Advanced chronic kidney disease

Chronic kidney disease (CKD), like other chronic diseases, is a serious public health problem because of both its high incidence and prevalence and its significant morbidity and mortality and socioeconomic cost. Advanced chronic kidney disease (ACKD) includes stages 4 and 5 of the CKD classification. It is defined as chronic kidney disease in which there is a severe reduction in glomerular filtration rate (GFR < 30 ml/min). The treatment goals are to reduce and treat the complications associated with chronic kidney failure and to prepare the patient adequately and sufficiently in advance for kidney replacement therapy. The prevalence of ACKD is 0.2-0.6% of the adult population. This prevalence increases with age and in Spain is 1.6% in persons older than 64 years. CKD is easily detected in clinical practice with simple tests (GFR estimated by equations based on serum creatinine, albuminuria and urine sediment) (Strength of Recommendation B). It is recommended to detect the presence of CKD in all persons older than 60 years or with hypertension, diabetes or cardiovascular disease (Strength of Recommendation B). Early detection and appropriate referral to the nephrology of patients with ACKD improves long-term morbidity and reduces costs for both the patient and the health care system (Strength of Recommendation B). Adequate communication and coordination between the primary care and nephrology is essential for this early detection: Referral to nephrology should be made based on the stage of CKD, age of the patient, rate of progression of kidney failure, degree of albuminuria and presence or appearance of early warning signs*. All patients with CKD stages 4-5 should be referred to nephrology (Strength of Recommendation C). A protocol should be established in each health area for joint follow-up between primary care and nephrology (Strength of Recommendation C). The creation of multidisciplinary ACKD units including a nephrologist, nephrology nurse, dietitian and social worker allows an integrated approach to the different aspects of management of patients with ACKD and is cost-effective (Strength of Recommendation B).