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Updated CKD Guidelines
Updated Guidelines for Chronic Kidney Disease Evaluation and Management

Released: December 11, 2024

Expiration: December 10, 2025

Mark J. Sarnak
Mark J. Sarnak, MD, MS
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Key Takeaways
  • Focus on early intervention, optimizing treatment, and slowing the progression of CKD, particularly as the prevalence of kidney disease rises globally.
  • Risk stratification and individualized treatment plans are key to improving patient outcomes.

The 2024 Kidney Disease: Improving Global Outcomes (KDIGO) Clinical Practice Guideline for the Evaluation and Management of Chronic Kidney Disease presents essential updates and evidence-based recommendations aimed at improving the diagnosis, management, and overall care of patients with chronic kidney disease (CKD). These guidelines provide valuable insights for healthcare professionals (HCPs), with a focus on early intervention, optimizing treatment, and slowing the progression of CKD, particularly as the prevalence of kidney disease rises globally.

Here, I summarize several of the more impactful aspects of the 2024 KDIGO guidelines, highlighting how they can enhance clinical practice and patient outcomes.

Revised Criteria for CKD Diagnosis and Classification
The 2024 KDIGO guidelines reiterate the importance of early detection and a consistent approach to diagnosing CKD. CKD is defined as abnormalities in kidney structure or function, present for more than 3 months, with health implications. The guidelines reaffirm the use of both estimated glomerular filtration rate (eGFR) and urine albumin–to-creatinine ratio (ACR) as critical markers for identifying CKD and determining its progression.

The primary measure for assessing kidney function remains eGFR, with CKD classified into stages based on eGFR levels. The ACR, however, has taken on a greater emphasis in the 2024 guidelines, with thresholds established to identify significant albuminuria, a key marker for CKD progression and cardiovascular risk. Of importance, HCPs are encouraged to assess both markers (eGFR and ACR) regularly to detect CKD at earlier stages and take proactive steps for disease management. In addition, when possible, cystatin C levels should also be used to estimate eGFR, especially in cases where eGFR based on creatinine levels is not thought to be accurate.

Risk Stratification and Individualized Treatment Plans
Certain updated risk stratification models now incorporate not only eGFR and ACR but also other relevant factors. The most commonly used equation, the Kidney Failure Risk Equation, includes age, gender, ACR, and eGFR. In people with CKD GFR categories G3-G5, it is recommended to use an externally validated risk equation to estimate the absolute risk of kidney failure (1A recommendation). The 2024 KDIGO guidelines advocate for a more personalized approach to CKD management, emphasizing that treatments be tailored based on the patient’s specific risk factors and disease stage.

In addition to assessing ACR and eGFR, patients with diabetes, poorly controlled blood pressure, cardiovascular disease, or a history of acute kidney injury are at an elevated risk for CKD progression. Early referral to a nephrologist and more aggressive management are recommended for these groups of patients, as they benefit the most from targeted interventions. HCPs should consider both CKD-specific risks and broader comorbidities, tailoring treatment approaches accordingly to optimize outcomes.

Hypertension Management
Hypertension management remains a cornerstone in CKD care, given its close association with CKD progression. The 2024 KDIGO guidelines suggest targeting a systolic blood pressure of <120 mm Hg, when tolerated, for patients with CKD, assuming blood pressure is measured using standardized methods (2B recommendation).

Angiotensin-converting enzyme (ACE) inhibitors or angiotensin receptor blockers (ARBs) are recommended as first-line treatments for patients with CKD and hypertension, particularly those with albuminuria, because they provide kidney-protective benefits. The guidelines highlight the importance of consistent use of these agents, because they can slow progression and may reduce the risk of cardiovascular complications.

The guidelines recommend avoiding combination therapy with ACE inhibitors and ARBs because of the potential for adverse effects. HCPs may consider prescribing additional antihypertensive agents such as calcium channel blockers or diuretics in cases where blood pressure targets are not achieved with monotherapy and should regularly monitor for adverse effects like hyperkalemia or worsening kidney function.

Diabetes Management
The 2024 guidelines stress the importance of glycemic control in patients with CKD and diabetes, because poor control can accelerate kidney damage. The recommendation from the KDIGO 2020 Clinical Practice Guideline for Diabetes Management in CKD is to individualize A1C targets, ranging from 6.5% to 8.0%, for patients with diabetes and CKD who are not treated with dialysis (1C recommendation). Adjustments should be made based on factors such as age, comorbidities, and risk of hypoglycemia.

Sodium-glucose cotransporter-2 (SGLT2) inhibitors are recommended for patients with CKD who have diabetes, as well as patients with CKD who do not have diabetes but have significant proteinuria (ACR >200 mg/g). These inhibitors have been shown to slow CKD progression and reduce cardiovascular events (1A recommendation). Nonsteroidal mineralocorticoid receptor antagonists are suggested for patients with CKD and diabetes who have an ACR of >30 mg/g (2A recommendation).

The guidelines also endorse long-acting glucagon-like peptide-1 receptor agonists for those who have not reached their individualized glycemic targets despite the use of SGLT2 inhibitors and metformin.

Nutritional Management and Lifestyle Modifications
Dietary and lifestyle interventions are central to managing CKD, particularly in slowing disease progression and managing complications. The 2024 KDIGO guidelines provide comprehensive advice on nutrition, emphasizing the importance of a balanced diet and salt restriction for patients with CKD.

The guidelines suggest a protein intake of 0.8 g/kg body weight per day for adults with CKD GFR categories G3-G5 not treated with dialysis (2C recommendation). Sodium intake should also be limited to <2000 mg/day (2C recommendation), especially for patients with hypertension. Dietitians can have a crucial role in creating individualized meal plans that balance these needs while supporting overall health.

Physical activity is encouraged to improve cardiovascular health and enhance overall quality of life. Smoking cessation remains a priority because smoking can exacerbate kidney damage and increase the risk of cardiovascular events.

Potassium and Phosphate Management
Electrolyte abnormalities, particularly abnormal potassium and phosphate levels, are common in advanced CKD and can complicate disease management. The guidelines emphasize the importance of potassium management. Patients, particularly those receiving renin–angiotensin–aldosterone system inhibitors, should have their potassium levels monitored regularly to avoid hyperkalemia, a potentially life-threatening condition. Dietary modifications and the use of potassium binders may be necessary in certain cases.

Dietary phosphate restriction may be recommended as described in previous CKD–Mineral and Bone Disorder guidelines. For patients with hyperphosphatemia, phosphate binders may be required to try to prevent complications such as vascular calcification and bone disease. The choice of binder should consider individual patient tolerability and the presence of comorbid conditions.

Early Referral to a Nephrologist
Early referral to a nephrologist is encouraged for patients with rapidly progressing CKD, high albuminuria, or significant comorbidities. The 2024 guidelines emphasize that timely specialist care can improve CKD management, especially for those at higher risk of progression or those approaching end-stage kidney disease.

Patient Education and Self-Management
Finally, patient education is highlighted as a critical component in the management of CKD. The guidelines encourage HCPs to engage patients in self-management practices, including medication adherence, dietary choices, and regular monitoring of key markers like blood pressure and blood glucose level.

In conclusion, the 2024 KDIGO guidelines for CKD provide a comprehensive, evidence-based approach to managing CKD, emphasizing early detection, individualized treatment, and proactive lifestyle and dietary interventions. By integrating these recommendations into clinical practice, HCPs can improve outcomes significantly, slow disease progression, and enhance the quality of life for patients with CKD. Adherence to these guidelines, particularly in managing hypertension, diabetes, and lifestyle factors, can help mitigate the burden of CKD and reduce its impact on both patients and healthcare systems.

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If applicable, how do you plan on incorporating the updated guidelines into patient care? Leave a comment to join the discussion!

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