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Top 10 Takeaways for Nephrologists on Evaluation of People with or at Risk of CKD from the KDIGO 2024 Clinical Practice Guideline for the Evaluation and Management of Chronic Kidney Disease$7.99
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Top 10 Takeaways for Nephrologists on Evaluation of People with or at Risk of CKD from the KDIGO 2024 Clinical Practice Guideline for the Evaluation and Management of Chronic Kidney Disease
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Top 10 Takeaways for Nephrologists on Evaluation
of People with or at Risk of CKD from the KDIGO
2024 Clinical Practice Guideline for the Evaluation
and Management of Chronic Kidney Disease
top 10 takeaways for nephrologists on evaluation o
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Top Top 10 Takeaways for Nephrologists on Evaluation
of People with or at Risk of CKD from the KDIGO
10 2024 Clinical Practice Guideline for the Evaluation
and Management of Chronic Kidney Disease
Promote participation in high-quality research in CKD across the lifespan
Figure 1 Physical
1
CKD definition Nephrotoxic
exam
Symptoms and signs
of urinary tract
CKD is defined as abnormalities of kidney structure or function, present for >3 medications
abnormalities
months, with implications for health. The definition includes many different
markers of kidney damage, not just decreased GFR and ACR and the cause of Medical Social and
CKD should be actively sought (Figure 1). CKD is classified according to Cause, history environmental
history
GFR and ACR to establish severity and guide the type and timing of interven-
tions. Obtain careful family history
Symptoms and signs
for possible genetic causes,
of systemic diseases
including family pedigree for CKD
2
Laboratory tests, imaging, and tissue sample, such as:
Distinguish between AKD and CKD • Urinalysis and urine sediment • Ultrasound
• Urine albumin-to-creatinine ratio • Kidney biopsy
It is important to distinguish between AKD and CKD and to establish • Serologic tests • Genetic testing
chronicity (Figure 2).
Figure 2 Identify adults at risk for CKD
Test for GFR and ACR ± other markers of kidney damage
3
CKD care across the lifespan
CKD impacts people across the lifespan and as a chronic condition, care is GFR <60 ml/min per 1.73 m2 or ACR ≥30 mg/g [3 mg/mmol]
influenced by changes in life circumstances (Figure 3). Use a personalized and/or other markers of kidney damage present
approach to diagnosis, risk assessment, and management that considers age, sex,
and gender. At the extremes of age - the very young and the very old - diagnostic Test for GFR or ACR if not performed and exclude AKI/AKD
procedures, treatment aims, treatment modalities, and decision-making differ
due to differences in prognosis, treatment options, and prioritization.
GFR <60 ml/min per 1.73 m2 AKI/AKD present: GFR ≥60 ml/min per 1.73 m2 and
and/or ACR ≥30 mg/g follow AKI/AKD ACR <30 mg/g [3 mg/mmol]
4
[3 mg/mmol] after 3 months guidance and no other markers of
Diagnosis of CKD in older adults or earlier if evidence kidney damage present
of chronicity
Epidemiological population data support retaining the threshold GFR of CKD not present
60 ml/min/1.73 m2 for diagnosis of CKD in older adults, even in the absence Measure eGFRcr-cys if not Timing of retesting based on
of significant albuminuria, with consistently elevated and increasing performed and available individual characteristics such
as risk of progression
relative risk of adverse outcomes below this threshold (Figure 4).
Stage according to GFR and ACR
Establish underlying cause
Estimate risk of progression
Initiate treatment
5
Improving accuracy of GFR assessment
Estimating GFR from a combination of creatinine and cystatin C Figure 3
Child/adolescent Special considerations for CKD care across the lifespan
(eGFRcr-cys) improves accuracy and strengthens risk relationships. GFR
• Growth
should be measured where more accurate ascertainment of GFR will • Nutrition Sex
impact treatment decisions. • Weight/BSA-based drug dosing • Menopause
• Neurocognitive development • Contraception
• Supporting education • Differential drug effects
• Transition to adult care • Differing epidemiology
6
• Holistic approach to care for of risk factors and
the whole family unit
Accuracy and reliability complications
Understand the variability of GFR and urinary albumin and the value
Older adults
and limitations of the methodology of assessment when determining • Multidimensionality of
whether a change is a true change. Implement the requisite laboratory chronic conditions/
multimorbidity
standards of care to ensure accuracy and reliability. • Frailty (including sarcopenia)
Gender
Pregnancy/lactation • Cognitive function
• Gender identity
• Drug pharmacokinetics • Polypharmacy
• Gender roles
and pharmacodynamics • Prioritization
• Gender relations
7
• Drug teratogenicity • End-of-life care
Use a validated GFR estimating equation • Risk of CKD progression
• Increased risk of pregnancy
• Institutionalized
gender
Use a validated GFR estimating equation to derive GFR from serum complications, preterm birth and
filtration markers (eGFR) and use the same equation within geographical small for gestational age babies
• Fertility
regions recognizing that these equations may differ for adults and
children (Figure 2).
Figure 4 Age 65+ ACR, mg/g ACR, mg/g
eGFRcr-cys <10 10–29 30–299 300+ <10 10–29 30–299 300+
All-cause mortality Myocardial infarction
105+ 1.2 1.4 1.9 3.5 0.97 1.4 2.0 19
10
105+ 1.0 1.1 1.2 2.2 1.1 2.3 2.9 4.9
90–104 ref 1.1 1.3 1.4 ref 1.3 2.0 4.8
Timing assessment and reevaluation 60–89
45–59
1.1
1.2
1.2
1.2
1.3
1.4
1.5
1.6
1.3
2.0
1.6
2.8
2.0
3.1
3.2
3.1
Timing of follow up and reassessment using validated risk prediction 30–44
<30
1.5
1.9
1.4
1.9
1.6
2.0
2.0
2.6
3.5
8.4
2.8
4.1
3.8
5.9
5.9
10
tools and clinical evaluation, together with education, may inform better
selection of targets of care to support people and families living with
CKD. This approach is part of longitudinal care. ACR, albumin-to-creatinine ratio; AKD, acute kidney disease; CKD, chronic
kidney disease; cr, creatinine; cys, cystatin C; (e)GFR, (estimated) glomerular
filtration rate
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