CKD
Corey Diamond, PharmD
Chronic kidney disease (CKD) affects millions globally and presents significant challenges in diagnosis, management, and long-term care planning. A synopsis of the KDIGO clinical guidelines for managing CKD, published in Annals of Internal Medicine in March 2025, highlights key updates from the full guideline, which includes both evidence-based recommendations and expert-driven practice points.
These guidelines address evolving evidence and improve care for individuals with CKD who are not on kidney replacement therapy.
Major changes include a stronger emphasis on using cystatin C for assessing kidney function, broader use of SGLT-2 inhibitors, individualized risk assessment models, and guidance on statin therapy.
The final product includes 28 formal recommendations and 141 practice points. These are intended to guide a broad range of clinical decisions, from initial CKD diagnosis and risk stratification to treatment selection, care planning, and transitions toward kidney replacement therapies.
Summary of major changes
The 2024 KDIGO guideline update included several important shifts in the clinical approach to managing CKD. One of the central updates was the recommendation for clinicians to use both creatinine and cystatin C to estimate glomerular filtration rate, which could improve diagnostic accuracy, particularly in situations in which creatinine alone may be unreliable. Testing for urine albumin to creatinine ratio (uACR) remains a cornerstone of CKD staging, and its use is now emphasized alongside eGFR in both diagnosis and monitoring.
Additionally, the 2024 KDIGO guidelines support a move toward individualized, risk-based care rather than reliance on eGFR thresholds alone. For instance, the guidelines now recommend using risk calculators, such as the Kidney Failure Risk Equation to estimate a patient’s likelihood of progressing to kidney failure within defined time frames, helping guide referrals and treatment intensity.
The new KDIGO guidelines also contain a strong recommendation to broadly utilize SGLT-2 inhibitors for adults with CKD, regardless of diabetes status, based on consistent benefits in slowing disease progression and reducing cardiovascular complications.
Finally, the updated guideline also strengthens recommendations for statin use in CKD populations. Adults aged 50 years and older with reduced kidney function (eGFR less than 60 mL/min/1.73 m²) who are not on dialysis or post-transplant are advised to begin statin therapy, either alone or in combination with ezetimibe.
For younger adults aged 18 to 49 years, the guideline authors suggest statins if the patient has additional risk factors, such as diabetes, coronary disease, prior stroke, or a high predicted 10-year cardiovascular risk. These recommendations reflect the guideline’s broader effort to reduce cardiovascular events, which remain a leading cause of morbidity and mortality in CKD.
Expert opinion
In the discussion section, the authors underscore that the 2024 KDIGO guideline represents a meaningful shift toward personalized and proactive care in CKD. They emphasize that moving from rigid eGFR thresholds to risk-based models can better guide treatment timing and care planning. By using validated tools like the Kidney Failure Risk Equation, clinicians can estimate the likelihood of kidney failure over 2 to 5 years and tailor referrals and interventions accordingly. As the authors note, this approach allows for “navigation of care and management” based on an individual’s projected risk rather than just lab values alone.
They also highlight that expanding the role of cystatin C in estimating kidney function improves accuracy in diverse clinical situations, ultimately leading to better medication dosing, fewer adverse drug events, and reduced misclassification. Though cost is a concern, they argue that targeted cystatin C testing could prove cost effective by preventing errors and improving outcomes.
Overall, the authors suggest that the guideline reflects a broader shift in nephrology, one that emphasizes risk stratification, equity in diagnostic access, and integration of new evidence into practice. They call for greater clinical trial inclusion of underrepresented CKD populations and encourage health care systems to support the adoption of these updated recommendations. ■