Managing CKD in Primary Care: Latest Guidelines

An explosion of new treatments can stave off the need for dialysis in many patients with CKD.
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I'm Dr Neil Skolnik and today we are going to talk about the KDIGO 2024 Clinical Practice Guideline for the Evaluation and Management of Chronic Kidney Disease (CKD). The explosion of knowledge about CKD over the past decade has been nothing short of phenomenal. We now have medicines that can slow the rate of decline in kidney function, help people avoid dialysis, and decrease the elevated risk for heart disease in patients with CKD. These guidelines give us much-needed direction in this rapidly changing area.
The heart and the kidney are interconnected; increasing severity of CKD increases the risk for cardiovascular disease and all-cause mortality. In addition, worsening CKD substantially raises the likelihood of needing dialysis at some point in the future.
Let's go on to screening. The guidelines are nonspecific, saying we should test people at risk for CKD and those who already have CKD. Screening should be done with a serum creatinine (Cr) level for the eGFR and a urine test for albumin-to-creatinine ratio (UaCr). Both are required when screening and following patients with CKD.
So, who should be screened? Patients with diabetes should receive annual screening. We can consider screening people with hypertension, CVD (including heart failure), or a history of acute kidney injury. The reality is that in many people, CKD is found incidentally, when we get a basic metabolic panel for some other reason. When creatinine or UaCr are abnormal they should be repeated before making the diagnosis of CKD because there is significant biologic and assay variability in both tests.
The KDIGO update is most helpful in clarifying what to do with the lab results; for example, when should we act to delay CKD progression and reduce cardiovascular risk? The main methods for slowing the rate of decline of eGFR are good blood pressure (BP) control, the use of renin-angiotensin system (RAS) inhibitors, SGLT2 inhibitors, and in selected patients with diabetes, a non-steroidal mineralocorticoid antagonist.
In discussing these guidelines, be aware that the term, "recommended" implies a strong recommendation based on strong evidence, and the term "suggested" is based on evidence that is not as strong.
KIDIGO suggests a goal of systolic BP 120 mm Hg (2b), with the rationale that "by aiming for a systolic BP 120 mm Hg, more adults with CKD will achieve a systolic BP of 130 mm Hg." I might use the 130 mm Hg target that is consistent with the general hypertension guidelines for high-risk patients. (For more details, see our discussion of hypertension.)
RAS inhibitors (includes ACE inhibitors and ARBs). These recommendations apply to patients with CKD whether or not they have elevated BP:
- For diabetes and CKD with moderate to severe albuminuria (UaCr 30 mg/g), RAS inhibitors are recommended (1b).
- Without diabetes, RAS inhibitors are recommended for those with CKD and severe albuminuria (UaCr 300 mg/g) (1b) and suggested for people with CKD and moderate albuminuria (UaCr 30-300 mg/g) (2c).
Additional actions:
- Titrate RAS inhibitors to the highest approved dose tolerated by the patient.
- Check BP, Cr, and potassium 2-4 weeks after starting or increasing the RAS inhibitor dose.
-Continue the RAS inhibitor in patients with CKD, even when the eGFR falls 30 mL/min/1.73 m2.
SGLT2 inhibitors belong to an important new class of medicines, with randomized trials showing beneficial effect on slowing the rate of renal decline and major adverse cardiovascular events. One trial even showed a substantial effect over 2.5 years in reducing cardiovascular and total mortality.
Recommendations for use of SGLT2 inhibitors in patients with CKD are:
- Patients with diabetes and eGFR 20 mL/min/1.73 m2: SGLT2 inhibitor is recommended (1a).
- Patients without diabetes: SGLT2 inhibitor is recommended for those with eGFR 20 mL/min/1.73 m2 with UaCR 200 mg/g and for patients with heart failure, regardless of albuminuria level (1a).
- Patients with eGFR 20-45 mL/min/1.73 m2 with UaCR 200 mg/g: SGLT2 inhibitor is suggested (2b).
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Once started, the SGLT2 inhibitor can be continued even if eGFR falls 20 mL/min/1.73 m2, until dialysis is initiated.
Mineralocorticoid receptor antagonists (MRAs). The MRA finerenone is suggested for adults with type 2 diabetes, an eGFR 25 mL/min/1.73 m2, normal serum potassium concentration, and albuminuria ( 30 mg/g) despite maximum tolerated dose of RAS inhibitor (2a). MRAs are most appropriate in those with persistent albuminuria, despite other standard-of-care therapies.
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