Suspected or confirmed CKD (adults)
Adult (18 years or older), not on dialysis, with reduced eGFR or markers of kidney damage.
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NephrologyManagement
Chronic Kidney Disease (CKD) Evaluation and Management (KDIGO 2024)
Chronic Kidney Disease (CKD) Evaluation and Management (KDIGO 2024): Suspected or confirmed CKD (adults) → First exclude rapid decline, AKI, pregnancy, ...
Pathway Overview
19 steps
Algorithm Steps
19 total
01Start 02Warning First exclude rapid decline, AKI, pregnancy, children and transplant
These need urgent advice or a different pathway.
- Rapid eGFR fall (>15% in 3 months) or acute nephritis (oliguria, haematuria, new hypertension, oedema): possible emergency. Refer to nephrology without delay
- Unstable creatinine or possible AKI: eGFR is not valid. Assess and treat as AKI first
- Pregnancy, age under 18, on dialysis, or kidney transplant: this pathway does not apply. Get nephrology, transplant team (and obstetric or paediatric) advice
03Action Confirm CKD: abnormality present for more than 3 months
Repeat the tests. Do not diagnose CKD from a single eGFR or ACR result.
- Test both eGFR (creatinine) and urine albumin-to-creatinine ratio (ACR)
- eGFR <60 mL/min/1.73 m² for more than 3 months, OR
- Kidney damage for more than 3 months: urine ACR ≥3 mg/mmol (≥30 mg/g), urine sediment abnormality or persistent haematuria, tubular disorder, structural abnormality on imaging, abnormal histology, or kidney transplant
- Use past results, imaging and history to show chronicity
- If CKD is likely, treatment can start at first presentation
04Action Stage CKD by cause, GFR (G) and albuminuria (A)
Use the laboratory eGFR (CKD-EPI, no race term). Add cystatin C (eGFRcr-cys) when creatinine may be inaccurate, e.g. extremes of muscle mass.
- eGFR (mL/min/1.73 m²): G1 ≥90, G2 60-89, G3a 45-59, G3b 30-44, G4 15-29, G5 <15 (kidney failure). G1-G2 count as CKD only with kidney damage
- A1: ACR <3 mg/mmol (<30 mg/g)
- A2: ACR 3-30 mg/mmol (30-300 mg/g)
- A3: ACR >30 mg/mmol (>300 mg/g)
05Action Find the cause of CKD
The cause guides prognosis and treatment.
- Common: diabetes, hypertension. Also glomerular disease, polycystic kidney disease, obstruction, reflux, drugs
- History: family history, nephrotoxic drugs, systemic disease
- Tests: urinalysis and urine microscopy, urine ACR, kidney ultrasound; serology as indicated
- Cause unclear: refer for biopsy or genetic testing
06Action Assess progression risk and set monitoring
KDIGO heat map. High or very high risk (orange or red): ACR >30 mg/mmol at any eGFR, eGFR 45-59 with ACR ≥3 mg/mmol, or eGFR <45.
- Low or moderate risk (green or yellow): eGFR and ACR at least once a year
- High or very high risk (orange or red): eGFR and ACR 2-3 times a year; 4 or more times a year in G4/A3 and G5
- G3-G5: estimate kidney failure risk with a validated equation (KFRE)
- Green (low): G1-G2/A1
- Yellow (moderate): G1-G2/A2, G3a/A1
- Orange (high): G1-G2/A3, G3a/A2, G3b/A1
- Red (very high): G3a/A3, G3b/A2-A3, G4-G5 any A
- Give all the treatment steps below at every risk level
07Action All CKD: lifestyle
Advise every person with CKD.
- Stop smoking
- Moderate physical activity, at least 150 min a week, as tolerated
- Sodium <2 g a day (<90 mmol a day)
- Protein 0.8 g/kg a day in G3-G5; avoid more than 1.3 g/kg a day. Frail older adults may need more
- Weight loss if obese; renal dietitian if available
08Action All CKD: control blood pressure
KDIGO 2024: systolic BP <120 mmHg if tolerated (standardised office BP). Less intensive in frailty, falls risk, postural hypotension or very limited life expectancy.
- Kidney Health Australia 2024: keep BP below 130/80 mmHg for all; <120 systolic may suit very high CV risk
- ACEi or ARB first-line when albuminuria is present (next steps)
09Warning Before ACEi/ARB, SGLT2i, finerenone, GLP-1 RA: check pregnancy, K+, diabetes
These conditions change or stop the next drug steps.
- Pregnancy possible or planned: ACEi and ARB are teratogenic; SGLT2i and finerenone are not advised. Stop before conception (semaglutide: at least 2 months before) and give contraception advice. Breastfeeding: do not use SGLT2i, finerenone or semaglutide; check ACEi choice with obstetric medicine
- High K+: treat it first; K+ ≥6.5 mmol/L or ECG changes: urgent hospital assessment now. Start finerenone only if K+ ≤4.8 mmol/L. Never give finerenone with spironolactone, eplerenone, amiloride or strong CYP3A4 inhibitors (e.g. clarithromycin, itraconazole), or in adrenal insufficiency
- Type 1 diabetes: SGLT2i not approved in Australia (ketoacidosis risk). Kidney transplant: ask the transplant team
10Action Kidney-protective drugs (1): ACEi or ARB
Slow CKD progression and lower cardiovascular risk. Indicated by albuminuria (A2-A3). First check for past angioedema and sacubitril/valsartan.
- Past angioedema on an ACEi, or hereditary or idiopathic angioedema: do not give an ACEi. After ACEi angioedema, an ARB can be considered with close monitoring. On sacubitril/valsartan: it replaces the ACEi or ARB, so add neither; start an ACEi only 36 h or more after its last dose
- ACEi or ARB (never both; never with a renin inhibitor): A2-A3 with diabetes, A3 without diabetes; consider for A2 without diabetes. Use the highest approved dose that is tolerated
- Check BP, creatinine and K+ 2-4 weeks after start or dose increase. Continue unless creatinine rises >30% within 4 weeks
- Creatinine rise >30% or symptomatic hypotension: check volume status and NSAIDs or diuretics; reduce the dose or stop; consider renal artery stenosis
- High K+ on ACEi or ARB: first lower K+ (diet, diuretic, K+ binder); reduce or stop only if uncontrolled
- Continue ACEi or ARB when eGFR falls below 30
11Action Kidney-protective drugs (2): SGLT2 inhibitor if eGFR ≥20
Slows CKD progression and lowers heart failure risk. Not for type 1 diabetes.
- SGLT2i (e.g. dapagliflozin, empagliflozin) if eGFR ≥20 and any of: type 2 diabetes, ACR ≥20 mg/mmol (≥200 mg/g), heart failure. Consider if eGFR 20-45 with ACR <20 mg/mmol
- Australia: start empagliflozin only if eGFR ≥20 and dapagliflozin only if eGFR ≥25
- An early eGFR dip is expected. Continue if eGFR later falls below 20, until dialysis starts
12Action All CKD: drug safety (sick days, surgery, NSAIDs, contrast)
Give every person a written sick-day plan. Avoid NSAIDs.
- Sick days (vomiting, diarrhoea, fever, poor intake): pause ACEi, ARB, diuretics, metformin, SGLT2i, sulfonylureas, NSAIDs (SADMANS). Give a written restart plan
- Elective surgery: consider stopping ACEi, ARB, SGLT2i and metformin 48-72 h before. With diabetes, omit SGLT2i for 2 days before and on the day of a procedure with a hospital stay
- Avoid NSAIDs. Review nephrotoxins and over-the-counter or herbal products
- Elective contrast CT: consider holding ACEi or ARB for 48 h before if at risk of AKI. Stop metformin before contrast if eGFR <30 or AKI
- Adjust renally cleared drug doses to eGFR
13Action Type 2 diabetes only: glucose-lowering drugs with kidney and heart benefit
Skip this step if the person does not have type 2 diabetes. Individual HbA1c target from <6.5% to <8.0% (<48 to <64 mmol/mol).
- Metformin if eGFR ≥30: halve the dose at eGFR 30-44; stop if eGFR <30
- SGLT2i for all with eGFR ≥20 (dapagliflozin: ≥25 in Australia); see the SGLT2i step. Also a GLP-1 RA with proven kidney and CV benefit (e.g. semaglutide) to slow CKD and lower CV risk, whatever the HbA1c. With insulin or a sulfonylurea, consider a lower dose of these to avoid hypoglycaemia. Past pancreatitis: use with caution. Retinopathy: monitor for worsening
- Finerenone if eGFR ≥25, K+ ≤4.8 mmol/L and ACR ≥3 mg/mmol despite maximum tolerated ACEi or ARB; can add to SGLT2i. Not with spironolactone, eplerenone, amiloride or strong CYP3A4 inhibitors, or in adrenal insufficiency
- Finerenone: check K+ and creatinine at 1 month, then every 4 months. Hold if K+ >5.5 mmol/L
14Action All CKD: lower cardiovascular risk
CKD raises cardiovascular risk.
- Statin or statin/ezetimibe: all adults aged 50 or more with CKD (not on dialysis, no transplant)
- Age 18-49: statin if coronary disease, diabetes, prior ischaemic stroke, or 10-year coronary risk >10%
- Low-dose aspirin only for established ischaemic CVD (secondary prevention)
- Atrial fibrillation: NOAC preferred to warfarin in G1-G4; adjust the NOAC dose to kidney function
15Action Check and treat CKD complications
Mainly from G3 onwards; check more often as eGFR falls.
- K+ ≥6.5 mmol/L or hyperkalaemia ECG changes: urgent hospital assessment now; call 000 if unwell or ECG changes. K+ 5.5-6.4 mmol/L and acutely unwell or AKI: hospital assessment
- Hyperkalaemia, not urgent: review drugs, potassium diet advice, diuretic or K+ binder; keep ACEi or ARB where possible
- Anaemia: Hb and iron studies at least yearly in G3, twice a year in G4 and every 3 months in G5. ESA through nephrology
- Mineral and bone disorder: calcium, phosphate, PTH and ALP from G3a
- Metabolic acidosis: consider treatment (drug with or without diet) if bicarbonate <18 mmol/L. Do not raise it above the normal range
- Fluid overload or oedema: diuretic
- Gout: allopurinol (xanthine oxidase inhibitor) preferred. Flares: avoid NSAIDs; use low-dose colchicine or a corticosteroid
- Progressive CKD: ask about uraemic symptoms at each visit
16Decision Nephrology referral criteria met?
Yes if any one applies, e.g. eGFR <30, 5-year KFRE >3-5%, ACR >70 mg/mmol, or a sustained eGFR fall (full list below).
- eGFR <30 mL/min/1.73 m²
- 5-year kidney failure risk (KFRE) above 3-5%
- Sustained eGFR fall >20% (>30% after starting ACEi, ARB, SGLT2i or MRA); KHA: fall ≥25% in 12 months or ≥15 mL/min/1.73 m² a year
- ACR ≥30 mg/mmol with haematuria, or ACR >70 mg/mmol; KHA: persistent ACR ≥30 mg/mmol
- ACR doubles in a person with significant albuminuria
- Red cell casts, or more than 20 red cells per high-power field, not explained
- Hypertension not controlled on 4 or more drugs (KHA: 3 or more)
- Persistent potassium abnormality, acidosis, anaemia, bone disease or malnutrition
- Cause uncertain, hereditary kidney disease, or recurrent extensive kidney stones
- First Nations Australians: consider earlier referral
- If Yes
17Action Criteria met: refer to nephrology
Co-manage with a nephrologist. Send bloods, urine ACR, urine microscopy, BP history and a kidney ultrasound if done.
- 2-year kidney failure risk >10%: start multidisciplinary care
- 2-year kidney failure risk >40%: kidney replacement therapy education, vascular access planning and transplant referral
- Discuss conservative kidney management where appropriate
- Continue all treatment steps above
18Outcome Kidney failure planning with nephrology
Dialysis, transplant or conservative care, chosen with the person.
If No19Outcome Criteria not met: continue in primary care
Monitor at the interval for the risk category. Recheck the referral criteria at each review.
Guideline Source
KDIGO 2024 Clinical Practice Guideline for the Evaluation and Management of Chronic Kidney Disease
Clinical Safety Information
Clinical Decision Support — Not a Substitute for Clinical Judgment
Individual patient factors may require deviation from these recommendations.
Known Limitations
- Adults not on dialysis only. Not for AKI, pregnancy, children or kidney transplant recipients.
- Referral and BP thresholds differ between KDIGO 2024 and Kidney Health Australia 2024; both are shown. Follow local referral pathways.
- Drug doses are not given; use product information and renal dosing references.
- Anaemia and mineral bone guidance is a summary; see the KDIGO 2026 anaemia and KDIGO 2017 CKD-MBD guidelines.
- Does not replace nephrology advice for complex or rapidly progressive disease.
Contraindicated Populations
children and adolescents under 18 (use paediatric equations and referral criteria)pregnancy (ACEi, ARB, SGLT2i, finerenone and semaglutide not advised; planned pregnancy and breastfeeding are covered by the drug warning)acute kidney injury or unstable creatininepeople on dialysiskidney transplant recipients (transplant team manages)
Applicable Regions
AUUSEUUKglobal
AU: Australian laboratories report eGFR (CKD-EPI) for adults and urine ACR in mg/mmol. Kidney Health Australia CKD Management in Primary Care (5th ed, 2024): BP below 130/80 mmHg; refer for eGFR <30, persistent ACR ≥30 mg/mmol, eGFR fall ≥25% in 12 months or ≥15 mL/min/1.73 m² a year, or BP not at target on 3 or more drugs. SGLT2i are not approved for type 1 diabetes in Australia.
US: Race-free eGFR equations (CKD-EPI 2021) are standard. Urine ACR is often reported in mg/g.
global: KDIGO 2024 is the international reference for CKD evaluation and management.
Version 2Next review: 2027-09-30
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eGFR (CKD-EPI 2021)
Estimated glomerular filtration rate using CKD-EPI 2021 equation (race-free)
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Frequently Asked Questions
What is the Chronic Kidney Disease (CKD) Evaluation and Management (KDIGO 2024)?
The Chronic Kidney Disease (CKD) Evaluation and Management (KDIGO 2024) is a management clinical algorithm for Nephrology. It provides a structured decision tree to guide clinical decision-making, based on KDIGO 2024 Clinical Practice Guideline for the Evaluation and Management of Chronic Kidney Disease.
What guideline is the Chronic Kidney Disease (CKD) Evaluation and Management (KDIGO 2024) based on?
This algorithm is based on KDIGO 2024 Clinical Practice Guideline for the Evaluation and Management of Chronic Kidney Disease (DOI: 10.1016/j.kint.2023.10.018).
What are the limitations of the Chronic Kidney Disease (CKD) Evaluation and Management (KDIGO 2024)?
Known limitations include: Adults not on dialysis only. Not for AKI, pregnancy, children or kidney transplant recipients.; Referral and BP thresholds differ between KDIGO 2024 and Kidney Health Australia 2024; both are shown. Follow local referral pathways.; Drug doses are not given; use product information and renal dosing references.; Anaemia and mineral bone guidance is a summary; see the KDIGO 2026 anaemia and KDIGO 2017 CKD-MBD guidelines.; Does not replace nephrology advice for complex or rapidly progressive disease.. Individual patient factors may require deviation from these recommendations.
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