What are the KDIGO (Kidney Disease: Improving Global Outcomes) guidelines?

From the Guidelines

The KDIGO guidelines provide a comprehensive framework for the evaluation and management of chronic kidney disease (CKD), emphasizing the importance of staging based on GFR and albuminuria categories, regular monitoring of kidney function and complications, and timely preparation for kidney replacement therapy. The guidelines cover various aspects of CKD management, including blood pressure control, glycemic control, and cardiovascular risk reduction. According to the most recent guideline update 1, the KDIGO 2020 Clinical Practice Guideline for Diabetes Management in Chronic Kidney Disease provides actionable recommendations for clinicians and patients, focusing on comprehensive care, glycemic monitoring and targets, lifestyle and antihyperglycemic interventions, and approaches to self-management and optimal models of care.

Key recommendations from the KDIGO guidelines include:

• Staging CKD based on GFR and albuminuria categories
• Regular monitoring of kidney function and complications
• Blood pressure control (target <120/80 mmHg for most patients) using ACE inhibitors or ARBs for those with albuminuria
• Glycemic control for diabetic patients (HbA1c ~6.5-7%)
• Statin therapy for cardiovascular risk reduction
• Timely preparation for kidney replacement therapy, including vascular access planning and transplant evaluation, for patients with advanced CKD (stage G4-G5)

The guidelines also emphasize the importance of comprehensive care addressing complications like anemia, mineral bone disorders, and metabolic acidosis. The development of the KDIGO guidelines follows an explicit process of evidence review and appraisal, using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach 1. The guidelines are regularly updated to incorporate new evidence and improve outcomes for kidney disease patients worldwide.

From the Research

KDIGO Guidelines for Acute Kidney Injury (AKI)

• The KDIGO guidelines provide a framework for the diagnosis, evaluation, and management of AKI, including the use of diuretics such as furosemide 2, 3, 4, 5, 6.
• According to the guidelines, furosemide may be used to manage fluid overload and promote diuresis in patients with AKI, but its use should be carefully considered and monitored 3, 4, 6.
• The furosemide stress test (FST) has been proposed as a tool to predict the progression of AKI and the need for renal replacement therapy (RRT) 5.
• Studies have shown that the FST can be useful in predicting the progression of AKI, with a urinary flow rate of less than 200mls in the first 2 hours after the test being predictive of progression to stage III AKI 5.
• However, the use of furosemide in AKI remains controversial, and its impact on mortality and the need for RRT is still unclear 3, 4, 6.
• A systematic review and meta-analysis of randomized trials found that furosemide had no significant impact on mortality or the need for RRT in adult patients with AKI 6.
• Overall, the KDIGO guidelines recommend a cautious approach to the use of furosemide in AKI, with careful consideration of the potential benefits and risks, and close monitoring of patients receiving the medication 2, 3, 4, 5, 6.

Furosemide Stress Test (FST)

• The FST involves the administration of a single dose of furosemide (1-1.5mg/kg) to patients with AKI, with subsequent measurement of urinary flow rate 5.
• The test can be used to predict the progression of AKI and the need for RRT, with a low urinary flow rate being indicative of a higher risk of progression 5.
• The FST has been shown to be a useful tool in the management of AKI, particularly in critically ill patients 5.
• However, further studies are needed to fully evaluate the utility and safety of the FST in clinical practice 5.

Management of AKI

• The management of AKI involves a multifaceted approach, including the use of diuretics such as furosemide, as well as other interventions such as fluid management and renal replacement therapy 2, 3, 4, 5, 6.
• The KDIGO guidelines provide a framework for the management of AKI, including the use of furosemide and other diuretics, as well as other interventions such as fluid management and RRT 2, 3, 4, 5, 6.
• The goal of management is to prevent progression of AKI, reduce morbidity and mortality, and promote recovery of renal function 2, 3, 4, 5, 6.