Guidelines for Managing Chronic Kidney Disease
The KDIGO 2024 guidelines recommend a comprehensive treatment strategy centered on SGLT2 inhibitors as first-line therapy for most CKD patients, combined with RAS inhibition (ACE inhibitor or ARB) at maximum tolerated dose when hypertension or albuminuria is present, targeting systolic blood pressure <120 mmHg, alongside statin-based lipid therapy. 1, 2
Core Pharmacologic Therapy
First-Line Medications
SGLT2 inhibitors should be initiated in most CKD patients and continued until dialysis or transplant. 2 This represents the most significant advancement in CKD management, with robust evidence for delaying progression and reducing cardiovascular complications. 1
RAS inhibition (ACE inhibitor or ARB) must be prescribed at maximum tolerated dose when albuminuria is present, and is first-line when hypertension exists. 2, 3 Titrate to the highest approved dose that is tolerated to maximize kidney protection. 3
Statin therapy (moderate to high-intensity) or statin/ezetimibe combination is mandatory for all adults ≥50 years with eGFR <60 mL/min/1.73 m² (CKD G3a-G5). 4, 2, 3 Choose regimens that maximize absolute LDL cholesterol reduction. 1, 3
Additional Pharmacotherapy
For adults aged 18-49 years with CKD, prescribe statins when they have coronary disease, diabetes mellitus, prior ischemic stroke, or estimated 10-year incidence of coronary death or nonfatal MI >10%. 1, 4
Nonsteroidal mineralocorticoid receptor antagonists (ns-MRA) should be used in patients with diabetes. 2 This includes agents like finerenone, which target fibrosis and inflammation. 5
PCSK-9 inhibitors should be considered for people with CKD who have an indication for their use. 1, 4, 2
GLP-1 receptor agonists should be used where indicated for diabetes management. 2
Blood Pressure Management
Target systolic blood pressure <120 mmHg for most CKD patients. 2 This represents a more aggressive target than previous guidelines and is supported by cardiovascular outcome data. 1
For patients without albuminuria, target blood pressure <140/90 mmHg. 4, 3
For patients with albuminuria ≥30 mg/24h, target blood pressure <130/80 mmHg. 4, 3
When albuminuria is present, ACE inhibitor or ARB must be first-line antihypertensive therapy. 2, 3 This is non-negotiable given the proven kidney protective effects. 3
Lifestyle Modifications
Physical Activity
Advise patients to undertake moderate-intensity physical activity for at least 150 minutes per week, adjusted to their cardiovascular and physical tolerance. 1, 4, 2, 3
Patients should be advised to avoid sedentary behavior. 1, 4, 3
For people at higher risk of falls, provide specific advice on the intensity of physical activity (low, moderate, or vigorous) and the type of exercises (aerobic vs. resistance, or both). 1
Weight Management
Encourage weight loss for patients with obesity and CKD. 1, 4, 3
Tobacco and Alcohol
Encourage patients to not use tobacco products. 1 Smoking increases the risk of CKD progression. 5
Advise patients to limit alcohol consumption, as binge drinking increases the risk of CKD progression. 5
Dietary Management
General Dietary Principles
Advise patients to adopt healthy, diverse diets with higher consumption of plant-based foods compared to animal-based foods and lower consumption of ultra-processed foods. 1, 4, 2, 3
Consider a plant-based "Mediterranean-style" diet in addition to lipid-modifying therapy to reduce cardiovascular risk. 1
Protein Intake
Maintain protein intake at 0.8 g/kg body weight/day in adults with CKD G3-G5. 1, 4, 2, 3
Avoid high protein intake (>1.3 g/kg body weight/day) in adults with CKD at risk of progression. 1, 4, 2, 3
In adults with CKD who are willing and able, and who are at risk of kidney failure, consider prescribing, under close supervision, a very low-protein diet (0.3-0.4 g/kg body weight/day) supplemented with essential amino acids or ketoacid analogs (up to 0.6 g/kg body weight/day). 1
Do not prescribe low- or very low-protein diets in metabolically unstable people with CKD. 1
Sodium Intake
Sodium intake should be <2 g of sodium per day (or <90 mmol of sodium per day, or <5 g of sodium chloride per day). 1
Dietary sodium restriction is usually not appropriate for patients with sodium-wasting nephropathy. 1
Specialized Dietary Counseling
Use renal dietitians or accredited nutrition providers to educate people with CKD about dietary adaptations regarding sodium, phosphorus, potassium, and protein intake, tailored to their individual needs, and severity of CKD and other comorbid conditions. 1
Cardiovascular Disease Management
Antiplatelet Therapy
Prescribe oral low-dose aspirin for secondary prevention in people with CKD and established ischemic cardiovascular disease. 1, 4, 2
Consider other antiplatelet therapy (e.g., P2Y12 inhibitors) when there is aspirin intolerance. 1
Coronary Artery Disease
In stable stress-test confirmed ischemic heart disease, an initial conservative approach using intensive medical therapy is an appropriate alternative to an initial invasive strategy. 1
Initial management with an invasive strategy may still be preferable for people with CKD with acute or unstable coronary disease, unacceptable levels of angina, left ventricular systolic dysfunction attributable to ischemia, or left main disease. 1
Atrial Fibrillation
Use non-vitamin K antagonist oral anticoagulants (NOACs) in preference to vitamin K antagonists (e.g., warfarin) for thromboprophylaxis in atrial fibrillation in people with CKD G1-G4. 1, 4, 2
NOAC dose adjustment for GFR is required, with caution needed at CKD G4-G5. 1
Risk Assessment and Monitoring
Use validated risk prediction tools to guide management decisions. 4, 3 The Kidney Failure Risk Equation can support identification of patients at high risk of progressive kidney disease. 6
Estimate 10-year cardiovascular risk using a validated risk tool. 1, 2
Test people at risk for CKD using both urine albumin measurement and assessment of glomerular filtration rate (GFR). 4, 3
Repeat tests to confirm presence of CKD following incidental detection of elevated urinary albumin-to-creatinine ratio (ACR), hematuria, or low estimated GFR (eGFR). 3
Perform regular risk factor reassessment every 3-6 months. 2
Medication Management
Consider GFR when dosing medications cleared by the kidneys. 4, 3
For most clinical settings, validated eGFR equations using serum creatinine are appropriate for drug dosing. 4, 3
Perform thorough medication review periodically and at transitions of care to assess adherence, continued indication, and potential drug interactions. 4, 3
Referral to Specialist Kidney Care
Refer adults with CKD to specialist kidney care services when they have ACR ≥30 mg/g (3 mg/mmol) or PCR ≥200 mg/g (20 mg/mmol). 4, 3
Refer adults with CKD to specialist kidney care services when they have persistent hematuria. 4, 3
Refer adults with CKD to specialist kidney care services when they have any sustained decrease in eGFR. 4, 3
Special Populations
Pediatric Considerations
Encourage children with CKD to undertake physical activity aiming for WHO-advised levels (≥60 minutes daily) and to achieve a healthy weight. 1, 4, 3
Do not restrict protein intake in children with CKD due to the risk of growth impairment. 1, 4, 3 The target protein and energy intake in children with CKD G2-G5 should be at the upper end of the normal range for healthy children to promote optimal growth. 1
Older Adults
In older adults with underlying conditions such as frailty and sarcopenia, consider higher protein and calorie dietary targets. 1
Reproductive Considerations
When prescribing medications to people with CKD who are of child-bearing potential, always review teratogenicity potential and provide regular reproductive and contraceptive counseling. 3
Critical Pitfalls to Avoid
Never prescribe NSAIDs in CKD due to nephrotoxicity risk and potential for acute kidney injury—use low-dose colchicine or glucocorticoids instead for inflammatory conditions like acute gout. 2
Do NOT use agents to lower serum uric acid in CKD patients with asymptomatic hyperuricemia to delay CKD progression. 2
Do not discontinue RAS inhibitors due to modest increases in serum creatinine or potassium unless there are specific contraindications. 1 Reassurances as to when to maintain people on these agents despite changes in bloodwork are provided in the guidelines. 1