Chronic Kidney Disease

Adriano Luiz Ammirati1,2

1. Doutor em Nefrologia pela Universidade Federal de São Paulo, São Paulo, SP, Brasil
2. Coordenador Ambulatório de Uremia, Universidade Federal de São Paulo, São Paulo, SP, Brasil

http://dx.doi.org/10.1590/1806-9282.66.S1.3

SUMMARY
Chronic kidney disease is highly prevalent (10-13% of the population), irreversible, progressive, and associated with higher cardiovascular
risk. Patients with this pathology remain asymptomatic most of the time, presenting the complications typical of renal dysfunction
only in more advanced stages. Its treatment can be conservative (patients without indication for dialysis, usually those with glomerular
filtration rate above 15 ml/minute) or replacement therapy (hemodialysis, peritoneal dialysis, and kidney transplantation). The objectives
of the conservative treatment for chronic kidney disease are to slow down the progression of kidney dysfunction, treat complications
(anemia, bone diseases, cardiovascular diseases), vaccination for hepatitis B, and preparation for kidney replacement therapy.
KEYWORDS: Conservative Kidney Management. Chronic Kidney Disease End Stage. Renal Failure.

DEFINITION

Chronic kidney disease (CKD) is a clinical syn- albuminuria, changes in renal imaging, hematuria/
drome secondary to the definitive change in function leukocyturia, persistent hydroelectrolytic disorders,
and/or structure of the kidney and is characterized histological changes in kidney biopsy, and previous
by its irreversibility and slow and progressive evolu- kidney transplantation 1. Albuminuria is defined by
tion. Another important aspect is the pathology rep- the presence of more than 30 mg of albumin in the
resents a higher risk of complications and mortality, 24-hour urine or more than 30 mg/g of albumin in an
especially cardiovascular-related1. isolated urine sample adjusted by urinary creatinine.
An adult patient is identified with CKD when The main causes of CKD include diabetes, hy-
they present, for a period equal to or greater than pertension, chronic glomerulonephritis, chronic
three months, glomerular filtration rate (GFR) low- pyelonephritis, chronic use of anti-inflammatory
er than 60 ml/min/1.73 m2, or GFR greater than 60 medication, autoimmune diseases, polycystic kidney
ml/min/1.73 m2, but with evidence of injury of the disease, Alport disease, congenital malformations,
renal structure. Some indicators of renal injury are and prolonged acute renal disease.

CORRESPONDING AUTHOR: Adriano Luiz Ammirati

Rua Pedro de Toledo, 299 – CEP 04039-030 – São Paulo - SP – Brasil. Tel. 55 11 5904-0799
E-mail: [email protected]

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CHRONIC KIDNEY DISEASE

CLASSIFICATION The staging system shown above helps physicians

CKD is categorized into five stages, according to determine the method and intensity of monitoring
the GFR, and in three stages, according to the albu- that will be applied to CKD patients. A more accurate
minuria, as shown in the tables below:2 risk prediction for individual patients can be achieved
by the development of risk prediction tools. In addi-
TABLE 1. CKD STAGE; GFR = GLOMERULAR FILTRATION tion to the GFR and albuminuria, the cause of the kid-
RATE. ney disease, as well as other factors (such as age, sex,
race, cholesterol levels, smoking, and others), should
Stages GFR value ml/ Classification
min/1.73m2 also be considered in the prognosis estimate.
I >90 Normal or High
II 60-89 Slightly decreased
STAGING
III A 45-59 Mild to moderately decreased
III B 30-44 Moderately to severely de- The justification for staging asymptomatic in-
creased
dividuals for CKD is that early detection may allow
IV 15-29 Severely decreased
the implementation of therapeutic interventions
V <15 Kidney failure
and avoid the inappropriate exposure to nephrotoxic
agents, which can slow the CKD progression to the
TABLE 2. CATEGORIES ALBUMINURIA; A/C RATIO = terminal stage. Another important aspect is that the
ALBUMIN/CREATININE RATIO IN ISOLATED URINE detection of CKD also identifies an important risk
SAMPLES. factor for cardiovascular disease. An additional ad-
vantage of an early diagnosis is to facilitate the ad-
Category 24-Hour A/C Ratio Classification
Albuminuria Mg/g justment of medication dose and allow better prepa-
mg/24 h ration for renal replacement therapy if indicated3.
A1 <30 <30 Normal to discrete The presence of the following risk factors deter-
A2 30-300 30-300 Moderate mines the screening for CKD in adults4:
A3 >300 >300 Severe • History of diabetes, hypertension, cardiovascular
disease (CVD), human immunodeficiency virus
Therefore, an adult patient with diabetic nephrop- (HIV) or hepatitis C virus infection, malignancy,
athy, GFR estimated = 42 ml/min, and albuminuria of autoimmune diseases, nephrolithiasis, or recur-
200 mg/24 hours for over three months is classified rent urinary tract infections.
as a CKD stage IIIB A2 patient. • Family history of renal disease.
It is worth remembering that albuminuria be- Patients selected for CKD assessment should un-
tween 30-300 mg/g used to be called ‘’microalbu- dergo:
minúria’’, and greater than 300 mg/g, “macroalbu- • Measurement of serum creatinine and GFR esti-
minuria’’. The inclusion of the degree of albuminuria mate by mathematical formulae;
in the CKD classification is justified as a way of esti- • Determination of albuminuria, for which the pre-
mating the risk of progression of renal dysfunction, ferred method is the measurement of the albu-
as shown in the table below: min/creatinine ratio in the urine of an isolated
urine sample due to its ease and good correlation
TABLE 3. RISK OF RENAL OUTCOMES ACCORDING with the excretion in the 24-hour urine5;
TO THE GFR AND ALBUMINURIA; GFR: GLOMERULAR • Imaging exam, particularly an ultrasound of the
FILTRATION RATE IN ML/MIN/1.73 M2. kidney and urinary tract.
Albuminuria
Some practical aspects of detecting CKD should
GFR <30 mg/g 30-300 mg/g >300 mg/g
be remembered6:
Stage 1 ≥90 Low risk Moderate risk High risk
• The detection of CKD based on the estimated
Stage 2 60-89 Low risk Moderate risk High risk GFR is a more accurate assessment of renal func-
Stage 3A 45-59 Moderate risk High risk Very high risk tion than the serum creatinine alone.
Stage 3B 30-44 High risk Very high risk Very high risk • Recent studies show that the EPI-CKD (Chronic
Stage 4 15-29 Very high risk Very high risk Very high risk Kidney Disease Epidemiology Collaboration)
Stage 5 <15 Very high risk Very high risk Very high risk formula provides a more accurate prediction of

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 AMMIRATI, A. L.

prognosis of renal outcomes and presents less 5. Persistent unexplained hematuria.

bias that the MDRD (Chronic Kidney Disease 6. Secondary hyperparathyroidism, persistent
Epidemiology Collaboration equation) formula. metabolic acidosis, anemia due to a erythropoietin
• The albumin/creatinine ratio in the urine of an deficiency.
isolated sample is a more sensitive and specific 7. Hypertension resistant to treatment with four
marker of CKD than the protein/creatinine ratio. or more antihypertensive agents.
8. Persistent abnormalities of serum potassium.
9. Recurrent or extensive nephrolithiasis.
EPIDEMIOLOGY
10. Hereditary kidney disease or unknown cause
CKD is very prevalent in the general adult popu- of CKD.
lation. Data from the United States estimate a prev-
alence of 13.1% among adults, which has increased
ROUTINE TREATMENT AND MANAGEMENT
over time7. In Brasil, estimates of the prevalence of
the disease are uncertain8. A recent study reviewed The care of CKD patients includes:
the data available in the literature and found that the • slowing the progression of CKD;
prevalence varied according to the method employed • treat complications related to the pathology, such
in the definition of the disease; by populational cri- as anemia, mineral and bone disorder, hydro-
teria, 3-6 million individuals are estimated to have electrolytic disorders, metabolic acidosis, and
CKD9. The 2017 census by the Brazilian Society of cardiovascular disease;
Nephrology (BSN) reported that the total estimated • prepare the patient for renal replacement ther-
number of patients on dialysis was 126,583, and the apy (RRT);
national estimates of the prevalence rates and inci- • establish a immunization routine, especially for
dence of patients under dialysis treatment per mil- hepatitis B.
lion population (pmp) was 61010. It is important to highlight that, in all levels of
In addition to being highly prevalent, CKD is as- treatment, it is necessary to have a multidisciplinary
sociated with a higher risk of cardiovascular disease, team, particularly of nutrition, nursing, psychology,
severity, and death. In fact, global data from 2013 and social assistance.
showed that the reduction in GFR was associated
with 4% of deaths worldwide, i.e., 2.2 million deaths. Routine for the assessment and management
More than half of those deaths were due to cardio- of CKD progression
vascular causes, while 0.96 million were related to The evaluation of CKD progression is based on the
end-stage renal disease11. The aforementioned SBN evaluation of three aspects: decline in renal function
census found a gross annual mortality rate of 19.9% in patients who were monitored in a longitudinal
on dialysis. way with comparable methods; occurrence of renal
failure, defined by the initiation of RRT; symptoms or
complications of decrease of renal function and the
REFERRAL TO A NEPHROLOGIST
development or worsening of proteinuria, particular-
The referral of patients with chronic renal dys- ly in diabetic nephropathy1.2.
function to a nephrologist varies according to the Data from the literature with approximately two
characteristics of the health care system of each re- years of follow-up of patients with CKD show that
gion, which are oftentimes not uniform, even in the the average decrease in the glomerular filtration rate
same country. However, the following characteris- was 4-5 mL/min/year and that 85% of the patients had
tics usually indicate the necessity of follow-up with this average decline13. Therefore, we must periodical-
a nephrologist12: ly evaluate the decrease of the glomerular filtration
1. GFR <30 mL/min/1.73 m2. rate (GFR), and consider a decrease greater than 5
2. A decrease greater than or equal to 25% in the ml/min/1.73 m2/year2 to be an indicator of accelerat-
GFR. ed progression. In Table 4, we suggest a frequency of
3. Progression of the CKD with a sustained de- monitoring; however, this scheme should be tailored
crease in the GRF of more than 5 ml/min per year. according to the clinical status of the patient and the
4. A consistent finding of significant albuminuria. underlying renal disease.

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CHRONIC KIDNEY DISEASE

TABLE 4. FREQUENCY OF FOLLOW-UP (NUMBER OF

TIMES PER YEAR), ACCORDING TO THE GFR AND lating agents, the hemoglobin and iron control must
LEVEL OF ALBUMINURIA (ADAPTED FROM 3); GFR: be done at every patient consultation or at least every
GLOMERULAR FILTRATION RATE IN ML/MIN/1.73 M2.
three months.
Albuminuria

GFR <30 mg/g 30-300 mg/g >300 mg/g
Routine for the evaluation of mineral
Stage 1 ≥90 1 if CKD 1 2
and bone disorder in CKD
Stage 2 60-89 1 if CKD 1 2
Mineral and bone disorder in CKD is defined as a
Stage 3A 45-59 1 2 3
set of changes in the mineral metabolism of CKD pa-
Stage 3B 30-44 2 3 3
Stage 4 15-29 3 3 4 or more
tients, including renal osteodystrophy, a histological
Stage 5 <15 4 or more 4 or more 4 or more manifestation of the disease.
To diagnose mineral and bone disorder in CKD,
it is necessary to determine the serum levels of cal-
In general, the strategies used to reduce the pro- cium, phosphorus, alkaline phosphatase, and intact
gression of CKD are: parathyroid hormone (PTH), in addition to venous
• use of angiotensin-converting enzyme inhibitors blood gas. These examinations should be performed
or angiotensin receptor blockers for patients in all CKD patients with GFR below 60 ml/min/1.73
with proteinuria above 500 mg/24 hours; m2. The frequency of the exams must be based on the
• reach target blood pressure below 130x80 stage and risk of progression of CKD, as suggested in
mmHg; Table 515.
• reach levels of glycated hemoglobin lower than Another aspect that could be part of the routine
7% for diabetic patients; treatment is the assessment of vitamin D deficiency
• protein restriction indicated and managed by since its incidence is high in CKD under conservative
a nutritionist; treatment16 and is associated with the progression
• correction of metabolic acidosis; of hyperparathyroidism, lower bone mineral den-
• stimulation for smoking cessation. sity, and risk of fractures17.18. In addition, vitamin D
In addition, it is essential to assess the presence deficiency has been associated with changes in the
of factors of exacerbation of CKD, such as volume de- immune response, insulin resistance, changes in vas-
pletion, use of nephrotoxic substances, such as iodin- cular function, and cardiomyopathy19.
ated contrast, antibiotics, non-steroidal anti-inflam-
matory drugs, and obstruction of the urinary tract. Routine for the evaluation of metabolic acido-
sis and electrolytic changes in CKD
Routine for the evaluation of anemia in CKD Metabolic acidosis occurs in most CKD patients
Anemia is a frequent complication in individuals when the glomerular filtration rate is less than 30
with CKD14, and the erythropoietin deficiency is its ml/min20. It is usually mild to moderate, with bicar-
most common factor, together with iron, folic acid, bonate ranging between 12 and 22 mEq/L.
and vitamin B12 deficiency. Therefore, it is part of The benefits of correcting metabolic acidosis
the routine treatment of CKD patients to investigate have been described in the literature. In fact, Brito-
the presence of anemia and indicate and follow-up its Ashurst and col.21 evaluated 134 patients with CKD
treatment. (creatinine clearance of 15 to 30 ml/min/1.73 m2) and
For patients without anemia, the hemoglobin serum bicarbonate between 16 and 20 mmol/L and
concentration should be requested when clinically found that the supplementation with bicarbonate
indicated or according to the suggestion presented in slowed progression to the final stages of CKD, as well
Table 514. as improving the nutritional status of patients.
For patients with anemia, defined by hemoglobin The determination of bicarbonate should be rou-
lower than 13 g/dl for men and 12 for women14, he- tinely done according to the stage of CKD, and the
moglobin concentration tests should be requested target level of bicarbonate must be greater than or
when clinically indicated or every three months for equal to 22 mEq/L; alkaline salts should be used to
patients in stages III to V of CKD. achieve this target.
For patients under treatment for anemia with The main electrolyte disorder in CKD patients
iron replacement and/or using erythropoiesis-stimu- under conservative treatment is hyperkalemia.

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 AMMIRATI, A. L.

The measurement of potassium levels should be schemes carried out in basic health units is to
done at every patient consultation, and, when hy- make four applications with a double dose (4 ml) of
perkalemia is detected, it is important to assess Engedrix B© on the deltoid muscle in months 0, 1,
errors in diet, medications that can lead to hy- 2, and 6. After 30 days of the end of the scheme, the
perkalemia, the presence of metabolic acidosis, AntiHbs are monitored - if lower than 10 miu/ml, a
and question the use or dose increase of potassi- booster dose is recommended with a double dose
um-sparing diuretics. (4 ml) of Engedrix B©; the maximum booster doses
allowed are three.
Routine for the evaluation of cardiovascular
disease in CKD Routine to prepare for renal replacement
Cardiovascular disease (CVD) is the main cause therapy
of morbidity and mortality among the population The decision to start dialysis in a CKD patient
with CKD22. Based on data from the literature, all involves considering subjective and objectives
patients with CKD should be considered at high parameters by the physician and patient. There
risk for CVD, evaluated based on “traditional” and are no absolute laboratory values that indicate a
“non-traditional” (related to uremia) risk factors for requirement to begin dialysis. The following are
CVD, and treated for the reduction of modifiable considered when deciding to initiate RRT: aspects
cardiovascular risk factors23. of quality of life, psychological aspects associated
The following can be established as routine iden- with the anxiety of undergoing complex therapy,
tification of CVD in these patients: yearly electro- the perception of the nephrologist on the health
cardiogram and echocardiogram, and non-invasive state of the patient, the decline of renal function,
tests, such as myocardial scintigraphy or stress and the risks associated with renal replacement
echocardiography for patients who are symptomatic therapy.
or have changes in segmental motility, with three or In the follow-up of CDK patients that present a
more traditional risk factors, or with a history of pe- progressive decrease of renal function and in those
ripheral vascular insufficiency and cerebral vascular with GFR less than 20 ml/min, it is essential to ad-
accident. In the presence of clinical symptoms and dress the types of RRT, along with their Indications,
positive results in invasive or non-invasive exams, it advantages, and disadvantages. Once the patient
is recommended to refer the patient to a specialized has opted for a particular type of RRT and provided
cardiac assessment. there are no medical contraindications, it is neces-
In addition to identifying CVD, it is important to sary to initiate the appropriate preparations, espe-
establish strategies to reduce risk factors, such as cially the manufacturing of the arteriovenous fis-
control of hypertension and diabetes, dyslipidemia tula for hemodialysis, peritoneal dialysis training,
assessment, smoking cessation, stimulation of phys- implantation of the Tenckhoff catheter, serology
ical exercises, treatment of anemia, and reduction of for hepatitis B, C, and HIV. If the patient is inter-
proteinuria levels. ested and meets the clinical conditions, they can
also be forwarded to outpatient clinics specialized
Routine for hepatitis B immunization in in pre-renal transplantation evaluation.
CKD As soon as the patient presents very reduced GFR
According to the 2012 dialysis census by the and/or compatible symptoms, such as nausea, vom-
SBN, the prevalence of hepatitis B in patients iting, drowsiness, weight loss, hiccups, among oth-
undergoing hemodialysis in Brasil is 1%. The cor- ers, we must request RRT to the competent organs
rect application of a vaccination scheme is one of of the Single Health System or through complemen-
the main factors responsible for the reduction in tary medical services. It is important to emphasize
the incidence of this infection in dialysis. It is worth that if these symptoms are accentuated or if there
pointing out that the response to vaccination in are changes in laboratory findings that indicate high
this population varies from 40% to 60%, and that risk, the patient must be referred to the urgent start
the maintenance of the antibodies titer is not sus- of RRT.
tained. It is important to establish a routine vaccina- In Table 5, we suggest a model of test grouping
tion for non-immune patients. One of the proposed according to the risk of progression of CKD.

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CHRONIC KIDNEY DISEASE

TABLE 5. ROUTINE OF EXAMS ACCORDING TO THE RISK OF PROGRESSION OF CKD.

Department Low Moderate High Very high

Renal function
GFR Every consultation Every consultation Every consultation Every consultation
Urine 1 Yearly Every six months Every six months Every six months
Proteinuria Yearly Every six months Every six months Every six months
Anemia
Complete blood count Yearly Every six months Every consultation Every consultation
Iron - Every six months Quarterly # Quarterly #
Transferrin - Every six months Quarterly # Quarterly #
Ferritin - Every six months Quarterly # Quarterly #
Bone disease
Ionized calcium Yearly Every six months Quarterly Every consultation
Phosphorus Yearly Every six months Quarterly Every consultation
PTH - Yearly Every six months Quarterly #
Metabolism
Cholesterol Yearly CV Risk* CV Risk* CV Risk*
Triglycerides Yearly CV Risk* CV Risk* CV Risk*
Uric acid Yearly Every six months Every six months Every six months
Venous blood gas - Yearly Quarterly Every consultation
Glycemia Yearly If diabetes Quarterly Every consultation
Hb1Ac - If diabetes Quarterly Quarterly
TGO, TGP; CPK Consultation &
Consultation &
Consultation &
Consultation&
Nutrition
Urea clearance - Every six months Quarterly Bimonthly
Urine Sodium Yearly Every six months Every six months Every six months
Potassium Yearly Every consultation Every consultation Every consultation
Viral profile
HbsAg - Yearly Yearly Dialysis**
Anti-HbsAg - Yearly Yearly Dialysis**
Anti-Hbc - Yearly Yearly Dialysis**
Anti-HIV - Dialysis**
Anti-HCV - Dialysis**
Others
Echocardiogram Yearly Yearly Yearly Yearly

GFR = estimated glomerular filtration rate or by 24-hour urine creatinine clearance; # if treatment; * according to the cardiovascular risk; ** at the moment of referral to dialysis;
&
if under treatment with statins or fibrates.

CONCLUSION

Chronic renal disease has an important impact with a positive impact on the prognosis of the af-
on the morbidity and mortality of patients. The or- fected population. Another important aspect is the
ganization of the conservative treatment is crucial preparation for renal replacement treatment, which
to slow the progression of kidney dysfunction, as greatly facilitates the adaptation of patients to the
well as to lessen the occurrence of complications, chosen therapy.

PALAVRAS-CHAVE: Doença renal crônica. Doença renal crônica estágio final. Tratamento conservador.

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 AMMIRATI, A. L.

REFERENCES
1. National Kidney Foundation. K-DOQI clinical practice guidelines for chronic 12. Moyer VA, U.S. Preventive Services Task Force. Screening for chronic kidney
kidney disease: evaluation, classification and stratification. Am J Kidney Dis. disease: U.S. Preventive Services Task Force recommendation statement.
2002;39(2 Suppl 1):S1-266. Ann Intern Med. 2012;157(8):567-70.
2. KDIGO. KDIGO 2012 Clinical practice guideline for the evaluation and 13. Hunsicker LG, Adler S, Caggiula A, England BK, Greene T, Kusek JW, et al.
management of chronic kidney disease. Kidney Int Suppl. 2013;3(1):1-150. Predictors of the progression of renal disease in the Modification of Diet in
3. Pereira BJ. Optimization of pre-ESRD care: the key to improved dialysis Renal Disease Study. Kidney Int. 1997;51(6):1908-19.
outcomes. Kidney Int. 2000;57(1):351-65. 14. Kidney Disease: Improving Global Outcomes (KDIGO) Anemia Work Group.
4. Moyer VA; U.S. Preventive Services Task Force. Screening for chronic kidney KDIGO clinical practice guideline for anemia in chronic kidney disease.
disease: U.S. Preventive Services Task Force recommendation statement. Kidney Inter Suppl. 2012;2(4):279-335.
Ann Intern Med. 2012;157(8):567-70. 15. Carvalho AB. Brazilian clinical practice guidelines for mineral and bone
5. Ginsberg JM, Chang BS, Matarese RA, Garella S. Use of single voided disorders in chronic renal disease. J Bras Nefrol. 2011;33(2):191.
urine samples to estimate quantitative proteinuria. N Engl J Med. 16. Cuppari L, Garcia-Lopes MG. Hypovitaminosis D in chronic kidney disease
1983;309(25):1543-6. patients: prevalence and treatment. J Ren Nutr. 2009;19(1):38-43.
6. Vassalotti JA, Centor R, Turner BJ, Greer RC, Choi M, Sequist TD; National 17. Boudville NC, Hodsman AB. Renal function and 25-hydroxyvitamin D con-
Kidney Foundation Kidney Disease Outcomes Quality Initiative. Practical centrations predict parathyroid hormone levels in renal transplant patients.
approach to detection and management of chronic kidney disease for the Nephrol Dial Transplant. 2006;21(9):2621-4.
primary care clinician. Am J Med. 2016;129(2):153-62. 18. Ooms ME, Roos JC, Bezemer PD, van der Vijgh WJ, Bouter LM, Lips P.
7. Coresh J, Selvin E, Stevens LA, Manzi J, Kusek JW, Eggers P, et al. Prevalence Prevention of bone loss by vitamin D supplementation in elderly women: a
of chronic kidney disease in the United States. JAMA. 2007;298(17):2038-47. randomized double-blind trial. J Clin Endocrinol Metab. 1995;80(4):1052-8.
8. Lugon JR. Doença renal crônica no Brasil: um problema de saúde pública. 19. Ravani P, Malberti F, Tripepi G, Pecchini P, Cutrupi S, Pizzini P, et al. Vita-
J Bras Nefrol. 2009;31(supl 1):2-5. min D levels and patient outcome in chronic kidney disease. Kidney Int.
9. Marinho AWGB, Penha AP, Silva MT, Galvão TF. Prevalência de doença 2009;75(1):88-95.
renal crônica em adultos no Brasil: revisão sistemática da literatura. Cad 20. Kraut JA, Kurtz I. Metabolic acidosis of CKD: diagnosis, clinical character-
Saúde Colet. 2017;25(3):379-88. istics, and treatment. Am J Kidney Dis. 2005;45(6):978-93.
10. Thomé FS, Sesso RC, Lopes AA, Lugon JR, Martins CT. Brazilian chronic 21. Brito-Ashurst I, Varagunam M, Raftery MJ, Yaqoob MM. Bicarbonate sup-
dialysis survey 2017. J Bras Nefrol. 2019;41(2):208-14. plementation slows progression of CKD and improves nutritional status. J
11. Thomas B, Matsushita K, Abate KH, Al-Aly Z, Ärnlöv J, Asayama K, et al; Am Soc Nephrol. 2009;20(9):2075-84.
Global Burden of Disease 2013 GFR Collaborators; CKD Prognosis Con- 22. Levin A. Clinical epidemiology of cardiovascular disease in chronic kidney
sortium; Global Burden of Disease Genitourinary Expert Group. Global disease prior to dialysis. Semin Dial. 2003;16(2):101-5.
cardiovascular and renal outcomes of reduced GFR. J Am Soc Nephrol. 23. European Renal Association. Medical Expert Group. V. Clinical algorithms
2017;28(7):2167-79. on cardiovascular risk factors in renal patients. Nephrol Dial Transplant.
2000;15(Suppl 5):123-54.

9 REV ASSOC MED BRAS 2020; 66(SUPPL 1):S3-S9