The CKD Classification System in the Precision Medicine Era: My Thought and Recommendations

Once again NephJC is proud to have Kevin Fowler present his views on our NephJC discussion.

I thoroughly enjoyed reading this thought provoking article. The authors make a persuasive argument that the CKD classification system is not aligned with the precision medicine initiative.  Namely, the CKD classification system does not take into the account the complexity of the kidney. By extension, the lack of alignment may be creating a barrier to industry investment and the effectiveness of kidney disease research.

The other downside of the current system is that it may not be optimizing patient care. I can relate to that argument based upon my personal experience with kidney disease. Because of my family history of PKD, I had been seeing a primary care physician to monitor my kidney function.  Based upon my measurement of SCr and GFR, my primary care physician said my kidney function was “normal”. 

Due to back pain, I asked my doctor to conduct an ultrasound test to determine if I had PKD.   The test revealed that my kidneys were being engulfed with cysts. Thus, I went from having “normal” kidney function to a diagnosis that I would experience renal failure in 3-5 years.

Since both the nephrology profession and patient care are in the midst of transformation, I think this is a good time to assess the classification system.  A multi-stakeholder conference with nephrologists, pharma, diagnostic companies, private equity, and patients/patient advocacy groups would serve everyone well.  If this meeting is held, it must be designed with these stakeholders in mind.

While the vision of precision medicine is prevention, it is important to not lose sight of current prevention opportunities.  The passage of Medicare Authorization and CHIP Act (MACRA) provides the opportunity for Alternative Payment Models (APM).  The APM offer the chance to create models of care that improve the delivery of CKD patient care, to potentially prevent renal failure. 

If these new models of care are developed, it will still be important that patients understand their GFR. The fact only 9% of patients with GFR less than <60 know their function is both appalling and reflects a US healthcare system that has not supported prevention.

While the authors make a compelling argument for revising the CKD classification system, we must not lose sight of the current prevention opportunities. We need a CKD classification system with reimbursement incentives that support patient awareness of their kidney function. Although efforts to improve awareness of kidney function have not demonstrated significant progress, this should not be used as a basis to stop efforts. Rather, I would like to see this a continued priority with reimbursement incentives. Patient awareness of kidney function is the first step to patient engagement.