Chronic Kidney Disease (CKD) Evaluation & Management (KDIGO 2024)

Algorithm Steps

1. ▶

   Start

   Suspected or Confirmed CKD

   Patient with reduced eGFR or markers of kidney damage

   1. ●

      Action

      Confirm CKD Diagnosis

      Requires abnormality for >3 months

      • eGFR <60 mL/min/1.73m² on 2+ occasions ≥90 days apart, OR
      • Markers of kidney damage present ≥3 months:
      • - Albuminuria (ACR ≥30 mg/g)
      • - Urine sediment abnormalities
      • - Structural abnormalities on imaging
      • - History of kidney transplant
      1. ●

         Action

         Stage CKD (GFR + Albuminuria)

         Use CKD-EPI 2021 equation (race-free)

         • G1: eGFR ≥90 (with kidney damage markers)
         • G2: eGFR 60-89 (with kidney damage markers)
         • G3a: eGFR 45-59
         • G3b: eGFR 30-44
         • G4: eGFR 15-29
         • G5: eGFR <15
         • ---
         • A1: ACR <30 mg/g (normal-mild)
         • A2: ACR 30-300 mg/g (moderate)
         • A3: ACR >300 mg/g (severe)
         1. ●

            Action

            Determine Cause of CKD

            Identify underlying etiology

            • Most common: Diabetes, hypertension
            • Consider: Glomerulonephritis, PKD, obstruction
            • Workup: Urinalysis, renal US, consider biopsy if unclear
            • Document cause for prognosis and treatment planning
            1. ◆

               Decision

               Assess Progression Risk

               Use KDIGO heat map (GFR × Albuminuria)

               • Green (Low): G1-2/A1, G3a/A1
               • Yellow (Moderate): G1-2/A2, G3a/A2, G3b/A1
               • Orange (High): G1-2/A3, G3a/A3, G3b/A2, G4/A1
               • Red (Very High): G3b/A3, G4/A2-3, G5 all
               1. ●

                  Action

                  Low-Moderate Risk

                  Primary care management, annual monitoring

                  • Annual eGFR and uACR
                  • BP target <130/80 mmHg
                  • Cardiovascular risk management
                  • SGLT2i if diabetic or high CV risk
                  1. ●

                     Action

                     Kidney-Protective Therapies

                     Evidence-based interventions to slow progression

                     • ACEi or ARB: First-line for proteinuria (max tolerated dose)
                     • SGLT2i: Add for eGFR ≥20 (dapagliflozin, empagliflozin)
                     • Finerenone: Add for T2DM with albuminuria despite ACEi/ARB
                     • GLP-1 RA: Consider for T2DM with CKD
                     • Avoid NSAIDs
                     1. ●

                        Action

                        Manage CKD Complications

                        Address metabolic consequences

                        • Anemia: Target Hgb 10-11.5 g/dL (ESA + iron)
                        • MBD: Monitor Ca, PO4, PTH; phosphate binders if needed
                        • Acidosis: Sodium bicarbonate if HCO3 <22 mEq/L
                        • Hyperkalemia: Dietary, K+ binders if needed
                        • Volume: Diuretics for edema
                        1. ◆

                           Decision

                           Nephrology Referral Indicated?

                           KDIGO 2024 referral criteria

                           • eGFR <30 (G4-5)
                           • Persistent ACR >300 despite treatment
                           • Rapid progression (eGFR decline >5/year)
                           • Unexplained hematuria
                           • Resistant hypertension
                           • Hereditary kidney disease
                           1. ✓

                              Outcome

                              Continue Primary Care

                              Ongoing monitoring per risk category

                           2. ●

                              Action

                              Nephrology Referral

                              Co-management with specialist

                              • RRT planning (dialysis, transplant) for G4-5
                              • Vascular access planning 6-12 months before RRT
                              • Living donor evaluation
                              • Conservative care discussion if appropriate
                              1. ✓

                                 Outcome

                                 RRT Planning

                                 Prepare for dialysis or transplant as needed

               2. ●

                  Action

                  High-Very High Risk

                  Intensive management, nephrology referral

                  • eGFR + uACR every 3-6 months
                  • BP target <130/80 with RAAS blockade
                  • SGLT2i (first-line for high risk)
                  • MRA (finerenone) if diabetic with albuminuria
                  • Nephrology referral