Chronic Kidney Disease Management (KDIGO 2024)

Algorithm Steps

1. ▶

   Start

   CKD Identified

   eGFR <60 or albuminuria >30mg/g for ≥3 months

   1. ●

      Action

      Stage CKD (GFR + Albuminuria)

      Use CGA staging system

      • G1: eGFR ≥90 (normal)
      • G2: eGFR 60-89 (mild decrease)
      • G3a: eGFR 45-59 (mild-moderate)
      • G3b: eGFR 30-44 (moderate-severe)
      • G4: eGFR 15-29 (severe)
      • G5: eGFR <15 (kidney failure)
      • A1: UACR <30 | A2: 30-300 | A3: >300
      1. ◆

         Decision

         Assess Progression Risk

         Use KFRE calculator for 2/5-year risk

         • KFRE: Kidney Failure Risk Equation
         • Variables: age, sex, eGFR, UACR
         • High risk: >5% at 5 years
         • Very high risk: >15% at 5 years
         1. ●

            Action

            Lifestyle Interventions (All CKD)

            Foundation of management

            • Smoking cessation
            • Exercise: 150 min/week moderate
            • Sodium <2g/day
            • Protein: 0.8g/kg/day if advanced CKD
            • Weight management
            • Avoid NSAIDs
            1. ◆

               Decision

               Diabetes Present?

               Additional considerations for DKD

               1. ●

                  Action

                  Diabetic Kidney Disease

                  Glycemic + kidney-focused therapy

                  • A1c target ~7% (individualize)
                  • Metformin: can use to eGFR 30
                  • GLP-1 RA: CV/renal benefits
                  • SGLT2i: always if eligible
                  • Finerenone: if persistent albuminuria on ACE/ARB
                  1. ●

                     Action

                     Monitor/Treat CKD Complications

                     Stage-appropriate screening

                     • Anemia: check Hgb if eGFR <45
                     • Mineral bone: PTH, Ca, Phos if eGFR <45
                     • Acidosis: HCO3 target 22-26
                     • Hyperkalemia: dietary, diuretics, K-binders
                     • Volume: loop diuretics for edema
                     1. ●

                        Action

                        CV Risk Management

                        CKD = high CV risk

                        • Statin: all patients ≥50 with CKD
                        • Aspirin: if established ASCVD
                        • Smoking cessation critical
                     2. ●

                        Action

                        Monitoring Frequency

                        Based on stage and risk

                        • G1-2, A1: yearly
                        • G3a, A2: 6-12 monthly
                        • G3b-4, A3: 3-6 monthly
                        • G5: 1-3 monthly
                        • More frequent if rapid progression
                     3. ⚠

                        Warning

                        Nephrology Referral

                        When to refer

                        • eGFR <30 (plan for RRT)
                        • UACR >300 persistent
                        • Rapid progression (eGFR drop >5/year)
                        • Resistant hypertension
                        • Unexplained CKD, hematuria
                        • Hereditary kidney disease
               2. ●

                  Action

                  Non-Diabetic CKD

                  Focus on BP and SGLT2i

                  • ACE-I/ARB for proteinuria
                  • SGLT2i if significant proteinuria
                  • Treat underlying cause (GN, PKD, etc.)
                  • Avoid nephrotoxins
         2. ●

            Action

            BP Control

            Target <120/80 if tolerated

            • ACE-I or ARB first-line (especially if albuminuria)
            • Target SBP <120 if tolerated, <130 otherwise
            • Avoid ACE-I + ARB combination
            • Monitor K+ and creatinine after initiation
         3. ●

            Action

            SGLT2 Inhibitor

            Strongly recommended if eligible

            • Dapagliflozin or empagliflozin
            • Indicated: eGFR ≥20, especially if UACR ≥200
            • Continue even if eGFR falls initially
            • Benefits: kidney protection, CV protection
            • Hold for surgery, acute illness