KDIGO 2024 Recommendations for Pharmacologic Management of Chronic Kidney Disease in Adults

SGLT2 Inhibitors – First‑Line Kidney‑Protective Therapy

Initiate an SGLT2 inhibitor in all adults with type 2 diabetes and CKD when estimated GFR is ≥20 mL/min/1.73 m² (strong recommendation, grade 1A). 1
For non‑diabetic CKD patients, start an SGLT2 inhibitor if eGFR ≥ 20 mL/min/1.73 m² and urine albumin‑to‑creatinine ratio (ACR) ≥ 200 mg/g (≥20 mg/mmol), or in any CKD patient with heart failure regardless of albuminuria (grade 1A). 1
Consider an SGLT2 inhibitor in patients with eGFR 20–45 mL/min/1.73 m² and urine ACR < 200 mg/g (grade 2B). 1
Continue the SGLT2 inhibitor even if eGFR falls below 20 mL/min/1.73 m² after initiation, unless the patient becomes intolerant or requires kidney‑replacement therapy (no grade specified). 1
Temporarily withhold the SGLT2 inhibitor during prolonged fasting, surgery, or critical illness because of ketosis risk (no grade specified). 1
Do not increase laboratory monitoring frequency or discontinue the drug solely for the expected, reversible decline in eGFR that occurs after initiation (no grade specified). 1

Start an ACE inhibitor or ARB in CKD patients with severely increased albuminuria (A3) who do not have diabetes (strong recommendation, grade 1B). 2
Consider RAS inhibition in CKD patients with moderately increased albuminuria (A2) without diabetes (grade 2C). 2
Initiate RAS inhibition in all CKD patients with moderate‑to‑severe albuminuria (A2 or A3) who have diabetes (grade 1B). 2
Titrate the ACEi/ARB to the highest approved dose that the patient tolerates, as trial benefits were demonstrated at maximal doses (no grade specified). 4
Check blood pressure, serum creatinine, and potassium 2–4 weeks after starting or up‑titrating a RAS inhibitor (no grade specified). 4
Continue the RAS inhibitor unless serum creatinine rises > 30 % within 4 weeks of initiation or dose increase (no grade specified). 4
Maintain RAS inhibition even when eGFR declines below 30 mL/min/1.73 m² (no grade specified). 4
Manage hyper‑kalemia with dietary measures or potassium‑binding agents rather than stopping the RAS inhibitor (no grade specified). 4
Reduce or discontinue the RAS inhibitor only for symptomatic hypotension, refractory hyper‑kalemia despite treatment, or uremic symptoms when eGFR < 15 mL/min/1.73 m² (no grade specified). 1

Add finerenone (a non‑steroidal MRA) in adults with type 2 diabetes, eGFR > 25 mL/min/1.73 m², normal serum potassium, and albuminuria > 30 mg/g (>3 mg/mmol) despite maximally tolerated RAS inhibition (strong recommendation, grade 2A). 1
Non‑steroidal MRAs are especially appropriate for high‑risk patients with persistent albuminuria despite standard therapy (no grade specified). 1
Finerenone may be started concurrently with both a RAS inhibitor and an SGLT2 inhibitor (no grade specified). 1
Initiate finerenone at 10 mg once daily when eGFR is 25–59 mL/min/1.73 m², or 20 mg once daily when eGFR ≥ 60 mL/min/1.73 m² (no grade specified). 1
Monitor serum potassium 1 month after starting finerenone and then every 4 months (no grade specified). 1
Hold finerenone if potassium exceeds 5.5 mmol/L; continue if potassium is 4.9–5.5 mmol/L; consider dose escalation if potassium is ≤ 4.8 mmol/L (no grade specified). 1
Prefer non‑steroidal MRAs over steroidal agents when kidney or cardiovascular benefit has been demonstrated (no grade specified). 1

Use a long‑acting GLP‑1 receptor agonist in adults with type 2 diabetes and CKD who have not reached individualized glycemic targets despite metformin and an SGLT2 inhibitor, or who cannot use those agents (moderate recommendation, grade 1B). 3
Prioritize GLP‑1 receptor agonists that have proven cardiovascular benefit (no grade specified). 3

Measure serum creatinine, eGFR, potassium, and blood pressure 2–4 weeks after initiating or increasing the dose of a RAS inhibitor (no grade specified). 4
For patients on a non‑steroidal MRA, obtain a potassium level at 1 month and then every 4 months (no grade specified). 1
No additional CKD monitoring frequency is required solely because an SGLT2 inhibitor is started (no grade specified). 1

Address hyper‑kalemia with dietary counseling, potassium‑binding agents, or adjustment of concomitant medications rather than reducing the dose of kidney‑protective drugs (no grade specified). 4
Continue RAS inhibition unless hyper‑kalemia remains uncontrolled despite these measures (no grade specified). 4
For non‑steroidal MRAs, hold therapy if potassium > 5.5 mmol/L, implement dietary or medication adjustments, and restart when potassium ≤ 5.0 mmol/L (no grade specified). 1

Initiate pharmacologic (or dietary) treatment when serum bicarbonate falls below 18 mmol/L in adults with CKD, aiming to avoid severe acidosis while ensuring bicarbonate does not exceed the normal upper limit or adversely affect blood pressure, potassium, or fluid status (no grade specified). 3

Do not discontinue an SGLT2 inhibitor for the expected, reversible eGFR decline after initiation; this reflects a hemodynamic effect, not kidney injury (no grade specified). 1
Do not stop a RAS inhibitor for mild hyper‑kalemia; first employ potassium binders and dietary measures (no grade specified). 4
Do not reduce doses of RAS inhibitors or SGLT2 inhibitors solely because eGFR declines; maintain therapy to preserve kidney protection (no grade specified). 4
Do not start a non‑steroidal MRA in patients with baseline hyper‑kalemia; select only those with consistently normal potassium levels (no grade specified). 1
Do not use steroidal MRAs as first‑line agents for CKD; reserve them for heart failure, primary hyperaldosteronism, or refractory hypertension (no grade specified). 3