Evaluation and Management of Chronic Kidney Disease

Publication Date: March 13, 2024
Last Updated: March 13, 2024

Summary of Graded Recommendations

Evaluation of CKD

In adults at risk for CKD, we recommend using 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]). (Level 1, B)
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We suggest performing a kidney biopsy as an acceptable, safe, diagnostic test to evaluate cause and guide treatment decisions when clinically appropriate. (Level 1, D)
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We recommend using eGFRcr-cys in clinical situations when eGFRcr is less accurate and GFR affects clinical decision-making. (Level 1, C)
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We recommend using a validated GFR estimating equation to derive GFR from serum filtration markers (eGFR) rather than relying on the serum filtration markers alone. (Level 1, D)
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We 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. (Level 2, C)
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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. (Level 1, A)
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Delaying CKD progression and managing its complications

We 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. (Level 1, D)
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We suggest maintaining a protein intake of 0.8 g/kg body weight/d in adults with CKD G3–G5. (Level 2, C)
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We suggest that sodium intake be <2 g of sodium per day (or <90 mmol of sodium per day, or <5 g of sodium chloride per day) in people with CKD. (Level 2, C)
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We 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. (Level 2, B)
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We 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. (Level 2, C)
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We recommend 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. (Level 1, B)
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We suggest starting RASi (ACEi or ARB) for people with CKD and moderately increased albuminuria (G1–G4, A2) without diabetes. (Level 2, C)
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We recommend starting RASi (ACEi or ARB) for people with CKD and moderately-toseverely increased albuminuria (G1–G4, A2 and A3) with diabetes. (Level 1, B)
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We recommend avoiding any combination of ACEi, ARB, and direct renin inhibitor (DRI) therapy in people with CKD, with or without diabetes. (Level 1, B)
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We recommend treating patients with type 2 diabetes (T2D), CKD, and an eGFR ‡20 ml/min per 1.73 m2 with an SGLT2i. (Level 1, A)
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We recommend treating adults with CKD with an SGLT2i for the following:
  • eGFR ‡20 ml/min per 1.73 m2 with urine ACR ‡200 mg/g (‡20 mg/mmol), or
  • heart failure, irrespective of level of albuminuria.
(Level 1, A)
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We suggest treating adults with eGFR 20 to 45 ml/min per 1.73 m2 with urine ACR <200 mg/g (<20 mg/mmol) with an SGLT2i. (Level 2, B)
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We suggest a nonsteroidal mineralocorticoid receptor antagonist with proven kidney or cardiovascular benefit for adults with T2D, an eGFR >25 ml/min per 1.73 m2 , normal serum potassium concentration, and albuminuria (>30 mg/g [>3 mg/mmol]) despite maximum tolerated dose of RAS inhibitor (RASi). (Level 2, A)
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In adults with T2D and CKD who have not achieved individualized glycemic targets despite use of metformin and SGLT2 inhibitor treatment, or who are unable to use those medications, we recommend a long-acting GLP-1 RA. (Level 1, B)
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We recommend people with CKD and symptomatic hyperuricemia should be offered uric acid–lowering intervention. (Level 1, C)
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We suggest not using agents to lower serum uric acid in people with CKD and asymptomatic hyperuricemia to delay CKD progression. (Level 2, D)
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In adults aged ‡50 years with eGFR <60 ml/min per 1.73 m2 but not treated with chronic dialysis or kidney transplantation (GFR categories G3a–G5), we recommend treatment with a statin or statin/ezetimibe combination. (Level 1, A)
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In adults aged ‡50 years with CKD and eGFR ‡60 ml/min per 1.73 m2 (GFR categories G1–G2), we recommend treatment with a statin. (Level 1, B)
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In adults aged 18–49 years with CKD but not treated with chronic dialysis or kidney transplantation, we suggest statin treatment in people with one or more of the following:
  • known coronary disease (myocardial infarction or coronary revascularization),
  • diabetes mellitus,
  • prior ischemic stroke, or
  • estimated 10-year incidence of coronary death or nonfatal myocardial infarction >10%.
(Level 2, A)
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We recommend oral low-dose aspirin for prevention of recurrent ischemic cardiovascular disease events (i.e., secondary prevention) in people with CKD and established ischemic cardiovascular disease. (Level 1, C)
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We 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. (Level 2, D)
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We recommend use of 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. (Level 1, C)
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Medication management and drug stewardship in CKD

No graded recommendations in this chapter.

Optimal models of care

No graded recommendations in this chapter.

Recommendation Grading

Overview

Title

Evaluation and Management of Chronic Kidney Disease

Authoring Organization

Kidney Disease Improving Global Outcomes

Publication Month/Year

March 13, 2024

Last Updated Month/Year

March 25, 2024

Document Type

Guideline

External Publication Status

Published

Country of Publication

US

Document Objectives

The KDIGO 2024 Clinical Practice Guideline for the Evaluation and Management of Chronic Kidney Disease (CKD), an update to the 2012 guideline, was published in March 2024 in Supplement to Kidney International. The Executive Summary was published in the April 2024 issue of Kidney International. The guideline, an update to the KDIGO 2012 CKD Guideline, was co-chaired by Professor Adeera Levin, MD (Canada) and Paul Stevens, MB (United Kingdom). The guideline is intended for healthcare professionals who provide kidney care, for people with suspected or diagnosed CKD and their caregivers, and for policymakers and commissioners of CKD services. The aim is to provide a useful resource that clearly and concisely addresses relevant questions with actionable recommendations to guide clinical practice based on a formal evidence review and consensus-based practice points. A wide range of key topics are addressed, including optimal CKD evaluation and classification, kidney disease risk assessment, management of complications, medication management and drug stewardship in CKD, and strategies for delivering patient-centered care across diverse clinical settings. Key highlights of the KDIGO CKD Guideline include guidance updates on the measurements of estimated glomerular filtration rate and albuminuria, utilization of CKD risk prediction equations, and personalized treatment recommendations for kidney and cardiovascular risk reductions tailored to individual patient needs and preferences.

Inclusion Criteria

Male, Female, Adolescent, Adult, Child, Infant, Older adult

Health Care Settings

Ambulatory, Hospital, Outpatient

Intended Users

Dietician nutritionist, nurse, nurse practitioner, physician, physician assistant

Scope

Counseling, Assessment and screening, Management, Prevention

Diseases/Conditions (MeSH)

D002318 - Cardiovascular Diseases, D007676 - Kidney Failure, Chronic, D007674 - Kidney Diseases

Keywords

chronic kidney disease, Albuminuria, Proteinuria

Source Citation

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

Supplemental Methodology Resources

Data Supplement