Episode 73: The KDIGO CKD 2024 Guideline Draft

The draft order:

Sophia Ambruso

Nayan Arora

Swapnil Hiremath

AC Gomez

Joel Topf

Editor

Nayan Arora

Show Notes

Previous drafts:

2021 KDIGO Hypertension —Joel, Sophia, Swap, Nayan, Josh

2021 ASN Kidney Week Draft—Joel, Sophia, Swap, Nayan, Jennie

2022 The ISPD Peritonitis Guideline— Joel, Sophia, Swap, Nayan

2022 ASN Kidney Week Draft—Joel, Sophia, Swap, Nayan

2023 ASN Kidney Week Draft—Joel, Sophia, Swap, Nayan, AC, Josh

2024 KDIGO CKD Clinical Practice Guideline —Joel, Sophia, Swap, Nayan, Josh, AC

The guideline

The NephJC discussion Part 1 | Part 2

First Round

Sophia’s Pick 3.7.1 We recommend treating patients with type 2 diabetes (T2D), CKD, and an eGFR ≥20 ml/min per 1.73 m2 with an SGLT2i (1A).

Not Nayan’s Pick 3.7.3: We suggest treating adults with eGFR 20 to 45 ml/min per 1.73 m2 with urine ACR <200 mg/g (<20 mg/mmol) with an SGLT2i (2B).

Nayan’s Pick 2.2.1: In people with CKD G3–G5, we recommend using an externally validated risk equation to estimate the absolute risk of kidney failure (1A).

A birdie told me there will not be a Tangri KFRE vs the World debate at Kidney Week

The action points based on absolute risk results:

Practice Point 2.2.1: A 5-year kidney failure risk of 3%–5% can be used to determine need for nephrology referral in addition to criteria based on eGFR or urine ACR, and other clinical considerations.

Practice Point 2.2.2: A 2-year kidney failure risk of >10% can be used to determine the timing of multidisciplinary care in addition to eGFR-based criteria and other clinical considerations.

Practice Point 2.2.3: A 2-year kidney failure risk threshold of >40% can be used to determine the modality education, timing of preparation for kidney replacement therapy (KRT) including vascular access planning or referral for transplantation, in addition to eGFR-based criteria and other clinical considerations.

Swap’s Pick 3.15.1.1: In adults aged ‡50 years with eGFR <60 ml/min per 1.73 m2 but not treated with chronic dialysis or kidney transplantation (GFR categories G3a–G5), we recommend treatment with a statin or statin/ezetimibe combination (1A).

AC’s Pick 3.7.2: We recommend treating adults with CKD with an SGLT2i for the following (1A):

eGFR ≥20 ml/min per 1.73 m2 with urine ACR ≥200 mg/g (≥20 mg/mmol), or

heart failure, irrespective of level of albuminuria. (1A)

Joel’s Pick 3.10.1: In people with CKD, consider use of pharmacological treatment with or without dietary intervention to prevent development of acidosis with potential clinical implications (e.g., serum bicarbonate <18 mmol/l in adults).

Practice Point 3.10.2: Monitor treatment for metabolic acidosis to ensure it does not result in serum bicarbonate concentrations exceeding the upper limit of normal and does not adversely affect BP control, serum potassium, or fluid status.

Freely Filtered 061: Bicarb in Transplant with Nav Tangri

Second Round

Joel’s Pick 3.3.1.1: We suggest maintaining a protein intake of 0.8 g/kg body weight/d in adults with CKD G3–G5 (2C).

Practice points related to protein intake:

3.3.1.1: Avoid high protein intake (>1.3 g/kg body weight/d) in adults with CKD at risk of progression.

3.3.1.2: In adults with CKD who are willing and able, and who are at risk of kidney failure, consider prescribing, under close supervision, a very low–protein diet (0.3–0.4 g/kg body weight/d) supplemented with essential amino acids or ketoacid analogs (up to 0.6 g/kg body weight/d).

3.3.1.3: Do not prescribe low- or very low–protein diets in metabolically unstable people with CKD.

AC’s Pick 3.9.1: In adults with T2D and CKD who have not achieved individualized glycemic targets despite use of metformin and SGLT2 inhibitor treatment, or who are unable to use those medications, we recommend a long-acting GLP-1 RA (1B).

Swapnil’s Pick Practice Point 5.4.1: Initiate dialysis based on a composite assessment of a person’s symptoms, signs, QoL, preferences, level of GFR, and laboratory abnormalities.

IDEAL Trial: A Randomized, Controlled Trial of Early versus Late Initiation of Dialysis NEJM

Timing of dialysis initiation to reduce mortality and cardiovascular events in advanced chronic kidney disease: nationwide cohort study NephJC

Nayan’s Pick Practice Point 1.1.4.2: Use tests to establish a cause based on resources available (Table 6b).

Sophia’s Pick Practice Point 1.1.1.2: Following incidental detection of elevated urinary albumin-to-creatinine ratio (ACR), hematuria, or low estimated GFR (eGFR), repeat tests to confirm presence of CKD.

Joel’s cystatin C Tweet

The cystatin C guideline recommendation 1.1.2.1: In adults at risk for CKD, we recommend using creatinine-based estimated glomerular filtration rate (eGFRcr). If cystatin C is available, the GFR category should be estimated from the combination of creatinine and cystatin C (creatinine and cystatin C– based estimated glomerular filtration rate [eGFRcr-cys]) (1B).

Nayan’s additional thoughts. He is not a fan of Practice Points 3.6.4 and 3.6.5

Practice Point 3.6.4 Continue ACEi or ARB therapy unless serum creatinine rises by more than 30% within 4 weeks following initiation of treatment or an increase in dose.

and

Practice Point 3.6.5: Consider reducing the dose or discontinuing ACEi or ARB in the setting of either symptomatic hypotension or uncontrolled hyperkalemia despite medical treatment, or to reduce uremic symptoms while treating kidney failure (estimated glomerular filtration rate [eGFR] <15 ml/min per 1.73 m2).

Tubular Secretion

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AC Rosie Revere, Engineer

Sophia Bassnectar

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