What are the newest guidelines for managing Chronic Kidney Disease (CKD)?

2024 KDIGO Guidelines for Chronic Kidney Disease Management

The 2024 KDIGO guidelines for CKD management recommend a comprehensive approach focusing on risk stratification, pharmacological interventions targeting kidney and cardiovascular protection, and lifestyle modifications to reduce morbidity and mortality in CKD patients.

Risk Assessment and Monitoring

• Use externally validated risk equations to estimate absolute risk of kidney failure in CKD G3-G5 1

  • 5-year kidney failure risk of 3-5% can determine need for nephrology referral
  • 2-year kidney failure risk >10% can determine timing for multidisciplinary care
  • 2-year kidney failure risk >40% can guide KRT preparation planning

• Monitor kidney function and albuminuria at least annually, with more frequent monitoring for high-risk patients 2

  • Consider cystatin C-based equations in older adults where serum creatinine may be unreliable

Pharmacological Management

Renin-Angiotensin System Inhibition

• For patients with CKD and moderately-to-severely increased albuminuria (G1-G4, A2 and A3) with diabetes, RASi (ACEi or ARB) is strongly recommended (1B) 1
• For patients with CKD and moderately increased albuminuria (G1-G4, A2) without diabetes, RASi is suggested (2C) 1
• Avoid combination therapy with ACEi, ARB, and direct renin inhibitors (1B) 1
• Use highest approved tolerated dose of RASi to achieve maximum benefits 1
• Continue RASi even when eGFR falls below 30 ml/min/1.73 m² 1

SGLT2 Inhibitors

• Treat patients with type 2 diabetes, CKD, and eGFR ≥20 ml/min/1.73 m² with an SGLT2i (1A) 1
• Treat adults with CKD having eGFR ≥20 ml/min/1.73 m² with urine ACR ≥200 mg/g or heart failure with an SGLT2i (1A) 1
• Consider continuing SGLT2i even if eGFR falls below 20 ml/min/1.73 m² unless not tolerated or KRT is initiated 1
• Consider withholding SGLT2i during prolonged fasting, surgery, or critical illness 1

Mineralocorticoid Receptor Antagonists

• Consider nonsteroidal MRA for adults with T2D, eGFR >25 ml/min/1.73 m², normal potassium, and albuminuria despite maximum RASi (2A) 1
• Nonsteroidal MRA may be added to RASi and SGLT2i in T2D and CKD 1
• Monitor serum potassium regularly after initiating nonsteroidal MRA 1

Lipid Management

• Treat adults ≥50 years with eGFR <60 ml/min/1.73 m² with statin or statin/ezetimibe (1A) 1
• Treat adults ≥50 years with CKD and eGFR ≥60 ml/min/1.73 m² with statin (1B) 1
• For adults 18-49 years with CKD, consider statin if they have coronary disease, diabetes, prior stroke, or 10-year cardiovascular risk >10% (2A) 1

Antiplatelet and Anticoagulation Therapy

• Use low-dose aspirin for secondary prevention in CKD patients with established cardiovascular disease (1C) 1
• Use non-vitamin K antagonist oral anticoagulants (NOACs) over warfarin for thromboprophylaxis in atrial fibrillation in CKD G1-G4 (1C) 1

Lifestyle Modifications

• Recommend moderate-intensity physical activity for at least 150 minutes per week (1D) 1
• Advise patients to avoid sedentary behavior 1
• Consider weight loss for patients with obesity and CKD 1
• Encourage children with CKD to achieve 60 minutes of daily physical activity 1
• Advise healthy and diverse diets 1

Comprehensive Treatment Approach

The 2024 KDIGO guidelines emphasize a holistic approach to CKD management that includes:

1. Blood pressure control:

   • Target ≤140/90 mmHg for albuminuria <30 mg/24h
   • Target ≤130/80 mmHg for albuminuria ≥30 mg/24h 2

2. Cardiovascular risk reduction:

   • Statin therapy
   • Blood pressure management
   • Antiplatelet therapy for established cardiovascular disease 1

3. Management of CKD complications:

   • Anemia
   • Mineral and bone disorders
   • Acidosis
   • Potassium abnormalities 1

Special Considerations

• For elderly patients, carefully tailor blood pressure treatment with gradual escalation and monitoring for postural hypotension 2
• Consider deprescribing potentially inappropriate medications to reduce pill burden 2
• Adjust medication dosages based on kidney function 2

Implementation Challenges

• CKD remains underdiagnosed, with less than 5% of patients with early CKD reporting awareness of their disease 3
• The prevalence of CKD (G3-5) ranges from 2% to 17% in different populations 4
• Most CKD patients are detected in the community, requiring organized care at the primary care level 5

These updated guidelines represent significant advances in CKD care since the previous 2012 guidelines, incorporating evidence from multiple high-quality clinical trials showing benefits of newer medications in reducing the risk of kidney failure, kidney function decline, and cardiovascular disease 1.