What are the 2026 KDIGO (Kidney Disease: Improving Global Outcomes) guidelines for the evaluation and management of chronic kidney disease?

2024 KDIGO Guidelines for Chronic Kidney Disease: Key Updates

The 2024 KDIGO guidelines (note: there are no published 2026 CKD evaluation/management guidelines—the most recent comprehensive CKD guideline is from 2024) introduce major therapeutic advances centered on SGLT2 inhibitors as foundational therapy for most adults with CKD, alongside continued emphasis on RAS inhibition for proteinuric disease and refined blood pressure targets. 1

CKD Diagnosis and Staging

Diagnostic Criteria

• CKD requires kidney abnormalities persisting ≥3 months—transient changes do not qualify 2
• Stages 1–2 (eGFR ≥60 mL/min/1.73 m²): Require documented kidney damage (proteinuria, albuminuria, hematuria, or imaging/pathological abnormalities) in addition to GFR 2
• Stages 3–5 (eGFR <60 mL/min/1.73 m²): Can be diagnosed by GFR alone, regardless of other markers 2

GFR Estimation

• Use validated equations incorporating age, sex, race, and body size (CKD-EPI 2021 or regional equations like EKFC in Europe)—serum creatinine alone grossly overestimates kidney function 2, 3
• Combined creatinine-cystatin C equations (eGFRcr-cys) improve diagnostic accuracy and should be used when initial eGFR is uncertain or clinically insufficient 3
• For drug dosing specifically, incorporate serum cystatin C into GFR estimates for high-risk populations 4

Staging System

• Stage 1: ≥90 mL/min/1.73 m² plus kidney damage 2
• Stage 2: 60–89 mL/min/1.73 m² plus kidney damage 2
• Stage 3: 30–59 mL/min/1.73 m² (moderate decrease) 2
• Stage 4: 15–29 mL/min/1.73 m² (severe decrease; begin preparing for renal replacement therapy) 2
• Stage 5: <15 mL/min/1.73 m² or dialysis requirement (classified as "5D" on dialysis, "5T" post-transplant) 2

Pharmacologic Management: The New Therapeutic Paradigm

SGLT2 Inhibitors: First-Line for Most CKD Patients

SGLT2 inhibitors now represent foundational therapy with the broadest indication across CKD populations, regardless of diabetes status. 1

Strong Recommendations (1A Evidence)

• Type 2 diabetes + CKD + eGFR ≥20 mL/min/1.73 m²: Start SGLT2i universally 1
• Adults with CKD + eGFR ≥20 mL/min/1.73 m² AND either:
  • Urine ACR ≥200 mg/g (≥20 mg/mmol), OR
  • Heart failure (any albuminuria level) 1

Conditional Recommendation (2B Evidence)

• eGFR 20–45 mL/min/1.73 m² + ACR <200 mg/g (<20 mg/mmol): Consider SGLT2i 1

Critical Practice Points

• Continue SGLT2i even if eGFR falls below 20 mL/min/1.73 m² after initiation, unless intolerance or dialysis starts 1
• Withhold during prolonged fasting, surgery, or critical illness (ketosis risk) 1
• The reversible eGFR dip at initiation is not an indication to stop—do not alter CKD monitoring frequency 1

RAS Inhibitors: Targeted for Proteinuric Disease

Strong Recommendations (1B Evidence)

• CKD without diabetes + severely increased albuminuria (A3, stages G1–G4): Start ACEi or ARB 1
• CKD with diabetes + moderately-to-severely increased albuminuria (A2 or A3, stages G1–G4): Start ACEi or ARB 1

Conditional Recommendation (2C Evidence)

• CKD without diabetes + moderately increased albuminuria (A2, stages G1–G4): Consider ACEi or ARB 1

Dosing and Monitoring

• Use the highest approved tolerated dose—trial benefits were achieved at these doses 1
• Check BP, creatinine, and potassium within 2–4 weeks of initiation or dose increase 1
• Continue therapy unless creatinine rises >30% within 4 weeks of starting or dose escalation 1
• Continue ACEi/ARB even when eGFR falls below 30 mL/min/1.73 m² 1

Managing Adverse Effects

• Hyperkalemia: Manage with potassium-lowering measures rather than stopping RASi 1
• Reduce dose or discontinue only for:
  • Symptomatic hypotension 1
  • Uncontrolled hyperkalemia despite medical treatment 1
  • Uremic symptom management when eGFR <15 mL/min/1.73 m² 1

Mineralocorticoid Receptor Antagonists

• Finerenone is now supported for patients with type 2 diabetes and CKD, providing additional kidney-protective and cardiovascular benefits 4, 5
• The 2024 guideline references key recommendations from the 2022 KDIGO Diabetes guideline regarding MRA use 1

Additional Cardioprotective Therapies

• GLP-1 receptor agonists: Provide kidney-protective effects in addition to glycemic and cardiovascular benefits 4, 5
• Statins: Recommended to reduce atherosclerotic cardiovascular disease risk in CKD patients 4, 5

Blood Pressure Management

• When ambulatory BP monitoring is unavailable, target manual auscultatory office SBP at 50th–75th percentile for age, sex, and height, unless limited by hypotension symptoms 1
• BP control remains a cornerstone intervention to slow CKD progression 6, 5

Nephrotoxin Stewardship and AKI Prevention

• Educate patients on "sick day" medication management—withhold certain medications during acute illness to prevent acute kidney injury 4
• Implement comprehensive nephrotoxin stewardship programs, with pharmacists playing a crucial role in medication review and dose adjustments 4
• Prevent contrast-associated acute kidney injury through appropriate risk stratification and prophylaxis 5

Monitoring and Referral

Regular Monitoring

• Frequency depends on CKD stage and comorbidities—use risk prediction models like the Kidney Failure Risk Equation (KFRE) to tailor monitoring intensity 3
• Standardize creatinine and cystatin C measurements with traceability to international reference materials 3

Nephrology Referral Indications

• Stage 4 CKD: Prepare for renal replacement therapy (dialysis access planning or transplant evaluation) 2, 5
• Rapidly declining kidney function, uncontrolled proteinuria, or complex management needs 5
• Shared decision-making regarding kidney replacement therapy vs. conservative management 5

Common Pitfalls to Avoid

• Do not stop SGLT2i or RASi prematurely due to expected, reversible eGFR decreases 1
• Do not rely on serum creatinine alone for GFR estimation—use validated equations 2
• Do not delay SGLT2i initiation in patients without diabetes who meet criteria—the 2024 guideline expands indications beyond diabetes 1
• Do not overlook CKD in younger adults, women, and Hispanic populations—awareness gaps are largest in these groups despite high prevalence 7

Implementation Considerations

Pharmacists are essential for implementing these guidelines through comprehensive medication management, dose adjustments based on kidney function, and patient education on sick-day protocols 4. The multidisciplinary team approach, emphasized across all recent guidelines, optimizes outcomes by coordinating early detection, risk stratification, and timely intervention 8, 6, 5.