Summary

KDIGO 2024 updates the 2012 CKD guideline with major changes including endorsement of eGFRcr-cys (creatinine + cystatin C) for accurate staging, race-free GFR estimation, validated risk equations (KFRE) to drive referral and modality decisions, and strong recommendations for SGLT2 inhibitors across diabetic and non-diabetic CKD. New emphasis on a holistic, multi-drug treatment paradigm (RASi + SGLT2i + statin + nonsteroidal MRA in T2D), risk-based rather than eGFR-only management, and structured drug stewardship/imaging guidance. Scope covers adults and children with non-dialysis, non-transplant CKD.

Key Recommendations

Test at-risk people with both urine ACR and eGFR; confirm abnormal results on repeat testing to establish CKD (≥3 months).
Use creatinine-based eGFR (2021 CKD-EPI, race-free) as initial test; use eGFRcr-cys when greater accuracy is needed or eGFRcr is unreliable (1B).
Avoid race in eGFR computation; use measured GFR when high accuracy is required (e.g., transplant donor evaluation, narrow-therapeutic-index drug dosing).
Use first morning urine ACR as preferred albuminuria test; quantify any positive dipstick with lab ACR.
Use an externally validated kidney failure risk equation (e.g., KFRE) in CKD G3–G5 to guide referral, multidisciplinary care, and KRT planning (1A).
Treat adults with T2D and CKD (eGFR ≥20) with an SGLT2 inhibitor (1A); treat all adults with CKD with SGLT2i if eGFR ≥20 with ACR ≥200 mg/g or heart failure (1A).
Start ACEi or ARB at maximum tolerated dose for CKD with A2/A3 albuminuria (diabetic or non-diabetic); continue even if eGFR falls below 30; avoid combination ACEi+ARB+DRI.
Target SBP <120 mm Hg using standardized office measurement when tolerated; in children target 24-h MAP ≤50th percentile by ABPM.
Add a nonsteroidal MRA (finerenone) in T2D with eGFR >25, K+ normal, and persistent albuminuria despite maximum RASi (2A).
Treat adults ≥50 with eGFR <60 with statin or statin/ezetimibe (1A); use low-dose aspirin for secondary CVD prevention in CKD (1C); prefer NOACs over warfarin in CKD G1–G4 with atrial fibrillation (1C).
Maintain protein intake ~0.8 g/kg/d in CKD G3–G5; avoid >1.3 g/kg/d; restrict sodium to <2 g/d; encourage plant-based, minimally processed diet.
Refer to nephrology for eGFR <30, 5-year KFRE risk >3–5%, ACR ≥300 mg/g with hematuria, refractory hypertension/electrolytes, or uncertain cause; plan KRT/transplant when 2-year KFRE risk >40% or eGFR 15–20.
Offer uric acid–lowering therapy (xanthine oxidase inhibitor preferred) for symptomatic hyperuricemia/gout in CKD (1C); do not treat asymptomatic hyperuricemia to slow CKD (2D).
Avoid nephrotoxic drugs (NSAIDs, aminoglycosides, certain herbals); perform medication review at transitions of care; implement sick-day rules with clear restart plan.

Thresholds & Doses

CKD definition: abnormalities of kidney structure/function present ≥3 months; eGFR <60 ml/min/1.73 m² or ACR ≥30 mg/g (≥3 mg/mmol).
GFR categories: G1 ≥90, G2 60–89, G3a 45–59, G3b 30–44, G4 15–29, G5 <15 ml/min/1.73 m².
Albuminuria categories: A1 <30, A2 30–300, A3 >300 mg/g (<3, 3–30, >30 mg/mmol).
Children: flag eGFR <90 ml/min/1.73 m² as low (age >2 years).
Significant change thresholds: >20% eGFR change warrants evaluation; >30% drop after hemodynamically active therapy; doubling of ACR exceeds variability.
Continue ACEi/ARB unless serum creatinine rises >30% within 4 weeks of initiation; check BP, creatinine, K+ within 2–4 weeks of starting/up-titration.
SGLT2i: initiate if eGFR ≥20; continue until dialysis/transplant even if eGFR falls below 20.
Finerenone dosing: 10 mg daily if eGFR 25–59; 20 mg daily if eGFR ≥60; initiate only if K+ ≤4.8 (or ≤5.0 per FDA); hold if K+ >5.5 mmol/l; monitor K+ at 1 month then every 4 months.
BP target: SBP <120 mm Hg (adults, standardized office); children 24-h MAP ≤50th percentile; office SBP 50th–75th percentile if no ABPM.
Protein intake: 0.8 g/kg/d in CKD G3–G5; avoid >1.3 g/kg/d; very low-protein 0.3–0.4 g/kg/d + ketoacids only with supervision.
Sodium <2 g/d (<90 mmol/d, <5 g salt/d); physical activity ≥150 min/week moderate intensity (≥60 min/d in children).
Statins: recommended for adults ≥50 with CKD; for ages 18–49 with CKD, statin if 10-year coronary death/MI risk >10%.
Bicarbonate: consider treatment when serum bicarbonate <18 mmol/l; avoid exceeding upper limit of normal.
Hyperkalemia: K+ >5.5 mmol/l triggers management; K+ ≥6.5 mmol/l requires immediate hospital assessment.
Uric acid–lowering: consider initiation after first gout episode or serum urate >9 mg/dl (535 µmol/l); use colchicine/steroids over NSAIDs for acute gout in CKD.
Referral/KRT planning thresholds: 5-year KFRE risk 3–5% → nephrology referral; 2-year risk >10% → multidisciplinary care; 2-year risk >40% → modality education and access/transplant planning; dialysis usually initiated at eGFR 5–10 ml/min/1.73 m².
Gadolinium: for eGFR <30, use ACR group II or III gadolinium-based agents only.
Monitoring frequency: assess ACR and GFR at least annually; more frequently in higher-risk CKD.

Citations

Chapter 1, Recommendation 1.1.2.1 — eGFRcr with eGFRcr-cys when available for staging (1B).
Chapter 1, Recommendation 1.2.4.1 and Practice Point 1.2.4.2 — use validated GFR estimating equations; avoid race in computation.
Chapter 2, Recommendation 2.2.1 and Practice Points 2.2.1–2.2.3 — externally validated KFRE; risk thresholds (3–5%/5y, >10%/2y, >40%/2y) for referral, multidisciplinary care, KRT preparation.
Chapter 3, Recommendations 3.7.1–3.7.3 — SGLT2i in T2D+CKD with eGFR ≥20 (1A); broader CKD indications with ACR ≥200 mg/g or heart failure (1A).
Chapter 3, Recommendations 3.6.1–3.6.4 and Practice Points 3.6.1–3.6.7 — RASi for albuminuric CKD; avoid ACEi+ARB+DRI combinations.
Chapter 3, Recommendation 3.8.1 and Figure 26 — finerenone in T2D+CKD with K+ monitoring protocol.
Chapter 3, Recommendations 3.15.1.1–3.15.3.1 and 3.16.1 — statins, aspirin secondary prevention, NOACs over warfarin in CKD+AF.
Chapter 5, Figure 48 and Practice Points 5.4.1–5.4.3, Table 41 — referral criteria and indications for initiating dialysis.