What are the key recommendations from the 2025 nephrology guidelines for managing patients with Chronic Kidney Disease (CKD)?

Key Recommendations from the 2025 KDIGO Guidelines for Managing CKD

The 2025 KDIGO guidelines strongly recommend a multi-drug approach for CKD management, prioritizing SGLT2 inhibitors, RAS inhibitors, and nonsteroidal MRAs based on albuminuria status and eGFR to reduce mortality and improve quality of life. 1

Pharmacological Management

Renin-Angiotensin System Inhibitors (RASi)

• RASi (ACEi or ARB) are recommended for:
  • CKD with severely increased albuminuria (G1-G4, A3) without diabetes (strong recommendation) 1
  • CKD with moderately increased albuminuria (G1-G4, A2) without diabetes (conditional recommendation) 1
  • CKD with moderately-to-severely increased albuminuria (G1-G4, A2 and A3) with diabetes (strong recommendation) 1
• Use the highest approved dose that is tolerated to achieve maximum benefits 1
• Continue ACEi/ARB even when eGFR falls below 30 ml/min per 1.73 m² 1
• Avoid any combination of ACEi, ARB, and direct renin inhibitor therapy 1
• Monitor serum creatinine and potassium within 2-4 weeks of initiation or dose increase 1
• Continue therapy unless serum creatinine rises by more than 30% within 4 weeks 1

SGLT2 Inhibitors

• Strongly recommended for:
  • Type 2 diabetes with CKD and eGFR ≥20 ml/min per 1.73 m² 1
  • CKD with eGFR ≥20 ml/min per 1.73 m² and urine ACR ≥200 mg/g 1
  • CKD with heart failure, regardless of albuminuria level 1
• Conditionally recommended for adults with eGFR 20-45 ml/min per 1.73 m² with urine ACR <200 mg/g 1
• Continue SGLT2i even if eGFR falls below 20 ml/min per 1.73 m² unless not tolerated or kidney replacement therapy is initiated 1
• Withhold during prolonged fasting, surgery, or critical illness due to ketosis risk 1

Nonsteroidal Mineralocorticoid Receptor Antagonists (MRAs)

• Suggested for adults with T2D, eGFR >25 ml/min per 1.73 m², normal potassium, and albuminuria >30 mg/g despite maximum tolerated RASi 1
• May be added to RASi and SGLT2i for treatment of T2D and CKD 1
• Monitor serum potassium regularly after initiation 1
• Prioritize agents with documented kidney or cardiovascular benefits 1

GLP-1 Receptor Agonists

• Recommended for adults with T2D and CKD who haven't achieved glycemic targets despite metformin and SGLT2i, or who cannot use these medications 1
• Prioritize agents with documented cardiovascular benefits 1

Blood Pressure Management

• Target systolic BP <120 mmHg in adults with high BP and CKD, when tolerated 1
• Consider less intensive BP-lowering therapy in patients with frailty, high fall risk, limited life expectancy, or symptomatic postural hypotension 1
• For children with CKD, target 24-hour mean arterial pressure by ABPM to ≤50th percentile for age, sex, and height 1
• Monitor BP in children once yearly with ABPM and every 3-6 months with standardized office BP 1

Dietary and Lifestyle Recommendations

Protein Intake

• Maintain protein intake of 0.8 g/kg body weight/day in adults with CKD G3-G5 1
• Avoid high protein intake (>1.3 g/kg/day) in adults with CKD at risk of progression 1
• Consider higher protein and calorie targets in older adults with frailty and sarcopenia 1
• Do not restrict protein intake in children with CKD due to growth impairment risk 1

Sodium Intake

• Limit sodium intake to <2 g/day (<5 g sodium chloride/day) in people with CKD 1
• Exception: Sodium restriction is not appropriate for patients with sodium-wasting nephropathy 1

Physical Activity

• Recommend moderate-intensity physical activity for at least 150 minutes per week 1
• Avoid sedentary behavior 1
• Tailor physical activity recommendations based on age, ethnicity, comorbidities, and fall risk 1

Metabolic Management

Lipid Management

• For adults ≥50 years with eGFR <60 ml/min per 1.73 m², recommend statin or statin/ezetimibe combination 1
• For adults ≥50 years with CKD and eGFR ≥60 ml/min per 1.73 m², recommend statin treatment 1
• Consider PCSK-9 inhibitors for CKD patients with appropriate indications 1
• Consider a plant-based "Mediterranean-style" diet in addition to lipid-modifying therapy 1

Hyperuricemia Management

• Treat symptomatic hyperuricemia in CKD patients 1
• Prefer xanthine oxidase inhibitors over uricosuric agents 1
• Do not use uric acid-lowering agents for asymptomatic hyperuricemia to delay CKD progression 1

Metabolic Acidosis

• Consider pharmacological treatment with/without dietary intervention to prevent acidosis (serum bicarbonate <18 mmol/l) 1
• Monitor treatment to ensure bicarbonate doesn't exceed upper limit of normal 1

Common Pitfalls and Caveats

• RASi Discontinuation: Many clinicians inappropriately stop RASi when eGFR falls below 30 ml/min per 1.73 m², but guidelines recommend continuation unless specific adverse effects occur 1
• SGLT2i Initiation: The reversible decrease in eGFR upon SGLT2i initiation is not an indication to discontinue therapy 1
• Hyperkalemia Management: Hyperkalemia with RASi should be managed with measures to reduce potassium rather than immediately stopping the medication 1
• Protein Restriction: Low or very low-protein diets should not be prescribed in metabolically unstable CKD patients 1
• BP Targets: While targeting <120 mmHg SBP, this should be individualized for frail patients or those with postural hypotension 1, 2