The draft order:
Sophia Ambruso
Nayan Arora
Swapnil Hiremath
AC Gomez
Joel Topf
Editor
Nayan Arora
Show Notes
Previous drafts:
2021 KDIGO Hypertension âJoel, Sophia, Swap, Nayan, Josh
2021 ASN Kidney Week DraftâJoel, Sophia, Swap, Nayan, Jennie
2022 The ISPD Peritonitis Guidelineâ Joel, Sophia, Swap, Nayan
2022 ASN Kidney Week DraftâJoel, Sophia, Swap, Nayan
2023 ASN Kidney Week DraftâJoel, Sophia, Swap, Nayan, AC, Josh
2024 KDIGO CKD Clinical Practice Guideline âJoel, Sophia, Swap, Nayan, Josh, AC
The guideline
The NephJC discussion Part 1 | Part 2
First Round
Sophiaâs Pick 3.7.1 We recommend treating patients with type 2 diabetes (T2D), CKD, and an eGFR âĽ20 ml/min per 1.73 m2 with an SGLT2i (1A).
Not Nayanâs Pick 3.7.3: We suggest treating adults with eGFR 20 to 45 ml/min per 1.73 m2 with urine ACR <200 mg/g (<20 mg/mmol) with an SGLT2i (2B).
Nayanâs Pick 2.2.1: In people with CKD G3âG5, we recommend using an externally validated risk equation to estimate the absolute risk of kidney failure (1A).
A birdie told me there will not be a Tangri KFRE vs the World debate at Kidney Week
The action points based on absolute risk results:
Practice Point 2.2.1: A 5-year kidney failure risk of 3%â5% can be used to determine need for nephrology referral in addition to criteria based on eGFR or urine ACR, and other clinical considerations.
Practice Point 2.2.2: A 2-year kidney failure risk of >10% can be used to determine the timing of multidisciplinary care in addition to eGFR-based criteria and other clinical considerations.
Practice Point 2.2.3: A 2-year kidney failure risk threshold of >40% can be used to determine the modality education, timing of preparation for kidney replacement therapy (KRT) including vascular access planning or referral for transplantation, in addition to eGFR-based criteria and other clinical considerations.
Swapâs Pick 3.15.1.1: In adults aged âĄ50 years with eGFR <60 ml/min per 1.73 m2 but not treated with chronic dialysis or kidney transplantation (GFR categories G3aâG5), we recommend treatment with a statin or statin/ezetimibe combination (1A).
ACâs Pick 3.7.2: We recommend treating adults with CKD with an SGLT2i for the following (1A):
eGFR âĽ20 ml/min per 1.73 m2 with urine ACR âĽ200 mg/g (âĽ20 mg/mmol), or
heart failure, irrespective of level of albuminuria. (1A)
Joelâs Pick 3.10.1: In people with CKD, consider use of pharmacological treatment with or without dietary intervention to prevent development of acidosis with potential clinical implications (e.g., serum bicarbonate <18 mmol/l in adults).
Practice Point 3.10.2: Monitor treatment for metabolic acidosis to ensure it does not result in serum bicarbonate concentrations exceeding the upper limit of normal and does not adversely affect BP control, serum potassium, or fluid status.
Freely Filtered 061: Bicarb in Transplant with Nav Tangri
Second Round
Joelâs Pick 3.3.1.1: We suggest maintaining a protein intake of 0.8 g/kg body weight/d in adults with CKD G3âG5 (2C).
Practice points related to protein intake:
3.3.1.1: Avoid high protein intake (>1.3 g/kg body weight/d) in adults with CKD at risk of progression.
3.3.1.2: In adults with CKD who are willing and able, and who are at risk of kidney failure, consider prescribing, under close supervision, a very lowâprotein diet (0.3â0.4 g/kg body weight/d) supplemented with essential amino acids or ketoacid analogs (up to 0.6 g/kg body weight/d).
3.3.1.3: Do not prescribe low- or very lowâprotein diets in metabolically unstable people with CKD.
ACâs Pick 3.9.1: In adults with T2D and CKD who have not achieved individualized glycemic targets despite use of metformin and SGLT2 inhibitor treatment, or who are unable to use those medications, we recommend a long-acting GLP-1 RA (1B).
Swapnilâs Pick Practice Point 5.4.1: Initiate dialysis based on a composite assessment of a personâs symptoms, signs, QoL, preferences, level of GFR, and laboratory abnormalities.
IDEAL Trial: A Randomized, Controlled Trial of Early versus Late Initiation of Dialysis NEJM
Timing of dialysis initiation to reduce mortality and cardiovascular events in advanced chronic kidney disease: nationwide cohort study NephJC
Nayanâs Pick Practice Point 1.1.4.2: Use tests to establish a cause based on resources available (Table 6b).
Sophiaâs Pick Practice Point 1.1.1.2: Following incidental detection of elevated urinary albumin-to-creatinine ratio (ACR), hematuria, or low estimated GFR (eGFR), repeat tests to confirm presence of CKD.
Joelâs cystatin C Tweet
The cystatin C guideline recommendation 1.1.2.1: In adults at risk for CKD, we recommend using creatinine-based estimated glomerular filtration rate (eGFRcr). If cystatin C is available, the GFR category should be estimated from the combination of creatinine and cystatin C (creatinine and cystatin Câ based estimated glomerular filtration rate [eGFRcr-cys]) (1B).
Nayanâs additional thoughts. He is not a fan of Practice Points 3.6.4 and 3.6.5
Practice Point 3.6.4 Continue ACEi or ARB therapy unless serum creatinine rises by more than 30% within 4 weeks following initiation of treatment or an increase in dose.
and
Practice Point 3.6.5: Consider reducing the dose or discontinuing ACEi or ARB in the setting of either symptomatic hypotension or uncontrolled hyperkalemia despite medical treatment, or to reduce uremic symptoms while treating kidney failure (estimated glomerular filtration rate [eGFR] <15 ml/min per 1.73 m2).
Tubular Secretion
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