16.2 KDIGO & Companion Guidelines: CKD 2024, CKD-MBD, Anemia 2026, Diabetes, BP, Lipids & AKI

KDIGO in brief

Kidney Disease: Improving Global Outcomes (KDIGO) is an international foundation that issues guidelines graded with the same system KDOQI uses: Level 1 "we recommend" or Level 2 "we suggest", evidence A–D, plus ungraded practice points. The NKF's KDOQI program writes U.S. commentaries on KDIGO guidelines. The CDR reference list names many KDIGO documents and several NKF commentaries. The exam can therefore ask about a KDIGO number, a KDOQI number, or the difference between them.

CKD Evaluation and Management (2024)

Nutrition-relevant content:

• Staging: cause, GFR category (G1–G5) and albuminuria category (A1–A3). Use race-free creatinine equations. Use cystatin C (eGFRcr-cys) when creatinine-based eGFR is less accurate or confirmation matters. Use validated risk equations (for example, the Kidney Failure Risk Equation) to estimate kidney-failure risk in G3–G5.
• Diet: healthy, diverse diets with more plant-based and fewer ultra-processed foods (practice point). Renal dietitians should educate on sodium, phosphorus, potassium and protein, tailored to the person (practice point).
• Protein: 0.8 g/kg/day for adults with CKD G3–G5 (2C). Avoid more than 1.3 g/kg/day in people at risk of progression (practice point). Consider a very low-protein diet (0.3–0.4 g/kg/day) with essential amino acids or ketoacids (up to 0.6 g/kg/day) under supervision for willing people at risk of kidney failure. Never restrict protein in metabolically unstable people.
• Sodium: below 2 g/day (below 90 mmol, or below 5 g of sodium chloride) (2C).
• Physical activity: at least 150 minutes per week of moderate activity, or as tolerated (1D).
• Metabolic acidosis: consider treatment, with or without dietary change, to prevent acidosis with clinical implications, for example bicarbonate below 18 mmol/L in adults. Do not raise bicarbonate above the upper limit of normal or harm BP, potassium or fluid status.
• Hyperkalemia: use an individualized approach combining diet and medication, with renal dietitian assessment (practice point).
• Kidney-protective drugs: RAAS blockade for albuminuria; SGLT2 inhibitors for many adults with CKD at eGFR 20 or above, including type 2 diabetes, heart failure or ACR of 200 mg/g or more (1A); a nonsteroidal MRA for type 2 diabetes with albuminuria; GLP-1 receptor agonists for glycemic and cardiovascular benefit in type 2 diabetes.

CKD-Mineral and Bone Disorder (2017 update)

• In G3a–G5D, lower elevated phosphate toward the normal range (2C) rather than treating to fixed numbers, and avoid hypercalcemia (2C).
• Restrict the dose of calcium-based phosphate binders in adults (2B), and avoid long-term aluminum binders.
• Limit dietary phosphate alone or with other treatments (2D), and consider the phosphate source (animal, vegetable or additives) when giving dietary advice.
• Dialysate calcium of 1.25–1.50 mmol/L (2.5–3.0 mEq/L) in G5D (2C).
• PTH in G5D: about 2–9 times the upper limit of normal for the assay (2C). Act on trends, not single values.
• Calcitriol and vitamin D analogs are not routine in G3a–G5 not on dialysis. Reserve them for severe, progressive hyperparathyroidism in G4–G5.
• Bone density testing to assess fracture risk if the result will change treatment.
• KDIGO no longer recommends using the calcium × phosphorus product; that <55 mg²/dL² target came from KDOQI 2003.

Anemia in CKD (2026 update, replacing 2012)

KDIGO published its updated anemia guideline in Kidney International 2026;109(1S):S1–S99.

• Iron in HD: start iron if ferritin is 500 ng/mL or less and TSAT is 30% or less (2D). Prefer IV iron (2D), given proactively to keep iron status stable.
• Iron in non-dialysis CKD and PD: start iron if ferritin is below 100 ng/mL with TSAT below 40%, or if ferritin is 100–300 ng/mL with TSAT below 25%. Use oral or IV iron based on preference and severity.
• Withhold routine iron when ferritin is above 700 ng/mL or TSAT is 40% or higher (practice point).
• Iron testing: every 3 months (non-dialysis and PD) and every 1–3 months (HD).
• ESA first: use an ESA rather than a HIF-PH inhibitor as first-line treatment once correctable causes are addressed (2D). Avoid HIF-PH inhibitors in people at high risk, such as those with prior cardiovascular or thrombotic events or active cancer.
• Start an ESA in G5D when hemoglobin is 9.0–10.0 g/dL or lower (2D). Aim below 11.5 g/dL during ESA maintenance (1D).

Diabetes Management in CKD (2022)

• HbA1c target individualized from below 6.5% to below 8.0%. Consider CGM or self-monitoring when HbA1c is unreliable.
• Protein about 0.8 g/kg/day for diabetes with CKD not on dialysis. Sodium below 2 g/day. A diet rich in vegetables, fruits, whole grains, fiber, legumes and plant proteins.
• Metformin when eGFR is 30 or above (dose-adjusted), an SGLT2 inhibitor when eGFR is 20 or above, and a GLP-1 RA when more glucose lowering is needed.

Blood pressure in CKD (2021)

• A systolic target below 120 mmHg, when tolerated, using standardized office measurement, for adults with CKD not on dialysis (2B).
• Sodium below 2 g/day and moderate physical activity.

Lipids in CKD (2013)

• Statin or statin/ezetimibe for adults 50 or older with eGFR below 60 not on dialysis (1A).
• Do not start statins in dialysis (2A), but continue existing therapy (2C). Statins are suggested for transplant recipients (2B).

Acute Kidney Injury (2012)

• Energy 20–30 kcal/kg/day in any stage of AKI (2C).
• Do not restrict protein to prevent or delay kidney replacement therapy (2D).
• Protein: 0.8–1.0 g/kg/day in non-catabolic AKI without dialysis; 1.0–1.5 g/kg/day on KRT; up to 1.7 g/kg/day on CRRT and in hypercatabolic patients (all 2D).
• Enteral feeding is preferred (2C). Critical-care nutrition guidance (ASPEN/SCCM 2016) goes higher, up to 2.5 g/kg/day on frequent or continuous KRT.

Transplantation

• The 2009 KDIGO transplant-recipient guideline covers lifestyle, lipids, diabetes, bone and infection after transplant.
• The 2020 KDIGO candidate guideline covers pre-transplant evaluation, including obesity, frailty and nutrition.

Where KDOQI and KDIGO differ

On the exam, read which source a question names. If none is named, choose the answer consistent with both sources, or the one the CDR reference list emphasizes for that topic (KDOQI 2020 for nutrition prescriptions).