KDIGO Releases 2024 Clinical Practice Guideline for Chronic Kidney Disease Evaluation and Management

Chronic kidney disease poses a substantial public health challenge, affecting millions of individuals globally and imposing a significant burden on healthcare systems. Despite advances in CKD research and management, significant variations in clinical practice persist, highlighting the need for standardized guidelines to promote consistency and excellence in care delivery.

Led by a multidisciplinary panel of renowned experts in nephrology, the KDIGO 2024 guideline represents a comprehensive synthesis of the most up-to-date evidence and clinical insights in the field. Drawing upon rigorous systematic reviews and meta-analyses, the guideline offers practical recommendations across the spectrum of CKD evaluation, diagnosis, and management.

Furthermore, the guideline offers clear recommendations for the management of CKD complications and comorbidities, including hypertension, diabetes, and cardiovascular disease. By addressing these modifiable risk factors comprehensively, healthcare providers can mitigate the progression of CKD and reduce the burden of associated complications, ultimately improving patient outcomes and quality of life. The key recommendations are given below:

Evaluation of CKD

• In adults at risk for CKD, we recommend using a creatinine-based estimated glomerular filtration rate (eGFRcr). If cystatin C is available, the GFR category should be estimated from the combination of creatinine and cystatin C (creatinine and cystatin C–based estimated glomerular filtration rate [eGFRcr-cys]).
• The researchers suggest performing a kidney biopsy as an acceptable, safe, diagnostic test to evaluate cause and guide treatment decisions when clinically appropriate.
• The researchers recommend using eGFRcr-cys in clinical situations when eGFRcr is less accurate, and GFR affects clinical decision-making.
• Using a validated GFR estimating equation to derive GFR from serum filtration markers (eGFR) rather than relying on the serum filtration markers alone.
• The researchers suggest that point-of-care testing (POCT) may be used for creatinine and urine albumin measurement where access to a laboratory is limited or providing a test at the point-of-care facilitates the clinical pathway.

Risk assessment in people with CKD

• In people with CKD G3–G5, we recommend using an externally validated risk equation to estimate the absolute risk of kidney failure.

Delaying CKD progression and managing its complications

• The researchers recommend that people with CKD be advised to undertake moderate-intensity physical activity for a cumulative duration of at least 150 minutes per week, or to a level compatible with their cardiovascular and physical tolerance.
• Maintaining a protein intake of 0.8 g/kg body weight/d in adults with CKD G3–G5 is suggested.
• The researchers suggest that sodium intake be < 2g of sodium per day (or < 90 mmol of sodium per day, or < 5 g of sodium chloride per day) in people with CKD.
• The researchers suggest that adults with high BP and CKD be treated with a target systolic blood pressure (SBP) of < 120 mm Hg, when tolerated, using standardized office BP measurement.
• The researchers suggest that in children with CKD, 24-hour mean arterial pressure (MAP) by ambulatory blood pressure monitoring (ABPM) should be lowered to £50th percentile for age, sex, and height.
• The team recommends starting renin-angiotensin-system inhibitors (RASi) (angiotensin-converting enzyme inhibitor [ACEi] or angiotensin II receptor blocker [ARB]) for people with CKD and severely increased albuminuria (G1–G4, A3) without diabetes.
• Starting RASi (ACEi or ARB) for people with CKD and moderately increased albuminuria (G1–G4, A2) without diabetes is suggested.
• Starting RASi (ACEi or ARB) for people with CKD and moderately to severely increased albuminuria (G1–G4, A2 and A3) with diabetes is recommended.
• The team recommends avoiding any combination of ACEi, ARB, and direct renin inhibitor (DRI) therapy in people with CKD, with or without diabetes.
• Not using agents to lower serum uric acid in people with CKD and asymptomatic hyperuricemia to delay CKD progression, is recommended.
• The team recommends people with CKD and symptomatic hyperuricemia should be offered uric acid–lowering intervention.
• In adults with T2D and CKD who have not achieved individualized glycemic targets despite the use of metformin and SGLT2 inhibitor treatment, or who are unable to use those medications, we recommend a long-acting GLP-1 RA.
• The researchers recommend non–vitamin K antagonist oral anticoagulants (NOACs) in preference to vitamin K antagonists (e.g., warfarin) for thromboprophylaxis in atrial fibrillation in people with CKD G1–G4.
• They suggest that in stable stress-test confirmed ischemic heart disease, an initial conservative approach using intensive medical therapy is an appropriate alternative to an initial invasive strategy.
• They recommend oral low-dose aspirin for the prevention of recurrent ischemic cardiovascular disease events (i.e., secondary prevention) in people with CKD and established ischemic cardiovascular disease.
• They suggest not using agents to lower serum uric acid in people with CKD and asymptomatic hyperuricemia to delay CKD progression.
• They recommend people with CKD and symptomatic hyperuricemia should be offered uric acid–lowering intervention.

As healthcare systems worldwide grapple with the challenges posed by the rising prevalence of CKD, the release of the KDIGO 2024 clinical practice guideline heralds a new era of evidence-based, patient-centered care for individuals affected by this chronic condition. By adhering to these recommendations, healthcare professionals can strive towards achieving optimal outcomes and improving the lives of CKD patients on a global scale.

In conclusion, the KDIGO 2024 clinical practice guideline for CKD evaluation and management represents a milestone achievement in nephrology, offering a roadmap for healthcare providers to navigate the complexities of CKD care with confidence and competence. As implementation efforts gain momentum, the guideline has the potential to revolutionize CKD management practices and pave the way for a brighter future for individuals living with this challenging condition.

Reference:

Kidney Disease: Improving Global Outcomes (KDIGO) CKD Work Group. KDIGO 2024 Clinical Practice Guideline for the Evaluation and Management of Chronic Kidney Disease. Kidney Int. 2024;105(4S):S117–S314.