Nephrology · KDIGO

Chronic kidney disease — assessment and management

KDIGO

Source:KDIGO 2024 Clinical Practice Guideline for the Evaluation and Management of Chronic Kidney Disease

Verified Apr 2026

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Red Flags

AKI on background CKD (creatinine rise ≥0.3 mg/dL within 48 h or ≥1.5× baseline within 7 days) — pause nephrotoxins, urgent nephrology if not resolving^[1]
5-year kidney failure risk ≥10% on KFRE — prepare for kidney replacement therapy; access planning, transplant evaluation if eligible^[1]
Symptomatic uraemia or refractory hyperkalaemia >6.0 mmol/L — emergency dialysis evaluation^[1]
eGFR fall >25% within 4 weeks of starting RAS inhibitor or SGLT2 inhibitor — investigate for renal artery stenosis, volume depletion, or nephrotoxin co-administration; the expected SGLT2 dip is up to ~10%^[1]

First-line treatment

Interventions

Comprehensive cardio-renal protective bundle^[1]
All adults with CKD: RAS inhibitor + SGLT2 inhibitor (when eGFR ≥20 with ACR ≥30 mg/g) + statin per CV risk + smoking cessation + sodium <2 g/day; add finerenone in T2DM with persistent albuminuria; add GLP-1 RA in T2DM with elevated CV risk
Blood-pressure target SBP <120 mm Hg by standardised office measurement^[1]
Adults with CKD without diabetic nephropathy. Standardised KDIGO measurement protocol critical (automated, seated rest 5 min, correct cuff, ≥2 readings averaged). Individualise in frail elderly and severe orthostatic intolerance
Plant-based protein-moderated diet 0.8 g/kg/day^[1]
Non-dialysis CKD G3–G5; dietitian-led; emphasis on plant-based protein for lower phosphate and acid load; adjust upward (1.0–1.2 g/kg) on dialysis

First-line drug therapy

Drug	Class	Adult	Paediatric	Notes
ACE inhibitor or ARB^[1]	RAS inhibitor	Ramipril 2.5–10 mg PO daily; lisinopril 10–40 mg PO daily; losartan 50–100 mg PO daily; titrate to maximum tolerated	—	All with diabetic CKD or UACR ≥30 mg/g; titrate to maximum tolerated; tolerate eGFR fall up to 30%; check K and creatinine 1–2 weeks after change
Dapagliflozin or empagliflozin^[1]	SGLT2 inhibitor	Dapagliflozin 10 mg PO daily; empagliflozin 10 mg PO daily	—	Adults with CKD and ACR ≥30 mg/g regardless of diabetes status; start at eGFR ≥20; continue until KRT initiation; sick-day rules; risk of euglycaemic DKA, mycotic genitourinary infection
Finerenone^[1]	Non-steroidal mineralocorticoid receptor antagonist	10–20 mg PO once daily — start 10 mg if eGFR 25–60 or K ≤4.8; titrate after 4 weeks	—	Adults with T2DM and CKD with persistent ACR ≥30 mg/g despite optimal RAS inhibitor + SGLT2 inhibitor; avoid eGFR <25 or K >5.0
Atorvastatin or rosuvastatin^[1]	HMG-CoA reductase inhibitor	Atorvastatin 20–80 mg PO daily; rosuvastatin 5–20 mg PO daily (renal-adjusted)	—	Primary and secondary cardiovascular prevention in CKD G3a–G5 not on dialysis; benefit unproven in dialysis patients started afresh
GLP-1 receptor agonist^[1]	Glucagon-like peptide-1 receptor agonist	Semaglutide 0.25 mg SC weekly start, titrate to 1 mg; liraglutide 0.6 mg SC daily start, titrate to 1.8 mg	—	T2DM + CKD with elevated cardiovascular risk; complementary to SGLT2 inhibitor; nausea and weight loss expected; not a primary kidney protector

ACE inhibitor or ARB^[1]

RAS inhibitor

Adult: Ramipril 2.5–10 mg PO daily; lisinopril 10–40 mg PO daily; losartan 50–100 mg PO daily; titrate to maximum tolerated
Paediatric: —

All with diabetic CKD or UACR ≥30 mg/g; titrate to maximum tolerated; tolerate eGFR fall up to 30%; check K and creatinine 1–2 weeks after change

Dapagliflozin or empagliflozin^[1]

SGLT2 inhibitor

Adult: Dapagliflozin 10 mg PO daily; empagliflozin 10 mg PO daily
Paediatric: —

Adults with CKD and ACR ≥30 mg/g regardless of diabetes status; start at eGFR ≥20; continue until KRT initiation; sick-day rules; risk of euglycaemic DKA, mycotic genitourinary infection

Finerenone^[1]

Non-steroidal mineralocorticoid receptor antagonist

Adult: 10–20 mg PO once daily — start 10 mg if eGFR 25–60 or K ≤4.8; titrate after 4 weeks
Paediatric: —

Adults with T2DM and CKD with persistent ACR ≥30 mg/g despite optimal RAS inhibitor + SGLT2 inhibitor; avoid eGFR <25 or K >5.0

Atorvastatin or rosuvastatin^[1]

HMG-CoA reductase inhibitor

Adult: Atorvastatin 20–80 mg PO daily; rosuvastatin 5–20 mg PO daily (renal-adjusted)
Paediatric: —

Primary and secondary cardiovascular prevention in CKD G3a–G5 not on dialysis; benefit unproven in dialysis patients started afresh

GLP-1 receptor agonist^[1]

Glucagon-like peptide-1 receptor agonist

Adult: Semaglutide 0.25 mg SC weekly start, titrate to 1 mg; liraglutide 0.6 mg SC daily start, titrate to 1.8 mg
Paediatric: —

T2DM + CKD with elevated cardiovascular risk; complementary to SGLT2 inhibitor; nausea and weight loss expected; not a primary kidney protector

Safety-net

Sick-day rules — temporarily hold ACE inhibitor/ARB, SGLT2 inhibitor, finerenone, metformin, NSAIDs, and diuretics during dehydrating illness; restart when eating and drinking normally^[1]
Avoid NSAIDs (ibuprofen, diclofenac, naproxen) including over-the-counter and topical preparations — they accelerate CKD^[1]
Inform every prescriber and radiographer of your kidney function — many drugs and contrast agents need dose adjustment or substitution^[1]

Referral criteria

5-year kidney failure risk ≥5% on KFRENephrology^[1]
Sustained eGFR fall ≥25% within 12 months, accelerated decline >5 mL/min/year, or new ACR ≥220 mg/mmolNephrology^[1]
Resistant hypertension, suspected genetic kidney disease, glomerulonephritis, or unexplained anaemiaNephrology^[1]
Pregnancy with CKDJoint nephrology and obstetric clinic^[1]

Clinical summary

Diagnosis, classification by eGFR and albuminuria, prognosis, and progression-modifying therapy in adults with CKD; SGLT2 + RAS + finerenone framework.

References

1.KDIGO 2024 Clinical Practice Guideline for the Evaluation and Management of Chronic Kidney Disease (2024)

Drug

Class

Adult

Paediatric

Notes