KDIGO-2024-CKD-Guideline-Key-Takeaways-Slide-Set.pptx

KEY TAKEAWAYS FROM THE KDIGO 2024
CLINICAL PRACTICE GUIDELINE FOR THE
EVALUATION AND MANAGEMENT OF CKD
KDIGO GUIDELINE CO-CHAIRS:
ADEERA LEVIN, MD, FRCPC
PAUL E. STEVENS, MB, FRCP

TOP 10 TAKEAWAYS ON
EVALUATION OF PEOPLE WITH
OR AT RISK OF CKD

EVALUATION – CKD DEFINITION
CKD is defined as abnormalities of kidney structure or function, present for
>3
months, with implications for health. The definition includes many different
markers of kidney damage, not just decreased GFR and ACR and the cause of
CKD should be actively sought (Figure). CKD is classified according to Cause,
GFR, and ACR to establish severity and guide the type and timing of
interventions.

EVALUATION – DISTINGUISH BETWEEN AKD AND CKD
It is important to distinguish between AKD and CKD and to establish
chronicity.

EVALUATION –CKD CARE ACROSS THE LIFE SPAN
CKD impacts people across the lifespan and as a chronic condition, care is
influenced by changes in life circumstances. Use a personalized
approach to diagnosis, risk assessment, and management that considers age,
sex,
and gender. At the extremes of age - the very young and the very old -
diagnostic
procedures, treatment aims, treatment modalities, and decision-making differ
due to differences in prognosis, treatment options, and prioritization.

EVALUATION – DIAGNOSIS OF CKD IN OLDER ADULTS
Epidemiological population data support retaining the threshold GFR of 60
ml/min/1.73 m2 for diagnosis of CKD in older adults, even in the absence of
significant albuminuria, with consistently elevated and increasing relative risk
of adverse outcomes below this threshold.

EVALUATION – IMPROVING ACCURACY OF GFR
ASSESSMENT
Estimating GFR from a combination of creatinine and cystatin C (eGFRcr-cys)
improves accuracy and strengthens risk relationships. GFR should be measured
where more accurate ascertainment of GFR will impact treatment decisions.

EVALUATION – ACCURACY AND RELIABILITY
Understand the variability of GFR and urinary albumin and the value and
limitations of the methodology of assessment when determining whether a
change is a true change. Implement the requisite laboratory standards of care
to ensure accuracy and reliability.

EVALUATION – USE A VALIDATED GFR ESTIMATING
EQUATION
Use a validated GFR estimating equation to derive GFR from serum filtration
markers (eGFR) and use the same equation within geographical regions recognizing
that these equations may differ for adults and children.

EVALUATION – POINT-OF-CARE TESTS
Point-of-care tests (POCT) for creatinine (blood and saliva) and urine albumin
measurement are available, and if adequately quality-assured, are accurate enough
to facilitate the clinical pathway where access to a laboratory is limited.

EVALUATION – USE VALIDATED RISK ASSESSMENT TOOLS
Use validated risk assessment tools to aid in decision-making and timing
of multidisciplinary care. Choose the appropriate tool for the event of
interest: kidney failure treatment, cardiac events, or mortality.

EVALUATION – TIMING ASSESSMENT AND REEVALUATION
Timing of follow up and reassessment using validated risk prediction tools and
clinical evaluation, together with education, may inform better selection of targets
of care to support people and families living with CKD. This approach is part of
longitudinal care.

TOP 10 TAKEAWAYS ON
MANAGEMENT OF PEOPLE
WITH OR AT RISK OF CKD

MANAGEMENT – COMPREHENSIVE TREATMENT STRATEGY
Treat people with CKD with a comprehensive treatment strategy to reduce risks of
progression of CKD and its associated complications encompassing education,
lifestyle, exercise, smoking cessation, diet, and medications, where indicated.

MANAGEMENT – HEALTHY AND DIVERSE DIET
Adopting a healthy and diverse diet with a higher consumption of plant-based
foods compared to animal-based foods and a lower consumption of ultra-
processed foods has the potential to benefit complications related to progressive
CKD such as acidosis, hyperkalemia, and hyperphosphatemia with less risk of
protein energy-wasting.

MANAGEMENT – INDIVIDUALIZE BP CONTROL
Individualize BP-lowering therapy and treatment targets in people with frailty, high
risk of falls, very limited life expectancy, or symptomatic postural hypotension.

MANAGEMENT – RASI AND SGLT2I
Treatments that delay progression of CKD with a strong evidence base include RASi
and SGLT2i. In people with CKD and heart failure, SGLT2i confer benefits irrespective
of albuminuria.

MANAGEMENT – ACUTE CHANGES IN EGFR
Initial dips in eGFR are expected following initiation of hemodynamically active
therapies, including both RASI and SGLT2i. GFR reductions of ≥30% from baseline
exceed the expected variability and warrant evaluation.

MANAGEMENT – CARDIOVASCULAR DISEASE AND IMAGING
Estimate 10-year cardiovascular risk using a validated risk tool that incorporates
CKD to guide treatment for prevention of cardiovascular disease. CKD is not a
contraindication to an invasive strategy for people with acute or unstable heart
disease. Imaging studies are not necessarily contraindicated in people with CKD and
the risks and benefits should be determined on an individual basis. Strategies to
mitigate risks from imaging studies using contrast media are easily implemented.

MANAGEMENT – PERFORM THOROUGH MEDICATION
REVIEW
Perform thorough medication review periodically and at transitions of care to assess
adherence, continued indication, and potential drug interactions because people
with CKD often have complex medication regimens and are seen by multiple
specialists. Review and limit the use of over-the-counter medicines, dietary, or
herbal remedies that may be harmful for people with CKD. For most people and
clinical settings, validated eGFR equations using SCr are appropriate for drug-
dosing. Remember, a validated measured GFR is most accurate.

MANAGEMENT – DISCONTINUATION AND RESTART OF
MEDICATIONS
If medications are discontinued during an acute illness, communicate a clear plan of
when to restart the discontinued medications to the affected person and healthcare
providers, and ensure documentation in the medical record. Failure to restart these
medications may lead to unintentional harm.

MANAGEMENT – SYMPTOM CONTROL IN CKD
The identification and assessment of symptoms in people with progressive CKD is
important for highlighting changes in clinical management, redirecting treatment
toward patient-centered management, and may lead to discussion about
appropriate supportive care options. Effective communication and shared decision-
making should be key principles between healthcare providers and the people they
treat, allowing them to work in partnership to identify symptom burden, possible
treatment strategies and person-centered solutions.

MANAGEMENT – ADVANCED CARE PLANNING
Plans addressing future health care states should be jointly agreed with people with
CKD and their families/carers and known to all. Advanced care planning for those
choosing supportive care is particularly important.

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