Rethinking the Chronic Kidney Disease Staging System

OK, I am going to say it. Many within the nephrology community may not agree... but, I know I am not alone here... anyway.. here it goes... the CKD staging system sucks. There, I said it.

I was thinking about a more politically correct way to say it, but why sugar-coat it? Stage 1 and 2 are nearly meaningless. When we speak of CKD we are really speaking about only stages 3 through stage 5. So, why not just drop Stage 1 and 2 CKD? I believe they could easily be grouped together and renamed "Pre-CKD" in much the same way as we have "Prehypertension".

Moreover, I think there would be a psychological benefit of renaming stage 3 CKD as stage 1. Patients are often concerned that they are at stage 3. I have been told, "Why hasn't anyone told me about this when I was at Stage 1 or 2?" It can give the appearance the physician (PCP) is late to discovering a "disease" which has already "progressed" to this more advanced frightful stage 3. Patients and families alike are confused and upset by this arbitrary nomenclature.

This is an example of an email I just received, and it is a VERY common scenario:

My dad is almost 76 yrs. old. Due to other health concerns we got copies of all his medical records. In May of this year it was written down dads diagnosis of stage 3 ckd. This is the first we knew of this. The dr did not advise dad to go to a nephrologist. Mom called the drs office about this and she was told he has been stable since 07 but if they want a referral they would be glad to do this. So, my father has had this disease and his dr sits on it. Why?
Is this common practice for a physican? We certainly do not understand why he wasn't verbally told and then advised to seek specialized care. What is your opinion of this situation?
Thank you for your time and expertise
Sincerely
(name withheld)


I will give you another example.... There is a 60ish year old woman, let's call her Hilliary. Imagine Hilliary's BUN 14, Creatinine 1.1 mg/dL, and albumin 3.8 g/dL. Using the MDRD Eq, Hilliary's eGFR is 56 ml/min. She could now be considered by some to have stage 3 CKD. Well, does she really have Stage 3 CKD? Furthermore, I will tell you her urine is completely bland without a trace of proteinuria, cells or casts and she is neither diabetic or hypertensive. Now, is this really a pathologic entity deserving of the label stage 3 chronic kidney disease? Does a family member need to deal with the angst of deciphering the meaning of stage 3 CKD? Is it a productive use of time for the PCP to enbark upon a long discussion as to whether or not Hillary has stage 3 CKD, and its meaning? Is the anger directed towards a PCP that does not share this with Hillary or her family justified? Is the PCP obligated to work up Hillary further? Does she need to see a Nephrologist?

Additionally, another point I have made before is, all 'stage 3's' are not created equally. Please see my earlier post, 'Should all Stage 3 CKD Patients See a Nephrologist? What About Stage 3b?'

Is it time to rethink the staging system for CKD? I believe so.