What are the main recommendations in the latest Kidney Disease: Improving Global Outcomes (KDIGO) guideline for the evaluation and management of kidney diseases?

KDIGO 2024 CKD Guideline: Comprehensive Summary

Definition and Classification of CKD

CKD is defined as kidney damage or GFR <60 ml/min/1.73 m² for ≥3 months, with severity classified into five stages based on GFR level and albuminuria stage. 1

• The classification now includes subdivision of stage 3 (into 3a and 3b) and emphasizes both GFR categories (G1-G5) and albuminuria categories (A1-A3) to better stratify prognosis 2, 3
• Use validated equations incorporating serum creatinine and, when indicated, serum cystatin C for GFR estimation 4
• Albuminuria is defined as albumin-to-creatinine ratio >30 mg/g, with A2 (moderately increased) at 30-300 mg/g and A3 (severely increased) at >300 mg/g 1

Pharmacological Management: Multi-Drug Approach

KDIGO 2024 strongly recommends a comprehensive multi-drug strategy prioritizing SGLT2 inhibitors, RAS inhibitors, and nonsteroidal MRAs based on albuminuria status and eGFR. 3

SGLT2 Inhibitors (First-Line)

• Strongly recommend SGLT2 inhibitors for type 2 diabetes with CKD and eGFR ≥20 ml/min/1.73 m² 3
• Strongly recommend for CKD with eGFR ≥20 ml/min/1.73 m² and urine ACR ≥200 mg/g, regardless of diabetes status 3
• Strongly recommend for CKD with heart failure, regardless of albuminuria level 3
• Continue SGLT2 inhibitors even when glucose-lowering efficacy diminishes below eGFR 45 ml/min/1.73 m², as kidney and cardiovascular benefits persist 3
• The reversible eGFR decrease upon initiation is expected and not an indication to discontinue 3

RAS Inhibitors (ACEi or ARB)

• Strongly recommend starting RASi for CKD with severely increased albuminuria (G1-G4, A3) without diabetes 1, 3
• Suggest starting RASi for CKD with moderately increased albuminuria (G1-G4, A2) without diabetes 1, 3
• Strongly recommend starting RASi for CKD with moderately-to-severely increased albuminuria (G1-G4, A2 and A3) with diabetes 1, 3
• Administer the highest approved dose tolerated to achieve maximum benefits demonstrated in trials 1, 3
• Continue RASi even when eGFR falls below 30 ml/min/1.73 m² unless serum creatinine rises >30% within 4 weeks of initiation or dose increase 3
• Monitor serum creatinine and potassium within 2-4 weeks of initiation or dose increase 1, 3
• Manage hyperkalemia with potassium-lowering measures rather than immediately discontinuing RASi 1, 3
• Never combine ACEi, ARB, and direct renin inhibitor 3

Nonsteroidal Mineralocorticoid Receptor Antagonists

• Suggest nonsteroidal MRAs (finerenone) for adults with type 2 diabetes, eGFR >25 ml/min/1.73 m², normal potassium, and albuminuria >30 mg/g despite maximum tolerated RASi 3, 4

GLP-1 Receptor Agonists

• Recommend long-acting GLP-1 RAs with documented cardiovascular benefits for adults with type 2 diabetes and CKD who haven't achieved glycemic targets despite metformin and SGLT2 inhibitors, or who cannot use these medications 3
• Do not combine with DPP-4 inhibitors, as there is no added glucose-lowering benefit 3
• Do not withhold based solely on reduced eGFR; no dose adjustment needed even in ESRD 3
• Do not discontinue SGLT2 inhibitors when adding GLP-1 RAs, as the combination provides complementary benefits 3

Blood Pressure Management

Target systolic BP <120 mmHg using standardized office measurement when tolerated in adults with CKD and hypertension. 1, 2, 3

• Consider less intensive BP-lowering in patients with frailty, high fall risk, very limited life expectancy, or symptomatic postural hypotension 1, 2, 3
• For children with CKD, lower 24-hour mean arterial pressure by ABPM to ≤50th percentile for age, sex, and height 1, 2, 3
• Monitor BP in children once yearly with ABPM and every 3-6 months with standardized auscultatory office BP 1, 3
• When ABPM unavailable in children, target manual auscultatory office SBP of 50th-75th percentile for age, sex, and height unless limited by hypotension symptoms 1

Dietary Recommendations

Protein Intake

• Maintain protein intake of 0.8 g/kg body weight/day in adults with CKD G3-G5 1, 3
• Avoid high protein intake (>1.3 g/kg/day) in adults with CKD at risk of progression 1, 3
• In willing and able adults at risk of kidney failure, consider prescribing under close supervision a very low-protein diet (0.3-0.4 g/kg/day) supplemented with essential amino acids or ketoacid analogs (up to 0.6 g/kg/day) 1
• Do not prescribe low or very low-protein diets in metabolically unstable patients 1, 3
• Do not restrict protein in children with CKD due to growth impairment risk; target protein and energy intake at the upper end of normal range for healthy children 1
• In older adults with frailty and sarcopenia, consider higher protein and calorie targets 1

Sodium Intake

• Restrict sodium intake to <2 g/day (<90 mmol/day or <5 g sodium chloride/day) 1, 2, 3
• Dietary sodium restriction is not appropriate for patients with sodium-wasting nephropathy 1
• For children with CKD and BP >90th percentile, follow age-based Recommended Daily Intake 1

Overall Dietary Pattern

• Adopt healthy, diverse diets with higher consumption of plant-based foods compared to animal-based foods and lower consumption of ultraprocessed foods 1, 2
• Use renal dietitians or accredited nutrition providers to educate about dietary adaptations regarding sodium, phosphorus, potassium, and protein intake, tailored to individual needs 1

Lifestyle Modifications

Physical Activity

• Recommend moderate-intensity physical activity for cumulative duration of at least 150 minutes per week, or to a level compatible with cardiovascular and physical tolerance 1, 3
• Recommendations should consider age, ethnic background, comorbidities, and access to resources 1
• Advise avoiding sedentary behavior 1, 3
• For patients at higher risk of falls, provide specific advice on intensity (low, moderate, or vigorous) and type of exercises (aerobic vs. resistance) 1
• Encourage children with CKD to undertake physical activity aiming for WHO-advised levels (≥60 minutes daily) 1

Weight Management

• Advise/encourage people with obesity and CKD to lose weight 1
• Achieve optimal BMI compatible with cardiovascular health and level of frailty 1, 2

Tobacco Cessation

• Encourage not using tobacco products, with referral to smoking cessation programs where indicated and available 1

Lipid Management and Cardiovascular Protection

• For adults ≥50 years with eGFR <60 ml/min/1.73 m² (CKD G3a-G5) not on dialysis or transplant, prescribe statin or statin/ezetimibe combination therapy 2, 3
• For adults ≥50 years with eGFR ≥60 ml/min/1.73 m² (CKD G1-G2), prescribe statin monotherapy 2, 3
• Maximize absolute LDL cholesterol reduction to achieve largest treatment benefit 2

Antiplatelet and Anticoagulation Therapy

• Use low-dose aspirin for secondary prevention in CKD patients with established ischemic cardiovascular disease 2
• Substitute P2Y12 inhibitors when aspirin intolerance exists 2
• For atrial fibrillation in CKD G1-G4, prescribe non-vitamin K antagonist oral anticoagulants (NOACs) over warfarin 2

Hyperuricemia Management

• Offer uric acid-lowering intervention for symptomatic hyperuricemia (gout) in CKD patients 2, 3
• Initiate therapy after first gout episode, particularly if serum uric acid >9 mg/dl (535 mmol/l) 2
• Prescribe xanthine oxidase inhibitors over uricosuric agents 2, 3

Hyperkalemia Management

• Implement individualized approach combining dietary and pharmacologic interventions for emergent hyperkalemia in CKD G3-G5 2
• Provide assessment and education through renal dietitian 2
• Limit foods rich in bioavailable potassium (especially processed foods) for patients with hyperkalemia history 2
• Consider pharmacological treatment with/without dietary intervention to prevent acidosis (serum bicarbonate <18 mmol/l) 3

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 2
• Initial invasive strategy remains preferable for acute/unstable coronary disease, unacceptable angina, left ventricular systolic dysfunction from ischemia, or left main disease 2

Multidisciplinary Care and Patient Education

• Enable access to patient-centered multidisciplinary care team including dietary counseling, medication management, education about kidney replacement therapy modalities, transplant options, dialysis access surgery, and psychological/social care 2
• Involve care partners in education programs to promote informed, activated patients 2
• Referral to providers and programs (psychologists, renal dietitians, pharmacists, physical and occupational therapy, smoking cessation programs) should be offered where indicated and available 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 2
• Screen patients with CKD G4-G5, age >65, poor growth (pediatrics), or symptoms of weight loss/frailty twice annually for malnutrition using validated tool 2

Dialysis Initiation and Kidney Replacement Therapy Planning

• 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/1.73 m² 2
• Plan for preemptive kidney transplantation and/or dialysis access when GFR <15-20 ml/min/1.73 m² or risk of kidney replacement therapy >40% over 2 years 2

Pediatric Transition to Adult Care

• Prepare adolescents for transfer to adult care starting at 11-14 years using checklists to assess readiness 2
• Conduct visits partly without parents present 2
• Provide comprehensive written transfer summary and ideally oral handover to receiving providers 2
• Transfer during times of medical and social stability when possible 2

Nephrotoxin Stewardship and Acute Kidney Injury Prevention

• Emphasize nephrotoxin stewardship and prevention of acute kidney injury through patient education on sick day medication management 4
• Pharmacists play crucial role in implementing guidelines through comprehensive medication management, nephrotoxin stewardship, drug dosing adjustments, and patient education 4

Common Pitfalls to Avoid

• Do not discontinue RASi when eGFR falls below 30 ml/min/1.73 m² unless specific adverse effects occur (>30% creatinine rise within 4 weeks) 3
• Do not stop SGLT2 inhibitors due to reversible eGFR decrease upon initiation 3
• Do not immediately discontinue RASi for hyperkalemia; manage with potassium-lowering measures first 1, 3
• Do not restrict protein in children due to growth impairment risk 1
• Do not prescribe low-protein diets in metabolically unstable patients 1, 3
• Do not combine ACEi, ARB, and direct renin inhibitor 3
• Do not combine GLP-1 RAs with DPP-4 inhibitors 3
• Do not discontinue SGLT2 inhibitors when adding GLP-1 RAs 3