KDIGO executive conclusions www.kidney-international.org
Executive summary of the KDIGO 2024 Clinical
Practice Guideline for the Evaluation and OPEN
Management of Chronic Kidney Disease: known
knowns and known unknowns
Adeera Levin1, Sofia B. Ahmed2, Juan Jesus Carrero3, Bethany Foster4, Anna Francis5, Rasheeda K. Hall6,
lu10, Edmund Lamb11, Peter Lin12,
Will G. Herrington7, Guy Hill8, Lesley A. Inker9, Rümeyza Kazancıog
Magdalena Madero13, Natasha McIntyre14, Kelly Morrow15,16, Glenda Roberts17,
Dharshana Sabanayagam18, Elke Schaeffner19, Michael Shlipak20, Rukshana Shroff21, Navdeep Tangri22,
Teerawat Thanachayanont23, Ifeoma Ulasi24, Germaine Wong18, Chih-Wei Yang25, Luxia Zhang26,
Karen A. Robinson27, Lisa Wilson27, Renee F. Wilson27, Bertram L. Kasiske28, Michael Cheung29,
Amy Earley29 and Paul E. Stevens30
1
Division of Nephrology, University of British Columbia, Vancouver, British Columbia, Canada; 2Department of Medicine, University of
Alberta, Edmonton, Alberta, Canada; 3Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden;
4
Department of Pediatrics, McGill University, Montreal, Quebec, Canada; 5Department of Medicine, Queensland Children’s Hospital,
Brisbane, Queensland, Australia; 6Division of Nephrology, Duke School of Medicine, Durham, North Carolina, USA; 7Nuffield Department
of Population Health, University of Oxford, Oxford, UK; 8Manchester, UK; 9Division of Nephrology, Tufts Medical Center, Boston,
Massachusetts, USA; 10Division of Nephrology, Bezmialem Vakif University, Istanbul, Turkey; 11Department of Clinical Biochemistry, East
Kent Hospitals University NHS Foundation Trust, Canterbury, UK; 12Director of Primary Care Initiatives, Canadian Heart Research Center,
Toronto, Ontario, Canada; 13Division of Nephrology, Instituto Nacional de Cardiología Ignacio Chavéz, Mexico City, Mexico; 14London
Health Sciences Centre-Victoria Hospital, Western University, London, Ontario, Canada; 15Department of Nutrition and Exercise Science,
Bastyr University, Kenmore, Washington, USA; 16Osher Center for Integrative Medicine, University of Washington, Kenmore, Washington,
USA; 17UW Center for Dialysis Innovation & Kidney Research Institute, Seattle, Washington, USA; 18Western Renal Service, University of
Sydney, Sydney, New South Wales, Australia; 19Division of Nephrology and Intensive Care Medicine, Charité Universitätsmedizin Berlin,
Berlin, Germany; 20Department of Medicine, University of California, San Francisco, San Francisco, California, USA; 21Department of
Paediatric Nephrology, UCL Great Ormond Street Hospital Institute of Child Health, London, UK; 22Division of Nephrology, University of
Manitoba, Winnipeg, Manitoba, Canada; 23Division of Nephrology, Bhumirajanagarindra Kidney Institute, Bangkok, Thailand;
24
Department of Medicine, Ituku-Ozalla Campus, University of Nigeria, Enugu, Nigeria; 25Division of Nephrology, Chang Gung University,
Taoyuan, Taiwan; 26Renal Division, Peking University First Hospital, Beijing, China; 27The Johns Hopkins University Evidence-based
Practice Center, Johns Hopkins University, Baltimore, Maryland, USA; 28Hennepin County Medical Center, University of Minnesota,
Minneapolis, Minnesota, USA; 29KDIGO, Brussels, Belgium; and 30Department of Nephrology, Kent Kidney Care Centre, East Kent Hospitals
University NHS Foundation Trust, Canterbury, UK
The Kidney Disease: Improving Global Outcomes (KDIGO) been available, reflects an exciting time in nephrology. New
Clinical Practice Guideline for the Evaluation and therapies and strategies have been tested in large and
Management of Chronic Kidney Disease (CKD) updates the diverse populations that help to inform care; however, this
KDIGO 2012 guideline and has been developed with guideline is not intended for people receiving dialysis nor
patient partners, clinicians, and researchers around the those who have a kidney transplant. The document is
world, using robust methodology. This update, based on a sensitive to international considerations, CKD across the
substantially broader base of evidence than has previously lifespan, and discusses special considerations in
implementation. The scope includes chapters dedicated to
the evaluation and risk assessment of people with CKD,
Correspondence: Adeera Levin, St Paul’s Hospital, University of British management to delay CKD progression and its
Columbia, 1081 Burrard Street, Room 6010A, Vancouver, British Columbia complications, medication management and drug
V6Z1Y6, Canada. E-mail: alevin@providencehealth.bc.ca; or Paul Stevens, stewardship in CKD, and optimal models of CKD care.
Kent Kidney Care Centre, Kent and Canterbury Hospital, Ethelbert Road,
Canterbury, Kent CT1 3NG, UK. E-mail: pstevens@nhs.net
Treatment approaches and actionable guideline
recommendations are based on systematic reviews of
The complete KDIGO 2024 Clinical Practice Guideline for the Evaluation
and Management of Chronic Kidney Disease is published in Kidney Inter-
relevant studies and appraisal of the quality of the evidence
national, volume 105, issue 4S, 2024, which is available online at www. and the strength of recommendations which followed the
kidney-international.org. “Grading of Recommendations Assessment, Development,
Received 11 October 2023; revised 27 October 2023; accepted 31 and Evaluation” (GRADE) approach. The limitations of the
October 2023 evidence are discussed. The guideline also provides practice
684 Kidney International (2024) 105, 684–701
,A Levin et al.: Executive summary of KDIGO 2024 CKD Guideline KDIGO executive conclusions
points, which serve to direct clinical care or activities for on the framework methodology from the KDIGO Methods
which a systematic review was not conducted, and it Committee and aligns with other international guideline
includes useful infographics and describes an important groups using the “Grading of Recommendations Assessment,
research agenda for the future. It targets a broad audience Development, and Evaluation” (GRADE) methodology.
of people with CKD and their healthcare, while being New developments in the refinement of evaluation of
mindful of implications for policy and payment. glomerular filtration rate (GFR), population and individual risk
Kidney International (2024) 105, 684–701; https://doi.org/10.1016/ prediction, and novel treatments have all positively influenced
j.kint.2023.10.016 the prognosis for people with CKD and are presented here. The
KEYWORDS: chronic kidney disease; CKD; evaluation; guideline; KDIGO; Work Group has aimed to generate a guideline that is both
management rigorously devoted to new and existing evidence, and that is
Copyright ª 2023, Kidney Disease: Improving Global Outcomes (KDIGO). clinically useful. Research recommendations are presented in a
Published by Elsevier Inc. on behalf of the International Society of
separate section of the document and are intended to guide the
Nephrology. This is an open access article under the CC BY-NC-ND
license (http://creativecommons.org/licenses/by-nc-nd/4.0/). next set of important research questions to inform and improve
the outcomes of people living with CKD. We specifically urge
T
the community to be inclusive of people across the lifecycle and
his 2024 update of the Kidney Disease: Improving Global include sex (referring to biological factors including genetics,
Outcomes (KDIGO) Clinical Practice Guideline for the sex steroids, physiology, and anatomy), gender (referring to
Evaluation and Management of Chronic Kidney Disease sociocultural factors such as identity, roles, and relations), and
(CKD) heralds a new era in the care of people with kidney etiology of CKD as important variables in all studies.
diseases. The majority of statements from the 2012 guideline We offer recommendations to clinicians and clinical labo-
have been updated based on current knowledge and practice. ratories to understand and promote the standardization and
Only 6 statements were retained in their original form in 2012. accuracy of testing tools including assays and equipment. The
There is clear and increasing recognition of CKD as a global effective use of clinical practice guidelines and, therefore,
public health problem. The inclusion of people with CKD in effective patient care, including accurate diagnosis and referral
clinical trials has improved substantially, thus generating an prioritization, clinical research, and public health prioritiza-
evidence base upon which to recommend care and treatments tion, requires comparability of laboratory results independent
that have not previously existed. There are increasing efforts to of time, place, and measurement procedure. Key to this is
improve diagnostic evaluation of cause, with increased so- establishing precision of testing and between-laboratory
phistication of imaging methods, biopsy interrogation, and agreement with traceability to accepted international refer-
genetic evaluation, as well as methods to optimize blood and ence standards wherever available. Therefore, this guidance
urine testing. With advances in technology, such as molecular document includes standards for laboratory tests. Specifically,
diagnostics for tissue samples, integrated omics platforms, we focus on creatinine and cystatin C, with the goal of
and the use of machine learning/artificial intelligence to normalizing access to both tests for increased accuracy of GFR
explore large databases of both clinical and biological data, assessment, and the assessment of urine albumin which is also
we are truly at the beginning of a new era in nephrology. critical to risk assessment and care plans.
This guideline integrates existing and new knowledge to The guideline is organized into 6 chapters (Tables 1, 4, and 5
guide the care of people with CKD. It has been developed by cover Chapters 1–5). In this summary, we outline the key
an international Work Group that included patient partners, evidence-based recommendations together with selected prac-
clinicians, and researchers with diverse experience across the tice points by chapter. Readers are referred to the full guideline
spectrum of populations, a dedicated Evidence Review Team, for a comprehensive description of benefits and harms, certainty
and professional KDIGO staff. This clinical practice guideline of evidence, values and preferences, resource use and costs,
includes 2 different types of statements: graded recommen- factors affecting implementation, special considerations, and
dations, which are supported by systematic reviews (i.e., de both general and specific research recommendations.
novo reviews conducted by the independent Evidence Review
Team or existing high-quality reviews that have been sys- Qualifying statements, key concepts, special considerations,
tematically identified), and ungraded practice points, which Chronic Kidney Disease Prognosis Consortium (CKD-PC)
serve to direct clinical care or activities for which a systematic Clarifying definition and classification. We begin with
review was not conducted for various reasons (e.g., lack of a acknowledgment that the definition and classification system is
sufficient evidence base or randomized controlled trials that widely accepted by the community. Specifically, we remind
would be impractical/unethical). Both recommendations and readers of the difference between the definition of CKD, which is
practice points are intended to help guide clinical practice and inclusive of various markers of kidney damage, and the classi-
aid in decision-making; thus, collectively are the guideline fication system that highlights the importance of the CGA sys-
statements. They are clearly articulated, actionable, and pre- tem (i.e., Cause/Glomerular filtration rate level/Albuminuria
sented together so that all guideline statements can be level) for the purposes of management, treatment, risk assess-
implemented. The distinction between them is based on the ment, and research. The relative risk of many outcomes (CKD
process by which they are derived, and that process is based progression, kidney failure, acute kidney injury, infection,
Kidney International (2024) 105, 684–701 685
, KDIGO executive conclusions A Levin et al.: Executive summary of KDIGO 2024 CKD Guideline
hospitalizations, cardiovascular mortality, myocardial infarc- provide economic benefits and prevent the development of
tion, atrial fibrillation, stroke, and peripheral vascular disease) is kidney failure and cardiovascular complications. A systematic
increased for all people with CKD, whereas absolute risks for review of care models in low- and middle-income countries
individuals are modified by age, sex, and other factors. We found that those supporting primary care providers or allied
highlight the difference between relative and absolute risks (the health workers achieved effectiveness in slowing GFR decline,
latter derived by applying individual risk prediction scores), as opposed to interventions centered on specialty care alone.5
acknowledge that there are different risks for different pop- Where there are resource limitations, it is logical to deploy re-
ulations, and do not support any age-adjusted definitions of sources where they will be most cost-effective, for example, to
CKD, as there are no age-adjusted definitions for diabetes, car- higher-risk, preventable stages.
diovascular disease (CVD), nor hypertension, but rather Special considerations and updated population data. We
recognize that the individual implications of those conditions recognize that kidney diseases affect people at different times
for individuals differ by age group. and with different impacts across the whole lifespan. Thus,
Screening. Despite the increasing recognition of the true enabling a personalized approach, considering age, sex, and
burden of CKD, there remains controversy and lack of consensus gender for diagnosis, risk assessment, and treatment, is critical.
as to the utility of population screening for CKD1 or targeted At the extremes of age, the very young and the very old, diag-
screening programs2 due to the complexity of the underlying nostic procedures, treatment aims, treatment modalities, and
sociopolitical and resource environment. Public health policy decision-making differ due to differences in prognosis, treat-
has a role to play in identifying and addressing risk factors to ment options, and prioritization. In young and middle-aged
prevent CKD, to identify CKD early, and to delay its progression adults, treatment approaches may differ because of specific
and associated adverse outcomes. Incorporating evidence-based circumstances, such as pregnancy or menopause. Sex (biological
treatment of people with CKD with sodium-glucose cotrans- attributes) and gender (sociocultural factors), as well as other
porter-2 (SGLT2) inhibitors, together with a systematic review important intersectional factors, including, but not limited to,
in people with diabetes and hypertension, suggests that geographical location, socioeconomic position, and race/
screening adults for CKD could now be cost-effective.3,4 ethnicity, play important roles in kidney health and disease.
International considerations. In low- and middle-income Within the guideline document, we highlight concepts as to
countries and in the lower sociodemographic quintiles why age, sex, and gender should be considered, and how these
around the world, there is a large gap between CKD burden and specifically impact within each of the chapters (see Figure 1).
provision of adequate healthcare. There is limited access to Multinational population studies, assessing risks, based on
kidney replacement therapy combined with the rising preva- CKD-PC 2023 analyses,6 are presented as part of the intro-
lence of diabetes and hypertension and evidence of substantial ductory chapter to further highlight updated information
sex and gender disparities in access to CKD treatment. demonstrating epidemiological risk across CKD categories on
Importantly, slowing CKD progression at early stages should a population level. The data describe that the association of all
Sex
Child/adolescent • Menopause
• Growth • Contraception
• Nutrition • Differential drug effects
• Weight/BSA-based drug dosing • Differing epidemiology
• Neurocognitive development of risk factors and
• Supporting education complications
• Transition to adult care
• Holistic approach to care for
the whole family unit
Older adults
• Multidimensionality of
chronic conditions/
multimorbidity
• Frailty (including sarcopenia)
• Cognitive function
• Polypharmacy
• Prioritization
Pregnancy/lactation • End-of-life care
• Drug pharmacokinetics Gender
and pharmacodynamics • Gender identity
• Drug teratogenicity • Gender roles
• Risk of CKD progression • Gender relations
• Increased risk of pregnancy • Institutionalized
complications, preterm birth gender
and small for gestational
age babies
• Fertility
Figure 1 | Special considerations for chronic kidney disease (CKD) care across the lifespan. BSA, body surface area.
686 Kidney International (2024) 105, 684–701
