The KDIGO 2024 guidelines focus on improving kidney disease outcomes, particularly chronic kidney disease (CKD) and its relationship with diabetes mellitus (DM). It emphasizes the importance of early screening and management strategies, including SGLT2 inhibitors and non-steroidal mineralocorticoid receptor antagonists, to slow CKD progression and provide cardiovascular benefits. The guidelines highlight the efficacy and safety of various treatments while noting the economic advantages of managing CKD in diabetic patients.

1. KDIGO 2024
What is there for
diabetologist /
endocrinologist?
Dr. Mahmoud Naguib

2. Introduc
tion
• The word KDIGO stands for “Kidney Disease:
Improving Global Outcomes”
• KDIGO is the global nonprofit organization that
aims at Improving the care and outcomes of
patients with kidney disease worldwide through
developing and implementing evidence-based
clinical practice guidelines in kidney disease.
• KDIGO guidelines focus on topics related to the
prevention or management of individuals with
kidney diseases.
• This year 2024, KDIGO released new
guidelines for the Evaluation and Management
of Chronic Kidney Disease.

5. CKD and DM
• CKD is one of the most important causes of morbidity and mortality
globally.
• DM is the most common cause of CKD worldwide.
• A systematic review suggested that screening for CKD is cost-
effective in people with diabetes and hypertension.
• Early diagnosis and slowing CKD progression at early stages should
provide economic benefits and prevent the development of kidney
failure and cardiovascular complications.

6. CKD
screen
ing

7. DM with
CKD
comprehens
ive
management

8. Renin-angiotensin system inhibitors

10. Monitor
ing

11. Despite use of RAS blockers, substantial residual risk for DKD
progression persisted, as the rate of decline with RAS blockers
was estimated to be between 4 and 6 mL/min/year and the normal
annual decline is approximately 0.7–0.9 mL/min/year. Thus,
additional therapies were needed.
In 2014, the discovery of sodium–glucose cotransporter 2 (SGLT2)
inhibitors provided hope that DKD progression could be further
slowed. This has clearly been shown in multiple outcomes trials.
Around the same time, trials were started on a novel class of
agents, (NS-MRAs), specifically finerenone which also slowed DKD.
We now have two evidence-based medications, which, when combined
with RAS inhibition, are proven to slow DKD progression to
approximately 2.5–3 mL/min/year, provided blood pressure and
glucose levels are at guideline goals.

12. Sodium-glucose cotransporter-2
inhibitors

13. SGLT2i
2022, 2024 2024

14. SGLT2i
benefits
• These recommendations were based on
Several large, placebo-controlled RCTs that
showed the efficacy of SGLT2i which:
Greatly reduce the risk of kidney failure,
AKI, and hospitalization for heart failure,
Moderately reduce the risk of cardiovascular
death and myocardial infarction in people
with and without CKD.
These benefits appear to be irrespective of
diabetes status, cause of kidney disease, or
level of GFR

15. SGLT2i
benefits
• Two large RCTs (EMPA-KIDNEY) &
(DAPA-CKD) using 2 different SGLT2i
recruited 10,913 participants and focused on
CKD populations at risk of progression,
reporting benefits in terms of kidney disease
progression and cardiovascular mortality.

18. SGLT2i
benefits
• In a collaborative metanalysis including those 2 and
11 other trials (13 trials with just over 90,000
randomized participants) in comparison with
placebo, those allocated to an SGLT2i experienced:
37% reduction in the risk of kidney disease progression
23% reduction in the risk of AKI irrespective of diabetes
status.
Reduced risk of the composite of cardiovascular death or
hospitalization for heart failure by 23% irrespective of
diabetes status.
10% RR reduction in MACE (Major adverse cardiovascular
events).
Reduced risk of hospitalization from any cause, reduced
BP, uric acid levels, weight/fluid overload, the risk of
serious hyperkalemia.

20. Rate of GFR decline

22. SGLT2i
harms
• SGLT2i are well tolerated with high levels of
adherence in the RCTs in CKD.
• In the studied populations, any risk of ketoacidosis
or lower-limb amputation resulting from SGLT2i
use was substantially lower than the potential
absolute benefits and generally restricted to people
with diabetes.

23. SGLT2i
harms
• The vast majority of urinary tract infections in
people taking SGLT2i are not caused by SGLT2
inhibition.
• There is no increased risk of hypoglycemia.
• There is an increased risk of mycotic genital
infections (in men and women), but these are
generally mild and can be treated with low-cost
topical agents.

24. SGLT2i
benefits vs
harms
• Meta-analysis estimates of absolute benefits and
harms:
For each 1000 people with CKD and T2D treated for 1
year with an SGLT2i were: 11 fewer cardiovascular
deaths or hospitalizations for heart failure, 11 fewer
people developing kidney disease progression and 4
fewer people with AKI for approximately 1 episode of
ketoacidosis and approximately 1 lower-limb
amputation.
For each 1000 people with CKD without DM treated
for 1 year with an SGLT2i 15 fewer people with kidney
disease progression, 5 fewer with AKI, and 2 fewer
cardiovascular deaths or hospitalizations for heart
failure with no excess risk of ketoacidosis or
amputation observed

25. SGLT2i
2022, 2024 2024

26. SGLT2i
• The Work Group judged that fully informed adults without diabetes and low levels of
albuminuria (urine ACR <200 mg/g [<20 mg/mmol]) who have established CKD and an
eGFR of 20–45 ml/min per 1.73 m2 may be particularly motivated to take SGLT2i for the
benefits identified on rate of decline in GFR
• Evidence for benefits on CKD progression in people without diabetes and with low levels of
albuminuria is limited to eGFR slope analyses in heart failure trials and one CKD trial all with
relatively short follow-up periods. However, extrapolation of these eGFR slope results
suggests that important benefits would arise for such people if treated long term and the
initiation of RRT can be delayed.

29. Mineralocorticoid receptor
antagonists

30. MRAs

31. MRAs
• The large (FIDELIO-DKD)
and(FIGARO-DKD) placebo-
controlled trials and
their pooled analysis
(FIDELITY) demonstrated
that the nonsteroidal MRA
(ns-MRA) finerenone
reduced cardiovascular
risk in people with CKD
and T2D
• These trials excluded non-
diabetic patients

36. Glucagon-like peptide-1 receptor
agonists

37. • Current evidence from trials in people with T2D where kidney function was generally
preserved suggests GLP-1 RA safely improve glycemic control and may reduce weight
and risk of CVD in people with CKD.
• Meta-analysis of large, placebo-controlled cardiovascular outcome GLP-1 RA trials has
shown reduced MACE in people with prior CVD or at high risk.
• Also, Modestly reduced risk of hospitalization for heart failure and death from any cause
• The size of RR reductions on cardiovascular risk appears similar in people with or
without decreased GFR.
• KDIGO 2022 has recommended that long-acting GLP-1 RAs are preferred before insulin
in people with T2D and CKD.
• GLP-1 RAs with proven cardiovascular benefit that do not require dose adjustment in
CKD include liraglutide, semaglutide (injectable), and dulaglutide

38. CKD and
DM
managemen
t
approach

39. CKD
managemen
t
approach