Executive summary of the KDIGO 2024 Clinical Practice Guideline for the Evaluation and Management of Chronic Kidney Disease: known knowns and known unknowns

The Kidney Disease: Improving Global Outcomes (KDIGO) Clinical Practice Guideline for the Evaluation and Management of Chronic Kidney Disease (CKD) updates the KDIGO 2012 guideline and has been developed with patient partners, clinicians, and researchers around the world, using robust methodology. This update, based on a substantially broader base of evidence than has previously been available, reflects an exciting time in nephrology. New therapies and strategies have been tested in large and diverse populations that help to inform care; however, this guideline is not intended for people receiving dialysis nor those who have a kidney transplant. The document is sensitive to international considerations, CKD across the lifespan, and discusses special considerations in implementation. The scope includes chapters dedicated to the evaluation and risk assessment of people with CKD, management to delay CKD progression and its complications, medication management and drug stewardship in CKD, and optimal models of CKD care. Treatment approaches and actionable guideline recommendations are based on systematic reviews of relevant studies and appraisal of the quality of the evidence and the strength of recommendations which followed the "Grading of Recommendations Assessment, Development, and Evaluation" (GRADE) approach. The limitations of the evidence are discussed. The guideline also provides practice points, which serve to direct clinical care or activities for which a systematic review was not conducted, and it includes useful infographics and describes an important research agenda for the future. It targets a broad audience of people with CKD and their healthcare, while being mindful of implications for policy and payment. The Kidney Disease: Improving Global Outcomes (KDIGO) Clinical Practice Guideline for the Evaluation and Management of Chronic Kidney Disease (CKD) updates the KDIGO 2012 guideline and has been developed with patient partners, clinicians, and researchers around the world, using robust methodology. This update, based on a substantially broader base of evidence than has previously been available, reflects an exciting time in nephrology. New therapies and strategies have been tested in large and diverse populations that help to inform care; however, this guideline is not intended for people receiving dialysis nor those who have a kidney transplant. The document is sensitive to international considerations, CKD across the lifespan, and discusses special considerations in implementation. The scope includes chapters dedicated to the evaluation and risk assessment of people with CKD, management to delay CKD progression and its complications, medication management and drug stewardship in CKD, and optimal models of CKD care. Treatment approaches and actionable guideline recommendations are based on systematic reviews of relevant studies and appraisal of the quality of the evidence and the strength of recommendations which followed the "Grading of Recommendations Assessment, Development, and Evaluation" (GRADE) approach. The limitations of the evidence are discussed. The guideline also provides practice points, which serve to direct clinical care or activities for which a systematic review was not conducted, and it includes useful infographics and describes an important research agenda for the future. It targets a broad audience of people with CKD and their healthcare, while being mindful of implications for policy and payment. This 2024 update of the Kidney Disease: Improving Global Outcomes (KDIGO) Clinical Practice Guideline for the Evaluation and Management of Chronic Kidney Disease (CKD) heralds a new era in the care of people with kidney diseases. The majority of statements from the 2012 guideline have been updated based on current knowledge and practice. Only 6 statements were retained in their original form in 2012. There is clear and increasing recognition of CKD as a global public health problem. The inclusion of people with CKD in clinical trials has improved substantially, thus generating an evidence base upon which to recommend care and treatments that have not previously existed. There are increasing efforts to improve diagnostic evaluation of cause, with increased sophistication of imaging methods, biopsy interrogation, and genetic evaluation, as well as methods to optimize blood and urine testing. With advances in technology, such as molecular diagnostics for tissue samples, integrated omics platforms, and the use of machine learning/artificial intelligence to explore large databases of both clinical and biological data, we are truly at the beginning of a new era in nephrology. This guideline integrates existing and new knowledge to guide the care of people with CKD. It has been developed by an international Work Group that included patient partners, clinicians, and researchers with diverse experience across the spectrum of populations, a dedicated Evidence Review Team, and professional KDIGO staff. This clinical practice guideline includes 2 different types of statements: graded recommendations, which are supported by systematic reviews (i.e., de novo reviews conducted by the independent Evidence Review Team or existing high-quality reviews that have been systematically identified), and ungraded practice points, which serve to direct clinical care or activities for which a systematic review was not conducted for various reasons (e.g., lack of a sufficient evidence base or randomized controlled trials that would be impractical/unethical). Both recommendations and practice points are intended to help guide clinical practice and aid in decision-making; thus, collectively are the guideline statements. They are clearly articulated, actionable, and presented together so that all guideline statements can be implemented. The distinction between them is based on the process by which they are derived, and that process is based on the framework methodology from the KDIGO Methods Committee and aligns with other international guideline groups using the "Grading of Recommendations Assessment, Development, and Evaluation" (GRADE) methodology. New developments in the refinement of evaluation of glomerular filtration rate (GFR), population and individual risk prediction, and novel treatments have all positively influenced the prognosis for people with CKD and are presented here. The Work Group has aimed to generate a guideline that is both rigorously devoted to new and existing evidence, and that is clinically useful. Research recommendations are presented in a separate section of the document and are intended to guide the next set of important research questions to inform and improve the outcomes of people living with CKD. We specifically urge the community to be inclusive of people across the lifecycle and include sex (referring to biological factors including genetics, sex steroids, physiology, and anatomy), gender (referring to sociocultural factors such as identity, roles, and relations), and etiology of CKD as important variables in all studies. We offer recommendations to clinicians and clinical laboratories to understand and promote the standardization and accuracy of testing tools including assays and equipment. The effective use of clinical practice guidelines and, therefore, effective patient care, including accurate diagnosis and referral prioritization, clinical research, and public health prioritization, requires comparability of laboratory results independent of time, place, and measurement procedure. Key to this is establishing precision of testing and between-laboratory agreement with traceability to accepted international reference standards wherever available. Therefore, this guidance document includes standards for laboratory tests. Specifically, we focus on creatinine and cystatin C, with the goal of normalizing access to both tests for increased accuracy of GFR assessment, and the assessment of urine albumin which is also critical to risk assessment and care plans. The guideline is organized into 6 chapters (Tables 1, 4, and 5 cover Chapters 1–5). In this summary, we outline the key evidence-based recommendations together with selected practice points by chapter. Readers are referred to the full guideline for a comprehensive description of benefits and harms, certainty of evidence, values and preferences, resource use and costs, factors affecting implementation, special considerations, and both general and specific research recommendations.Table 1Recommendations and practice points from Chapters 1 and 2 of the KDIGO 2024 Clinical Practice Guideline for Evaluation and Management of CKDChapter 1. Evaluation of CKD1.1 Detection and evaluation of CKD1.1.1 Detection of CKDPractice Point 1.1.1.1: Test people at risk for and with chronic kidney disease (CKD) using both urine albumin measurement and assessment of glomerular filtration rate (GFR).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.1.1.2 Methods for staging of CKDRecommendation 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 C–based estimated glomerular filtration rate [eGFRcr-cys]) (1B).1.1.3 Evaluation of chronicityPractice Point 1.1.3.1: Proof of chronicity (duration of a minimum of 3 months) can be established by:(i)review of past measurements/estimations of GFR;(ii)review of past measurements of albuminuria or proteinuria and urine microscopic examinations;(iii)imaging findings such as reduced kidney size and reduction in cortical thickness;(iv)kidney pathological findings such as fibrosis and atrophy;(v)medical history, especially conditions known to cause or contribute to CKD;(vi)repeat measurements within and beyond the 3-month point.Practice Point 1.1.3.2: Do not assume chronicity based upon a single abnormal level for eGFR and ACR, as the finding could be the result of a recent acute kidney injury (AKI) event or acute kidney disease (AKD).Practice Point 1.1.3.3: Consider initiation of treatments for CKD at first presentation of decreased GFR or elevated ACR if CKD is deemed likely due to presence of other clinical indicators.1.1.4 Evaluation of causePractice Point 1.1.4.1: Establish the cause of CKD using clinical context, personal and family history, social and environmental factors, medications, physical examination, laboratory measures, imaging, and genetic and pathologic diagnosis (Figure 8aFigure 8 in full guideline.).Practice Point 1.1.4.2: Use tests to establish a cause based on resources available (Table 6bTable 6 in full guideline.). Recommendation 1.1.4.1: We suggest performing a kidney biopsy as an acceptable, safe, diagnostic test to evaluate cause and guide treatment decisions when clinically appropriate (2D).1.2 Evaluation of GFR1.2.1 Other functions of kidneys besides GFRPractice Point 1.2.1.1: Use the term "GFR" when referring to the specific kidney function of glomerular filtration. Use the more general term "kidney function(s)" when dealing with the totality of functions of the kidney.1.2.2 Guidance to physicians and other healthcare providersPractice Point 1.2.2.1: Use serum creatinine (SCr) and an estimating equation for initial assessment of GFR (Figure 11cFigure 11 in full guideline.).Recommendation 1.2.2.1: We recommend using eGFRcr-cys in clinical situations when eGFRcr is less accurate and GFR affects clinical decision-making (Table 8dTable 8 in full guideline.) (1C).Practice Point 1.2.2.2: Where more accurate ascertainment of GFR will impact treatment decisions, measure GFR using plasma or urinary clearance of an exogenous filtration marker (Table 9eTable 9 in full guideline.).Practice Point 1.2.2.3: Understand the value and limitations in both eGFR and measured glomerular filtration rate (mGFR) as well as the variability and factors that influence SCr and cystatin C measurements.Practice Point 1.2.2.4: Interpretation of SCr level requires consideration of dietary intake.Practice Point 1.2.2.5: Assess the potential for error in eGFR when assessing a change in GFR over time.Practice Point 1.2.2.6: Consider the use of cystatin C–based estimated glomerular filtration rate (eGFRcys) in some specific circumstances.Practice Point 1.2.2.7: Understand the implications of differences between eGFRcr and eGFRcys, as these may be informative, in both direction and magnitude of those differences.Practice Point 1.2.2.8: Consider timed urine collections for measured creatinine clearance if mGFR is not available and eGFRcr-cys is thought to be inaccurate.1.2.3 Guidance to clinical laboratoriesPractice Point 1.2.3.1: Implement the laboratory standards of care outlined in Table 11fTable 11 in full guideline. to ensure accuracy and reliability when assessing GFR using creatinine and cystatin C.Practice Point 1.2.3.2: Given available resources, clinical laboratories may consider the possibility of measurement of both creatinine and cystatin either as an in-house test or as a referred test.Special considerationsPediatric considerationsPractice Point 1.2.3.3: Laboratories measuring creatinine in infants or small children must ensure their quality control process include the lowest end of the expected range of values for the group of interest.Practice Point 1.2.3.4: Consider the consistent use of enzymatic creatinine assays in children, given the higher relative contribution of non-creatinine chromogens to measured creatinine in children when using the Jaffe assay, and the high prevalence of icteric and hemolyzed samples in the neonatal period.Practice Point 1.2.3.5: An eGFRcr level <90 ml/min per 1.73 m2 can be flagged as "low" in children and adolescents over the age of 2 years.1.2.4 Selection of GFR estimating equationsRecommendation 1.2.4.1: We recommend using a validated GFR estimating equation to derive GFR from serum filtration markers (eGFR) rather than relying on the serum filtration markers alone (1D).Practice Point 1.2.4.1: Use the same equation within geographical regions (as defined locally [e.g., continent, country, and region] and as large as possible). Within such regions, equations may differ for adults and children.Practice Point 1.2.4.2: Use of race in the computation of eGFR should be avoided.Special considerationsPediatric considerationsPractice Point 1.2.4.3: Estimate GFR in children using validated equations that have been developed or validated in comparable populations.1.3 Evaluation of albuminuria1.3.1 Guidance for physicians and other healthcare providersPractice Point 1.3.1.1: Use the following measurements for initial testing of albuminuria (in descending order of preference). In all cases, a first void in the morning midstream sample is preferred in adults and children.(i)urine ACR, or(ii)reagent strip urinalysis for albumin and ACR with automated reading.If measuring urine protein, use the following measurements:(i)urine protein-to-creatinine ratio (PCR),(ii)reagent strip urinalysis for total protein with automated reading, or(iii)reagent strip urinalysis for total protein with manual reading.Practice Point 1.3.1.2: Use more accurate methods when albuminuria is detected using less accurate methods.•Confirm reagent strip positive albuminuria and/or proteinuria by quantitative laboratory measurement and express as a ratio to urine creatinine wherever possible (i.e., quantify the ACR or PCR if initial semiquantitative tests are positive).•Confirm ACR ≥30 mg/g (≥3 mg/mmol) on a random untimed urine with a subsequent first morning void in the morning midstream urine sample.Practice Point 1.3.1.3: Understand factors that may affect interpretation of measurements of urine albumin and urine creatinine and order confirmatory tests as indicated (Table 16gTable 16 in full guideline.).Special considerationsPediatric considerationsPractice Point 1.3.1.4: In children, obtain a first morning urine sample for initial testing of albuminuria and proteinuria (in descending order of preference):(i)Both urine PCR and urine ACR,(ii)Reagent strip urinalysis for total protein and for albumin with automated reading, or(iii)Reagent strip urinalysis for total protein and for albumin with manual reading.1.3.2 Guidance to clinical laboratoriesPractice Point 1.3.2.1: Implement the laboratory reporting and handling standards outlined in Table 17hTable 17 in full guideline. to ensure accuracy and reliability of the findings when assessing urine samples.Practice Point 1.3.2.2: Implementation of an external quality assessment scheme/program for urine albumin and creatinine, including calculation of the ACR, is a preferred practice for laboratories.1.4 Point-of-care testingRecommendation 1.4.1: We suggest that point-of-care testing (POCT) may be used for creatinine and urine albumin measurement where access to a laboratory is limited or providing a test at the point-of-care facilitates the clinical pathway (2C).Practice Point 1.4.1: Whenever a POCT device is used for creatinine and urine albumin testing, ensure that the same preanalytical, analytical, and postanalytical quality criteria relating to the specimen collection and performance of the device, including external quality assessment, and the interpretation of the result is used.Practice Point 1.4.2: Where a POCT device for creatinine testing is being used, generate an estimate of GFR. Use the equation consistent with that used within the region.Practice Point 1.4.3: Where a POCT device is being used for albuminuria testing, the capability of also analyzing creatinine and producing an ACR is important. Assess the ability of the POCT ACR devices to produce a positive result in 85% of people with significant albuminuria (ACR ≥30 mg/g or ≥3 mg/mmol), as part of the evaluation and consideration of using the device.Chapter 2. Risk assessment in people with CKD2.1 Overview on monitoring for progression of CKD based upon GFR and ACR categoriesPractice Point 2.1.1: Assess albuminuria in adults, or albuminuria/proteinuria in children, and GFR at least annually in people with CKD.Practice Point 2.1.2: Assess albuminuria and GFR more often for individuals at higher risk of CKD progression when measurement will impact therapeutic decisions.Practice Point 2.1.3: For people with CKD, a change in eGFR of >20% on a subsequent test exceeds the expected variability and warrants evaluation.Practice Point 2.1.4: Among people with CKD who initiate hemodynamically active therapies, GFR reductions of >30% on subsequent testing exceed the expected variability and warrant evaluation.Practice Point 2.1.5: For albuminuria monitoring of people with CKD, a doubling of the ACR on a subsequent test exceeds laboratory variability and warrants evaluation.2.2 Risk prediction in people with CKDRecommendation 2.2.1: In people with CKD G3–G5, we recommend using an externally validated risk equation to estimate the absolute risk of kidney failure (1A).Practice Point 2.2.1: A 5-year kidney failure risk of 3%–5% 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.Practice Point 2.2.4: Note that risk prediction equations developed for use in people with CKD G3–G5, may not be valid for use in those with CKD G1–G2.Practice Point 2.2.5: Use disease-specific, externally validated prediction equations in people with immunoglobulin A nephropathy (IgAN) and autosomal dominant polycystic kidney disease (ADPKD).2.3 Prediction of cardiovascular risk in people with CKDPractice Point 2.3.1: For cardiovascular risk prediction to guide preventive therapies in people with CKD, use externally validated models that are either developed within CKD populations or that incorporate eGFR and albuminuria.Practice Point 2.3.2: For mortality risk prediction to guide discussions about goals of care, use externally validated models that predict all-cause mortality specifically developed in the CKD population.CKD, chronic kidney disease; KDIGO, Kidney Disease: Improving Global Outcomes.a Figure 8 in full guideline.b Table 6 in full guideline.c Figure 11 in full guideline.d Table 8 in full guideline.e Table 9 in full guideline.f Table 11 in full guideline.g Table 16 in full guideline.h Table 17 in full guideline. Open table in a new tab Table 4Recommendations and practice points from Chapter 3 of the KDIGO 2024 Clinical Practice Guideline for Evaluation and Management of CKDChapter 3. Delaying CKD progression and managing its complications3.1 CKD treatment and risk modificationPractice Point 3.1.1: Treat people with CKD with a comprehensive treatment strategy to reduce risks of progression of CKD and its associated complications (Figure 17aFigure 17 in full guideline.).3.2 Lifestyle factorsPractice Point 3.2.1: Encourage people with CKD to undertake physical activity compatible with cardiovascular health, tolerance, and level of frailty; achieve an optimal body mass index (BMI); and not to use tobacco products. Referral to providers and programs (e.g., psychologists, renal dietitians or accredited nutrition providers, pharmacists, physical and occupational therapy, and smoking cessation programs) should be offered where indicated and available.3.2.1 Avoiding use tobacco products[No specific recommendations or practice points]3.2.2 Physical activity and optimum weightRecommendation 3.2.2.1: We recommend that people with CKD be advised to undertake moderate-intensity physical activity for a cumulative duration of at least 150 minutes per week, or to a level compatible with their cardiovascular and physical tolerance (1D).Practice Point 3.2.2.1: Recommendations for physical activity should consider age, ethnic background, presence of other comorbidities, and access to resources.Practice Point 3.2.2.2: People with CKD should be advised to avoid sedentary behavior.Practice Point 3.2.2.3: For people at higher risk of falls, healthcare providers should provide advice on the intensity of physical activity (low, moderate, or vigorous) and the type of exercises (aerobic vs. resistance, or both).Practice Point 3.2.2.4: Physicians should consider advising/encouraging people with obesity and CKD to lose weight.Special considerationsPediatric considerationsPractice Point 3.2.2.5: Encourage children with CKD to undertake physical activity aiming for World Health Organization (WHO)-advised levels (i.e., ≥60 minutes daily) and to achieve a healthy weight.3.3 DietPractice Point 3.3.1: Advise people with CKD to adopt healthy and diverse diets with a higher consumption of plant-based foods compared to animal-based foods and a lower consumption of ultraprocessed foods.Practice Point 3.3.2: Use renal dietitians or accredited nutrition providers to educate people with CKD about dietary adaptations regarding sodium, phosphorus, potassium, and protein intake, tailored to their individual needs, and severity of CKD and other comorbid conditions.3.3.1 Protein intakeRecommendation 3.3.1.1: We suggest maintaining a protein intake of 0.8 g/kg body weight/d in adults with CKD G3–G5 (2C).Practice Point 3.3.1.1: Avoid high protein intake (>1.3 g/kg body weight/d) in adults with CKD at risk of progression.Practice Point 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 low–protein diet (0.3–0.4 g/kg body weight/d) supplemented with essential amino acids or ketoacid analogs (up to 0.6 g/kg body weight/d).Practice Point 3.3.1.3: Do not prescribe low- or very low–protein diets in metabolically unstable people with CKD.Special considerationsPediatric considerationsPractice Point 3.3.1.4: Do not restrict protein intake in children with CKD due to the risk of growth impairment. The target protein and energy intake in children with CKD G2–G5 should be at the upper end of the normal range for healthy children to promote optimal growth.Older adultsPractice Point 3.3.1.5: In older adults with underlying conditions such as frailty and sarcopenia, consider higher protein and calorie dietary targets.3.3.2 Sodium intakeRecommendation 3.3.2.1: We suggest that sodium intake be <2 g of sodium per day (or <90 mmol of sodium per day, or <5 g of sodium chloride per day) in people with CKD (2C).Practice Point 3.3.2.1: Dietary sodium restriction is usually not appropriate for patients with sodium-wasting nephropathy.Special considerationsPediatric considerationsPractice Point 3.3.2.2: Follow age-based Recommended Daily Intake when counseling about sodium intake for children with CKD who have systolic and/or diastolic blood pressure >90th percentile for age, sex, and height.3.4 Blood pressure controlRecommendation 3.4.1: We suggest that adults with high BP and CKD be treated with a target systolic blood pressure (SBP) of <120 mm Hg, when tolerated, using standardized office BP measurement (2B).Practice Point 3.4.1: Consider less intensive BP-lowering therapy in people with frailty, high risk of falls and fractures, very limited life expectancy, or symptomatic postural hypotension.Special considerationsPediatric considerationsRecommendation 3.4.2: We suggest that in children with CKD, 24-hour mean arterial pressure (MAP) by ambulatory blood pressure monitoring (ABPM) should be lowered to ≤50th percentile for age, sex, and height (2C).Practice Point 3.4.2: Monitor BP once a year with ABPM and every 3–6 months with standardized auscultatory office BP in children with CKD.Practice Point 3.4.3: In children with CKD, when ABPM is not available, it is reasonable to target manual auscultatory office SBP, obtained in a protocol-driven standardized setting, of 50th–75th percentile for age, sex, and height unless achieving this target is limited by signs or symptoms of hypotension.3.5 Glycemic controlPlease refer to the KDIGO 2022 Clinical Practice Guideline for Diabetes Management in Chronic Kidney Disease24Kidney Disease: Improving Global Outcomes Diabetes Work GroupKDIGO 2022 Clinical Practice Guideline for Diabetes Management in Chronic Kidney Disease.Kidney Int. 2022; 102: S1-S127Abstract Full Text Full Text PDF PubMed Scopus (234) Google Scholar for specific recommendations, practice points, and research recommendations.3.6 Renin-angiotensin system inhibitorsRecommendation 3.6.1: We recommend starting renin-angiotensin-system inhibitors (RASi) (angiotensin-converting enzyme inhibitor [ACEi] or angiotensin II receptor blocker [ARB]) for people with CKD and severely increased albuminuria (G1–G4, A3) without diabetes (1B).Recommendation 3.6.2: We suggest starting RASi (ACEi or ARB) for people with CKD and moderately increased albuminuria (G1–G4, A2) without diabetes (2C).Recommendation 3.6.3: We recommend starting RASi (ACEi or ARB) for people with CKD and moderately-to-severely increased albuminuria (G1–G4, A2 and A3) with diabetes (1B).Recommendation 3.6.4: We recommend avoiding any combination of ACEi, ARB, and direct renin inhibitor (DRI) therapy in people with CKD, with or without diabetes (1B).Practice Point 3.6.1: RASi (ACEi or ARB) should be administered using the highest approved dose that is tolerated to achieve the benefits described because the proven benefits were achieved in trials using these doses.Practice Point 3.6.2: Changes in BP, serum creatinine, and serum potassium should be checked within 2–4 weeks of initiation or increase in the dose of a RASi, depending on the current GFR and serum potassium.Practice Point 3.6.3: Hyperkalemia associated with use of RASi can often be managed by measures to reduce the serum potassium levels rather than decreasing the dose or stopping RASi.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.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).Practice Point 3.6.6: Consider starting people with CKD with normal to mildly increased albuminuria (A1) on RASi (ACEi or ARB) for specific indications (e.g., to treat hypertension or heart failure with low ejection fraction).Practice Point 3.6.7: Continue ACEi or ARB in people with CKD even when the eGFR falls below 30 ml/min per 1.73 m2.3.7 Sodium-glucose cotransporter-2 inhibitors (SGLT2i)Recommendation 3.7.1: We recommend treating patients with type 2 diabetes (T2D), CKD, and an eGFR ≥20 ml/min per 1.73 m2 with an SGLT2i (1A).Practice Point 3.7.1: Once an SGLT2i is initiated, it is reasonable to continue an SGLT2i even if the eGFR falls below 20 ml/min per 1.73 m2, unless it is not tolerated or KRT is initiated.Practice Point 3.7.2: It is reasonable to withhold SGLT2i during times of prolonged fasting, surgery, or critical medical illness (when people may be at greater risk for ketosis).Recommendation 3.7.2: We recommend treating adults with CKD with an SGLT2i for the following (1A):•eGFR ≥20 ml/min per 1.73 m2 with urine ACR ≥200 mg/g (≥20 mg/mmol), or•heart failure