Patterns of progression of chronic kidney disease at later stages

Abstract

Background: At later stages of chronic kidney disease (CKD), a pattern of linear and irreversible renal function decline is thought to be the most common. The objective of this study was to describe the characteristics of the different patterns of CKD progression, and to investigate potentially modifiable factors associated with the rate of decline of renal function.

Methods: This was a retrospective, observational study in a cohort of adult patients with CKD Stage 4 or 5 not on dialysis. Decline in renal function was estimated as the slope of the individual linear regression line of estimated glomerular filtration rate (eGFR) over time. The following patterns of CKD progression were considered: unidentifiable, linear, nonlinear (curvilinear) and positive (improvement of renal function).

Results: The study group consisted of 915 patients (mean ±SD age 65 ± 14 years, 48% females, median follow-up time 16 months). A linear pattern was observed in 38%, unidentifiable in 23%, nonlinear in 24% and positive in 15% of the study patients. The mean eGFR slope was: -3.35 ± 4.45 mL/min/year. Linear and unidentifiable patterns were associated with more rapid loss of renal function. By multiple linear and logistic regression analysis, the magnitude of proteinuria, the systolic blood pressure and the treatment with dual renin-angiotensin system blockade were associated with more rapid CKD progression. On the contrary, older age and discontinuation of commonly prescribed medication with potential influence on renal function or eGFR measurements were associated with slower CKD progression.

Conclusions: A majority of patients with advanced CKD show patterns of renal function decline different from linear, and several of the main determinants of CKD progression are potentially modifiable.

Keywords: chronic kidney disease; dual blockade renin–angiotensin system; patterns of CKD progression; proteinuria.

Fig. 1.

Example plots illustrating the different patterns of CKD progression. (A) Unidentifiable pattern in which the relationship between eGFR over time does not fit any significant linear or curvilinear pattern. (B) Linear pattern. (C) Nonlinear quadratic pattern. (D) and (E) Nonlinear cubic pattern. (F) Positive pattern with sustained improvement of renal function.

Fig. 2.

Histogram representing frequency distribution of eGFR slopes in the whole study group.

Fig. 3.

Kaplan–Meier ‘survival without dialysis’ curves according to different patterns of progression.

Fig. 4.

Kaplan–Meier ‘survival without dialysis’ curves according to the rate of progression of CKD (faster or slower).