The definition and classification for chronic kidney disease was proposed by the National Kidney Foundation Kidney Disease Outcomes Quality Initiative (NKF-KDOQI) in 2002 and endorsed by the Kidney Disease: Improving Global Outcomes (KDIGO) in 2004. This framework promoted increased attention to chronic kidney disease in clinical practice, research and public health, but has also generated debate. It was the position of KDIGO and KDOQI that the definition and classification should reflect patient prognosis and that an analysis of outcomes would answer key questions underlying the debate. KDIGO initiated a collaborative meta-analysis and sponsored a Controversies Conference in October 2009 to examine the relationship of estimated glomerular filtration rate (GFR) and albuminuria to mortality and kidney outcomes. On the basis of analyses in 45 cohorts that included 1,555,332 participants from general, high-risk, and kidney disease populations, conference attendees agreed to retain the current definition for chronic kidney disease of a GFR <60 ml/min per 1.73 m(2) or a urinary albumin-to-creatinine ratio >30 mg/g, and to modify the classification by adding albuminuria stage, subdivision of stage 3, and emphasizing clinical diagnosis. Prognosis could then be assigned based on the clinical diagnosis, stage, and other key factors relevant to specific outcomes. KDIGO has now convened a workgroup to develop a global clinical practice guideline for the definition, classification, and prognosis of chronic kidney disease.

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Chronic kidney disease (CKD) is increasingly recognized as a global public health problem. There is now convincing evidence that CKD can be detected using simple laboratory tests, and that treatment can prevent or delay complications of decreased kidney function, slow the progression of kidney disease, and reduce the risk of cardiovascular disease (CVD). Translating these advances to simple and applicable public health measures must be adopted as a goal worldwide. Understanding the relationship between CKD and other chronic diseases is important to developing a public health policy to improve outcomes. The 2004 Kidney Disease Improving Global Outcomes (KDIGO) Controversies Conference on 'Definition and Classification of Chronic Kidney Disease' represented an important endorsement of the Kidney Disease Outcome Quality Initiative definition and classification of CKD by the international community. The 2006 KDIGO Controversies Conference on CKD was convened to consider six major topics: (1) CKD classification, (2) CKD screening and surveillance, (3) public policy for CKD, (4) CVD and CVD risk factors as risk factors for development and progression of CKD, (5) association of CKD with chronic infections, and (6) association of CKD with cancer. This report contains the recommendations from the meeting. It has been reviewed by the conference participants and approved as position statement by the KDIGO Board of Directors. KDIGO will work in collaboration with international and national public health organizations to facilitate implementation of these recommendations.

We estimated glomerular cell number in 50 normotensive type 1 diabetic patients with raised albumin excretion rate (AER) and investigated any change after 3 years in a subgroup of 16 placebo-treated patients. Biopsies from 10 normal kidney donors were used as controls. Mesangial and endothelial cell number was increased in the 50 diabetic patients at the start of the study compared with control subjects. There was no difference in podocyte number. Glomerular volume was increased in diabetic patients, but surface area of glomerular basement membrane (GBM) underlying the podocytes did not differ between groups. AER correlated positively with mesangial cell number in microalbuminuric patients (r ‫؍‬ 0.44, P ‫؍‬ 0.012) and negatively with podocyte number in proteinuric patients (r ‫؍‬ ؊0.48, P ‫؍‬ 0.040). In the 16 placebo-treated patients, glomerular volume increased after 3 years owing to matrix accumulation and increased GBM surface area. Although overall cell number did not differ significantly from baseline, the decrease in podocyte number during follow-up correlated with AER at follow-up (r ‫؍‬ ؊0.72, P ‫؍‬ 0.002). In conclusion, crosssectional analysis of podocyte number in type 1 diabetic patients with raised AER but normal blood pressure shows no significant reduction compared with nondiabetic control subjects. Longitudinal data provide evidence for an association between podocyte loss and AER, but whether cellular changes are a response to, a cause of, or concomitant with the progression of nephropathy remains uncertain. Diabetes 51:3083-3089, 2002

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Baseline HbA1c, SBP, proteinuria and serum uric acid together with the presence of vascular co-morbidities are strongly and independently associated with faster DKD progression. A further prospective observational study is currently undertaken to evaluate these findings and to determine the predictive value of other biochemical peptides and cellular markers on DKD outcome.

Should current guidelines be changed to require age calibration for diagnosis and classification of chronic kidney disease? -Yes.The classifications of chronic kidney disease (CKD) used both for epidemiological studies in populations and for diagnosis in individual patients have evolved since the original Kidney Disease Quality Outcome Initiative iteration published more than one decade ago. The categorization of CKD, using glomerular filtration rate (GFR) and proteinuria (albuminuria), has undoubtedly raised the profile of CKD among physicians and the general public. However, concern has arisen that this approach incorrectly labels individuals, particularly older persons, as having CKD, thus inflating the prevalence of a generic CKD in the aging population. A paradox arises in that a steadily increasing frequency of such alleged CKD is accompanied by an unchanged or decreasing incidence of treated end-stage renal disease (ESRD), at least in developed nations. 1,2 Although several explanations are possible for this paradox, one is that it may be a direct consequence of flaws in the current diagnostic classification of CKD. Specifically, the persistent and serious criticism that successive iterations of the CKD classification systems, including those promulgated in 2013 by the Kidney Disease: Improving Global Outcome (KDIGO) CKD Work Group 2 and in 2014 by NICE (UK National Institute of Health and Care Excellence), 3 have not incorporated an age-based approach to diagnosis and classifications of CKD. Consequently, defining CKD on the basis of an absolute threshold of GFR regardless of age has resulted in overdiagnosis in a substantial proportion of the general population with potentially serious and unwarranted effects.The arguments underlying this assumption are simple and straightforward. First, the CKD diagnostic approach that uses an absolute, single (not calibrated by age), arbitrary threshold of GFR and estimated GFR (eGFR) of less than 60 mL/min/1.73 m 2 (persisting for Ն3 months even in the absence of corroborating features of kidney injury) as disease defining fails to clearly distinguish the common age-related decline in kidney function (most likely physiological organ senescence) 4 from that of more progressive CKD due to intrinsic renal diseases. Consequently, the most common category of CKD detected in community-based programs is 3A (ie, GFR of 45-59 mL/min/1.73 m 2 ), which predominantly affects older persons and is seldom progressive (there are only 0.6 to 0.8 cases of ESRD per 1000 patientyears in patients >65 years) in the absence of significant proteinuria. 5 This contrasts sharply with referred CKD, often accompanied by overt proteinuria, reflecting an underlying pathology that commonly progresses to ESRD.