What are the latest clinical guidelines for managing kidney disease according to KDIGO (Kidney Disease: Improving Global Outcomes) 2025?

KDIGO 2024 Clinical Practice Guidelines for Chronic Kidney Disease Management

Blood Pressure Management

Target systolic blood pressure <120 mmHg using standardized office measurement when tolerated in adults with CKD and hypertension. 1

• Avoid intensive BP lowering in patients with frailty, high fall risk, limited life expectancy, or symptomatic postural hypotension 1
• For children with CKD, lower 24-hour mean arterial pressure by ambulatory monitoring to ≤50th percentile for age, sex, and height 1
• Monitor pediatric BP annually with ambulatory monitoring and every 3-6 months with standardized office BP 1

Lipid Management and Cardiovascular Protection

All adults ≥50 years with eGFR <60 ml/min per 1.73 m² (CKD G3a-G5) not on dialysis or transplant should receive statin or statin/ezetimibe combination therapy. 1

• Adults ≥50 years with eGFR ≥60 ml/min per 1.73 m² (CKD G1-G2) should receive statin monotherapy 1
• Adults 18-49 years with CKD require statin therapy if they have coronary disease, diabetes, prior stroke, or >10% 10-year cardiovascular risk 1
• Maximize absolute LDL cholesterol reduction to achieve largest treatment benefit 1
• Consider PCSK-9 inhibitors for patients with CKD who have appropriate indications 1
• Add Mediterranean-style plant-based diet to lipid therapy for cardiovascular risk reduction 1

Antiplatelet and Anticoagulation Therapy

Use low-dose aspirin for secondary prevention in CKD patients with established ischemic cardiovascular disease. 1

• Substitute P2Y12 inhibitors when aspirin intolerance exists 1
• For atrial fibrillation in CKD G1-G4, prescribe non-vitamin K antagonist oral anticoagulants (NOACs) over warfarin 1
• Adjust NOAC doses based on GFR, with particular caution at CKD G4-G5 1

Dietary Recommendations

Maintain protein intake at 0.8 g/kg body weight/day in adults with CKD G3-G5. 1, 2

• Avoid high protein intake >1.3 g/kg body weight/day in adults at risk of CKD progression 1, 2
• For motivated patients at high risk of kidney failure, consider very low-protein diet (0.3-0.4 g/kg/day) supplemented with essential amino acids or ketoacid analogs under close supervision 1, 2
• Never restrict protein in children with CKD due to growth impairment risk; target upper end of normal range 1
• In older adults with frailty or sarcopenia, consider higher protein and calorie targets 1, 2

Restrict sodium intake to <2 g/day (<90 mmol/day or <5 g sodium chloride/day). 1

• Avoid sodium restriction in patients with sodium-wasting nephropathy 1
• For children with BP >90th percentile, follow age-based recommended daily intake 1

Adopt plant-based diets with higher consumption of plant foods versus animal foods and lower ultraprocessed food intake. 1

• Use renal dietitians to educate about sodium, phosphorus, potassium, and protein adaptations tailored to CKD severity 1

Physical Activity

Advise moderate-intensity physical activity for cumulative duration of at least 150 minutes per week, or to level compatible with cardiovascular and physical tolerance. 1

• Avoid sedentary behavior in all CKD patients 1
• For high fall risk patients, provide specific advice on exercise intensity (low, moderate, vigorous) and type (aerobic vs. resistance) 1
• Encourage weight loss in obese CKD patients 1
• Children with CKD should aim for WHO-advised 60 minutes daily physical activity 1

Hyperuricemia Management

Offer uric acid-lowering intervention for symptomatic hyperuricemia (gout) in CKD patients. 1

• Initiate therapy after first gout episode, particularly if serum uric acid >9 mg/dl (535 mmol/l) 1
• Prescribe xanthine oxidase inhibitors over uricosuric agents 1
• For acute gout, use low-dose colchicine or intra-articular/oral glucocorticoids instead of NSAIDs 1, 3
• Do not use uric acid-lowering agents for asymptomatic hyperuricemia to delay CKD progression 1
• Limit alcohol, meats, and high-fructose corn syrup intake 1

Hyperkalemia Management

Implement individualized approach combining dietary and pharmacologic interventions for emergent hyperkalemia in CKD G3-G5. 1

• Provide assessment and education through renal dietitian 1
• Limit foods rich in bioavailable potassium (especially processed foods) for patients with hyperkalemia history 1

Coronary Artery Disease Management

For stable stress-test confirmed ischemic heart disease, initial conservative approach using intensive medical therapy is appropriate alternative to invasive strategy. 1

• Initial invasive strategy remains preferable for acute/unstable coronary disease, unacceptable angina, left ventricular systolic dysfunction from ischemia, or left main disease 1

Multidisciplinary Care and Education

Enable access to patient-centered multidisciplinary care team including dietary counseling, medication management, education about KRT modalities, transplant options, dialysis access surgery, and psychological/social care. 1

• Involve care partners in education programs to promote informed, activated patients 1
• Consider telehealth technologies including web-based, mobile applications, virtual visiting, and wearable devices 1

Symptom Assessment and Nutritional Screening

Ask patients with progressive CKD about uremic symptoms (reduced appetite, nausea, fatigue) at each consultation using standardized validated assessment tool. 1

• Screen patients with CKD G4-G5, age >65, poor growth (pediatrics), or symptoms of weight loss/frailty twice annually for malnutrition using validated tool 1
• Enable medical nutrition therapy under renal dietitian supervision for signs of malnutrition 1

Dialysis Initiation Timing

Initiate dialysis based on composite assessment of symptoms, signs, quality of life, preferences, GFR level, and laboratory abnormalities, typically when GFR is 5-10 ml/min per 1.73 m². 1

• Plan for preemptive kidney transplantation and/or dialysis access when GFR <15-20 ml/min per 1.73 m² or risk of KRT >40% over 2 years 1
• In children, poor growth refractory to optimized nutrition, growth hormone, and medical management is additional indication for KRT 1

Pediatric Transition to Adult Care

Prepare adolescents for transfer to adult care starting at 11-14 years using checklists to assess readiness, conducting visits partly without parents present. 1

• Provide comprehensive written transfer summary and ideally oral handover to receiving providers 1
• Transfer during times of medical and social stability when possible 1
• Adult providers should recognize patients under 25 years are high-risk due to incomplete brain maturation 1
• Assess young adults more frequently than older patients with same CKD stage, including caregivers with patient agreement for first 1-3 years post-transfer 1

Critical Pitfalls to Avoid

• Never prescribe NSAIDs in CKD stage 3B or higher due to nephrotoxicity and acute kidney injury risk 3
• Avoid peritendinous injections around Achilles tendon due to rupture risk 3
• Do not prescribe low or very low-protein diets in metabolically unstable CKD patients 1, 2
• Avoid implementing protein restriction without proper nutritional counseling to prevent malnutrition 2