprehensive conservative for Merck and Otsuka. Shlipak. or a hospital setting). management 5. acid-base or people and families through either primary care or specialist electrolyte abnormalities. (Not valuable contributions to this guideline: Rudy W.M. including those people undergoing 5.review A Levin and PE Stevens: Summary of KDIGO 2012 CKD Guideline Persistent albuminuria categories Description and range A1 A2 A3 Normal to Moderately Severely mildly increased increased increased <30 mg/g 30 – 300 mg/g >300 mg/g <3 mg/mmol 3 – 30 mg/mmol >30 mg/mmol G1 Normal or high . Michael G.2: All CKD programs and care providers should be able to Miguel C. Levey.3: Timing the initiation of RRT need for end-of-life care. AL also has consulting and advising roles 5. Bilous. de Francisco. White.4. Canadian Institutes of Health Research. inability to control care as local circumstances dictate. pruritus). 5. 5.4. 49–61 . Kathryn E. PES declared no competing interests. 60 Kidney International (2014) 85. Griffith. Haiyan Wang. Brenda R. Colin T. Andrew S. Kunitoshi Iseki.1: We suggest that dialysis be initiated when one or more conservative kidney care. followed by the 5. graded) Hemmelgarn. DISCLOSURE (Not graded) AL has received research funding from Abbott.1: Conservative management should be an option in ACKNOWLEDGMENTS people who choose not to pursue RRT and this should be The authors thank the following Work Group members for their supported by a comprehensive management program.90 Monitor Refer* GFR categories (ml/min per 1.3: Coordinated end-of-life care should be available to attributable to kidney failure (serositis. Angel L. Winearls. Edmund J. Kidney Foundation of Canada. psychological care.4. (2B) at home. (Not graded) of the following are present: symptoms or signs 5. Genzyme.73 m2. Merck and Ortho. a progressive deterioration in 5. Josef Coresh.3. spiritual care. deliver advance care planning for people with a recognized Christopher G. Paul E. (Not graded) volume status or BP. Lamb.4: The comprehensive conservative management program nutritional status refractory to dietary intervention.3. *Referring clinicians may wish to discuss with their nephrology service depending on local arrangements regarding monitoring or referring.4. Riella. or should include protocols for symptom and pain manage- cognitive impairment. in a hospice.

classification. KDIGO CKD Work Group. 3: 1–150. Am J Kidney Dis 6. KDIGO clinical practice guideline for the 2013. 49–61 61 . K/DOQI clinical practice guidelines for chronic 2012. National Kidney Foundation. KDIGO clinical practice guideline for anemia public health problem: approaches and initiatives—a position statement in chronic kidney disease. 328: 1490. Best D. 3. KDIGO clinical practice guidelines for 247–259. Atkins D. KDIGO 2012 clinical practice guideline for the recommendations. Kidney Int Suppl 2012. 2: 1–143. Coresh J et al. injury. glomerulonephritis. Kidney Int Suppl 2. Chronic kidney disease as a global 7. kidney disease: evaluation. KDIGO clinical practice guideline for acute kidney 2002. 2: 279–335. KDIGO AKI Work Group. Atkins R. Levey AS. KDIGO GN Work Group. and stratification. Kidney Int 2007. evaluation and management of chronic kidney disease. from kidney disease improving global outcomes. Kidney Int Suppl 2012. Kidney Int Suppl 2012. Kidney Int Suppl 5. BMJ 2004. management of blood pressure in chronic kidney disease. 72: 8. Grading quality of evidence and strength of 1. Kidney International (2014) 85. KDIGO BP Work Group. Briss PA et al. KDIGO Anemia Work Group.A Levin and PE Stevens: Summary of KDIGO 2012 CKD Guideline review REFERENCES 4. 2: 337–414. 2: 1–138. 39: S1–S266.