What are the KDIGO (Kidney Disease: Improving Global Outcomes) guidelines for managing patients with impaired renal function?

KDIGO Guidelines for Managing Chronic Kidney Disease

All patients with CKD should receive SGLT2 inhibitors as first-line therapy (initiated when eGFR ≥20 mL/min/1.73m² and continued until dialysis or transplant), combined with RAS inhibition at maximum tolerated dose when hypertension or albuminuria is present, moderate-to-high intensity statin therapy, and a comprehensive lifestyle intervention program. 1, 2

Core Pharmacologic Framework

First-Line Medications (All CKD Patients)

• SGLT2 inhibitors are mandatory first-line therapy for CKD patients, initiated when eGFR ≥20 mL/min/1.73m² and continued until dialysis or transplantation 1, 2, 3
• RAS inhibition (ACE inhibitor or ARB) at maximum tolerated dose is required when hypertension is present and is mandatory when albuminuria ≥30 mg/24h is present 1, 2, 4
• Moderate-to-high intensity statin therapy (or statin/ezetimibe combination) for all adults ≥50 years with eGFR <60 mL/min/1.73m² 1, 2, 4
• Metformin should be used when eGFR ≥30 mL/min/1.73m² 1, 4

Additional Risk-Based Pharmacotherapy

• Nonsteroidal mineralocorticoid receptor antagonists (ns-MRA) should be added when albumin-to-creatinine ratio (ACR) ≥30 mg/g and potassium is normal, particularly in diabetic patients 1, 2
• GLP-1 receptor agonists are indicated when additional glycemic control is needed beyond SGLT2 inhibitors and metformin to achieve individualized targets 1, 4
• Ezetimibe, PCSK9 inhibitors, or icosapent ethyl should be added based on ASCVD risk and lipid levels 1, 2, 4
• Antiplatelet agents (low-dose aspirin) for secondary prevention in patients with established ischemic cardiovascular disease 2, 4

Blood Pressure Management Algorithm

Target Blood Pressure by Albuminuria Status

• Without albuminuria (<30 mg/24h): Target BP <140/90 mmHg 1, 4
• With albuminuria (≥30 mg/24h): Target BP <130/80 mmHg (KDIGO 2022 consensus suggests targeting systolic BP <120 mmHg for most patients) 1, 2, 4

Medication Selection Strategy

• First-line when albuminuria present: ACE inhibitor or ARB is mandatory 1, 2, 4
• Additional agents: Add dihydropyridine calcium channel blockers and/or diuretics to achieve BP targets 1, 4
• Resistant hypertension: Consider steroidal mineralocorticoid receptor antagonists 1

Lifestyle Interventions (Foundation of All Care)

Physical Activity

• 150 minutes per week of moderate-intensity physical activity, adjusted to cardiovascular and physical tolerance 2, 4
• Avoid sedentary behavior with specific guidance based on fall risk 4

Dietary Recommendations

• Protein intake: Maintain 0.8 g/kg body weight/day for CKD G3-G5; avoid high protein intake >1.3 g/kg/day 1, 2, 4
• Sodium restriction: <2000 mg/day (KDIGO) or 1500-2300 mg/day (ADA) 1, 4
• Diet composition: Higher plant-based foods, lower animal-based foods, minimal ultraprocessed foods 1, 4
• Potassium management: Limit bioavailable potassium-rich foods (especially processed foods) in patients with history of hyperkalemia 4

Weight and Smoking

• Target optimal body weight with weight loss for patients with obesity 4
• Mandatory smoking cessation as tobacco accelerates CKD progression 4

Diabetes Management in CKD

Glycemic Monitoring and Targets

• HbA1c monitoring: Every 3-6 months for stable patients; quarterly for those intensively managed or not meeting goals 1
• Target HbA1c: Approximately 7%, though recognize limitations in advanced CKD (stages G4-G5) 1, 4

Glucose-Lowering Medication Hierarchy

1. SGLT2 inhibitors (eGFR ≥20 mL/min/1.73m²) - continue until dialysis 1, 4
2. Metformin (eGFR ≥30 mL/min/1.73m²) 1, 4
3. GLP-1 receptor agonists when additional glycemic control needed 1, 4
4. Other glucose-lowering drugs as needed for individualized targets 1

CKD Classification and Monitoring

Definition and Staging

• CKD definition: Kidney damage or GFR <60 mL/min/1.73m² for ≥3 months 1, 5, 6
• Kidney damage markers: Albuminuria (ACR >30 mg/g), urine sediment abnormalities, structural abnormalities, or history of transplantation 1

GFR and Albuminuria Categories

• GFR stages: G1 (≥90), G2 (60-89), G3a (45-59), G3b (30-44), G4 (15-29), G5 (<15 mL/min/1.73m²) 1
• Albuminuria stages: A1 (<30 mg/g, normal to mildly increased), A2 (30-300 mg/g, moderately increased), A3 (>300 mg/g, severely increased) 1

Monitoring Frequency by Risk

• Low risk (green zone): Annual screening 1
• Moderate risk (yellow zone): 1-2 times per year 1
• High risk (orange-red zones): 2-4 times per year 1
• Very high risk (deep red zone): Every 1-3 months 1
• Risk factor reassessment: Every 3-6 months for glycemia, albuminuria, BP, CVD risk, and lipids 1, 2, 4

Management of CKD Complications

Metabolic Acidosis

• Consider pharmacological treatment (with or without dietary intervention) when serum bicarbonate <18 mmol/L 4
• Monitor to ensure bicarbonate doesn't exceed upper limit of normal or adversely affect BP, potassium, or fluid status 4

Hyperkalemia

• Implement individualized dietary and pharmacologic interventions for CKD G3-G5 patients with hyperkalemia 4
• Be aware of factors affecting potassium measurement including diurnal variation, sample type, and medication effects 4

Hyperuricemia and Gout

• Do NOT treat asymptomatic hyperuricemia to delay CKD progression 2
• Acute gout: Use low-dose colchicine or glucocorticoids (preferable to NSAIDs) with appropriate dose reduction for reduced kidney function and concomitant calcineurin inhibitor use 1, 2
• Avoid allopurinol in patients receiving azathioprine 1

CKD-Mineral and Bone Disorder

• Monitor calcium, phosphorus, and PTH based on CKD stage 1
• Measure 25(OH)D levels and correct deficiency using general population strategies 1

Critical Pitfalls to Avoid

Absolute Contraindications

• Never prescribe NSAIDs or COX-2 inhibitors in CKD due to nephrotoxicity risk and potential for acute kidney injury—use low-dose colchicine or glucocorticoids instead for inflammatory conditions 1, 2
• Avoid high protein intake (>1.3 g/kg/day) as it accelerates progression 2, 4

Common Errors

• Therapeutic inertia despite multiple available interventions—most patients have high residual risk despite treatment 1
• Failure to continue SGLT2 inhibitors until dialysis or transplant 1, 2
• Inadequate RAS inhibition dosing—must use maximum tolerated dose 1, 2
• Treating asymptomatic hyperuricemia unnecessarily 2

Multidisciplinary Care Model

Team Composition

• Patient as central member with active self-management role 1
• Physicians, nurse practitioners, physician assistants 1
• Diabetes care and education specialists 1
• Renal dietitians or accredited nutrition providers 1, 4
• Pharmacists, exercise specialists, mental health professionals 1, 4

Specialist Referral Indications

• Nephrology referral based on GFR/albuminuria risk stratification (see monitoring frequency grid) 1
• Nutrition referral for all patients requiring dietary education tailored to CKD stage 4
• Mental health referral as depression affects approximately 26.5% of CKD stages 1-4 patients 4

Special Populations

Kidney Transplant Recipients

• Monitor complete blood count with specific frequency post-transplant (daily for 7 days, then decreasing frequency) 1
• Use ACE inhibitors or ARBs for erythrocytosis treatment 1
• Measure growth and development in children every 3-6 months 1
• Consider recombinant human growth hormone (28 IU/m²/week) for persistent growth failure 1

Cardiovascular Disease Management

• Non-vitamin K antagonist oral anticoagulants (NOACs) preferred over warfarin for atrial fibrillation thromboprophylaxis in CKD G1-G4 2
• Estimate 10-year cardiovascular risk using validated risk tools 2