Executive summary of the KDIGO 2024 Clinical Practice Guideline for the Evaluation and Management of Chronic Kidney Disease: known knowns and known unknowns

The Kidney Disease: Improving Global Outcomes (KDIGO) Clinical Practice Guideline for the Evaluation and Management of Chronic Kidney Disease (CKD) updates the KDIGO 2012 guideline and has been developed with patient partners, clinicians, and researchers around the world, using robust methodology. This update, based on a substantially broader base of evidence than has previously been available, reflects an exciting time in nephrology. New therapies and strategies have been tested in large and diverse populations that help to inform care; however, this guideline is not intended for people receiving dialysis nor those who have a kidney transplant. The document is sensitive to international considerations, CKD across the lifespan, and discusses special considerations in implementation. The scope includes chapters dedicated to the evaluation and risk assessment of people with CKD, management to delay CKD progression and its complications, medication management and drug stewardship in CKD, and optimal models of CKD care. Treatment approaches and actionable guideline recommendations are based on systematic reviews of relevant studies and appraisal of the quality of the evidence and the strength of recommendations which followed the “Grading of Recommendations Assessment, Development, and Evaluation” (GRADE) approach. The limitations of the evidence are discussed. The guideline also provides practice points, which serve to direct clinical care or activities for which a systematic review was not conducted, and it includes useful infographics and describes an important research agenda for the future. It targets a broad audience of people with CKD and their healthcare, while being mindful of implications for policy and payment. The Kidney Disease: Improving Global Outcomes (KDIGO) Clinical Practice Guideline for the Evaluation and Management of Chronic Kidney Disease (CKD) updates the KDIGO 2012 guideline and has been developed with patient partners, clinicians, and researchers around the world, using robust methodology. This update, based on a substantially broader base of evidence than has previously been available, reflects an exciting time in nephrology. New therapies and strategies have been tested in large and diverse populations that help to inform care; however, this guideline is not intended for people receiving dialysis nor those who have a kidney transplant. The document is sensitive to international considerations, CKD across the lifespan, and discusses special considerations in implementation. The scope includes chapters dedicated to the evaluation and risk assessment of people with CKD, management to delay CKD progression and its complications, medication management and drug stewardship in CKD, and optimal models of CKD care. Treatment approaches and actionable guideline recommendations are based on systematic reviews of relevant studies and appraisal of the quality of the evidence and the strength of recommendations which followed the “Grading of Recommendations Assessment, Development, and Evaluation” (GRADE) approach. The limitations of the evidence are discussed. The guideline also provides practice points, which serve to direct clinical care or activities for which a systematic review was not conducted, and it includes useful infographics and describes an important research agenda for the future. It targets a broad audience of people with CKD and their healthcare, while being mindful of implications for policy and payment. This 2024 update of the Kidney Disease: Improving Global Outcomes (KDIGO) Clinical Practice Guideline for the Evaluation and Management of Chronic Kidney Disease (CKD) heralds a new era in the care of people with kidney diseases. The majority of statements from the 2012 guideline have been updated based on current knowledge and practice. Only 6 statements were retained in their original form in 2012. There is clear and increasing recognition of CKD as a global public health problem. The inclusion of people with CKD in clinical trials has improved substantially, thus generating an evidence base upon which to recommend care and treatments that have not previously existed. There are increasing efforts to improve diagnostic evaluation of cause, with increased sophistication of imaging methods, biopsy interrogation, and genetic evaluation, as well as methods to optimize blood and urine testing. With advances in technology, such as molecular diagnostics for tissue samples, integrated omics platforms, and the use of machine learning/artificial intelligence to explore large databases of both clinical and biological data, we are truly at the beginning of a new era in nephrology. This guideline integrates existing and new knowledge to guide the care of people with CKD. It has been developed by an international Work Group that included patient partners, clinicians, and researchers with diverse experience across the spectrum of populations, a dedicated Evidence Review Team, and professional KDIGO staff. This clinical practice guideline includes 2 different types of statements: graded recommendations, which are supported by systematic reviews (i.e., de novo reviews conducted by the independent Evidence Review Team or existing high-quality reviews that have been systematically identified), and ungraded practice points, which serve to direct clinical care or activities for which a systematic review was not conducted for various reasons (e.g., lack of a sufficient evidence base or randomized controlled trials that would be impractical/unethical). Both recommendations and practice points are intended to help guide clinical practice and aid in decision-making; thus, collectively are the guideline statements. They are clearly articulated, actionable, and presented together so that all guideline statements can be implemented. The distinction between them is based on the process by which they are derived, and that process is based on the framework methodology from the KDIGO Methods Committee and aligns with other international guideline groups using the “Grading of Recommendations Assessment, Development, and Evaluation” (GRADE) methodology. New developments in the refinement of evaluation of glomerular filtration rate (GFR), population and individual risk prediction, and novel treatments have all positively influenced the prognosis for people with CKD and are presented here. The Work Group has aimed to generate a guideline that is both rigorously devoted to new and existing evidence, and that is clinically useful. Research recommendations are presented in a separate section of the document and are intended to guide the next set of important research questions to inform and improve the outcomes of people living with CKD. We specifically urge the community to be inclusive of people across the lifecycle and include sex (referring to biological factors including genetics, sex steroids, physiology, and anatomy), gender (referring to sociocultural factors such as identity, roles, and relations), and etiology of CKD as important variables in all studies. We offer recommendations to clinicians and clinical laboratories to understand and promote the standardization and accuracy of testing tools including assays and equipment. The effective use of clinical practice guidelines and, therefore, effective patient care, including accurate diagnosis and referral prioritization, clinical research, and public health prioritization, requires comparability of laboratory results independent of time, place, and measurement procedure. Key to this is establishing precision of testing and between-laboratory agreement with traceability to accepted international reference standards wherever available. Therefore, this guidance document includes standards for laboratory tests. Specifically, we focus on creatinine and cystatin C, with the goal of normalizing access to both tests for increased accuracy of GFR assessment, and the assessment of urine albumin which is also critical to risk assessment and care plans. The guideline is organized into 6 chapters (Tables 1, 4, and 5 cover Chapters 1–5). In this summary, we outline the key evidence-based recommendations together with selected practice points by chapter. Readers are referred to the full guideline for a comprehensive description of benefits and harms, certainty of evidence, values and preferences, resource use and costs, factors affecting implementation, special considerations, and both general and specific research recommendations.Table 1Recommendations and practice points from Chapters 1 and 2 of the KDIGO 2024 Clinical Practice Guideline for Evaluation and Management of CKDChapter 1. Evaluation of CKD1.1 Detection and evaluation of CKD1.1.1 Detection of CKDPractice people at risk for and with kidney (CKD) using both urine albumin measurement and assessment of glomerular filtration rate of or GFR tests to of Methods for of In at risk for CKD, we recommend using glomerular filtration rate cystatin is available, the GFR be from the of creatinine and cystatin and cystatin glomerular filtration rate Evaluation of of of a of can be of of of of or and urine such as kidney and in such as and to or to and the not based upon a for and as the be the of a kidney or kidney of treatments for CKD at of GFR or CKD is to of other clinical Evaluation of the of CKD using clinical and and laboratory and genetic and diagnosis in full tests to a based on 6 in full We a kidney biopsy as an diagnostic to and guide clinically Evaluation of of the to the specific kidney of glomerular the general with the of of the to and other creatinine and an for assessment of GFR in full We recommend using in clinical is accurate and GFR clinical in full accurate of GFR GFR using or of an filtration in full the and limitations in both and glomerular filtration rate as well as the and factors that and cystatin of requires of the for in a in GFR the use of cystatin glomerular filtration rate in specific the implications of between and as be in both and of those urine for creatinine is not and is to be to clinical the laboratory standards of care in in full to accuracy and GFR using creatinine and cystatin clinical laboratories the of measurement of both creatinine and cystatin as an or as a referred creatinine in or their quality process include the of the of values for the of the use of creatinine assays in the of to creatinine in using the and the of and in the can be as in and the of 2 of GFR We recommend using a GFR to GFR from filtration than on the filtration the and and as large as such for and of in the of be GFR in using that have been developed or in Evaluation of for and 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