The Kidney Disease: Improving Global Outcomes (KDIGO) organization has released an updated April 2024 clinical practice guideline for the evaluation and management of Chronic Kidney Disease (CKD). The new 2024 KDIGO guidelines include 6 chapters dedicated to the evaluation of CKD, risk assessment in people with CKD, management to delay CKD progression and manage its complications, medical management, drug stewardship in CKD, and optimal models of CKD care.
Chapter 3 of the 2024 KDIGO Guidelines, titled “Delaying CKD progression and managing its complications”, provides important recommendations for managing disease states associated with CKD. We’ve highlighted some of the most important recommendations for pharmacists to be aware of; they include:
- “Recommendation 3.4.1: We suggest that adults with high BP and CKD be treated with a target systolic blood pressure (SBP) of <120 mmHg, when tolerated, using standardized office BP measurement.“
This is a 2B recommendation. In this new recommendation, they state that an individualized approach is encouraged, however, by targeting a SBP <120 mmHg, more adults with CKD will achieve a SBP <130 mmHg.
- “Recommendation 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.
- Practice Point 3.7.1: Once an SGLT2i is initiated, it is reasonable to continue an SGLT2i even if the eGFR falls below 20 ml/min per 1.73 m2, unless it is not tolerated or KRT is initiated.“
This is a 1A recommendation. This recommendation is new since the 2012 guidelines, as the first SGLT2i (Invokana) was not FDA approved until March 2013, after the original 2012 guidelines were released.
- “Recommendation 3.8.1: We suggest a nonsteroidal mineralocorticoid receptor antagonist with proven kidney or cardiovascular benefit for adults with T2D, an eGFR >25 ml/min per 1.73 m2, normal serum potassium concentration, and albuminuria (>30 mg/g [>3 mg/mmol]) despite maximum tolerated dose of RAS inhibitor (RASi).
- Practice Point 3.8.2: A nonsteroidal MRA may be added to a RASi and an SGLT2i for treatment of T2D and CKD in adults.“
This is a 2A recommendation. MRAs are known to reduce BP and albuminuria in CKA patients and are recommended for HFrEF due to reduced cardiovascular risk.
- “Recommendation 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.“
This is a 1B recommendation. GLP-1 RAs are shown to improve glycemic control and may reduce weight and CVD risk in CKD patients. The new guidelines also recommend prioritizing GLP-1 RAs over insulin in patients with T2D and CKD
- “Recommendation 3.14.1: We recommend people with CKD and symptomatic hyperuricemia should be offered uric acid–lowering intervention.
- Practice Point 3.14.2: Prescribe xanthine oxidase inhibitors in preference to uricosuric agents in people with CKD and symptomatic hyperuricemia.
- Practice Point 3.14.3: For symptomatic treatment of acute gout in CKD, low-dose colchicine or intra-articular/oral glucocorticoids are preferable to nonsteroidal anti-inflammatory drugs (NSAIDs).“
This is a 1C recommendation. This is updated from the 2012 guideline which found insufficient evidence for or against uric acid-lowering therapy in CKD patients with hyperuricemia. The new guideline emphasized the importance of managing the unpleasant symptoms and complications of gout, and it found that uric acid-lowering therapy did not increase adverse events among people with CKD. The overall certainty of evidence for delaying progression and the critical harm outcomes is very low.
- “Recommendation 3.16.1: We recommend use of non–vitamin K antagonist oral anticoagulants (NOACs) in preference to vitamin K antagonists (e.g., warfarin) for thromboprophylaxis in atrial fibrillation in people with CKD G1–G4.“
This is a 1C recommendation. The guideline recommends NOACs (also known as DOACs) in people with CKD due to their simpler pharmacokinetic profile, dosing, and monitoring than vitamin K antagonists. They also have improved efficacy and relatively similar safety profile. However, this recommendation was determined to have low certainty of evidence.
Looking for more on CKD than just the 2024 KDIGO Guidelines? Here’s a case study on medication management in CKD.
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This article was written by Sara Hoag, PharmD Candidate in collaboration with Eric Christianson, PharmD, BCPS, BCGP.
Resources:
KDIGO. KDIGO 2012 Clinical Practice Guideline for the Evaluation and Management of Chronic Kidney Disease. Vol 3.; 2013. https://kdigo.org/wp-content/uploads/2017/02/KDIGO_2012_CKD_GL.pdf.
