What are the Kdigo (Kidney Disease: Improving Global Outcomes) guidelines for managing kidney disease?

KDIGO Guidelines for Managing Chronic Kidney Disease

The KDIGO guidelines recommend a comprehensive treatment strategy for CKD that includes SGLT2 inhibitors, RAS inhibitors, and statin therapy as first-line pharmacological interventions, alongside lifestyle modifications targeting physical activity, diet, and smoking cessation to reduce disease progression and associated complications. 1

Diagnosis and Classification

• CKD diagnosis requires:

  • Estimated GFR (eGFR) using CKD-EPI creatinine equation
  • Urine albumin-to-creatinine ratio (ACR)
  • Confirmation of abnormalities persisting >3 months 2

• Risk stratification using the KDIGO heat map:

  Risk Level	Categories
  Low	G1A1, G2A1
  Moderately elevated	G1A2, G2A2, G3aA1
  High	G1A3, G2A3, G3aA2, G3bA1
  Very high	G3aA3, G3bA2-A3, G4A1-A3, G5A1-A3

Core Treatment Approach

1. First-line pharmacological therapy:

   • SGLT2 inhibitors (initiate if eGFR ≥20; continue until dialysis or transplant)
   • RAS inhibitors (ACEi/ARB) at maximum tolerated dose for hypertension
   • Moderate or high-intensity statin therapy 1

2. Blood pressure targets:

   • For patients without albuminuria: <140/90 mmHg
   • For patients with albuminuria: <130/80 mmHg 1

3. Lifestyle interventions:

   • Physical activity: ≥150 minutes of moderate-intensity activity weekly 1
   • Diet: Plant-dominant, Mediterranean-style with sodium restriction (<2 g/day) 2
   • Protein intake: 0.6-0.8 g/kg/day for adults with CKD G3+ 1
   • Complete avoidance of tobacco products 1
   • Weight management: Achieve optimal BMI (20-25 kg/m²) 1

Monitoring and Follow-up

• Monitoring frequency based on risk category:

  Risk Level	Monitoring Frequency
  Low	Annual
  Moderate	1-2 times per year
  High/Very High	3-4 times per year

• Regular risk factor reassessment every 3-6 months 1

Management of Specific Complications

Diabetes and CKD

1. Glycemic management:

   • SGLT2 inhibitors for T2D with eGFR ≥20 ml/min/1.73m² 1
   • Metformin if eGFR ≥30 ml/min/1.73m² 1
   • GLP-1 receptor agonists if glycemic targets not achieved 1

2. Medication dosing in CKD:

   • For metformin:
     • eGFR ≥60: Standard dosing
     • eGFR 45-59: Continue same dose
     • eGFR 30-44: Half the dose
     • eGFR <30: Discontinue 1

Albuminuria Management

• ACEi or ARB for all patients with albuminuria ≥30 mg/g 1
• Consider nonsteroidal MRA (finerenone) for persistent albuminuria despite RAS inhibition 1

CKD-Mineral Bone Disorder

• Monitor and manage phosphate, calcium, PTH, and vitamin D levels 1
• Consider oral bicarbonate supplementation for serum bicarbonate <22 mmol/L 1

Special Populations

Children with CKD

• Encourage ≥60 minutes of daily physical activity 1
• Achieve healthy weight appropriate for age 1

Kidney Transplant Recipients

• Blood pressure management with similar targets as non-transplant CKD patients 1
• Consider immunosuppression regimen when selecting antihypertensive medications 1

Common Pitfalls to Avoid

1. Do not discontinue ACEi/ARB when eGFR falls below 30 ml/min/1.73m² unless serum creatinine rises >30% within 4 weeks of initiation 2

2. Avoid combining ACEi, ARB, and direct renin inhibitors due to increased risk of adverse events 2

3. Do not restrict protein in malnourished, sarcopenic, or cachectic patients 1

4. Avoid nephrotoxic medications (especially NSAIDs) 2

5. Do not rely solely on HbA1c for glycemic monitoring in advanced CKD (stages G4-G5) as it may be less accurate 2

6. Never attribute reduced eGFR to age alone - always investigate for underlying causes 2

The KDIGO guidelines emphasize a holistic approach to CKD management that addresses modifiable risk factors, optimizes pharmacological therapy, and provides regular monitoring to slow disease progression and reduce complications. The evidence supporting these recommendations is strongest for blood pressure control, RAS inhibition for albuminuria, and SGLT2 inhibitors in diabetic CKD.