Nephrologists often encounter people with chronic kidney disease (CKD) who may present with different circumstances, such as an octogenarian with a high pill burden or a young adult making the transition from pediatric to adult care.
“One size does not fit all,” said Adeera Levin, MD, professor of medicine and head of the Division of Nephrology at The University of British Columbia, Vancouver, Canada. “You have to take the individual into consideration.”
With that in mind, a new CKD guideline from the Kidney Disease: Improving Global Outcomes (KDIGO) consortium aims to help nephrologists leverage the latest evidence, diagnostic tools, and medications to help them better personalize patient care (1). Levin, who cochaired the work group that created the guideline, noted that although some of the recommendations apply to all people with CKD, others acknowledge that the best patient care may sometimes depend on patient characteristics, such as life stage, gender, or the underlying cause of their condition.
New medications, developments in genetics and diagnostics, and research on subsets of patients have facilitated these more patient-centric recommendations. For example, the guideline recommends sodium-glucose cotransporter-2 inhibitors (SGLT2is) even for people with CKD who do not have diabetes to prevent CKD progression. It concurs with recommendations from a previous KDIGO guideline recommending SGLT2is for people with CKD and diabetes.
“Everyone is very excited; we now have drugs that we can recommend to modify kidney disease progression that also have other benefits,” Levin said. “This is the first time we’ve had strong evidence-based recommendations for the treatment of chronic kidney disease at all stages.”
The breadth of new recommendations in the guideline is the result of major progress in the field, according to a statement from the cochairs of the National Kidney Foundation's Kidney Disease Outcomes Quality Initiative (KDOQI), Sankar Navaneethan, MD, MS, MPH, FASN, Garabed Eknoyan, MD, Endowed Professor in Nephrology at Baylor College of Medicine in Houston, TX, and Jeffrey William, MD, assistant professor of medicine in nephrology at Harvard Medical School and internal medicine–nephrology physician at the Beth Israel Deaconess Medical Center in Boston, MA: “This is a testament to the broader effort by the nephrology scientific community and the funding agencies that have focused on improving early diagnosis, development of risk prediction tools, and generation of high-quality clinical trial evidence for various therapeutic options for CKD, a common, progressive, and expensive clinical condition.”
Diagnostic tools
Levin noted that an accurate evaluation of kidney function using all of the diagnostic tools available is the first step to providing good CKD care. The guideline recommends estimating glomerular filtration rates (GFRs) using creatinine and, when available, adding cystatin C. The evidence of the advantages of this approach has been accumulating over the past 10 years, but in the last 2 to 3 years, there has been a groundswell of support for making the change.
“We all know that [the] eGFR [estimated GFR] is still not perfect, but in some instances, we need the most accurate approach that we can get,” said workgroup member Rasheeda Hall, MD, MS, MBA, FASN, a nephrologist and associate professor of medicine at Duke University School of Medicine and staff physician at the Durham Veterans Affairs Health Care System in Durham, NC. “We felt like [the recommendation] was the best way to move everyone forward.”
The guideline also recommends using race-free equations to estimate GFR. Many countries already use race-free equations, but race-adjusted kidney function estimation has been common in the United States until recently. Based on evidence showing that race-corrected eGFRs disadvantaged Black individuals and delayed kidney care, the National Kidney Foundation-ASN Task Force on Reassessing the Inclusion of Race in Diagnosing Kidney Diseases in 2021 recommended dropping race-based formulas and using creatinine or, ideally, creatinine plus cystatin C for kidney function (2). The task force recommendation has led to rapid uptake of the change at many hospitals and prompted many laboratories to add in-house cystatin C. Hall noted that the guideline recommendation may help support policy changes needed to get more hospitals and laboratories on board.
The guideline also emphasizes the importance of identifying the cause of CKD in an individual based on their clinical evaluation, medical and family history, social and environmental factors, medications, and genetic or pathologic testing. “More and more we have targeted therapies for specific conditions, so it behooves us to know what the cause of kidney disease is [in an individual person] so that we can target the right therapy and even use the right prediction equation,” Levin said.
Reinforcing the guideline's benefits, another member of the workgroup, Lesley Inker, MD, director of the Kidney and Blood Pressure Center and the Kidney Function and Evaluation Center at Tufts Medical Center, Burlington, MA, explained that some kidney diseases, such as polycystic kidney disease or immunoglobulin A nephropathy, have specific therapies, and for other kidney diseases, there may be ongoing clinical trials in which patients may want to participate. Levin predicted that even more targeted therapies are on the horizon as nephrologists identify and learn more about the genetic causes of CKD.
LaVarne A. Burton, president and chief executive officer of the American Kidney Fund, in a statement in March applauded the new guideline's focus on both patient-centered care and its emphasis on finding undiagnosed causes for kidney diseases (3). She noted that 5% to 15% of people with kidney diseases do not know the cause of their condition. The American Kidney Fund launched its Unknown Causes of Kidney Disease Project in 2020 to research the impact of undiagnosed or misdiagnosed kidney diseases on patient care and outcomes.
Life-cycle approach
The CKD guideline also emphasizes a life-cycle-based approach that balances goal-directed therapy with the patient's needs, age, gender, use of gender-affirming therapies, and other circumstances. “People at different phases of life [experience] different kinds of kidney disease. Understanding the disease-specific and person-specific issues will help nephrologists make the best treatment plan for every individual,” Inker said.
Inker noted that treatment plans and treatment goals also must evolve over time as people age or their condition changes. Given the large number of older adults with CKD, Hall said, it was important for the guideline to emphasize the complexity of care for this subpopulation. She noted that in addition to frailty and loss of muscle mass with advanced age, these individuals are likely to be on multiple medications and have multiple prescribers. They may also have cognitive impairments that make medication changes and other instructions difficult to remember or follow.
The guideline also highlights the need for frequent medication reviews, dose adjustments, and collaborative care with pharmacists and other specialists to manage patients taking multiple medications. Levin stated that it is essential to check for known or unexpected drug interactions regularly and to make sure the medications that patients are taking are evidence informed. “The totality of patients’ medications needs to be looked at, again, in the context of the individual,” she said.
The guideline also encourages nephrologists to deploy a full spectrum of interventions to preserve kidney function, including nutrition and exercise, and provides information on managing patients’ symptoms. Additionally, it outlines steps for the management of co-occurring cardiovascular disease with medications such as statins in individuals with elevated cholesterol or SGLT2is in people with CKD and heart failure.
“Cardiac disease is the most common complication in chronic kidney disease,” Inker said. She noted a growing convergence of treatments for CKD, cardiovascular disease, and metabolic diseases like diabetes and obesity, such as glucagon-like peptide-1 receptor agonists (GLP-1RAs), which are also discussed in the guideline. Inker anticipates that convergence will grow.
Navaneethan and William noted that the medication recommendations reflect the results of recent large clinical trials. “Despite slow uptake, nephrologists are now getting more comfortable in using [SGLT2is], and we believe they should continue to focus on adapting their practice to incorporate goal-directed medical therapy, which includes the use of [renin-angiotensin-aldosterone system inhibitors] as well,” they wrote. “As evidence for other drugs such as GLP-1RA and ns-MRA [nonsteroidal mineralocorticoid receptor antagonist] emerges, sequential or combination therapy, especially for those with diabetic kidney disease, is also being recommended.”
They also highlight the guideline's emphasis on personalizing care, which they note is an increasing focus across medical specialties. “With several new therapeutic options becoming available (such as GLP-1RA and ns-MRA) and CKD being more common in the geriatric population, the KDIGO guideline provides a framework for adoption of these agents by considering various elements such as age, comorbid conditions, and access to medication.”
Navaneethan and William also applauded the guideline's emphasis on multidisciplinary, team-based care to achieve care personalization, reduce barriers to adherence, and match care to patients’ values.
“Nephrology is a team sport, and it's very hard to do all of these things and manage the complexity of the patient journey as a solo practitioner,” Levin said. She hopes the KDIGO guideline will help more institutions and countries embrace team-based care models.
References
- 1.↑
Kidney Disease: Improving Global Outcomes (KDIGO) CKD Work Group. KDIGO 2024 Clinical Practice Guideline for the Evaluation and Management of Chronic Kidney Disease. Kidney Int 2024 105:S117–S314. doi: 10.1016/j.kint.2023.10.018
- 2.↑
Delgado C, et al. A unifying approach for GFR estimation: Recommendations of the NKF-ASN Task Force on Reassessing the Inclusion of Race in Diagnosing Kidney Disease. J Am Soc Nephrol 2021; 32:2994–3015. doi: 10.1681/ASN.2021070988
- 3.↑
American Kidney Fund. American Kidney Fund applauds new KDIGO 2024 Chronic Kidney Disease Guideline. March 14, 2024. Accessed April 12, 2024. https://www.kidneyfund.org/article/american-kidney-fund-applauds-new-kdigo-2024-chronic-kidney-disease-guideline
