KDIGO Guidelines for Chronic Kidney Disease Management
Definition and Classification
Chronic kidney disease is defined as abnormalities of kidney structure or function present for more than 3 months with health implications, classified by cause, GFR category (G1-G5), and albuminuria category (A1-A3). 1
CKD requires either GFR <60 mL/min/1.73 m² (categories G3a-G5) OR markers of kidney damage (albuminuria, urinary sediment abnormalities, electrolyte disturbances, structural abnormalities on imaging, histological abnormalities, or history of kidney transplant) present for ≥3 months 2, 3
Test all at-risk patients using both urine albumin measurement and GFR assessment, as these provide independent prognostic information for cardiovascular events, CKD progression, and mortality 4
Use creatinine-based eGFR for initial assessment; when eGFR accuracy is questionable and GFR affects clinical decisions, use combined creatinine and cystatin C-based eGFR 4
Confirm CKD by repeating tests after incidental detection of elevated albumin-to-creatinine ratio, hematuria, or low eGFR 4
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 4, 2
Risk Stratification
CKD prognosis is determined by the combination of GFR and albuminuria categories, with color-coded risk levels: green (low risk), yellow (moderately increased risk), orange (high risk), and red (very high risk). 1
Use validated risk prediction tools, particularly the Kidney Failure Risk Equation, to identify high-risk patients requiring more intensive management 4, 5
Estimate 10-year cardiovascular risk using validated tools, as CKD patients have substantially elevated cardiovascular mortality 4, 5
Monitoring frequency should be 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
Core Pharmacologic Management
SGLT2 inhibitors are 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. 4, 5
First-Line Therapies
SGLT2 inhibitors are first-line for most CKD patients, particularly those with albuminuria, regardless of diabetes status 1, 4, 5
RAS inhibition (ACE inhibitor or ARB) is mandatory at maximum tolerated dose when albuminuria ≥30 mg/g is present; first-line when hypertension exists 1, 4, 5
Titrate RAS inhibitors to maximum approved dose that is tolerated to maximize kidney protection 4, 5
Statin therapy (moderate to high-intensity) or statin/ezetimibe combination is mandatory for all adults ≥50 years with eGFR <60 mL/min/1.73 m² (CKD G3a-G5) 4, 5
Nonsteroidal mineralocorticoid receptor antagonists (ns-MRA) should be used in patients with type 2 diabetes and CKD 1, 4
Steroidal MRA can be added if needed for resistant hypertension 1
Additional Cardiovascular Therapies
Add ezetimibe and PCSK9 inhibitors based on ASCVD risk and lipid levels to maximize LDL cholesterol reduction 1, 4, 5
Prescribe oral low-dose aspirin for secondary prevention in CKD patients with established ischemic cardiovascular disease 4, 5
Consider other antiplatelet therapy (P2Y12 inhibitors) with aspirin intolerance 4, 5
Use non-vitamin K antagonist oral anticoagulants (NOACs) in preference to warfarin for thromboprophylaxis in atrial fibrillation in CKD G1-G4 4, 5
Blood Pressure Management
Target systolic blood pressure <120 mmHg for most CKD patients, representing a more aggressive approach than previous guidelines and supported by cardiovascular outcome data. 1, 4, 5
For patients without albuminuria: target BP <140/90 mmHg 1, 4, 5
For patients with albuminuria ≥30 mg/24h: target BP <130/80 mmHg 1, 4, 5
When albuminuria is present, ACE inhibitor or ARB must be first-line antihypertensive therapy due to proven kidney protective effects 1, 4, 5
Dihydropyridine calcium channel blocker and/or diuretic can be added if needed to achieve individualized BP target; all three classes are often needed 1
Diabetes Management in CKD
Manage hyperglycemia according to KDIGO Diabetes Guideline recommendations, with SGLT2 inhibitors as foundational therapy and GLP-1 receptor agonists where indicated for their kidney-protective effects. 1, 4, 5
SGLT2 inhibitors should be used in patients with diabetes and CKD to reduce progression and cardiovascular events 1, 4
Use GLP-1 receptor agonists where indicated for additional kidney and cardiovascular protection 1, 4, 5
Lifestyle Interventions
Physical Activity
Advise moderate-intensity physical activity for at least 150 minutes per week, adjusted to cardiovascular and physical tolerance. 1, 4, 5
For higher fall risk patients, provide specific advice on exercise intensity (low, moderate, or vigorous) and type (aerobic vs. resistance, or both) 1, 4
Children with CKD should aim for WHO-advised levels (≥60 minutes daily) 1, 4, 5
Encourage weight loss for patients with obesity and CKD 1, 4, 5
Dietary Management
Advise patients to adopt healthy, diverse diets with higher consumption of plant-based foods compared to animal-based foods and lower consumption of ultra-processed foods. 1, 4, 5
Consider plant-based "Mediterranean-style" diet in addition to lipid-modifying therapy for cardiovascular risk reduction 4, 5
Maintain protein intake at 0.8 g/kg body weight/day in adults with CKD G3-G5 1, 4, 5
Avoid high protein intake (>1.3 g/kg body weight/day) in adults with CKD at risk of progression 1, 4, 5
Lower salt intake to <90 mmol (<2 g) per day of sodium (corresponding to 5 g of sodium chloride) unless contraindicated 1
DO NOT restrict protein in children with CKD due to growth impairment risk; target upper end of normal range for healthy children to promote optimal growth 4, 5
In older adults with frailty and sarcopenia, consider higher protein and calorie dietary targets 5
Use renal dietitians or accredited nutrition providers for individualized dietary counseling 1
Tobacco Cessation
- Encourage patients to not use tobacco products, with referral to smoking cessation programs where available 1
Management of CKD Complications
CKD-Mineral and Bone Disorder
Base treatment on trends in laboratory values rather than a single abnormal result, and be cautious to avoid hypercalcemia when treating secondary hyperparathyroidism. 1
- Treatment should emphasize decreasing phosphate levels, maintaining calcium levels, and addressing elevated parathyroid hormone levels in adults with CKD stage G3a to G5 and those receiving dialysis 1
Acidosis
- In patients with CKD and serum bicarbonate concentrations <22 mmol/L, oral bicarbonate supplementation can be given to maintain serum bicarbonate within the normal range, unless contraindicated 1
Anemia, Potassium Abnormalities
- Manage anemia, acidosis, and potassium abnormalities where indicated according to specific KDIGO guidelines 1
Medication Management and Nephrotoxin Stewardship
Consider GFR when dosing medications cleared by kidneys, using validated eGFR equations for drug dosing. 4, 5
Perform thorough medication review periodically and at care transitions to assess adherence, continued indication, and drug interactions 4, 5
For diagnostic imaging with iodinated radiocontrast media in patients with GFR <60 mL/min/1.73 m²: avoid high-osmolar agents, use lowest possible radiocontrast dose, and withdraw potentially nephrotoxic agents before and after the procedure 1
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). 4, 5
Additional referral criteria include:
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. 4, 5
Do NOT use agents to lower serum uric acid in CKD patients with asymptomatic hyperuricemia to delay CKD progression 4, 5
Do not discontinue RAS inhibitors due to modest increases in serum creatinine (<30%) or potassium unless there are specific contraindications 4, 5
Avoid low protein intake in patients with malnutrition or at risk for malnutrition 1