The Kidney Disease: Improving Outcomes Globally (KDIGO) organization has released a new 2024 Clinical Practice Guidelines document for the evaluation and management of non-dialysis-dependent chronic kidney disease (CKD).

The guidelines are a long-awaited update from 2012 and include most new recommendations based on systematic reviews of moderate to high quality studies conducted up to July 2023. This guideline is designed to assist health care providers in decision-making regarding evaluation. CKD is defined as abnormalities in kidney structure or function that persist for more than 3 months (excluding dialysis and kidney transplantation).

Key highlights include updated guidance on measuring estimated glomerular filtration rate (eGFR) and albuminuria, use of CKD risk prediction formulas, and tailoring renal and cardiovascular risk reduction to individual patient needs and preferences. Includes personalized treatment recommendations for. Blood pressure, diabetes, lipids, CKD-MBD, and anemia management (to be updated in 2024) are covered in detail in other KDIGO guidelines.

The cause of each patient’s CKD, whether congenital or genetic, the result of a systemic disease, can be determined primarily using serology, urine tests, imaging, biopsies, and/or genetic testing. Still important.

“Recent advances in GFR assessment, risk prediction, and new treatments are poised to enhance the prognosis and management of CKD,” workgroup co-chair Adeera Levin, MD, said in a KDIGO news release. Stated. “We also believe that the guideline’s focus on interdisciplinary teamwork, patient engagement, and a holistic, evidence-based approach to care will foster positive change and help the world around the world. We look forward to bringing more coordinated CKD care management to the world.”

Measurement of glomerular filtration rate

This guideline provides practical recommendations based on established step-by-step evidence and consensus-based practice points for CKD, preferably including race-free eGFRcr-cys equation and albumin-to-creatinine ratio. It is staged step by step using . If a more accurate assessment of her GFR is needed for clinical decision-making, clinicians can measure her GFR using clearance of exogenous filtration markers in plasma or urine.

Guidelines recommend the use of externally validated risk equations to estimate the absolute risk of renal failure in patients with CKD G3-G5. According to a practice point, patients thought to have immunoglobulin A nephropathy (IgAN) or autosomal dominant polycystic kidney disease (ADPKD) will want to use disease-specific, externally validated prediction formulas. There may be cases. Risk prediction tools for cardiovascular disease or mortality should include eGFR and albuminuria or be specific to the CKD population.

Slow down the progression of CKD

The practice points encourage clinicians to develop comprehensive and individualized treatment strategies to reduce patients’ risk of developing CKD and its associated complications. Clinicians must prevent and treat clinical symptoms and signs such as blood pressure. Maintain bodily functions. We also monitor and treat laboratory abnormalities such as anemia, CKD-MBD, potassium disorders, and acidosis as needed.

Activities: According to the guidelines, adults with CKD should engage in at least 150 minutes of moderate-intensity physical activity per week if tolerated.

diet: Guidelines suggest maintaining dietary protein intake at 0.8 g/kg body weight/day in adults with CKD G3-G5 (Level of Evidence 2C). As a practical point of view, it is recommended to avoid high protein intake exceeding 1.3 g/kg body weight/day. A plant-based, Mediterranean-style diet seems prudent, and working with a renal nutritionist and receiving appropriate medical nutritional therapy may be beneficial. The guidelines also recommend limiting sodium intake to less than 2 g per day. Special consideration is given to children and the elderly.

blood pressure: For blood pressure management in adults, this guideline recommends using standardized office blood pressure measurements to treat hypertension and CKD, if tolerated, until the target systolic blood pressure (SBP) is less than 120 mm Hg. Recommended. In children, 24-hour mean arterial pressure by ambulatory blood pressure monitoring should be reduced to below the 50th percentile depending on age, sex, and height.

Guidelines recommend starting renin-angiotensin system inhibitors (RASi) (such as angiotensin-converting enzyme inhibitors). [ACEi] or angiotensin II receptor antagonists [ARB]) is for patients with severe increased albuminuria (G1-G4, A3) without diabetes, and this step is for patients with moderate increased albuminuria (G1-G4, A2) without diabetes. It is recommended. He also recommends RASi for diabetic patients with moderate to severe increased albuminuria (G1-G4, A2, and A3). Avoid the combination of ACEi, ARB, and direct renin inhibitor therapy in the CKD population.

When starting RASi or changing doses, practice points recommend checking for changes in blood pressure, serum creatinine, and serum potassium within 2 to 4 weeks. Clinicians should continue ACEi or ARB therapy unless the patient’s serum creatinine increases by more than 30% within 4 weeks. Reduce or discontinue the dose of an ACEi or ARB if there is symptomatic hypotension or uncontrolled hyperkalemia despite medical treatment, or to reduce symptoms of uremia during treatment of renal failure Please consider doing so.

The guidelines recommend nonsteroidal mineralocorticoid receptor antagonists with proven renal or cardiovascular effects for adults with type 2 diabetes with an eGFR greater than 25 mL/min/1.73 m.²normal serum potassium concentrations, and albuminuria greater than 30 mg/g despite the maximum tolerated dose of RASi.

Blood sugar control: Guidelines recommend treating patients with type 2 diabetes, CKD, and eGFR of at least 20 mL/min/1.73m.² Uses sodium-glucose cotransporter-2 inhibitors (SGLT2i). This advice also applies to patients with heart failure or her CKD only (not diabetes) with urinary ACR >200 mg/g. SGLT2i is also recommended for adults with eGFR between 20 and 45 mL/min/1.73m.² Urinary ACR less than 200mg/g.

For adults with type 2 diabetes and CKD who are not meeting their individual glycemic goals despite using metformin or SGLT2i, or are unable to use these drugs, the guidelines recommend long-acting glucagon-like peptides. 1 receptor agonist (GLP-1) is recommended. RA).

Hyperuricemia: Guidelines recommend that patients with CKD and symptomatic hyperuricemia should be offered urate-lowering interventions. Practical points recommend xanthine oxidase inhibitors rather than uric acid excretion enhancers. For acute gout, low-dose colchicine or intra-articular/oral glucocorticoids may be preferable to nonsteroidal anti-inflammatory drugs (NSAIDs). Urate-lowering drugs should not be given to asymptomatic patients.

Prevention and management of cardiovascular disease

lipid management: Statins are recommended for adults age 50 and older with stage 1-5 CKD who are not on dialysis or have had a transplant. The combination of statins and ezetimibe should only be considered for patients with stage 3 to 5 CKD. Young people with a history of coronary artery disease (myocardial infarction or coronary revascularization), diabetes, ischemic stroke, or an estimated 10-year incidence of coronary death or nonfatal myocardial infarction are also advised to use statins. should be considered.

antiplatelet therapy: Guidelines recommend oral low-dose aspirin for secondary prevention of recurrent ischemic cardiovascular disease events.

coronary artery disease: If the patient is stable and stress tests confirm ischemic heart disease, clinicians may first try intensive drug therapy. In unstable or acute conditions, invasive strategies may be required.

atrial fibrillation: Guidelines recommend non-vitamin K antagonist oral anticoagulants rather than vitamin K antagonists such as warfarin for the prevention of blood clots in atrial fibrillation in patients with CKD G1-G4.

Imaging: The guidelines recommend following advice from the Society of Radiology. Patients with CKD, acute kidney injury (AKI), diabetes, intravascular volume depletion, or concomitant use of nephrotoxic drugs are at increased risk of contrast-related AKI.

Drug management and drug management

The guidelines address safety issues, including restrictions on over-the-counter drugs, herbs, and nutritional supplements, consideration of drug nephrotoxicity, teratogenicity in pregnancy, and monitoring of eGFR to balance efficacy with potential side effects. A myriad of practice points are provided for effective drug use.

For drugs that are cleared by the kidneys, eGFR-based dose adjustments are often necessary. In most cases, creatinine-based eGFR is suitable for drug administration, but if the drug has a narrow therapeutic or toxic range, the use of a formula that combines both creatinine and cystatin C, or the use of a combination of both creatinine and cystatin C, or You may need to use it. Use unindexed eGFR for body surface area in extremely heavy people. If the volume of distribution is not at steady state, adjust the drug dose.

A plan for resumption is required for medications that are discontinued due to illness or prior to elective surgery or emergency management of side effects.

Periodic medication reviews and pharmacist involvement are required.

Optimal care model

This guideline provides a set of practice points to optimize care. If the cause of CKD is unknown, or in cases of inherited kidney disease or recurrent extensive nephrolithiasis, referral to specialized kidney care services is required. It is also covered if the 5-year risk of renal replacement therapy is greater than 5%, if eGFR declines by 20% to 30%, or if eGFR is less than 30 mL/min/1.73m.². Severe albuminuria and microscopic hematuria also require further evaluation and management.

Children and adolescents with a urine ACR of 30 mg/g or PCR of 200 mg/g or higher, or if they have persistent hematuria, persistently low eGFR, hypertension, renal outflow obstruction, or renal and urinary disease. Referral to specialized kidney care services is required. Urinary tract abnormalities, suspected CKD, or recurrent urinary tract infections. The transition from pediatric to adult care should begin at ages 11 to 14, with a checklist to assess readiness and guide preparation. Kidney transplantation is recommended prophylactically or if kidney failure occurs.

Timely referral to specialized renal care is paramount to avoid poor outcomes such as hospitalization.

Symptoms: Practice points use validated assessment tools to assess the absence of malnutrition in people with CKD G4-G5, over 65 years of age, stunted growth, or symptoms such as involuntary weight loss, frailty, and anorexia. We recommend that a screening test be performed twice a year. The guidelines also provide lifestyle and pharmacological options for managing other symptoms such as pain, sleep deprivation, and uremic pruritus.

Multidisciplinary care: Clinicians need to ensure that patients with CKD have access to counseling regarding dietary counseling, medication management, education, renal replacement therapy, transplant options, dialysis access surgery, and ethical, psychological, and social care.

Starting dialysis

According to the practice points, dialysis should be used to treat uremia, pericarditis, anorexia, medically resistant acidic or electrolyte abnormalities, intractable pruritus, serositis, acid-base or electrolyte neurological signs, etc. , is indicated if symptoms or signs due to renal failure are present. There is an abnormality or the patient is unable to control volume status or blood pressure. This often occurs when the GFR is between 5 and 10 mL/min/1.73 m.².

If GFR is less than 15-20 mL/min/1.73m, consider planning for preemptive kidney transplant and/or dialysis access in adults² or KRT risk >40% for 2 years. Pediatric patients require special consideration and ideally should seek transplantation.