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

Comprehensive Management of Chronic Kidney Disease

The KDIGO 2024 guidelines recommend a holistic, multi-pronged treatment strategy for CKD that simultaneously addresses blood pressure control, cardiovascular risk reduction, lifestyle modifications, dietary interventions, and metabolic complications to reduce progression and improve outcomes. 1

Risk Assessment and Monitoring

Use validated risk prediction tools incorporating eGFR and albuminuria to guide management intensity. 1, 2

• Apply a 2-year kidney failure risk threshold of >10% to determine timing for multidisciplinary care 2, 3
• Use a threshold of >40% to initiate kidney replacement therapy preparation, including vascular access planning and transplant referral 1, 2
• Test at-risk individuals using both urine albumin measurement and eGFR assessment 2, 3
• Confirm CKD diagnosis by repeating abnormal tests (elevated ACR, hematuria, or low eGFR) after initial detection 2, 3
• Establish CKD etiology through clinical context, family history, medications, physical examination, laboratory measures, imaging, and when indicated, genetic or pathologic diagnosis 2, 3

Blood Pressure Management

Target systolic blood pressure <120 mmHg when tolerated using standardized office measurement. 2

• For patients without albuminuria, a target of <140/90 mmHg is acceptable 4, 3
• For patients with albuminuria ≥30 mg/24h, target <130/80 mmHg 4, 3
• Use ACE inhibitors or ARBs as first-line therapy, particularly when albuminuria is present 1, 4, 3
• Titrate ACEi/ARBs to the highest approved tolerated dose to maximize kidney protection 3
• Add dihydropyridine calcium channel blockers and/or diuretics as needed to achieve BP targets 1
• Consider less intensive BP-lowering in patients with frailty, high fall risk, limited life expectancy, or symptomatic orthostatic hypotension 2

Pediatric Blood Pressure Targets

• Aim for 24-hour mean arterial pressure ≤50th percentile for age, sex, and height by ambulatory monitoring 2
• Monitor BP annually with ambulatory monitoring and every 3-6 months with standardized office BP 2

Cardiovascular Risk Reduction

Prescribe statins or statin/ezetimibe combination for all adults ≥50 years with eGFR <60 ml/min/1.73 m² (CKD G3a-G5). 4, 2

• Choose statin regimens that maximize absolute LDL cholesterol reduction 2, 3
• For adults ≥50 years with CKD G1-G2 (eGFR ≥60), prescribe statins based on cardiovascular risk 4
• For adults 18-49 years with CKD, prescribe statins if they have coronary disease, diabetes, prior ischemic stroke, or 10-year MI/coronary death risk >10% 4, 2
• Add PCSK-9 inhibitors for patients with CKD who have established indications 4, 2
• Prescribe low-dose aspirin for secondary prevention in patients with established ischemic cardiovascular disease 4, 2

Atrial Fibrillation Management

• Use non-vitamin K antagonist oral anticoagulants (NOACs) preferentially over warfarin in CKD G1-G4 4, 2
• Adjust NOAC dosing based on GFR, exercising particular caution in CKD G4-G5 2

Lifestyle Modifications

Advise moderate-intensity physical activity for at least 150 minutes per week, adjusted to cardiovascular tolerance and frailty level. 1, 4

• Counsel patients to avoid sedentary behavior 1, 4, 2
• Tailor physical activity recommendations to age, ethnic background, comorbidities, and resource access 1
• For patients at high fall risk, provide specific guidance on exercise intensity (low, moderate, or vigorous) and type (aerobic vs. resistance) 1
• Advise weight loss for patients with obesity and CKD 1, 4, 2
• Strongly encourage tobacco cessation and avoidance of all tobacco products 1, 2
• Refer to specialized programs (psychologists, renal dietitians, pharmacists, physical/occupational therapy, smoking cessation) as indicated 1

Pediatric Physical Activity

• Encourage children with CKD to achieve WHO-recommended levels of ≥60 minutes daily physical activity 1, 4, 2
• Support achievement and maintenance of healthy weight in pediatric CKD patients 1, 4, 2

Dietary Management

Advise adoption of healthy, diverse diets emphasizing plant-based foods over animal-based foods and minimizing ultra-processed foods. 1, 4

Protein Intake

• Maintain protein intake at 0.8 g/kg body weight/day in adults with CKD G3-G5 4, 2, 3
• Avoid high protein intake (>1.3 g/kg body weight/day) in adults with CKD at risk of progression 4, 2, 3
• In highly motivated adults with CKD at risk of kidney failure, consider very low-protein diets (0.3-0.4 g/kg/day) supplemented with essential amino acids or ketoacid analogs under close supervision 2
• Do not restrict protein in children with CKD due to growth impairment risk 4, 3

Sodium Restriction

• Limit sodium intake to <2 g per day (equivalent to <5 g sodium chloride per day) 2

Dietitian Involvement

• Utilize renal dietitians or accredited nutrition providers to educate patients about dietary adaptations for sodium, phosphorus, potassium, and protein tailored to individual needs and CKD severity 1

Medication Management

Consider GFR when dosing all medications cleared by the kidneys. 4, 2, 3

• Use validated eGFR equations based on serum creatinine for drug dosing in most clinical settings 4, 2, 3
• Perform thorough medication reviews periodically and at all care transitions to assess adherence, continued indication, and potential drug interactions 4, 2, 3
• Avoid nephrotoxins, particularly NSAIDs 5
• Review teratogenicity potential for all medications prescribed to patients of childbearing potential and provide regular reproductive and contraceptive counseling 3

Management of Metabolic Complications

Monitor and treat metabolic abnormalities including anemia, CKD-mineral and bone disorder, acidosis, and potassium abnormalities. 1

Hyperuricemia

• Treat symptomatic hyperuricemia (gout) with urate-lowering therapy, preferring xanthine oxidase inhibitors over uricosuric agents 2

Metabolic Acidosis

• Provide pharmacological treatment with or without dietary intervention to prevent acidosis (serum bicarbonate <18 mmol/L) 2
• Monitor treatment to ensure serum bicarbonate remains within normal limits without adversely affecting blood pressure, serum potassium, or fluid balance 2

Referral to Specialist Kidney Care

Refer adults with CKD to nephrology when ACR ≥30 mg/g (3 mg/mmol) or PCR ≥200 mg/g (20 mg/mmol). 4, 2, 3

Additional referral criteria include:

• Persistent hematuria 4, 2, 3
• Any sustained decrease in eGFR 4, 2, 3
• eGFR <30 ml/min/1.73 m² 5
• Albuminuria ≥300 mg per 24 hours 5
• Rapid decline in eGFR 5

Disease-Specific Therapies

For patients with diabetes and CKD, use SGLT2 inhibitors as foundational therapy alongside RAS blockade. 1

• Consider GLP-1 receptor agonists where indicated for additional cardiovascular and kidney protection 1
• Use nonsteroidal mineralocorticoid receptor antagonists (ns-MRA) for additional kidney protection when appropriate 1
• Consider steroidal MRA for resistant hypertension 1