Chronic kidney disease: evaluation, staging, and management

KDIGO2024

Stage by cause, eGFR (G1 >=90, G2 60-89, G3a 45-59, G3b 30-44, G4 15-29, G5 <15) and albuminuria ACR (A1 <30, A2 30-300, A3 >300 mg/g). Use creatinine plus cystatin C eGFR to confirm when decisions hinge on it. Target SBP <120 mm Hg by standardized office measurement.

KDIGO2024

SGLT2 inhibitor (1A) for adults with CKD and eGFR >=20 with ACR >=200 mg/g, for T2D plus CKD with eGFR >=20, or with heart failure regardless of albuminuria; suggested (2B) for eGFR 20-45 with ACR <200. Continue if eGFR later falls below 20; expected initial eGFR dip is not a reason to stop.

KDIGO2024

ACEi or ARB at highest approved, tolerated dose for CKD with moderate to severe albuminuria (ACR >=300, or 30-300 with diabetes). Recheck BP, SCr, and potassium within 2-4 weeks of start or dose increase. Continue when eGFR falls below 30 if tolerated. Do not combine ACEi, ARB, and direct renin inhibitor.

KDIGO2024Grade 1A / 1B / 2A

Statin or statin/ezetimibe for adults ≥50 with eGFR <60 not on dialysis or transplant (1A); statin for adults ≥50 with CKD and eGFR ≥60 (1B). Type 2 diabetes with eGFR >25, normal potassium, and albuminuria (ACR >30 mg/g) despite maximum tolerated RASi: add a nonsteroidal MRA such as finerenone (2A). Type 2 diabetes and CKD not at glycemic target on metformin plus SGLT2i, or unable to use them: long-acting GLP-1 RA (1B).

ADA2026Grade A / B

Diabetes: check urine albumin-to-creatinine ratio and eGFR at least yearly in type 2 diabetes and in type 1 diabetes of 5 or more years' duration (B). With CKD, monitor UACR and eGFR 1 to 4 times a year by stage (B). Refer to nephrology for eGFR <30, rapidly rising albuminuria, or rapidly falling eGFR (A), or when the cause or management is uncertain (B).