What are the KDIGO (Kidney Disease: Improving Global Outcomes) guidelines for managing a patient with kidney disease, such as chronic kidney disease (CKD) or acute kidney injury (AKI)?

KDIGO Guidelines for Kidney Disease Management

Core Definition and Classification of CKD

Chronic kidney disease is defined as abnormalities of kidney structure or function present for >3 months with health implications, classified by cause, GFR category (G1-G5), and albuminuria category (A1-A3). 1

• Test all at-risk patients using both urine albumin measurement and GFR assessment, as both provide independent prognostic information for cardiovascular events, CKD progression, and mortality 1, 2
• Use creatinine-based eGFR (eGFRcr) for initial assessment, but when eGFRcr is less accurate and GFR affects clinical decisions, use combined creatinine and cystatin C-based eGFR (eGFRcr-cys) 1
• Confirm CKD by repeating tests after incidental detection of elevated urinary albumin-to-creatinine ratio (ACR), hematuria, or low eGFR 1
• Establish chronicity through review of past GFR/albuminuria measurements, imaging showing reduced kidney size/cortical thickness, kidney pathology showing fibrosis, or medical history of conditions causing CKD 1

First-Line Pharmacologic Management

SGLT2 inhibitors represent the cornerstone of CKD treatment and should be initiated in most CKD patients with proteinuria, continued until dialysis or transplant, as they provide the most significant advancement in delaying progression and reducing cardiovascular complications. 2, 3

Comprehensive Four-Pillar Therapy

• SGLT2 inhibitors: First-line for most CKD patients, particularly those with albuminuria, regardless of diabetes status 2, 3
• RAS inhibition (ACE inhibitor or ARB): Mandatory at maximum tolerated dose when albuminuria ≥30 mg/g is present; first-line when hypertension exists 2, 3
• Statin therapy: Moderate to high-intensity statin or statin/ezetimibe combination for all adults ≥50 years with eGFR <60 mL/min/1.73 m² (CKD G3a-G5) 2, 3
• Nonsteroidal mineralocorticoid receptor antagonists (ns-MRA): Use finerenone in patients with type 2 diabetes and CKD 1, 3

Blood Pressure Targets and Management

Target systolic blood pressure <120 mmHg for most CKD patients, representing a more aggressive approach than previous guidelines. 2, 3

• For patients without albuminuria: target BP <140/90 mmHg 2
• For patients with albuminuria ≥30 mg/24h: target BP <130/80 mmHg 2
• When albuminuria is present, ACE inhibitor or ARB must be first-line antihypertensive therapy due to proven kidney protective effects 2, 3
• Titrate RAS inhibitors to maximum approved dose that is tolerated to maximize kidney protection 2

Lifestyle Interventions

Physical Activity

• Advise moderate-intensity physical activity for at least 150 minutes per week, adjusted to cardiovascular and physical tolerance 2, 3
• Patients should avoid sedentary behavior 2
• For higher fall risk patients, provide specific advice on exercise intensity and type 2
• Children with CKD should aim for WHO-advised levels (≥60 minutes daily) 2

Dietary Management

• Adopt healthy, diverse diets with higher plant-based foods compared to animal-based foods and lower ultra-processed foods 2, 3
• Consider plant-based "Mediterranean-style" diet in addition to lipid-modifying therapy for cardiovascular risk reduction 2
• Maintain protein intake at 0.8 g/kg body weight/day in adults with CKD G3-G5 2, 3
• Avoid high protein intake (>1.3 g/kg body weight/day) as it accelerates CKD progression 2, 3
• Do NOT restrict protein in children with CKD due to growth impairment risk; target upper end of normal range 2
• Encourage weight loss for patients with obesity and CKD 2

Cardiovascular Disease Management

• Prescribe oral low-dose aspirin for secondary prevention in CKD patients with established ischemic cardiovascular disease 2, 3
• Consider other antiplatelet therapy (P2Y12 inhibitors) with aspirin intolerance 2
• Use non-vitamin K antagonist oral anticoagulants (NOACs) in preference to warfarin for thromboprophylaxis in atrial fibrillation in CKD G1-G4 2, 3
• Add ezetimibe and PCSK9 inhibitors based on ASCVD risk and lipid levels 3

Diabetes Management in CKD

• Manage hyperglycemia according to KDIGO Diabetes Guideline recommendations 1, 3
• Use GLP-1 receptor agonists where indicated for their kidney-protective effects 1, 3
• SGLT2 inhibitors should be used in patients with diabetes and CKD to reduce progression and cardiovascular events 1, 4

Monitoring and Risk Stratification

• Use validated risk prediction tools, with the Kidney Failure Risk Equation supporting identification of high-risk patients 2
• Estimate 10-year cardiovascular risk using validated tools 2, 3
• Regular risk factor reassessment every 3-6 months 3
• Monitoring frequency based on combined eGFR and albuminuria categories: moderate risk (2 times/year), high risk (3 times/year), very high risk (4 times/year with nephrology referral) 4

Medication Management and Nephrotoxin Stewardship

• Consider GFR when dosing medications cleared by kidneys, using validated eGFR equations for drug dosing 2, 5
• Perform thorough medication review periodically and at care transitions to assess adherence, continued indication, and drug interactions 2, 5
• Emphasize nephrotoxin stewardship and prevention of acute kidney injury through patient education on sick day medication management 5

Referral to Specialist Kidney Care

Refer adults with CKD to specialist kidney care when they have:

• ACR ≥30 mg/g (3 mg/mmol) or PCR ≥200 mg/g (20 mg/mmol) 2
• Persistent hematuria 2
• Any sustained decrease in eGFR 2
• eGFR <30 mL/min/1.73 m² 4
• Continuously increasing urinary albumin levels or continuously decreasing eGFR 4
• Uncertainty about etiology or atypical features suggesting non-diabetic kidney disease 4
• Difficulty managing CKD complications 4

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, 3

• Do NOT use agents to lower serum uric acid in CKD patients with asymptomatic hyperuricemia to delay CKD progression 2, 3
• Do not discontinue RAS inhibitors due to modest increases in serum creatinine (<30%) or potassium unless specific contraindications exist 4
• Do not combine ACE inhibitors with ARBs, as this increases adverse events without additional benefit 4
• Do not rely on serum creatinine alone; always calculate eGFR using validated equations (CKD-EPI 2021) 4
• Do not skip albuminuria testing, as eGFR and UACR provide independent prognostic information 4

Relationship Between AKI and CKD

• Underlying CKD is a clear risk factor for AKI, as both decreased GFR and increased proteinuria are strongly associated with AKI 1, 6
• AKI accelerates CKD progression, particularly dialysis-requiring AKI, which increases vulnerability to worse long-term renal outcomes including end-stage renal disease 6, 7
• Acute kidney disease (AKD) is defined as post-AKI status persisting 7-90 days after initial AKI diagnosis, occurring in approximately 25% of AKI survivors 8