Chronic kidney disease: new KDIGO guidelines

KDIGO (Kidney Disease: Improving Global Outcomes) is a global non-profit organization that develops and implements evidence-based clinical practice guidelines for kidney disease. The KDIGO Guidelines translate global scientific evidence into practical recommendations for doctors and patients.

This set of clinical recommendations, developed by experts in nephrology and the care of patients with kidney diseases, provides recommendations based on the most up-to-date scientific evidence for the diagnosis, management and treatment of various pathologies with the main aim of improving patient care. Does. and promoting better outcomes in terms of kidney health and quality of life.

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The 2023 KDIGO guidelines for chronic kidney disease are an update of the 2012 guidelines for the evaluation and management of this condition. These guidelines have not been published in their final version as they were available for public review until 4 September after their presentation at the 2023 European Renal Association (ERA) Congress. The document consists of 325 pages, divided into five parts.

Classification of Chronic Kidney Disease

The classification of chronic kidney disease based on glomerular filtration rate and albuminuria remained unchanged from the 2012 guidelines. However, this new guide places great emphasis on exploring the cause of chronic kidney disease in all individuals, even with kidney biopsy, as this has an impact on the patient’s treatment and prognosis.

Similarly, they emphasize the use of cystatin C as a biomarker for the diagnosis of kidney disease, especially in patients where serum creatinine levels are not reliable (e.g., malnutrition, cancer patients, amputation, etc.). . They recommend the use of the CKD-EPI cystatin-creatinine formula to estimate glomerular filtration rate in these patients.

Risk of increasing chronic kidney disease

To assess the risk of developing chronic kidney disease, guidelines recommend using calculators validated for this purpose. The most widely used is the KFRE (Kidney Failure Risk Equation), which uses readily available laboratory parameters to evaluate the risk of progression to renal replacement therapy at 2 and 5 years. This information is useful for making clinical decisions, such as:

  • KFRE of 3% to 5% at 5 years: Referral to a nephrologist is recommended.
  • KFRE of 10% at 2 years: Multidisciplinary management is recommended.
  • KFRE of 40% at 2 years: It is recommended to refer the patient for transplantation and prepare him for renal replacement therapy.

There are other sources for predicting progression to chronic kidney disease in people with immunoglobulin A nephropathy and autosomal dominant polycystic kidney disease.

Delaying the progression of chronic kidney disease

In this section, updates were more relevant due to new advances in the treatment of chronic kidney disease provided by the guidelines. The document recommends among other things:

  • Plant-based diet, protein intake of 0.8 g/kg/day (in patients with chronic kidney disease grades 3 to 5) without sarcopenia, cachexia or malnutrition and reduced consumption of ultra-processed foods. In addition to evaluation by a certified nutritionist. On the other hand, the diet must be individualized according to the needs of each patient.
  • Use of sodium-glucose cotransporter type 2 inhibitors in patients with chronic kidney disease (regardless of their diabetic status) with a glomerular filtration rate >20 ml/min/1.73m2. Serial measurements of serum creatinine are not recommended in patients starting these medications. Those who will benefit most are those who also have albuminuria and are at high cardiovascular risk.
  • Use of non-steroidal mineralocorticoid receptor antagonists (finerenone) in all patients with chronic kidney disease with type 2 diabetes, glomerular filtration rate >25 ml/min/1.73 m2 and albuminuria despite maximum doses of renin-angiotensin-aldosterone despite system blockade -converting enzyme inhibitors or angiotensin 2 receptor antagonists. Patients with persistent potassium >4.8 mmol/l despite medical treatment are not candidates for these medications.

Guidelines argue against treating asymptomatic hyperuricemia to slow the progression of chronic kidney disease.


Regarding metabolic acidosis, if it fell below 22 mmol/l, treatment with sodium bicarbonate was first recommended; However, new guidelines recommend treating it with dietary modification (plant-based diet) and only with oral sodium bicarbonate if it falls below 16 mmol/L.

proper use of medicines

The new KDIGO guidelines emphasize changes in the pharmacodynamics and kinetics of drugs in patients with chronic kidney disease. They assure that it is very important to adjust the dosage of drugs according to the kidney function of each patient.

Similarly, without evidence at this time, it is recommended to suspend sick day regimens for medications that may interfere with renal hemodynamics during diseases associated with extracellular volume contraction or before surgery.

On the other hand, it is suggested to avoid “renalism”, that is, withholding procedures or studies on patients for fear of altering kidney function. The most obvious example is the use of contrast media for diagnostic/medical studies or procedures. We know that patients who are not properly studied or treated because of this “precaution” have worse outcomes. Gadolinium can be used safely in patients with advanced kidney disease, as long as it is group II or III gadolinium.

KDIGO What is it and what is its scope?

KDIGO is a global organization that develops and implements evidence-based clinical practice guidelines in kidney disease. It is an independent, self-managed and volunteer-led foundation established in Belgium and accountable to the public and patients. It has a network of dedicated volunteers around the world who promote awareness, dissemination, adoption and clinical integration of KDIGO guidelines both globally and in their own countries or regions.

Its name in Spanish is “Kidney Disease: Improving Global Outcomes” and was originally established in 2003 by the National Kidney Foundation, a US foundation with experience in developing and implementing guidelines. In 2013, KDIGO became an independently incorporated non-profit foundation and is governed by an international volunteer executive committee.

In terms of its funding, KDIGO relies on corporate and volunteer support to educate the global kidney community and improve outcomes for patients around the world. They create knowledge and awareness through KDIGO and their donations here. Are recognized for. KDIGO partners provide general and strategic support to the KDIGO Foundation, as well as direct support for specific programs, such as conflict conferences and educational resource development. However, KDIGO does not receive corporate support for clinical practice guidelines.

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