Nephrol Dial Transplant (2010) 25: 2832–2836
doi: 10.1093/ndt/gfq370
Advance Access publication 1 July 2010
Editorial Comments
The KDOQI 2002 classification of chronic kidney disease: for whom
the bell tolls
Stein Ivar Hallan1,2 and Stephan Reinhold Orth3,4
1
Department of Medicine, Division of Nephrology, St Olav University Hospital, Trondheim, Norway, 2Department of Cancer Research
and Molecular Medicine, Faculty of Medicine, Norwegian University of Science and Technology, Trondheim, Norway,
3
Dialysis Centre Bad Aibling, Bad Aibling, Germany and 4Department of Internal Medicine II, University of Regensburg,
Regensburg, Germany
Correspondence and offprint requests to: Stein Hallan; E-mail: stein.hallan@ntnu.no
Keywords: albuminuria; cardiovascular disease; chronic kidney disease;
classification; eGFR
The current definition of chronic kidney disease
In 2002, the Kidney Disease Outcomes Quality Initiative
(KDOQI) published a new chronic kidney disease (CKD)
classification based on five categories of estimated glom-
erular filtration rate (eGFR) [1]. For near-normal kidney
function, additional signs of kidney damage were required
(Table 1). Previously, there was no commonly accepted def-
inition of CKD, and serum creatinine values from 120 to
350 µmol/L had been used as cut-off [2,3]. The new classi-
fication was, therefore, nothing else than a paradigm shift in
nephrology: the main attention was moved from end-stage
CKD to less advanced stages of the disease with the aim to
improve early CKD detection. The latter is fundamental to
enable preventive measures. In 2004, the Kidney Disease
Improving Global Outcome (KDIGO) foundation con-
ducted a survey to nephrologists worldwide (12% of 10
000 responded) on their opinion on the new classification
and later hosted two conferences (2004 and 2006) to reana-
lyse the KDOQI CKD classification. Global use of the
KDOQI 2002 classification system was endorsed after
minor modifications (i.e. specifying the presence of dialysis
or transplantation) [4], and the classification has over the
subsequent years had a very strong and positive impact on
CKD awareness, research and public health policy.
CKD—a major health problem of worldwide
dimensions
The prevalence of CKD has been found to be high world-
wide [5–7]. Furthermore, CKD has emerged as a strong
independent risk factor for cardiovascular and total mortal-
ity [8–10]. CKD is, therefore, increasingly recognized as a
global public health problem and not only a sub-speciality
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end-organ damage problem needing renal replacement
therapy (RRT) [11]. CKD screening has been suggested
to improve the clinical outcome in CKD patients and to
potentially reduce the need of RRT, which has increased
strongly during the last decades and imposes a major bur-
den on health budgets [12]. However, there are still some
important aspects of CKD screening that need to be im-
proved before a general recommendation can be made.
The major questions are who and how we should test for
CKD and are those cases identified really at risk of pro-
gression to kidney failure? These aspects are closely re-
lated to the CKD def inition, and the KDOQI 2002
classification is, therefore, currently under vivid debate.
The current debate on the KDOQI 2002
classification of CKD
A substantial number of letters and editorials have been
published lately challenging the current CKD definition
[13–17]. No common solution has been reached so far,
but all seem to agree that a revision of the KDOQI 2002
classification system is needed, including the leadership
of KDOQI and KDIGO [18]. The appropriateness of the
KDOQI definition was questioned already in 2004. Cathe-
rine Clase warned against relying on eGFR only and sug-
gested the inclusion of proteinuria [19]. This excellent and
clear-sighted article did not, however, generate much debate
on the topic. It was not until Glassock and Winearls revita-
lized the debate in a series of articles during 2008 and 2009
[16,17,20–22] that serious discussions about the KDOQI
2002 classification started. Some of the major concerns
put forward in this debate are highlighted in Table 2.
eGFR is the backbone, but also the soft spot, of the
current CKD classification. The initial Modification of Diet
in Renal Disease (MDRD) study equation led to a substan-
tial underestimation of GFR and overinflated CKD preva-
lence estimates. This has been improved with more recent
equations, but the low accuracy of eGFR is still a problem
Nephrol Dial Transplant (2010): Editorial Comments 2833
Table 1. Definition of CKD Stages 1–5 according to the KDOQI 2002 classification system

GFR (mL/min/1.73 m2)

≥90 60–89 30–59 15–29 <15

Normoalbuminuria No CKD No CKD Stage 3 Stage 4 Stage 5

Microalbuminuria/macroalbuminuria Stage 1 Stage 2 Stage 3 Stage 4 Stage 5

Findings should be present for more than 3 months.

Table 2. Major problems with the current KDOQI 2002 classification system of CKD

Problem Description Data Reference

GFR estimation Large negative bias at GFR >60 mL/min/1.73 m2 −11 (MDRD) to −4 (CKD-EPI) mL/min/1.73 m2 [41]
Only moderate accuracy Only 84% of estimates within ±30% [41]
Progression rate Few CKD Stage 3 patients progress to kidney failure 1–2% in 10 years [26]
Progression rate is low in most CKD Stage 3 cases −1 mL/min/1.73 m2/year [42]
CKD in the elderly Decreasing eGFR could be due to normal ageing [5–7]
Lower RR associations compared to younger RR death CKD 4: 4.9 in young, 1.9 in old [23]

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CKD prevalence Previously considered a rare disease, now very 10–13% in general populations worldwide [5–7]
common based on the KDOQI 2002 definition

CKD, chronic kidney disease; RR, relative risk; eGFR, estimated glomerular filtration rate; MDRD and CKD-EPI, equations for estimating GFR.

leading to misclassification of individual patients. The
prevalence of CKD, especially in the elderly, has, therefore,
been claimed to be implausibly high, and age- and sex-
specific cut-off values for defining abnormal GFR have
been suggested [17,23,24]. However, the history of medi-
cine has often shown that the 2.5th and 97.5th percentiles
do not necessarily reflect good health and low risk. For in-
stance, guidelines on hypertension and hypercholesterol-
aemia have repeatedly lowered their levels for intervention
below and beyond these percentiles over the past decades.
Furthermore, subjects of very good health, e.g. potential
120
100
eGFR (mL/min/1.73m2)
80
kidney donors, have a significantly lower loss of kidney
function per year compared to the general population [25].
Based on data from the population-based HUNT 2 study
(n = 65 123) and the new Chronic Kidney Disease Epi-
demiology Collaboration (CKD-EPI) equation, which has
a minimal negative bias even at near-normal GFR levels,
we find that the donor-based age-specific fifth percentile
equals 60 mL/min/1.73 m2 at age 87 (Figure 1). Therefore,
an eGFR<60 mL/min/1.73 m2 should clearly be consid-
ered as abnormal even at high age, supporting at least parts
of the current CKD definition.

60 mL/min/1.73m2
60

Age-spec. 5thperc. in Donors

Age-spec. 5thperc. in Gen. Pop.
40

Kidney failure, normoalbuminuria

Kidney failure, microalbuminuria
20

Kidney failure, macroalbuminuria

20 40 60 80 100
Age (years)

Fig. 1. Distribution of baseline eGFR values by age and risk of progression to kidney failure over 10 years in HUNT 2 participants with eGFR below a
fixed cut-off at eGFR 60 mL/min/1.73m2, below the age-specific fifth percentile in healthy kidney donors, and below the age-specific fifth percentile in
the general population.
2834
However, a very low risk of progression to kidney failure
among CKD Stage 3 patients has been used as an argu-
ment against the current CKD classification. Only 1–2%
of such patients will need RRT over a 10-year period
[26]. Likewise, the relative risk associated with lower
eGFR is substantially reduced in the elderly while the
prevalence of CKD increases with age [23]. These findings
illustrate the shortcomings of the current CKD classifica-
tion system and point towards the need for improvements.
Focus should be on patient prognosis and outcomes should
include cardiovascular disease and mortality in addition to
RRT.
Urinary albumin—the missing link on the way to a
revision of the KDOQI classification of CKD
Albuminuria has long been known as a very strong risk
factor for the progression of kidney disease, and espe-
cially, the Prevention of Renal and Vascular End-stage
Nephrol Dial Transplant (2010): Editorial Comments
failure. Likewise, a substantial number of future kidney
failure patients had eGFR above these cut-offs at base-
line in the HUNT 2 study—but, something that is of
major importance—most of them had microalbuminuria
(Figure 1, marked as yellow circles) or macroalbuminuria
(Figure 1, marked as red circles).
Reduced eGFR and increased albuminuria are related
variables, but the association between the combined
eGFR–albuminuria variable and a hard kidney endpoint
had not been described until the last 5 years. Data from
three reputable studies consistently showed that lower
eGFR and higher urinary albumin excretion were inde-
pendently associated with kidney failure [30–32]. The rela-
tive risk associated with the category of lowest eGFR and
highest albuminuria ranged from 30-fold in studies inves-
tigating high-risk populations (African American Study of
Kidney Disease, Multiple Risk Factor Intervention Trial)
[31,32] to 1000-fold in a low-risk population-based study
(Okinawa Study) [30].

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Disease (PREVEND) Study Group in the Netherlands
has published a large number of excellent articles on
this topic. They have, shown that albuminuria is a stron-
ger predictor of a rapid decline in kidney function than
baseline eGFR level [27] and that even increased levels
in the normoalbuminuric range are associated with an
increased risk for an adverse cardiovascular and renal
outcome [28], coming to the conclusion that pre-screen-
ing for albuminuria could be a useful strategy for CKD
detection [29].
Figure 1 illustrates some of the aspects of eGFR and
albuminuria. Subjects with eGFR below the fifth per-
centile are displayed as small dots and those progressing
to kidney failure are indicated as large dots (n=124). If
we use eGFR=60 mL/min/1.73 m2, the age-specific fifth
percentile based on healthy subjects eligible for kidney do-
nation and the age-specific fifth percentile based on the
general population for defining abnormality, we would
diagnose 2677, 7900 and 4007 subjects as CKD patients,
respectively. Regardless of the cut-off level used, it is
obvious that only a small percentage progress to kidney
Suggestions for a new CKD classification system
In April 2008, Ron Gansevoort and Paul de Jong suggested
that albuminuria should be used to adequately define CKD
Stage 3 [15]. In October 2008, new British guidelines sug-
gested a new CKD classification where CKD Stage 3 was
subdivided into Stages 3a and 3b and the presence or ab-
sence of macroalbuminuria was indicated at all levels of kid-
ney function [33]. These suggestions were mainly expert
opinion-based as (i) there were no data available on how
they would perform compared to the KDOQI 2002 system
and (ii) at that time-point only one population-based study
had been published on the topic (eGFR ± macroalbuminuria
in the Okinawa study) [30]. In May 2009, Hallan et al. docu-
mented that all levels of eGFR should be complemented by
urinary albumin–creatinine ratio (ACR) measurements to
get optimal kidney failure risk prediction [34]. This finding
was based on the 10-year follow-up of 65 123 subjects from
the Norwegian population-based HUNT 2 study using vari-
ous receiver operating characteristics and efficacy analyses

Table 3. Suggestion for new CKD classification system

Adjusted relative risk for kidney failure

eGFR ≥ 60 eGFR 45–59 eGFR 30–44 eGFR 15–29

Normal ACR 1 (not CKD) 23 (7–82) 52 (12–234) 369 (69–1964)

Microalbuminuria 27 (9–85) 147 (43–503) 449 (134–1508) 2202 (632–7669)
Macroalbuminuria 196 (28–1397) 641 (144–2862) 2036 (594–6973) 4146 (1187–14 480)

Observed data
Not CKD Low risk Moderate risk High risk
Proportion of the general population (%) 86.0 12.6 1.3 0.2
Kidney failure incidence rate 1.2 41.4 484.6 4635.8

All eGFR levels are complemented by information on urinary albumin excretion using a matrix of 4 eGFR categories × 3 ACR categories. Hazard ratios
(95% CI) for progression to kidney failure (n=124/65 123) are adjusted for age, sex, blood pressure, antihypertensive medication, diabetes, HDL
cholesterol and physical activity. Data are adapted with permission from Hallan et al. [34]. Low, medium and high renal risk categories are based on
arbitrary relative risk cut-offs (1–99, 100–999 and 1000+, respectively) as well as on clinical experience for how to handle CKD patients (controlled and
treated in general practice; cooperation between general practitioner and nephrologist; or nephrology outpatient clinic). Data on prevalence of the three
risk categories and the observed kidney failure incidence (per 100 000 population per year) for the three risk categories are also shown.
Nephrol Dial Transplant (2010): Editorial Comments
in addition to the traditional multi-adjusted relative risk ana-
lysis. A new CKD classification system using four categor-
ies of eGFR (≥60, 45–59, 30–44 and 15–30 mL/min/
1.73 m2) complemented by three categories of albuminuria
(normoalbuminuria, microalbuminuria and macroalbuminur-
ia) was suggested for the description of low, moderate and
high risk of progression to kidney failure (Table 3). It has to
be pointed out that the data shown in Table 3 are characterized
by wide 95% confidence intervals, which to a certain degree
weakens the validity of risk categorization performed on the
basis of these data.
In February 2010, the relative risk estimates underlying
the new classification system suggested above were con-
firmed by Hemmelgarn et al. in the much larger Alberta
study [35]. Using the same 4 × 3 matrix, they found a very
similar pattern of relative risks for kidney failure as in
the HUNT 2 study, but it has to be pointed out that it
would be statistically incorrect to directly compare the
relative risks found in these two studies. In the Alberta
study, the potential of improved risk classification based
on eGFR–albuminuria even extended to other important
outcomes, since robust data for mortality and myocardial
infarction risks were also given. Results from a meta-
analysis of 50 CKD cohorts (including the HUNT 2 and
the Alberta studies) using the same analytical approach as
described above are expected to be published soon giving
more precise risk estimates [36]. This KDIGO initiative
will also provide data on the risk for progressive CKD
and acute kidney injury, which are other important clin-
ical outcomes that need to be taken into account. A new
CKD classification system will then likely be agreed on.
Since (i) there are no generally accepted criteria for the
categorization of renal risk and (ii) the HUNT 2 study
results had rather wide confidence intervals, the new
CKD classification system may slightly differ from the
one proposed in Table 3. However, the main principles
are clearly shown in our suggestion, and it would anyway
be a significant improvement over the current KDOQI
2002 system regarding CKD prevalence distribution, risk
stratification and efficacy.
In most classification systems, there is a gradual decline
in prevalence with increasing severity of stages. However,
based on the KDOQI system and the MDRD study equation
for estimating GFR, we find the following non-standardized
distribution of CKD Stages 1–4 in the HUNT 2 popula-
tion: 3.4, 3.9, 4.5 and 0.2%. Some improvement is ob-
tained using the new CKD-EPI equation (5.3, 4.1, 3.9
and 0.2%), but a new classification system incorporating
albuminuria as suggested in Table 3 gives a much more
plausible frequency distribution (12.6, 1.3 and 0.2%). Fur-
thermore, it gives a much better resolution of associated
renal risk. The multi-adjusted relative risk of future kidney
failure range between 10.4, 36.2, 81.5 and 982 for KDOQI
Stages 1–4, while the new system assigns relative risks of
26.8, 239.8 and 2186.4 to low-, medium- and high-risk
CKD, respectively. Estimates from the HUNT 2 study in-
dicate that the number of CKD patients assigned to inten-
sive follow-up could be reduced without losing predictive
power for incident kidney failure [34]. These findings
have been highlighted as potentially important for a
much more efficient handling of the large number of
2835
CKD patients [36,37]. Whether the new classification
system also leads to better risk prediction of other out-
comes of interest in CKD (e.g. infections [38], cogni-
tive impairment [39] and fractures [40]) remains to be
studied.
Summary
The KDOQI 2002 classification system of CKD has several
weaknesses and will very likely be revised in the near future.
In our opinion, the new CKD classification system must be
evidence-based, focus on the risk of progression to renal as
well as cardiovascular end-points, combine all levels of
eGFR with ACR measurements and condense the informa-
tion into a simple nomenclature to facilitate cooperation
with general practitioners and other non-nephrologists.
Information on the background, key studies that will form
the scientific basis for the revised CKD system and an ex-
ample of a revised classification system for the definition
Downloaded from ndt.oxfordjournals.org by guest on October 24, 2010
of low-, medium- and high-risk CKD patients have been
presented here. We are convinced that physicians should
immediately start to evaluate renal and cardiovascular risk
in their patients by adopting the combined eGFR–ACR ap-
proach, particularly in the large group of patients with
eGFR 30–59 mL/min/1.73 m2.
Conflict of interest statement. None declared.
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Received for publication: 13.4.10; Accepted in revised form: 4.6.10