What are the KDIGO (Kidney Disease: Improving Global Outcomes) guidelines for managing Chronic Kidney Disease (CKD)?

KDIGO Guidelines for Chronic Kidney Disease Management

Core Pharmacologic Foundation

All CKD patients should receive SGLT2 inhibitors as first-line therapy, combined with maximum-dose RAS inhibition (ACE inhibitor or ARB) when hypertension or albuminuria is present, targeting systolic blood pressure <120 mmHg, alongside high-intensity statin therapy. 1, 2

First-Line Medications (Start These Immediately)

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

Diabetes-Specific Therapy

For patients with type 2 diabetes and CKD:

• Metformin should be continued when eGFR ≥30 mL/min/1.73 m² at 500-850 mg daily, titrated upward 1
• GLP-1 receptor agonists (long-acting) are recommended when glycemic targets are not met despite metformin and SGLT2 inhibitors 1, 2
• Nonsteroidal mineralocorticoid receptor antagonists should be added in diabetic patients for additional kidney and cardiovascular protection 1, 2

Blood Pressure Targets and Management

Target systolic blood pressure <120 mmHg for most CKD patients using standardized office measurement. 1, 2, 3

BP Target Algorithm

• Without albuminuria: Target <140/90 mmHg 1, 3
• With albuminuria ≥30 mg/24h: Target <130/80 mmHg 1, 3
• General recommendation: Target <120 mmHg systolic for cardiovascular protection 1, 2

Antihypertensive Selection

When albuminuria is present, the medication hierarchy is:

1. ACE inhibitor or ARB (mandatory first-line, titrate to maximum tolerated dose) 1, 2, 3
2. Dihydropyridine calcium channel blocker and/or diuretic to achieve BP target 1
3. Steroidal MRA if resistant hypertension persists 1

Lipid Management

Prescribe moderate-to-high intensity statin for all adults ≥50 years with eGFR <60 mL/min/1.73 m². 1, 2, 3

• Add ezetimibe when additional LDL reduction is needed 1, 2
• Add PCSK9 inhibitor based on ASCVD risk and lipid levels 1, 2
• Consider Mediterranean-style, plant-based diet as adjunct therapy 3

Lifestyle Interventions (Non-Negotiable Components)

Physical Activity

• 150 minutes per week of moderate-intensity exercise is the minimum target 1, 2, 3
• Avoid sedentary behavior entirely 3
• For fall-risk patients, provide specific guidance on low-to-moderate intensity aerobic and resistance exercises 1

Dietary Modifications

• Protein intake: exactly 0.8 g/kg body weight/day for CKD G3-G5 (never exceed 1.3 g/kg/day) 1, 2, 3
• Sodium restriction: <2 g sodium/day (<90 mmol/day or <5 g sodium chloride/day) 1
• Plant-based Mediterranean-style diet with higher plant-based foods, lower animal-based foods, and minimal ultra-processed foods 1, 2, 3

Weight Management

• Encourage weight loss in patients with obesity and CKD 1, 3
• Target optimal BMI through dietary modification and physical activity 1

Cardiovascular Disease Management

Antiplatelet Therapy

• Low-dose aspirin for secondary prevention in established ischemic cardiovascular disease 2, 3
• Consider P2Y12 inhibitors if aspirin intolerance exists 3

Anticoagulation for Atrial Fibrillation

• NOACs preferred over warfarin for CKD G1-G4 2, 3
• Use same diagnostic and management principles for ASCVD and atrial fibrillation as in non-CKD patients 1

Management of Metabolic Complications

Hyperuricemia

• Do NOT treat asymptomatic hyperuricemia to delay CKD progression 2, 3
• For acute gout: use low-dose colchicine or glucocorticoids (never NSAIDs) 2, 3

Anemia, CKD-MBD, Acidosis, Potassium

• Manage these complications where indicated per standard protocols 1
• Monitor electrolytes, particularly potassium, when using RAS inhibitors and MRAs 3

Monitoring and Risk Assessment

• Monitor eGFR, electrolytes, and urine albumin every 3-6 months 2, 3
• Use validated risk prediction tools (Kidney Failure Risk Equation) to identify high-risk patients 3
• Estimate 10-year cardiovascular risk using validated tools 2, 3

Specialist Referral Criteria

Refer to nephrology when any of the following are present:

• ACR ≥30 mg/g (3 mg/mmol) or PCR ≥200 mg/g (20 mg/mmol) 3
• Persistent hematuria 3
• Sustained decrease in eGFR 3
• eGFR <45 mL/min/1.73 m² with progressive decline 4

Pediatric Considerations

• ≥60 minutes daily physical activity (WHO-advised levels) 1, 3
• Do NOT restrict protein in children due to growth impairment risk; target upper end of normal range 3
• Encourage healthy weight achievement 1, 3

Critical Pitfalls to Avoid

• Never prescribe NSAIDs in CKD patients—they cause nephrotoxicity and acute kidney injury; use low-dose colchicine or glucocorticoids for inflammatory conditions instead 2, 3
• Never discontinue RAS inhibitors for modest creatinine or potassium increases unless specific contraindications exist 3
• Never exceed 1.3 g/kg/day protein intake—this accelerates CKD progression 2, 3
• Never ignore tobacco use—counsel cessation at every visit 1

Medication Dosing Adjustments

• Adjust all renally-cleared medications based on eGFR 3, 4
• Stop metformin if eGFR falls below 30 mL/min/1.73 m² 1
• Use extreme caution with iodinated contrast and gadolinium-based agents 4
• Perform comprehensive medication review at every transition of care 3

Patient Education and Self-Management

• Implement structured self-management educational programs for all CKD patients 1
• Use team-based, integrated care models focused on risk evaluation and patient empowerment 1
• Involve multidisciplinary team: nephrologists, primary care, dietitians, pharmacists, diabetes educators 1