KDIGO 2024 Guideline Recommendations for Managing Adults with Stage 2‑3a Chronic Kidney Disease

Diagnostic Workup

• Check serum potassium before initiating any kidney‑protective medication, as hyperkalemia risk must be assessed prior to prescribing RAS inhibitors or SGLT2 inhibitors. KDIGO 2024 1, 2

Pharmacologic Management

Patients with Albumin‑Creatinine Ratio (ACR) ≥ 200 mg/g or with Heart Failure

• Initiate an SGLT2 inhibitor immediately; this is a Grade 1A recommendation—the strongest evidence for slowing CKD progression, reducing cardiovascular events, and lowering mortality in adults with CKD (eGFR ≥ 20 mL/min/1.73 m²) who have ACR ≥ 200 mg/g or heart failure. KDIGO 2024 1, 2, 3, 4

Patients with ACR 30‑200 mg/g (Category A2)

• With diabetes: Start both a renin‑angiotensin system (RAS) inhibitor (ACE‑I or ARB) and an SGLT2 inhibitor. KDIGO 2024 1, 3
• Without diabetes: Begin a RAS inhibitor at the maximum tolerated dose; this is a Grade 2C recommendation. KDIGO 2024 2, 3
• Consider adding an SGLT2 inhibitor when eGFR is 20‑45 mL/min/1.73 m²; this carries a Grade 2B recommendation. KDIGO 2024 1, 3, 4

Patients with ACR < 30 mg/g (Category A1)

• Use a RAS inhibitor only for specific indications such as hypertension or heart failure with reduced ejection fraction. KDIGO 2024 2, 3
• An SGLT2 inhibitor may be considered despite weaker evidence; in patients with eGFR 20‑45 mL/min/1.73 m² this is a Grade 2B recommendation. KDIGO 2024 1, 4

Monitoring After Initiating Therapy

• Measure blood pressure, serum creatinine, and serum potassium 2‑4 weeks after starting or up‑titrating a RAS inhibitor. KDIGO 2024 1, 2, 3
• Continue the RAS inhibitor unless serum creatinine rises >30 % within 4 weeks of initiation. KDIGO 2024 1, 2, 3
• Manage hyperkalemia with potassium‑lowering strategies rather than discontinuing the RAS inhibitor whenever feasible. KDIGO 2024 1, 2
• No special monitoring schedule is required for SGLT2 inhibitors; an initial modest eGFR dip is expected and does not warrant drug cessation. KDIGO 2024 1, 4

Diabetes‑Specific Add‑On Therapy

• Add the non‑steroidal mineralocorticoid receptor antagonist finerenone (2A recommendation) when eGFR > 25 mL/min/1.73 m², serum potassium is normal, and ACR > 30 mg/g despite maximally tolerated RAS inhibition. KDIGO 2024 1, 3, 4
• Dose finerenone at 10 mg daily for patients with eGFR 25‑59 mL/min/1.73 m². KDIGO 2024 1, 4
• Monitor serum potassium at 1 month after starting finerenone, then every 4 months thereafter. KDIGO 2024 4

Critical Pitfalls to Avoid

• Do not stop a RAS inhibitor solely because eGFR falls below 30 mL/min/1.73 m²; continuation is advised unless a specific contraindication arises. KDIGO 2024 1, 2, 3, 4
• Do not discontinue an SGLT2 inhibitor in response to the expected early eGFR decline; the reduction is transient and reversible. KDIGO 2024 1, 4

Nephrology Referral Criteria

• Refer to nephrology when eGFR drops below 30 mL/min/1.73 m². KDIGO 2024 4
• Refer when ACR reaches ≥ 300 mg/g (macroalbuminuria). KDIGO 2024 4

Initiating SGLT2‑Inhibitors and Finerenone in Adults with CKD and Albuminuria

1. Immediate Initiation of an SGLT2‑Inhibitor

• Adults with chronic kidney disease (CKD) and urine albumin‑to‑creatinine ratio (UACR) ≥ 200 mg/g should receive an SGLT2‑inhibitor immediately, regardless of diabetes status, because this carries a Grade 1A recommendation (strongest level of evidence) for reducing CKD progression, cardiovascular events, and mortality. 5
• The expected modest decline in estimated glomerular filtration rate (eGFR) after starting an SGLT2‑inhibitor does not require special monitoring or discontinuation of therapy. 5

2. Prerequisites Before Adding Finerenone

• Finerenone may be considered only after the patient is on maximum tolerated doses of both a renin‑angiotensin system inhibitor (ARB) and an SGLT2‑inhibitor, and albuminuria remains elevated. This sequence follows the KDIGO 2024 guidance. [5][6]7
• KDIGO 2024 assigns a Grade 2A recommendation (moderate‑strength evidence) for finerenone when all of the following criteria are satisfied:

3. Optimizing Background Therapy

• Ensure the ARB is titrated to the maximum tolerated dose before considering finerenone. [5][6]
• Add an SGLT2‑inhibitor promptly (e.g., dapagliflozin 10 mg daily or empagliflozin 10 mg daily). This step is required irrespective of diabetes status. [5][6]

4. Criteria to Initiate Finerenone

• After 3–4 months of optimized ARB + SGLT2‑inhibitor therapy, re‑measure UACR. If albuminuria remains >30 mg/g, finerenone can be started. [5][6]

5. Monitoring After Finerenone Initiation

• Serum potassium should be checked at 1 month and then every 4 months. [5][7]
• Hold finerenone if potassium exceeds 5.5 mmol/L; continue if potassium is 4.9–5.5 mmol/L. 5
• If potassium is ≤4.8 mmol/L after an initial 10 mg dose, the dose may be escalated to 20 mg daily. 5

6. Safety and Common Pitfalls (KDIGO 2024)

• Do not skip the SGLT2‑inhibitor; its evidence base (Grade 1A) is stronger than that for finerenone (Grade 2A). [5][6]
• Do not start finerenone in patients with serum potassium > 5.0 mmol/L (FDA‑defined absolute contraindication).
• Confirm the presence of T2DM before prescribing finerenone, as the guideline recommendation applies specifically to diabetic kidney disease. [5][6]7
• Finerenone is an add‑on therapy, not a substitute for RAS inhibition; it should never be used as monotherapy. [5][6]