New Guideline Updates to Slow CKD Progression and Reduce Cardiovascular Risk

The expansion of SGLT2i use beyond diabetes marks a significant shift in CKD management, supported by robust clinical evidence.

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An updated clinical practice guideline for the evaluation and management of chronic kidney disease (CKD) places greater emphasis on cystatin C as a preferred biomarker to improve the accuracy of glomerular filtration rate (GFR) measurement in CKD assessment.1 Another key update highlights the use of point-of-care testing for creatinine and urine albumin in areas with limited laboratory access to address disparities in early detection, according to a summary of the guideline’s highest-evidence recommendations published in the Annals of Internal Medicine.

The Kidney Disease: Improving Global Outcomes (KDIGO) organization updated its 2024 guideline based on an extensive evidence synthesis and meta-analysis conducted by an evidence review team from Johns Hopkins University. Relevant studies published through July 2023 were analyzed and recommendations were shaped by nephrologists, primary care physicians, internal medicine physicians, and individuals living with CKD. The full guideline contains 28 recommendations and 141 practice points, emphasizing the importance of individualized care at all stages of CKD.

Risk stratification remains central to CKD management, with strong evidence supporting the use of validated prediction equations, such as the Kidney Failure Risk Equation, to assess the likelihood of disease progression. The guideline also reinforces the benefits of sodium glucose co-transporter-2 inhibitors (SGLT2i) for individuals with CKD with or without diabetes for kidney and cardiovascular protection, in line with recent evidence-based diabetes, cardiorenal, and metabolic multispecialty practice recommendations.2 In the KDIGO guideline, statins are recommended for adults with CKD aged 50 and older, with evidence supporting their role in preventing cardiovascular disease (CVD) in this high-risk population.1

Expanding Benefits Beyond Diabetes With SGLT2i

Based on extensive evidence from large-scale, placebo-controlled trials, SGLT2i have been shown to significantly reduce the risk of kidney failure, acute kidney injury, and hospitalization for heart failure. These benefits extend beyond individuals with type 2 diabetes, as the guideline now recommends SGLT2i for adults with CKD and an estimated GFR (eGFR) greater than 20 mL/min/1.73m², particularly those with albuminuria or heart failure.

A comprehensive meta-analysis of 13 randomized trials, encompassing over 90,000 participants, demonstrated a 37% reduction in kidney disease progression and a 23% reduction in acute kidney injury with SGLT2i use, irrespective of diabetes status. The EMPA-KIDNEY (NCT03594110) trial further reinforced these findings, showing the greatest benefits in individuals with higher albuminuria levels. However, some uncertainty remains regarding the impact of SGLT2i on kidney disease progression in individuals without diabetes who have lower levels of albuminuria.

The guideline advises that once an SGLT2i is initiated, it is reasonable to continue treatment even if eGFR falls below 20 mL/min/1.73m², unless there are concerns about tolerance or kidney replacement therapy is required. However, temporary discontinuation may be warranted in cases of prolonged fasting, surgery, or critical illness due to an increased risk of ketosis. Importantly, SGLT2i initiation does not require alterations in the frequency of CKD monitoring, as an initial dip in eGFR is expected but does not indicate a need for discontinuation.

A Targeted Approach to Hyperuricemia Treatment

KDIGO provides updated guidance on the management of hyperuricemia in individuals with CKD, emphasizing a targeted approach based on symptomatology. The guideline recommends uric acid–lowering therapy for individuals with CKD who have symptomatic hyperuricemia, including those with tophaceous gout, radiographic joint damage, or frequent gout flares. However, for patients with CKD and asymptomatic hyperuricemia, the guideline suggests against routine uric acid–lowering treatment to delay CKD progression.

Despite observational studies suggesting a link between elevated serum uric acid levels and CKD progression, recent clinical trials have not demonstrated a clear kidney-protective benefit from lowering uric acid in asymptomatic individuals. The guideline highlighted that in a 2017 Cochrane systematic review, along with 3 subsequent large randomized controlled trials, no significant advantage was found in treating asymptomatic hyperuricemia in CKD. As a result, KDIGO’s recommendations prioritize evidence-based treatment strategies that focus on symptomatic relief rather than attempting to modify disease progression in asymptomatic patients.

Addressing Cardiovascular Risk in CKD via Statin Use

Given the well-established link between CKD and an increased risk of CVD, KDIGO reinforces its recommendation for statin therapy in adults with CKD, particularly those aged 50 years and older. The guideline aligns with KDIGO’s broader lipid management recommendations, advocating for statin or statin–ezetimibe combination therapy in individuals with CKD who are not receiving chronic dialysis or kidney transplantation.

For adults with CKD under 50 years of age, statins are recommended if they have additional cardiovascular risk factors, such as a history of coronary artery disease, diabetes, prior ischemic stroke, or a high estimated 10-year risk of myocardial infarction or cardiovascular death. Despite evidence supporting their benefits, statins remain underutilized in patients with CKD, particularly among those presenting with acute coronary syndrome. By emphasizing the role of statins in reducing cardiovascular risk, KDIGO expressed its aim to improve guideline adherence and optimize cardiovascular outcomes in this high-risk population.

The expansion of SGLT2i use beyond diabetes marks a shift in CKD management, supported by robust clinical evidence. Additionally, a more nuanced approach to hyperuricemia treatment ensures that only symptomatic patients receive uric acid–lowering therapy. The continued emphasis on statin therapy for CVD prevention underscores the need for proactive risk management in CKD. By integrating these evidence-based recommendations into clinical practice, the authors stated that health care providers can better tailor treatment strategies, ultimately improving outcomes for individuals living with CKD.

References

1. Madero M, Levin A, Ahmed SB, et al. Evaluation and management of chronic kidney disease: synopsis of the kidney disease: improving global outcomes 2024 clinical practice guideline. Ann Intern Med. Published online: March 11, 2025. doi:10.7326/ANNALS-24-01926

2. Handelsman Y. Diabetes, cardiorenal, and metabolic multispecialty practice recommendations and early intensive managedment of cardio-renal-metabolic disease. Am J Manag Care. 2024;30(suppl 10):S189-S196. https://doi.org/10.37765/ajmc.2024.89671