Professional Documents
Culture Documents
org
The Kidney Disease: Improving Global Outcomes (KDIGO) been available, reflects an exciting time in nephrology. New
Clinical Practice Guideline for the Evaluation and therapies and strategies have been tested in large and
Management of Chronic Kidney Disease (CKD) updates the diverse populations that help to inform care; however, this
KDIGO 2012 guideline and has been developed with guideline is not intended for people receiving dialysis nor
patient partners, clinicians, and researchers around the those who have a kidney transplant. The document is
world, using robust methodology. This update, based on a sensitive to international considerations, CKD across the
substantially broader base of evidence than has previously lifespan, and discusses special considerations in
implementation. The scope includes chapters dedicated to
the evaluation and risk assessment of people with CKD,
Correspondence: Adeera Levin, St Paul’s Hospital, University of British management to delay CKD progression and its
Columbia, 1081 Burrard Street, Room 6010A, Vancouver, British Columbia complications, medication management and drug
V6Z1Y6, Canada. E-mail: alevin@providencehealth.bc.ca; or Paul Stevens, stewardship in CKD, and optimal models of CKD care.
Kent Kidney Care Centre, Kent and Canterbury Hospital, Ethelbert Road,
Canterbury, Kent CT1 3NG, UK. E-mail: pstevens@nhs.net
Treatment approaches and actionable guideline
recommendations are based on systematic reviews of
The complete KDIGO 2024 Clinical Practice Guideline for the Evaluation
and Management of Chronic Kidney Disease is published in Kidney Inter-
relevant studies and appraisal of the quality of the evidence
national, volume 105, issue 4S, 2024, which is available online at www. and the strength of recommendations which followed the
kidney-international.org. “Grading of Recommendations Assessment, Development,
Received 11 October 2023; revised 27 October 2023; accepted 31 and Evaluation” (GRADE) approach. The limitations of the
October 2023 evidence are discussed. The guideline also provides practice
points, which serve to direct clinical care or activities for on the framework methodology from the KDIGO Methods
which a systematic review was not conducted, and it Committee and aligns with other international guideline
includes useful infographics and describes an important groups using the “Grading of Recommendations Assessment,
research agenda for the future. It targets a broad audience Development, and Evaluation” (GRADE) methodology.
of people with CKD and their healthcare, while being New developments in the refinement of evaluation of
mindful of implications for policy and payment. glomerular filtration rate (GFR), population and individual risk
Kidney International (2024) 105, 684–701; https://doi.org/10.1016/ prediction, and novel treatments have all positively influenced
j.kint.2023.10.016 the prognosis for people with CKD and are presented here. The
KEYWORDS: chronic kidney disease; CKD; evaluation; guideline; KDIGO; Work Group has aimed to generate a guideline that is both
management rigorously devoted to new and existing evidence, and that is
Copyright ª 2023, Kidney Disease: Improving Global Outcomes (KDIGO). clinically useful. Research recommendations are presented in a
Published by Elsevier Inc. on behalf of the International Society of
separate section of the document and are intended to guide the
Nephrology. This is an open access article under the CC BY-NC-ND
license (http://creativecommons.org/licenses/by-nc-nd/4.0/). next set of important research questions to inform and improve
the outcomes of people living with CKD. We specifically urge
T
the community to be inclusive of people across the lifecycle and
his 2024 update of the Kidney Disease: Improving Global include sex (referring to biological factors including genetics,
Outcomes (KDIGO) Clinical Practice Guideline for the sex steroids, physiology, and anatomy), gender (referring to
Evaluation and Management of Chronic Kidney Disease sociocultural factors such as identity, roles, and relations), and
(CKD) heralds a new era in the care of people with kidney etiology of CKD as important variables in all studies.
diseases. The majority of statements from the 2012 guideline We offer recommendations to clinicians and clinical labo-
have been updated based on current knowledge and practice. ratories to understand and promote the standardization and
Only 6 statements were retained in their original form in 2012. accuracy of testing tools including assays and equipment. The
There is clear and increasing recognition of CKD as a global effective use of clinical practice guidelines and, therefore,
public health problem. The inclusion of people with CKD in effective patient care, including accurate diagnosis and referral
clinical trials has improved substantially, thus generating an prioritization, clinical research, and public health prioritiza-
evidence base upon which to recommend care and treatments tion, requires comparability of laboratory results independent
that have not previously existed. There are increasing efforts to of time, place, and measurement procedure. Key to this is
improve diagnostic evaluation of cause, with increased so- establishing precision of testing and between-laboratory
phistication of imaging methods, biopsy interrogation, and agreement with traceability to accepted international refer-
genetic evaluation, as well as methods to optimize blood and ence standards wherever available. Therefore, this guidance
urine testing. With advances in technology, such as molecular document includes standards for laboratory tests. Specifically,
diagnostics for tissue samples, integrated omics platforms, we focus on creatinine and cystatin C, with the goal of
and the use of machine learning/artificial intelligence to normalizing access to both tests for increased accuracy of GFR
explore large databases of both clinical and biological data, assessment, and the assessment of urine albumin which is also
we are truly at the beginning of a new era in nephrology. critical to risk assessment and care plans.
This guideline integrates existing and new knowledge to The guideline is organized into 6 chapters (Tables 1, 4, and 5
guide the care of people with CKD. It has been developed by cover Chapters 1–5). In this summary, we outline the key
an international Work Group that included patient partners, evidence-based recommendations together with selected prac-
clinicians, and researchers with diverse experience across the tice points by chapter. Readers are referred to the full guideline
spectrum of populations, a dedicated Evidence Review Team, for a comprehensive description of benefits and harms, certainty
and professional KDIGO staff. This clinical practice guideline of evidence, values and preferences, resource use and costs,
includes 2 different types of statements: graded recommen- factors affecting implementation, special considerations, and
dations, which are supported by systematic reviews (i.e., de both general and specific research recommendations.
novo reviews conducted by the independent Evidence Review
Team or existing high-quality reviews that have been sys- Qualifying statements, key concepts, special considerations,
tematically identified), and ungraded practice points, which Chronic Kidney Disease Prognosis Consortium (CKD-PC)
serve to direct clinical care or activities for which a systematic Clarifying definition and classification. We begin with
review was not conducted for various reasons (e.g., lack of a acknowledgment that the definition and classification system is
sufficient evidence base or randomized controlled trials that widely accepted by the community. Specifically, we remind
would be impractical/unethical). Both recommendations and readers of the difference between the definition of CKD, which is
practice points are intended to help guide clinical practice and inclusive of various markers of kidney damage, and the classi-
aid in decision-making; thus, collectively are the guideline fication system that highlights the importance of the CGA sys-
statements. They are clearly articulated, actionable, and pre- tem (i.e., Cause/Glomerular filtration rate level/Albuminuria
sented together so that all guideline statements can be level) for the purposes of management, treatment, risk assess-
implemented. The distinction between them is based on the ment, and research. The relative risk of many outcomes (CKD
process by which they are derived, and that process is based progression, kidney failure, acute kidney injury, infection,
hospitalizations, cardiovascular mortality, myocardial infarc- provide economic benefits and prevent the development of
tion, atrial fibrillation, stroke, and peripheral vascular disease) is kidney failure and cardiovascular complications. A systematic
increased for all people with CKD, whereas absolute risks for review of care models in low- and middle-income countries
individuals are modified by age, sex, and other factors. We found that those supporting primary care providers or allied
highlight the difference between relative and absolute risks (the health workers achieved effectiveness in slowing GFR decline,
latter derived by applying individual risk prediction scores), as opposed to interventions centered on specialty care alone.5
acknowledge that there are different risks for different pop- Where there are resource limitations, it is logical to deploy re-
ulations, and do not support any age-adjusted definitions of sources where they will be most cost-effective, for example, to
CKD, as there are no age-adjusted definitions for diabetes, car- higher-risk, preventable stages.
diovascular disease (CVD), nor hypertension, but rather Special considerations and updated population data. We
recognize that the individual implications of those conditions recognize that kidney diseases affect people at different times
for individuals differ by age group. and with different impacts across the whole lifespan. Thus,
Screening. Despite the increasing recognition of the true enabling a personalized approach, considering age, sex, and
burden of CKD, there remains controversy and lack of consensus gender for diagnosis, risk assessment, and treatment, is critical.
as to the utility of population screening for CKD1 or targeted At the extremes of age, the very young and the very old, diag-
screening programs2 due to the complexity of the underlying nostic procedures, treatment aims, treatment modalities, and
sociopolitical and resource environment. Public health policy decision-making differ due to differences in prognosis, treat-
has a role to play in identifying and addressing risk factors to ment options, and prioritization. In young and middle-aged
prevent CKD, to identify CKD early, and to delay its progression adults, treatment approaches may differ because of specific
and associated adverse outcomes. Incorporating evidence-based circumstances, such as pregnancy or menopause. Sex (biological
treatment of people with CKD with sodium-glucose cotrans- attributes) and gender (sociocultural factors), as well as other
porter-2 (SGLT2) inhibitors, together with a systematic review important intersectional factors, including, but not limited to,
in people with diabetes and hypertension, suggests that geographical location, socioeconomic position, and race/
screening adults for CKD could now be cost-effective.3,4 ethnicity, play important roles in kidney health and disease.
International considerations. In low- and middle-income Within the guideline document, we highlight concepts as to
countries and in the lower sociodemographic quintiles why age, sex, and gender should be considered, and how these
around the world, there is a large gap between CKD burden and specifically impact within each of the chapters (see Figure 1).
provision of adequate healthcare. There is limited access to Multinational population studies, assessing risks, based on
kidney replacement therapy combined with the rising preva- CKD-PC 2023 analyses,6 are presented as part of the intro-
lence of diabetes and hypertension and evidence of substantial ductory chapter to further highlight updated information
sex and gender disparities in access to CKD treatment. demonstrating epidemiological risk across CKD categories on
Importantly, slowing CKD progression at early stages should a population level. The data describe that the association of all
Sex
Child/adolescent • Menopause
• Growth • Contraception
• Nutrition • Differential drug effects
• Weight/BSA-based drug dosing • Differing epidemiology
• Neurocognitive development of risk factors and
• Supporting education complications
• Transition to adult care
• Holistic approach to care for
the whole family unit
Older adults
• Multidimensionality of
chronic conditions/
multimorbidity
• Frailty (including sarcopenia)
• Cognitive function
• Polypharmacy
• Prioritization
Pregnancy/lactation • End-of-life care
• Drug pharmacokinetics Gender
and pharmacodynamics • Gender identity
• Drug teratogenicity • Gender roles
• Risk of CKD progression • Gender relations
• Increased risk of pregnancy • Institutionalized
complications, preterm birth gender
and small for gestational
age babies
• Fertility
Figure 1 | Special considerations for chronic kidney disease (CKD) care across the lifespan. BSA, body surface area.
686 Kidney International (2024) 105, 684–701
A Levin et al.: Executive summary of KDIGO 2024 CKD Guideline KDIGO executive conclusions
Table 1 | Recommendations and practice points from Chapters 1 and 2 of the KDIGO 2024 Clinical Practice Guideline for
Evaluation and Management of CKD
Chapter 1. Evaluation of CKD
1.1 Detection and evaluation of CKD
1.1.1 Detection of CKD
Practice Point 1.1.1.1: Test people at risk for and with chronic kidney disease (CKD) using both urine albumin measurement and assessment of glomerular
filtration rate (GFR).
Practice Point 1.1.1.2: Following incidental detection of elevated urinary albumin-to-creatinine ratio (ACR), hematuria, or low estimated GFR (eGFR), repeat
tests to confirm presence of CKD.
Table 1 | (Continued) Recommendations and practice points from Chapters 1 and 2 of the KDIGO 2024 Clinical Practice
Guideline for Evaluation and Management of CKD
Chapter 1. Evaluation of CKD
Practice Point 1.2.3.4: Consider the consistent use of enzymatic creatinine assays in children, given the higher relative contribution of non-creatinine
chromogens to measured creatinine in children when using the Jaffe assay, and the high prevalence of icteric and hemolyzed samples in the neonatal
period.
Practice Point 1.2.3.5: An eGFRcr level <90 ml/min per 1.73 m2 can be flagged as “low” in children and adolescents over the age of 2 years.
Table 1 | (Continued)
Chapter 2. Risk assessment in people with CKD
Practice Point 2.1.5: For albuminuria monitoring of people with CKD, a doubling of the ACR on a subsequent test exceeds laboratory variability and
warrants evaluation.
complications of CKD is incrementally increased with worse in enabling clinicians and people with CKD to under-
categories of estimated GFR (eGFR) and albuminuria and stand, if possible, the cause of CKD.
include information using both updated eGFR equations for The chapter also reminds clinicians that the kidney has
creatinine alone, as well as those using creatinine and cystatin many functions (excretory, endocrine, and metabolic) and
C combined. that GFR is one component of excretory function. Under-
On this foundation of key concepts and inclusive framework, standing the best methods by which to evaluate GFR and
we now describe the key statements for each of the chapters. when to use estimating equations versus direct measurements
is highlighted.
Chapter 1: Evaluation of CKD The recommendations to use the most accurate, validated
This chapter highlights the importance of detecting CKD equations to estimate GFR, preferably with a combination of
in high-risk populations because CKD is often silent and serum creatinine and cystatin C, are important. From both a
patients may be asymptomatic at early stages. The patient and provider perspective, acknowledging that serum
screening algorithm for the diagnosis of CKD in adults creatinine–based equations have limitations that can be
highlights the use of basic testing methods, and then overcome with the use of an additional marker (cystatin C) is
details the importance of thorough evaluation for the notable and places a high value on accuracy and lower value
cause and accurate assessment of GFR and urine albumin- on resource utilization associated with the additional
to-creatinine ratio (ACR) to appropriately stage people biomarker. The chapter describes the value of using a com-
with CKD. There are special considerations in pediatric bined creatinine and cystatin C–based equation in specific
populations and those with advanced age regarding situations. Table 2 highlights clinical circumstances where this
screening and staging. The evaluation of cause should be might apply.7–23 As we acquire more knowledge and data
thorough, using all available information (clinical, social, about GFR estimating equations using cystatin C versus
and family history) and accessible testing (laboratory, creatinine or both, there are now recognized implications of
imaging, genetics, and biopsy), given that etiology impacts those differences that need to be understood by clinicians, in
prognosis, risk, and choice of therapies. Given that up to both direction and magnitude.
25% of all current CKD registries or study cohorts have There are issues related to how best to estimate GFR in
“unknown etiology” documented, there is renewed interest transgender, gender-diverse, or nonbinary individuals where a
Lifestyle Smoking9–11 Non-GFR determinants of SCys Minimal data, suggest eGFRcr if no changes to non-GFR determinants of SCr or
comorbid illness.
Illness other than CKD Malnutrition Chronic illness, presumed impact on eGFRcr-cys may be less accurate because of coexistence of malnutrition and
non-GFR determinants of SCr and SCys inflammation. Suggest using mGFR for treatment decisions based on the level
of GFR.
Cancera,12-16 Chronic illness, presumed impact on eGFRcr-cys demonstrated to be most accurate in populations studied but
non-GFR determinants of SCr and SCys likelihood of lesser accuracy in more frail people or in cancers with high cell
turnover. Suggest using mGFR for treatment decisions based on the level of GFR.
Heart failurea,17,18 Chronic illness, presumed impact on Although limited data, eGFRcys appears less biased but all have low accuracy.
non-GFR determinants of SCr and SCys Suggest using eGFRcr-cys or eGFRcys for routine GFR evaluation. Suggest
Medication effects Steroids (anabolic, hormone) Non-GFR determinants of SCr. Effect on Physiological effect on SCys unknown, suggest eGFRcr-cys.
SCys not known
Decreases in tubular secretion Non-GFR determinants of SCr eGFRcys may be appropriate if medication affects only creatinine and no comorbid
illness. Suggest using mGFR for treatment decisions based on the level of GFR.
Broad spectrum antibiotics that Non-GFR determinants of SCr eGFRcys may be appropriate if medication affects only creatinine and no comorbid
decrease extrarenal elimination illness. Suggest using mGFR for treatment decisions based on the level of GFR.
eGFR, estimated glomerular filtration rate; eGFRcr, creatinine-based estimated GFR; eGFRcr-cys, creatinine and cystatin C–based estimated GFR; mGFR, measured GFR; SCr, serum creatinine; SCys, serum cystatin C.
a
Data summarized in Adingwupu OM, Barbosa ER, Palevsky PM, et al. Cystatin C as a GFR estimation marker in acute and chronic illness: a systematic review. Kidney Med. 2023;5:100727.23
b
Obesity class III varies by region but commonly body mass index >40 or >35 kg/m2.
c
Catabolic consuming disease may include tuberculosis, AIDS, hematologic malignancies, and severe skin diseases. There are no data with mGFR to evaluate this directly.
A Levin et al.: Executive summary of KDIGO 2024 CKD Guideline KDIGO executive conclusions
Table 3 | Indications for measured glomerular filtration rate and proteinuria is not the same as albuminuria; clinicians
should appreciate those differences. There are factors that
Clinical conditions in which eGFRcr-cys is inaccurate or uncertain due to
potential non-GFR determinants of creatinine and cystatin C. This may influence variability in urine albumin or protein measures, as
include catabolic states, such as serious infections or inflammatory there are different ones that impact urine creatinine. Given
states, high cell turnover as in some cancers, advanced cirrhosis or heart that the ratios are used to ascertain risk, understanding
failure, use of high-dose steroids, or the very frail. See Figure 12 in the
full guideline for approach to individual decision-making.
sources of both analytical and biological variability is
important for the interpretation of fluctuations in urine ACR.
Clinical settings in which greater accuracy is needed than is achieved with The use of point-of-care testing may facilitate access to
eGFRcr-cys. For example, decisions about simultaneous kidney earlier diagnosis and care and can be implemented in rural
transplant at the time of other solid organ transplant, kidney donor
candidacy, and drug dosing if narrow therapeutic index or serious
and remote locations. The value of point-of-care testing for
toxicity (e.g., chemotherapies that are cleared by the kidney). currently underserved populations cannot be overstated and
eGFRcr-cys, creatinine and cystatin C–based estimated GFR; GFR, glomerular filtra- should include the capacity for generating creatinine-based
tion rate. eGFR equations. The point-of-care testing devices used
would ideally measure both blood creatinine and urine for
person’s gender identity is different from their sex assigned at albumin and creatinine to measure ACR and be standardized
birth, and they may or may not be taking gender hormone– and calibrated with similar rigor as is recommended for
affirming therapy or puberty-blocking therapies. The calcu- laboratory tests.
lation of estimated GFR by creatinine and cystatin C using Overall, this chapter presents statements that help HCPs to
either sex constant may be impacted by non-GFR de- fully evaluate people with the diagnosis of CKD and provides
terminants of creatinine, and a holistic approach should be data to aid the clinicians and the laboratories to understand
taken to determine appropriate management anchored to the and appreciate nuances of evaluating the common tests for
muscle mass of the individual and based on their sex hor- assessing GFR and albuminuria, and aims to aid in increasing
mone configuration and gender identity. Similarly, cystatin accuracy of risk assessments to guide therapeutic decision-
C–based equations may be affected by gender hormone– making.
affirming therapy. The assessment of gender in the context
of eGFR is therefore an area for shared decision-making and Chapter 2: Risk assessment in people with CKD
an evolving area for investigation. This chapter addresses the need to monitor the progression of
Where more accurate ascertainment of GFR will impact CKD using both blood and urine tests on a regular basis,
treatment decisions (e.g., oncology drug dosing, kidney donor informed by risk of the individual, and contextualized within
eligibility, etc.), clinicians are encouraged to measure GFR by healthcare system capacity. It provides guidance for both
established clearance methods of glomerular filtration markers monitoring and the interpretation of changes over time that
(Table 3). may prompt additional testing or evaluation. There is an
The chapter addresses and reinforces key points for clinical expected variability in GFR and urine ACR caused by both
laboratories including the implementation of laboratory biological and analytical factors of the biomarkers used, and
standards for reporting, the use of enzymatic assays instead of nuances regarding changes with the initiation of therapies and
Jaffe method for creatinine measurements (given the inter- when/how to further evaluate are also offered.
ference of many drugs and substances when using the latter), Importantly, this chapter recommends the use of validated
timing of processing of blood samples, and simultaneous risk equations to estimate the “absolute” risk of kidney fail-
measurement of creatinine and cystatin C on the same blood ure for individual people and offers thresholds by which to
sample. These are all intended to improve consistency and determine referral timing of multidisciplinary care, modality
comparability of laboratory values. education, and preparation for transition to kidney replace-
The chapter also recommends using validated GFR esti- ment therapy, either dialysis or transplantation. The differ-
mating equations that should be the same within geographical entiation of “relative risks” as presented in the heatmaps in
regions so that people with CKD and healthcare providers the introductory chapter and individual risks, as calculated
(HCPs) have access to the same information, derived using using these risk equations, is critical in the context of
the same methodology. improving communication between people with CKD and
The evaluation of albuminuria is also addressed in this HCPs, as well as planning for transitions in care, healthcare
chapter, so that clinicians are aware and understand the de- system resource utilization, and potentially for enrollment
terminants of albuminuria measurements, which will enable into clinical trials. It is noted that there are disease-specific
better interpretation and guide action. Given the established, tools (for immunoglobulin A nephropathy and polycystic
consistent strong relationship between the quantity of urine kidney disease) and evolving tools for predicting events and
albumin with both kidney disease and CVD risk, clinicians mortality in people with CKD. In the era of precision
are encouraged to pay attention to this measurement. Albu- medicine, the use of validated prediction tools will help tailor
minuria measurements may not be available in all regions, the frequency of visits, bloodwork, timing of educational
activities, and may inform a better selection of targets of care are highlighted, with the evidence to support those activities
to support people and families living with CKD. presented. It is noted that those with specific needs (children
or frail [older] adults) should have lifestyle counseling based
Chapter 3: Delaying CKD progression and managing its on capability and values.
complications There is an extensive review of diets now recommended
Chapter 3 provides a comprehensive discussion of the totality for people with CKD, including plant-based diets, and protein
of treatment strategies required to reduce the risk of both intake in accordance with needs and status. The importance
progression of CKD and its attendant comorbidities (Table 4). of not restricting protein in those who are cachexic, sarco-
Lifestyle factors that include optimizing physical activity penic, or undernourished is highlighted. Avoidance of high-
and weight, the avoidance of tobacco products, as well as protein intake and the need for close supervision if very low–
access to trained individuals (renal dietitians or accredited protein intake is attempted are all described in detail, again,
nutrition providers, pharmacists, psychologists, and others) underscoring the importance of individualization of care
Regular
risk factor
Lifestyle reassessment
Stop use of (every 3–6
Healthy diet Physical activity tobacco products Weight management months)
Figure 2 | Holistic approach to chronic kidney disease (CKD) treatment and risk modification. *Angiotensin-converting enzyme inhibitor
or angiotensin II receptor blocker should be first-line therapy for blood pressure (BP) control when albuminuria is present, otherwise
dihydropyridine calcium channel blocker (CCB) or diuretic can also be considered; all 3 classes are often needed to attain BP targets. Icons
presented indicate the following benefits: blood pressure cuff ¼ blood pressure–lowering; glucometer ¼ glucose-lowering; heart ¼ heart
protection; kidney ¼ kidney protection; scale ¼ weight management. ASCVD, atherosclerotic cardiovascular disease; CKD-MBD, chronic kidney
disease–mineral and bone disorder; eGFR, estimated glomerular filtration rate; GLP-1 RA, glucagon-like peptide-1 receptor agonist; HTN,
hypertension; KDIGO, Kidney Disease: Improving Global Outcomes; MRA, mineralocorticoid receptor antagonist; ns-MRA, nonsteroidal
mineralocorticoid receptor antagonist; PCSK9i, proprotein convertase subtilisin/kexin type 9 inhibitor; RAS, renin-angiotensin system; SBP,
systolic blood pressure; SGLT2i, sodium-glucose cotransporter-2 inhibitor. Modified from Kidney Disease: Improving Global Outcomes Diabetes
Work Group. KDIGO 2022 Clinical Practice Guideline for Diabetes Management in Chronic Kidney Disease. Kidney Int. 2022;102:S1–S127.24
Table 4 | Recommendations and practice points from Chapter 3 of the KDIGO 2024 Clinical Practice Guideline for Evaluation
and Management of CKD
Chapter 3. Delaying CKD progression and managing its complications
3.1 CKD treatment and risk modification
Practice Point 3.1.1: Treat people with CKD with a comprehensive treatment strategy to reduce risks of progression of CKD and its associated
complications (Figure 17a).
3.3 Diet
Practice Point 3.3.1: Advise people with CKD to adopt healthy and diverse diets with a higher consumption of plant-based foods compared to animal-
based foods and a lower consumption of ultraprocessed foods.
Practice Point 3.3.2: Use renal dietitians or accredited nutrition providers to educate people with CKD about dietary adaptations regarding sodium,
phosphorus, potassium, and protein intake, tailored to their individual needs, and severity of CKD and other comorbid conditions.
Table 4 | (Continued) Recommendations and practice points from Chapter 3 of the KDIGO 2024 Clinical Practice Guideline for
Evaluation and Management of CKD
Chapter 3. Delaying CKD progression and managing its complications
Practice Point 3.4.3: In children with CKD, when ABPM is not available, it is reasonable to target manual auscultatory office SBP, obtained in a protocol-
driven standardized setting, of 50th–75th percentile for age, sex, and height unless achieving this target is limited by signs or symptoms of
hypotension.
Table 4 | (Continued)
Chapter 3. Delaying CKD progression and managing its complications
3.10 Metabolic acidosis
Practice Point 3.10.1: In people with CKD, consider use of pharmacological treatment with or without dietary intervention to prevent development of
acidosis with potential clinical implications (e.g., serum bicarbonate <18 mmol/l in adults).
Practice Point 3.10.2: Monitor treatment for metabolic acidosis to ensure it does not result in serum bicarbonate concentrations exceeding the upper limit
of normal and does not adversely affect BP control, serum potassium, or fluid status.
3.11.3 Timing to recheck potassium after identifying moderate and severe hyperkalemia in adults
[No specific recommendations or practice points]
3.12 Anemia
Please refer to the KDIGO Clinical Practice Guideline for Anemia in Chronic Kidney Disease publications for specific recommendations, selection, and
dosing of specific therapeutic agents, and research recommendations.
3.14 Hyperuricemia
Recommendation 3.14.1: We recommend people with CKD and symptomatic hyperuricemia should be offered uric acid–lowering
intervention (1C).
Practice Point 3.14.1: Consider initiating uric acid–lowering therapy for people with CKD after their first episode of gout (particularly where there is no
avoidable precipitant or serum uric acid concentration is >9 mg/dl [535 mmol/l]).
Practice Point 3.14.2: Prescribe xanthine oxidase inhibitors in preference to uricosuric agents in people with CKD and symptomatic hyperuricemia.
Practice Point 3.14.3: For symptomatic treatment of acute gout in CKD, low-dose colchicine or intra-articular/oral glucocorticoids are preferable to
nonsteroidal anti-inflammatory drugs (NSAIDs).
Practice Point 3.14.4: Nonpharmacological interventions which may help prevent gout include limiting alcohol, meats, and high-fructose corn syrup
intake.
Recommendation 3.14.2: We suggest not using agents to lower serum uric acid in people with CKD and asymptomatic hyperuricemia to delay
CKD progression (2D).
3.15 Cardiovascular disease (CVD) and additional specific interventions to modify risk
3.15.1 Lipid management
Recommendation 3.15.1.1: 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 (1A).
Recommendation 3.15.1.2: 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 (1B).
Recommendation 3.15.1.3: 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 (2A):
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%.
Practice Point 3.15.1.1: Estimate 10-year cardiovascular risk using a validated risk tool.
Practice Point 3.15.1.2: In people with CKD, choose statin-based regimens to maximize the absolute reduction in low-density lipoprotein (LDL) cholesterol
to achieve the largest treatment benefits.
(Continued on following page)
Table 4 | (Continued) Recommendations and practice points from Chapter 3 of the KDIGO 2024 Clinical Practice Guideline for
Evaluation and Management of CKD
Chapter 3. Delaying CKD progression and managing its complications
Practice Point 3.15.1.3: In adults with CKD aged 18–49, a lower (i.e., <10%) estimated 10-year incidence of coronary death or nonfatal myocardial
infarction may also be appropriate thresholds for initiation of statin-based therapy.
Practice Point 3.15.1.4: Consider prescribing proprotein convertase subtilisin/kexin type 9 (PCSK-9) inhibitors to people with CKD who have an indication
for their use.
Practice Point 3.15.1.5: Consider a plant-based “Mediterranean-style” diet in addition to lipid-modifying therapy to reduce cardiovascular risk.
3.15.3 Invasive versus intensive medical therapy for coronary artery disease
Recommendation 3.15.3.1: 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 (2D).
Practice Point 3.15.3.1: Initial management with an invasive strategy may still be preferable for people with CKD with acute or unstable coronary disease,
unacceptable levels of angina (e.g., patient dissatisfaction), left ventricular systolic dysfunction attributable to ischemia, or left main disease.
plans based on the best evidence for different people at (anorexia and protein wasting), bone disease, and other
different points in their kidney journey. Salt intake and blood consequences. These can be addressed with both dietary in-
pressure management are concordant with other guidance terventions and medications. Suggestions to evaluate the risk-
documents, and again caveats for targets in vulnerable or frail benefit ratio and goals of therapy are described, and the
populations are highlighted. Measurements using 24-hour threshold for aggressive intervention has been moved to <18
ambulatory devices are underscored, as is the interpretation mmol/l from <22 mmol/l in the previous KDIGO guideline.
of those readouts for children. Hyperkalemia is discussed in terms of frequency of
Recommendations for using renin-angiotensin system in- occurrence, “expected” values for potassium at different levels
hibitors, where tolerated, in those with and without diabetes of GFR, and treatment strategies, which highlight newer at-
and in those with moderately high urine albumin excretion titudes toward dietary advice (avoidance of highly processed
are clearly articulated, as is the value of these medications in foods, but not of fruits and vegetables), an improved under-
the context of heart failure and CKD. Guidance for reduction standing of different factors that impact potassium, and tar-
or cessation of medication for those intolerant (due to side geted therapy based on thorough assessment and context.
effects or hypotension) is offered, as are reassurances as to Newer data on the value of treating hyperuricemia were
when to maintain people on these agents despite changes in evaluated. No data were found to support targeting hyper-
bloodwork (serum creatinine, potassium, etc.). uricemia in the absence of symptoms (e.g., gout or tophi
There is an abundance of literature on which to base formation).
guidance on the use of SGLT2 inhibitors to both delay CKD The treatment of common laboratory abnormalities of
progression and reduce cardiovascular complications. Nu- hemoglobin, parathyroid hormone, and phosphate follows
ances for those with and without diabetes, heart failure, and current KDIGO guideline documents on these specific en-
for those with higher and lower urine ACR levels are clearly tities. Importantly, tables are provided describing “expected”
articulated. Guidance for the use of mineralocorticoid an- values for common laboratory tests by eGFR so that clinicians
tagonists (both steroidal and nonsteroidal) is also offered, may be able to better identify aberrant values that require
given their value in blood pressure management, heart failure additional work-up or review.
treatment, and delay of progression of CKD in those with and A section on cardiovascular risk factor modification for
without diabetes. both atherosclerotic disease (myocardial infarction, stroke, and
The treatment of metabolic acidosis to delay progression peripheral vascular disease) and atrial fibrillation is offered
of CKD has not been proven; however, it is recognized that whereby specific interventions are highlighted and calculation
acidosis can lead to exacerbation of nutritional issues of risk scores promoted to guide initiation or modification of
therapy. The use of statins, antiplatelet therapy, and invasive with CKD are prescribed, this is an important component of
versus intensive medical therapy is addressed in detail, citing care, ensuring that people are prescribed the right drugs for
and interpreting an extensive evidence base. the right reasons at the right dose.
The chapter emphasizes the need to evaluate people with Lastly, the chapter highlights new literature that suggests
CKD comprehensively in order to address both progressive that intravenous contrast does not carry large risks in people
CKD and its attendant comorbidities in an integrated manner with CKD and that imaging studies should be performed
and draws on literature to support this holistic approach based on information they provide and how and if they will
(Figure 224). change management. The true low risk of associated acute
kidney injury is highlighted and will require ongoing edu-
Chapter 4: Medical management and drug stewardship in cation of all HCPs and people with CKD to enable appro-
CKD priate timely diagnostic imaging.
This chapter reminds HCPs and people with CKD about the
importance of assessing medications in the context of GFR, Chapter 5: Optimal models of care
and given that GFR changes over time, it emphasizes the need This chapter addresses the value of referral to nephrology
for and value of regular reassessment (Table 5). Drugs with specialists for comprehensive evaluation and work-up and
narrow therapeutic windows need to be dosed according to the importance of access to multidisciplinary care teams,
the most accurate assessment of GFR, which may require while recognizing the associated cost(s) and the nonavail-
direct measurement. ability of multidisciplinary care teams in different regions
Understanding of drug metabolism and excretion is poor (Table 5). There is an emphasis on standardized regular
in specific patient groups (children and in persons of child- assessment of symptoms, and the use of validated ques-
bearing age), and the impact of concomitant hormonal tionnaires to help both people with CKD and HCPs
therapy (for any reason, in male or female individuals) is not appreciate changes over time and the impact of symptom
known. Thus, we should proceed with caution and ensure management (Figure 3).
that we gather more data in these areas to better inform care The need for planned and extended transitions from pe-
for diverse individuals across the life spectrum. diatric to adult care is highlighted, as is the importance of true
Chapter 4 also promotes the concepts of recognizing the team-based care models. The value of supportive care and
risks of polypharmacy, the potential value of deprescribing, comprehensive conservative management is described for
and the need for good drug stewardship, both for people those who choose not to or who cannot access kidney
with CKD as well as providers. Accessible education and replacement therapy. The use of technology, digital platforms,
communication for people with CKD will support efforts at and tools, including, but not limited to, virtual care, to help
health literacy but also potentially mitigate issues of non- teams and individuals access the totality of the value of the
adherence. Given the very large number of drugs that people team and resources is described. We recognize that these
Figure 3 | Optimal care model by increasing severity of chronic kidney disease (CKD). CV, cardiovascular; KRT, kidney replacement
therapy.
Table 5 | Recommendations and practice points from Chapters 4 and 5 of the KDIGO 2024 Clinical Practice Guideline for
Evaluation and Management of CKD
Chapter 4. Medication management and drug stewardship in CKD
4.1 Medication choices and monitoring for safety
Practice Point 4.1.1: People with CKD may be more susceptible to the nephrotoxic effects of medications. When prescribing such medications to people
with CKD, always consider the benefits versus potential harms.
Practice Point 4.1.2: Monitor eGFR, electrolytes, and therapeutic medication levels, when indicated, in people with CKD receiving medications with
narrow therapeutic windows, potential adverse effects, or nephrotoxicity, both in outpatient practice and in hospital settings.
Practice Point 4.1.3: Review and limit the use of over-the-counter medicines and dietary or herbal remedies that may be harmful for people with CKD.
Practice Point 4.1.4: When prescribing medications to people with CKD who are of child-bearing potential, always review teratogenicity potential and
provide regular reproductive and contraceptive counseling in accordance with the values and preferences of the person with CKD.
Table 5 | (Continued)
Chapter 5. Optimal models of care
5.2.2 Identification and assessment of symptoms
Practice Point 5.2.2.1: Ask people with progressive CKD about uremic symptoms (e.g., reduced appetite, nausea, and level of fatigue/lethargy) at each
consultation using a standardized validated assessment of uremic symptoms tool.
5.5 Structure and process of supportive care and comprehensive conservative management
Practice Point 5.5.1: Inform people with CKD about the options for KRT and comprehensive conservative care.
Practice Point 5.5.2: Support comprehensive conservative management as an option for people who choose not to pursue KRT.
Practice Point 5.5.3: Provide access to resources that enable the delivery of advanced care planning for people with a recognized need for end-of-life
care, including those people undergoing comprehensive conservative care.
CKD, chronic kidney disease; KDIGO, Kidney Disease: Improving Global Outcomes; QoL, quality of life.
a
Figure 48 in full guideline.
b
Figure 55 in full guideline.
c
Table 41 in full guideline.
technologies are evolving rapidly so that definitive evaluation Fresenius Kabi, and GlaxoSmithKline. BF reports receiving research
of the value, harms, and benefits of these is not known. support from CIHR* and NIH*, and serving as Chair of the Women in
There is an emphasis on advanced care planning, directed Transplantation Initiative of The Transplantation Society. RKH reports
receiving consultancy fees from Bayer and United Health Group;
specifically to those choosing supportive care, but also research support from American Society of Nephrology Foundation
recognizing that all people with chronic diseases do need to for Kidney Research*, National Institute on Aging*, and Robert Wood
ensure that plans addressing future healthcare states are Johnson Foundation*; and serving on the Advancing Kidney Health
known to all. through Optimal Medication Management (AKHOMM). WGH reports
receiving research support from Boehringer Ingelheim* and Eli Lilly*,
Conclusion and serving on the Data Monitoring Committee for Bayer (unpaid).
Research recommendations are offered in the last chapter in LAI reports receiving consultancy fees from Diamtrix and Tricida*;
and research support from Chinook*, National Kidney Foundation*,
some detail to signpost priority areas for the field, such as NIH*, Otsuka, and Reata Pharmaceuticals. RK reports receiving
improving diagnostic and dynamic tests of kidney health and speaker honoraria from Astellas* and Baxter Healthcare*. EL reports
disease, improving and evaluating the implementation of receiving research support from National Institute of Health
validated prediction equations in specific situations, and Research*. PL reports receiving consultancy fees from AstraZeneca,
testing different combinations of disease-modifying drugs Bayer, Boehringer Ingelheim, Eli Lilly, Janssen, Merck, and Novo
with dietary regimens, to name but a few. Nordisk; speaker honoraria from AstraZeneca, Bayer, Boehringer
This comprehensive guidance document based on current Ingelheim, Eli Lilly, Janssen, Merck, and Novo Nordisk; funding for
development of educational presentations for AstraZeneca, Bayer,
best evidence indicates some exciting new approaches to Boehringer Ingelheim, Eli Lilly, Janssen, Merck, and Novo Nordisk; and
management strategies and treatment options for people serving as the Associate Editor of Elsevier Online Practice Update
living with CKD, with the goal of improving symptom Primary Care. MM reports receiving consultancy fees from AstraZe-
management, disease modification, and offering person- neca, Bayer, and Boehringer Ingelheim; research support from
centered approaches, while also recognizing the heterogene- AstraZeneca*, Bayer*, Boehringer Ingelheim*, Renal Research Insti-
ity of CKD. The fact that new therapies exist and others are tute*, and Tricida*; speaker honoraria and travel support from
being evaluated heralds an exciting time for people living with AstraZeneca; and funding for expert testimony for AstraZeneca,
Bayer, and Boehringer Ingelheim. ES reports receiving consultancy
kidney diseases, their families, and the HCP. fees from AstraZeneca, research support from Bayer AG* and E.N.D.I.
Stiftung*, speaker honoraria from Verband dt. Nierenzentren, and
DISCLOSURE serving on the Executive Board of the German Society of Nephrology
The development and publication of this guideline were supported and the Editorial Board of National Kidney Foundation. MS reports
by Kidney Disease: Improving Global Outcomes (KDIGO). The receiving research support from Bayer*, NIH (National Heart, Lung,
opinions or views expressed in this summary are those of the authors and Blood Institute [NHLBI], National Institute on Aging [NIA], and
and do not necessarily reflect the opinions or recommendations of National Institute of Diabetes and Digestive and Kidney Diseases
the International Society of Nephrology or Elsevier. Dosages, [NIDDK])*, VA Health Services Research & Development*, and VA
indications, and methods of use for products that are referred to in Clinical Science Research & Development*; speaker honoraria from
the supplement by the authors may reflect their clinical experience or AstraZeneca, Bayer, and Boehringer Ingelheim; and funding for
may be derived from the professional literature or other clinical expert testimony for Hagens Berman International Law Firm. RS re-
sources. Because of the differences between in vitro and in vivo ports receiving consultancy fees from AstraZeneca* and Fresenius
systems and between laboratory animal models and clinical data in Medical Care*, research support from Fresenius Medical Care* and
humans, in vitro and animal data do not necessarily correlate with Vitaflo*, and speaker honoraria from Amgen and Fresenius Medical
clinical results. Care. NT reports receiving consultancy fees from AstraZen-
AL reports receiving consultancy fees from AstraZeneca*, Bayer*, eca, Bayer, Boehringer Ingelheim, GlaxoSmithKline, Janssen, Otsuka,
Janssen*, Novo Nordisk*, OccuRx*, and Otsuka*; research support ProKidney, and Roche; research support from AstraZeneca*, Bayer*,
from AstraZeneca*, Boehringer Ingelheim*, Canadian Institutes of Boehringer Ingelheim*, and Janssen*; funding for development of
Health Research (CIHR)*, GlaxoSmithKline*, National Institutes of educational presentations for AstraZeneca; having stock/stock op-
Health (NIH)*, and Otsuka*; speaker honoraria from AstraZeneca*, tions from Clinpredict, Klinrisk, Marizyme, ProKidney, Pulsedata, and
Bayer*, and Boehringer Ingelheim*; and funding for the development Quanta; and a patent for a microfluidic device for measuring ACR at
of educational presentations for AstraZeneca*, Bayer*, Boehringer point of care. IU reports receiving speaker honoraria from AstraZen-
Ingelheim*, and Novo Nordisk*. SBA reports receiving research eca and Boehringer Ingelheim. LZ reports receiving research support
receiving support for CIHR*, Heart and Stroke Foundation*, and NIH*; from AstraZeneca* and Bayer*. All the other authors declared no
being a member of the CIHR Institute of Gender and Health Advisory competing interests. *Monies paid to institution.
Board, the Canadian Medical Association Journal Governance Council
(volunteer), the Data Safety Monitoring Board Member for ACKNOWLEDGMENTS
Adolescent Type 1 diabetes Treatment with sodium-glucose A special debt of gratitude is owed to the following people for their
cotransporter-2 inhibitors for hyperglycEMia & hyPerfilTration Trial contribution to this important guideline effort: Melissa Thompson,
(ATTEMPT) trial (trial sponsored by the CIHR and Juvenile Diabetes Debbie Maizels, Dipal Patel, Troy Gharibani, Xuhao Yang, Verna Lazar,
Research Foundation Canada) (volunteer); and serving as President- Jeongmin Hana Kim, Morgan Grams, Michel Jadoul, and Wolfgang
Elect, Organization for the Study of Sex Differences (volunteer). JJC Winkelmayer.
reports receiving research support from Amgen, Astellas, AstraZe-
neca, Boehringer Ingelheim, Merck Sharp and Dohme, Novo Nordisk, REFERENCES
and Vifor Pharma; speaker honoraria from Abbott, Baxter, and Fre- 1. Levin A, Okpechi IG, Caskey FJ, et al. Perspectives on early
senius Kabi; and serving as a board member for AstraZeneca, Baxter, detection of chronic kidney disease: the facts, the questions, and
a proposed framework for 2023 and beyond. Kidney Int. 2023;103: before and after allogeneic hematopoietic stem cell transplantation in
1004–1008. pediatric patients. Pediatr Blood Cancer. 2020;67:e28733.
2. Venuthurupalli SK, Hoy WE, Healy HG, et al. CKD screening and 14. Shibata K, Yasuda Y, Kobayashi R, et al. Renal function evaluation in
surveillance in Australia: past, present, and future. Kidney Int Rep. 2017;3: patients with cancer who were scheduled to receive carboplatin or S-1.
36–46. Clin Exp Nephrol. 2015;19:1107–1113.
3. Cusick MM, Tisdale RL, Chertow GM, et al. Population-wide screening for 15. Costa E, Silva VT, Gil LA, Caires RA, et al. Assessment of estimated
chronic kidney disease: a cost-effectiveness analysis. Ann Intern Med. glomerular filtration rate in a cohort of 1200 cancer patients using serum
2023;176:788–797. creatinine and cystatin C. J Am Soc Nephrol. 2020;31:11.
4. Komenda P, Ferguson TW, Macdonald K, et al. Cost-effectiveness of 16. Costa E, Silva VT, Gil LA, Jr, Inker LA, et al. A prospective cross-sectional
primary screening for CKD: a systematic review. Am J Kidney Dis. 2014;63: study estimated glomerular filtration rate from creatinine and cystatin C
789–797. in adults with solid tumors. Kidney Int. 2022;101:607–614.
5. Stanifer JW, Von Isenburg M, Chertow GM, Anand S. Chronic kidney 17. Kervella D, Lemoine S, Sens F, et al. Cystatin C versus creatinine for GFR
disease care models in low- and middle-income countries: a systematic estimation in CKD due to heart failure. Am J Kidney Dis. 2017;69:321–
review. BMJ Glob Health. 2018;3:e000728. 323.
6. Grams ME, Coresh J, Matsushita K, et al. Estimated glomerular filtration 18. Swolinsky JS, Nerger NP, Leistner DM, et al. Serum creatinine and cystatin
rate, albuminuria, and adverse outcomes: an individual-participant data C-based estimates of glomerular filtration rate are misleading in acute
meta-analysis. JAMA. 2023;330:1266–1277. heart failure. ESC Heart Fail. 2021;8:3070–3081.
7. Delanaye P, Cavalier E, Radermecker RP, et al. Cystatin C or creatinine for 19. De Souza V, Hadj-Aissa A, Dolomanova O, et al. Creatinine- versus
detection of stage 3 chronic kidney disease in anorexia nervosa. Nephron cystatine C-based equations in assessing the renal function of
Clin Pract. 2008;110:c158–c163. candidates for liver transplantation with cirrhosis. Hepatology. 2014;59:
8. Thurlow JS, Abbott KC, Linberg A, et al. SCr and SCysC concentrations 1522–1531.
before and after traumatic amputation in male soldiers: a case-control 20. Torre A, Aguirre-Valadez JM, Arreola-Guerra JM, et al. Creatinine versus
study. Am J Kidney Dis. 2014;63:167–170. cystatin C for estimating GFR in patients with liver cirrhosis. Am J Kidney
9. Knight EL, Verhave JC, Spiegelman D, et al. Factors influencing serum Dis. 2015;67:342–344.
cystatin C levels other than renal function and the impact on renal 21. Stammler F, Derain-Dubourg L, Lemoine S, et al. Impact of race-independent
function measurement. Kidney Int. 2004;65:1416–1421. equations on estimating glomerular filtration rate for the assessment of
10. Stevens LA, Schmid CH, Greene T, et al. Factors other than glomerular kidney dysfunction in liver disease. BMC Nephrol. 2023;24:83.
filtration rate affect serum cystatin C levels. Kidney Int. 2009;75:652–660. 22. Aldenbratt A, Lindberg C, Johannesson E, et al. Estimation of kidney
11. Wang Y, Adingwupu OM, Shlipak MG, et al. Discrepancies between function in patients with primary neuromuscular diseases: is serum
creatinine-based and cystatin C–based estimated GFR: interpretation cystatin C a better marker of kidney function than creatinine? J Nephrol.
according to performance compared to measured GFR. Kidney Med. 2022;35:493–503.
2023;5:100710. 23. Adingwupu OM, Barbosa ER, Palevsky PM, et al. Cystatin C as a GFR
12. Hingorani S, Pao E, Schoch G, et al. Estimating GFR in adult patients with estimation marker in acute and chronic illness: a systematic review.
hematopoietic cell transplant: comparison of estimating equations with Kidney Med. 2023;5:100727.
an iohexol reference standard. Clin J Am Soc Nephrol. 2015;10:601–610. 24. Kidney Disease: Improving Global Outcomes Diabetes Work Group.
13. Matsuoka D, Hirabayashi K, Murase T, et al. Assessment of kidney KDIGO 2022 Clinical Practice Guideline for Diabetes Management in
function using inulin-based and estimated glomerular filtration rates Chronic Kidney Disease. Kidney Int. 2022;102:S1–S127.