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Chronic Kidney Disease (CKD): Management with Current Guidelines (KDIGO 2024)

1. Definition and Classification

GFR Staging

G1 and G2 require additional evidence of kidney damage (e.g., proteinuria, structural abnormality) for diagnosis.

Albuminuria Staging (urine albumin-to-creatinine ratio)

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2. Diagnosis and Evaluation (KDIGO 2024 - Key Update)

GFR Estimation

• KDIGO 2024 now recommends using the average of creatinine-based eGFR AND cystatin C-based eGFR (CKD-EPI creatinine-cystatin C equation) for confirmatory testing, especially when creatinine results are uncertain or borderline. Cystatin C is less affected by muscle mass and diet.
• This is a major update from 2012, which relied primarily on creatinine alone.

Proteinuria Assessment

• Use urine albumin-to-creatinine ratio (ACR) as the first-line test.
• Repeat confirmatory testing: at least 2 abnormal results over 3+ months to confirm chronicity.

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3. Slowing CKD Progression

A. Blood Pressure Control

• KDIGO 2021/2024 target: SBP <120 mmHg using standardized office measurements (this is a notable change from older <130 mmHg targets).
• First-line agents: ACE inhibitors (ACEi) or ARBs, especially in proteinuric CKD (diabetic or non-diabetic).
  • Lower intraglomerular pressure; have renoprotective effects beyond BP control.
  • Anticipate a 30% rise in serum creatinine - this is acceptable. A further rise warrants evaluation for renal artery stenosis.
  • Check creatinine and potassium ~1 week after dose adjustment.
  • ACEi + ARB combination is NOT recommended - increased risk of hyperkalemia and AKI without mortality benefit.
• Thiazides become less effective when GFR <30; switch to loop diuretics at that stage.

B. SGLT2 Inhibitors - Major KDIGO 2024 Addition

• KDIGO 2024 strongly recommends SGLT2 inhibitors (empagliflozin, dapagliflozin, canagliflozin) for all patients with CKD and eGFR ≥20, with or without diabetes, to reduce CKD progression and cardiovascular events.
• Evidence base: DAPA-CKD and CREDENCE trials showed significant reduction in kidney failure, doubling of creatinine, and cardiovascular death.
• This is one of the most impactful updates in the 2024 guideline.

C. Diabetes Management

• Target HbA1c: ~7% (KDOQI recommendation) to prevent micro- and macrovascular complications and slow CKD progression.
• Avoid overly strict targets in older patients or those at risk of hypoglycemia.
• Metformin: can continue with caution down to eGFR 30; withhold if eGFR <30.

D. Dietary Modifications

• Sodium: restrict to <2 g/day (especially with hypertension or heart failure).
• Protein: moderate restriction (~0.8 g/kg/day) in non-dialysis CKD is reasonable; strict restriction has not shown clear benefit for slowing progression.
• Potassium: restrict to ~60 mEq/day if hyperkalemia is present.
• Phosphate: restrict to 800-1000 mg/day; avoid dairy, dark colas, nuts, processed meats in hyperphosphatemia.
• Plant-based diet: growing evidence supports benefit in CKD - lower acid load, phosphate bioavailability, and protein intake (2025 systematic review, PMID 40081608).
• Smoking cessation: smoking accelerates CKD progression; cessation is essential.

E. Metabolic Acidosis

• KDIGO: start oral bicarbonate supplementation when serum bicarbonate <22 mmol/L (NICE threshold: <20 mmol/L).
• Target: maintain bicarbonate within normal range.
• Dose: sodium bicarbonate 650-1300 mg 2-3 times/day to keep serum bicarb ≥22 mEq/L - this has been shown to slow CKD progression.
• Caution: associated sodium load may worsen hypertension/fluid retention.
• Severe acidosis in G5 may itself be an indication to start dialysis.

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4. Management of CKD Complications

A. Anemia

• Monitor Hb annually from G3a; twice yearly from G4-G5.
• Diagnosis: Hb <13.0 g/dL in males; <12.0 g/dL in females.
• Work up all causes: iron stores, B12, folate before attributing to CKD.
• Iron deficiency: correct first before starting ESAs.
• Erythropoiesis-stimulating agents (ESAs): start when Hb <10.0 g/dL (KDIGO), after correcting iron. Balance benefits (reduced transfusion, symptom relief) against potential harms (stroke, malignancy risk at high Hb targets).
• HIF-prolyl hydroxylase inhibitors (e.g., roxadustat, daprodustat): newer oral agents that stabilize HIF and stimulate erythropoiesis - an alternative to injectable ESAs, now available in several countries.
• Hb target: generally 10-11.5 g/dL (avoid targeting >13 g/dL).

B. CKD-Mineral Bone Disorder (CKD-MBD)

• Monitor calcium, phosphate, PTH, and alkaline phosphatase from G3b (eGFR <45).
• Hyperphosphatemia: dietary phosphate restriction + oral phosphate binders (calcium carbonate/acetate, sevelamer carbonate, lanthanum carbonate) taken with meals.
• Elevated PTH: address with phosphate control, active vitamin D (calcitriol/alfacalcidol). Routine vitamin D supplementation to suppress PTH is NOT recommended unless deficiency is documented.
• Calcimimetics (cinacalcet oral, etelcalcetide IV): generally reserved for dialysis patients.
• A 2025 KDIGO Controversies Conference updated guidance on CKD-MBD (PMID 39864017).

C. Cardiovascular Risk

• CKD patients are far more likely to die of CVD than to reach ESKD.
• Statins: KDIGO recommends routine statin therapy for CKD patients >50 years, and for younger patients with additional CV risk factors, irrespective of baseline lipid levels.
  • Statin + ezetimibe (e.g., rosuvastatin 10 mg + ezetimibe 10 mg) reduces major atherosclerotic events in moderate-severe CKD (SHARP trial evidence).
  • Do NOT initiate statins de novo in dialysis patients (no benefit shown), but continue if already on them.
• Antiplatelet therapy: for secondary prevention of CVD; weigh bleeding risk carefully.
• SGLT2 inhibitors and non-steroidal MRAs (finerenone) also provide significant CV protection.

D. Finerenone (Non-Steroidal Mineralocorticoid Receptor Antagonist) - New Agent

• FIDELIO-DKD and FIGARO-DKD trials: finerenone reduces proteinuria, cardiovascular events, and CKD progression in diabetic kidney disease.
• KDIGO 2024 includes finerenone as an add-on therapy in diabetic CKD, particularly when ACEi/ARB + SGLT2i is not sufficient.

E. Hyperkalemia

• A common barrier to ACEi/ARB use.
• Manage with dietary potassium restriction, correction of metabolic acidosis, diuretics.
• Novel potassium binders: patiromer and sodium zirconium cyclosilicate (SZC) allow continuation of RAAS blockade in patients who would otherwise need dose reduction.

F. Fluid and Electrolyte Management

• Fluid restriction generally not needed unless dilutional hyponatremia is present.
• Avoid NSAIDs - they block renal autoregulatory mechanisms and worsen GFR.
• Avoid nephrotoxins: aminoglycosides, contrast agents; adjust drug doses per eGFR.

G. Infections / Immunization

• Annual influenza vaccine for all CKD patients.
• Pneumococcal vaccine for eGFR <30 (G4-G5) or high-risk patients (nephrotic syndrome, diabetes, immunosuppression); re-vaccinate within 5 years.
• Hepatitis B vaccination for eGFR <30 (G4-G5); confirm seroconversion.
• COVID-19 vaccination response is attenuated in CKD; ensure up-to-date.

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5. Preparation for Renal Replacement Therapy (RRT)

• Dialysis initiation: should NOT be based solely on a GFR threshold - no mortality benefit shown from early initiation.
• Start dialysis when patient develops uremic symptoms, refractory fluid overload, severe refractory metabolic acidosis, or other complications, typically as GFR falls to 5-10 mL/min.
• Options: hemodialysis (HD), peritoneal dialysis (PD), kidney transplantation - discuss all options early (G4 stage).
• Arrange arteriovenous fistula creation well before anticipated dialysis start.
• Pre-emptive transplantation (before dialysis) provides the best outcomes.

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6. Cardiovascular/Cardiorenal Metabolic Syndrome - Emerging Framework

1. ACEi/ARB - foundational RAAS blockade
2. SGLT2 inhibitor - cardiorenal protection
3. Finerenone - additional renal/CV protection in diabetic CKD

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7. Referral to Nephrology

• eGFR <30 mL/min (G4-G5) - prepare for RRT
• Rapid decline in eGFR (>5 mL/min/year or >25% decline in 12 months)
• Persistent significant proteinuria (ACR >300 mg/g)
• Uncertain diagnosis requiring biopsy
• Refractory hypertension, hyperkalemia, or metabolic acidosis

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8. Monitoring Schedule by Stage

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Key KDIGO 2024 Updates at a Glance

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