Updated KDIGO CKD Guideline Ushers in the Future of More Patient-Centered Kidney Care

The global nonprofit organization Kidney Disease: Improving Global Outcomes (KDIGO) is focused on optimizing care delivery for chronic kidney disease (CKD) and improving quality of life for people living with CKD. Established in 2003, KDIGO’s mission is to develop and implement evidence-based clinical practice guidelines for the prevention of CKD and the care management of individuals with CKD. These guidelines are based on methodical reviews of relevant studies and serve as a useful resource because they translate scientific advances into practical and actionable CKD clinical practice recommendations.

KDIGO chronic kidney disease guidelines are intended to help the global CKD community, including healthcare professionals who provide kidney care, people with CKD and their caregivers, and policymakers and others involved with CKD services. They provide guidance for clinical practitioners and aid in decision-making.

The KDIGO CKD guidelines address a wide range of key topics, including:

• CKD evaluation and classification
• Kidney disease risk assessment and the use of CKD risk prediction equations
• Disease progression
• Symptom management
• Strategies to delay CKD progression
• Medication management and drug stewardship
• Recommendations for personalizing treatment

2024 update to the comprehensive KDIGO chronic kidney disease guideline

In 2024, KDIGO released a supplemental update to its comprehensive KDIGO 2012 CKD Guideline. Developed in collaboration with patient partners, clinicians, and researchers, the 2024 Clinical Practice Guideline for the Evaluation and Management of Chronic Kidney Disease (CKD) is a modernized reference based on current knowledge and evidence-based practices in CKD care, including use of new therapies, advanced molecular diagnostics, and artificial intelligence (AI)-powered modeling. ¹

Clinical updates include:

• New guidance around the detection and evaluation of CKD. The 2012 guideline introduced the concept of a “CGA” classification of CKD based on cause (C), level of kidney function determined by estimated glomerular filtration rate, or eGFR (G), and degree of albuminuria (A). Research over the past 12 years has further refined kidney disease evaluation, and the new guideline presents a detailed breakdown of the common tests for assessing eGFR and albuminuria to help healthcare providers understand what is available and provide more accurate risk assessments.
• Use of CKD risk prediction equations. Several risk prediction tools have been developed over the past decade and are now available as online calculators. As reported in the guideline, some of these new models have been externally validated in multiple populations and shown to effectively distinguish between groups or outcomes. For instance, in people with CKD stages 3-5, the guideline recommends using an externally validated risk equation to estimate the absolute risk of kidney failure.²
• Personalized care recommendations for kidney and cardiovascular risk reductions tailored to individual patient needs and preferences. The nephrology community, along with the healthcare community overall, has increasingly recognized the importance of personalized care for people with CKD given that most of these patients are living with complex, chronic health conditions. The new guideline notes the importance of individualized treatment plans that consider age, ethnic background, presence of other comorbidities, and access to resources.

For Professor Adeera Levin, MD, who co-chaired the 2024 update, it reflects a transformative period in nephrology and offers new hope for CKD patients.

“Recent advancements in GFR evaluation, risk prediction, and arrival of novel treatments are poised to enhance CKD prognosis and management,” Dr. Levin said. “We also hope the guideline’s emphasis on multidisciplinary teamwork, patient engagement, and a holistic, evidence-based approach to care will help catalyze positive change resulting in more coordinated CKD care management worldwide. By integrating the latest evidence and expert consensus, we aim to empower healthcare professionals, and patients, with actionable recommendations to optimize patient outcomes and enhance quality of life.” ³

The updated 2024 KDIGO guideline foretells the future of kidney care

As the executive summary of the 2024 update points out, representation of people with CKD in clinical trials has “improved substantially,” generating new evidence to inform care and treatments. In addition, advances in CKD evaluation, risk prediction, and treatments have “positively influenced the prognosis for people with CKD.” ⁴This forward momentum is not only driving the development of new CKD clinical practice guidelines, it also signals an evolution in the CKD care model overall. Thematically, there are five major changes clinicians should note in the 2024 update that will shape the future of CKD care.

1. 2024 KDIGO CKD guideline addresses the importance of interdisciplinary care teams.

Throughout the 2024 KDIGO CKD guideline, there is an emphasis on patient-centered, interdisciplinary care, which research has shown can lower the all-cause mortality of patients with CKD, reduce temporary catheter use in patients receiving dialysis, decrease hospitalization rates, and slow CKD progression. ⁵In particular, “Chapter 5: Optimal Models of Care” identifies access to team-based integrated CKD care as a key practice point for symptom management and provides a detailed discussion of management strategies and care models. ⁶

As explained in the guideline, optimal CKD care includes multi-modal interventions such as dietary counseling, medication management, education, counseling about different kidney replacement therapies (KRT), transplant options, dialysis access surgery, and psychological and social care. How individual teams are structured will vary with CKD severity, risk of progression, and local factors.

This interdisciplinary, wraparound approach to patient care is already demonstrating improved clinical outcomes in real-world practice. As a value-based kidney care provider, Interwell Health has achieved an 80 percent engagement rate among all patients under management, resulting in better outcomes including 140 percent more optimal dialysis starts, 50 percent higher home dialysis rates, and a 41 percent higher transplant rate than the national average. 

 

 

 

2. 2024 KDIGO CKD guideline highlights the need for early identification and referral to specialist kidney care services

The guideline also stresses that early identification and referral to nephrology care are central for optimal CKD management. As the authors report, this conclusion was based on a systematic review of 40 studies that showed “early referral was associated with better clinical and biochemical outcomes such as improvement in mortality at 3 and 5 years, decrease in hospitalizations, better access to vascular access and KRT with peritoneal dialysis, as well as improvements in [blood pressure], hemoglobin, and serum albumin.” ⁷

For Dr. Marc Brazie, a nephrologist at Metropolitan Nephrology Associates in Virginia, early referral provides a distinct advantage, enabling him to build rapport with patients who, at first, may feel overwhelmed with their CKD diagnosis. “When I have the opportunity, when someone is referred to me earlier, that gives us the luxury of spending a bit more time talking about chronic kidney disease in more general terms—how we measure it, how we stage it, what things cause it, what the interventions are that we know help to halt progression, or at a minimum slow progression,” Dr. Brazie explains.

In addition, the earlier the referral, the sooner CKD patients can be connected with other care team members, including renal care coordinators (RCCs) who actively engage patients between scheduled visits.

3. 2024 KDIGO CKD guideline identifies multiple factors that impact timing for the initiation of dialysis

A patient-centered, team-based approach to CKD care includes continuing to move away from the “one-size-fits-all” approach to dialysis that, in the past, had been centered on eGFR. Instead, the updated KDIGO CKD guideline advises a more personalized approach timing the start of dialysis on a composite assessment that incorporates not only eGFR levels and other laboratory values, but also other factors, such as patient symptoms, patient education and preparedness, and dialysis modality and access. ⁸

Dr. Ethan Hoerschgen, a nephrologist with Springfield Nephrology Associates and part of the Interwell Health Provider Network, uses eGFR as a guideline when personalizing care plans for his patients. “I follow a 30/20/10 philosophy,” he explains. “I first bring up dialysis when a patient’s eGFR is around 30. Discussions around therapies and preparedness start around 20. As patients get closer to an eGFR of 15, then we’re making sure they have at least met with our education team and are getting prepared for their choice of treatment. When a patient’s eGFR drops to 10, depending on other factors, that’s when I tell them it’s time to start with the modality of their choice.” As a result of this approach, up to 35 percent of Dr. Hoerschgen’s patients are able to start dialysis at home — more than twice the national average.

4. CKD education is key success factor in kidney disease management

As Dr. Hoerschgen mentions, patient education is foundational to value-based CKD care, and in the updated KDIGO guideline CKD education is identified as a critical success factor for self-care management strategies.

The guideline recommends engaging a coordinated team of community healthcare workers and other health education providers to improve the effectiveness of CKD education. This interdisciplinary approach ensures education covers three essential knowledge areas: information about CKD, strategies to slow progression and complications of CKD, and kidney failure management options. Moreover, the guideline indicates CKD education should be customized to patient needs, literacy level, and cultural norms, and incorporate telehealth technologies such as web-based, mobile applications, virtual visiting, and wearable devices whenever possible.

Related reading: Chronic Kidney Disease Patient Education: A Powerful Tool to Help Prevent CKD Progression

5. 2024 CKD KDIGO guideline updates medication recommendations with latest clinical trial results

Personalized renal care is becoming increasingly important as therapeutic options for CKD management expand, making it all the more critical for healthcare providers to understand and stay abreast of current and emerging treatment options. For example, the updated guideline includes recommendations for treatment with sodium glucose cotransporter-2 inhibitors (SGLT2is) and long-acting glucagon-like peptide-1 receptor agonists (GLP-1 RAs).

• SGLT2i: The KDIGO 2022 Clinical Practice Guideline for Diabetes Management in Chronic Kidney Disease recommends treating patients with type 2 diabetes, CKD, and an eGFR over 20 with an SGLT2i. In the 2024 updated guideline, KDIGO expands on the 2022 guideline and now includes recommendations for use of SGLT2i for adults with CKD without diabetes. According to the 2024 guideline, large clinical trials have consistently shown the efficacy of SGLT2i in many populations, and the new recommendation “places high value on the importance of reducing risk of kidney failure, cardiovascular mortality, and heart failure in people with CKD.” ^{9 10}
• GLP-1 RA: The updated guideline recommends treatment with a GLP-1 RA with documented cardiovascular benefit for adults with type 2 diabetes and CKD who are unable to manage their diabetes with other medications. The guideline references ongoing clinical research assessing the effects of GLP-1 RA in CKD while reviewing current evidence to conclude GLP-1 RAs have modestly reduced risk of hospitalization for heart failure and reduced risk of death from any cause. ¹¹

As the 2024 KDIGO guideline executive summary concludes, “the fact that new therapies exist and others are being evaluated heralds an exciting time for people living with kidney diseases, their families, and the [healthcare provider].” ¹² Yet the emergence of these new therapies and treatment strategies also adds to the challenges of managing an already complex patient population.

The updated KDIGO evidence-based recommendations ensure kidney care providers have the most up-to-date information available to advance their approach to patient care. Taken as a whole, the new guideline heralds a future of kidney care that promises to improve the lives of millions of patients.

 

References

1. KDIGO: KDIGO 2024 Clinical Practice Guideline for the Evaluation and Management of Chronic Kidney Disease. https://kdigo.org/wp-content/uploads/2024/03/KDIGO-2024-CKD-Guideline.pdf
2. International Society of Nephrology: Supplement to Kidney International: KDIGO 2024 Clinical Practice Guideline for the Evaluation and Management of Chronic Kidney Disease. https://kdigo.org/wp-content/uploads/2024/03/KDIGO-2024-CKD-Guideline.pdf#page=41
3. KDIGO: KDIGO Announces Publication of 2024 CKD Guideline. https://kdigo.org/kdigo-announces-publication-of-2024-ckd-guideline/
4. KDIGO: Executive summary of the KDIGO 2024 Clinical Practice Guideline for the Evaluation and Management of Chronic Kidney Disease: known knowns and known unknowns. https://kdigo.org/wp-content/uploads/2017/02/KDIGO-2024-CKD-Guideline-Executive-Summary.pdf
5. International Urology and Nephrology: The effectiveness of multidisciplinary care models for patients with chronic kidney disease: a systematic review and meta-analysis. https://pmc.ncbi.nlm.nih.gov/articles/PMC5811573/
6. KDIGO: KDIGO 2024 Clinical Practice Guideline for the Evaluation and Management of Chronic Kidney Disease. https://kdigo.org/wp-content/uploads/2024/03/KDIGO-2024-CKD-Guideline.pdf#page=140
7. KDIGO: KDIGO 2024 Clinical Practice Guideline for the Evaluation and Management of Chronic Kidney Disease. https://kdigo.org/wp-content/uploads/2024/03/KDIGO-2024-CKD-Guideline.pdf#page=141
8. KDIGO: KDIGO 2024 Clinical Practice Guideline for the Evaluation and Management of Chronic Kidney Disease. https://kdigo.org/wp-content/uploads/2024/03/KDIGO-2024-CKD-Guideline.pdf#page=151
9. KDIGO: KDIGO 2024 Clinical Practice Guideline for the Evaluation and Management of Chronic Kidney Disease. https://kdigo.org/wp-content/uploads/2024/03/KDIGO-2024-CKD-Guideline.pdf#page=101
10. KDIGO: KDIGO 2024 Clinical Practice Guideline for the Evaluation and Management of Chronic Kidney Disease. https://kdigo.org/wp-content/uploads/2024/03/KDIGO-2024-CKD-Guideline.pdf#page=99
11. KDIGO: KDIGO 2024 Clinical Practice Guideline for the Evaluation and Management of Chronic Kidney Disease. https://kdigo.org/wp-content/uploads/2024/03/KDIGO-2024-CKD-Guideline.pdf#page=106
12. KDIGO: Executive summary of the KDIGO 2024 Clinical Practice Guideline for the Evaluation and Management of Chronic Kidney Disease: known knowns and known unknowns. https://kdigo.org/wp-content/uploads/2017/02/KDIGO-2024-CKD-Guideline-Executive-Summary.pdf