KDIGO 2024 Clinical Practice Guideline for the Evaluation and Management of Chronic Kidney Disease
Consolidates CKD staging, risk stratification, and disease-modifying therapy into a single framework, with expanded guidance on SGLT2 inhibitors, finerenone, and GLP-1 receptor agonists across eGFR ranges.
What changed in this edition
- SGLT2 inhibitors recommended for most adults with CKD and eGFR ≥20 mL/min/1.73 m², with or without diabetes.
- Finerenone added as guideline-directed therapy for CKD with type 2 diabetes and albuminuria already on RAS blockade.
- GLP-1 receptor agonists endorsed for cardiorenal risk reduction in T2D with CKD (FLOW trial).
- Risk stratification formally incorporates the KFRE 2- and 5-year prediction scores for referral timing.
- Blood pressure target harmonized at SBP <120 mm Hg (standardized office measurement) when tolerated.
- Updated albuminuria screening: annual uACR for all adults with diabetes, hypertension, or eGFR <60.
- Cystatin C-based eGFR recommended for confirmation when creatinine-based eGFR is between 45–59 or discordant with clinical status.
- New section on CKD in pregnancy and peri-conception planning, including safe medication substitutions.
Clinical takeaways
Who gets an SGLT2 inhibitor
Any adult with CKD and eGFR ≥20 mL/min/1.73 m² should be considered, regardless of diabetes status. Initiate and continue even as eGFR declines; discontinue only at dialysis initiation or intolerance. Expect an early reversible eGFR dip of ~4 mL/min.
Layering cardiorenal therapy
For T2D with albuminuria: start ACEi or ARB at maximum tolerated dose, add SGLT2 inhibitor, add finerenone if uACR ≥30 mg/g and K+ ≤4.8, and consider GLP-1 RA for additional cardiorenal and metabolic benefit.
Blood pressure measurement
Use standardized office BP (rested, seated, correct cuff, multiple readings averaged) or validated home BP. Do not apply the <120 target to unstandardized casual readings.
When to refer to nephrology
Refer for eGFR <30, uACR >300 mg/g, 5-year KFRE >5%, rapid eGFR decline (>5/year), resistant hypertension, or unexplained hematuria. Early referral improves vascular access planning and mortality.
Nutrition and lifestyle
Sodium <2 g/day; protein 0.8 g/kg/day (not lower) for CKD G3–G5 not on dialysis; emphasize plant-forward dietary patterns; discourage protein restriction below 0.6 g/kg.
Quick reference
eGFR categories and recommended monitoring interval
| G1 (≥90) with albuminuria | At least annually |
|---|---|
| G2 (60–89) with albuminuria | At least annually |
| G3a (45–59) | Every 6–12 months |
| G3b (30–44) | Every 3–6 months |
| G4 (15–29) | Every 3 months + nephrology |
| G5 (<15) | Monthly + access planning |
Supporting trials
- EMPA-KIDNEYPubMed 36331190
Empagliflozin reduced progression of kidney disease or CV death by 28% across a broad CKD population.
- DAPA-CKDPubMed 32970396
Dapagliflozin reduced the composite kidney outcome by 39% in CKD with and without diabetes.
- FIDELIO-DKD / FIGARO-DKDPubMed 33264825
Finerenone reduced kidney and CV events in T2D with CKD on maximal RAS blockade.
- FLOWPubMed 38785209
Semaglutide 1.0 mg reduced major kidney events by 24% in T2D with CKD.
- CREDENCEPubMed 30990260
Canagliflozin demonstrated renal protection in T2D with albuminuric CKD.
Related reading
KDIGO 2026 CKD Guidelines: Key Updates for Nephrology Practice
The 2026 KDIGO guidelines introduce significant changes to CKD staging, SGLT2 inhibitor recommendations, and GLP-1 agonist integration. Here is what changed and what it means for your patients.
Evidence-Based MedicineSGLT2 Inhibitors in HFpEF with CKD: What the Evidence Shows
A 72-year-old with HFpEF, eGFR 34, type 2 diabetes, and a recent heart failure hospitalization. Should she start an SGLT2 inhibitor? The answer spans three trial programs, and the data are clearer than you might expect.
Clinical AIDiabetic Kidney Disease: Finerenone, Nonsteroidal MRAs, and the FIDELIO/FIGARO Evidence
Finerenone, the first nonsteroidal mineralocorticoid receptor antagonist, has demonstrated cardiorenal benefit in DKD beyond SGLT2 inhibitors and RAS blockade. This review covers the FIDELIO-DKD and FIGARO-DKD trials, practical implementation, and the emerging multi-pillar approach to DKD management.