Guideline sources The following summarized guidelines for the evaluation and management of chronic kidney disease are prepared by our editorial team based on guidelines from the American Diabetes Association (ADA 2023), the American College of Radiology (ACR 2023; 2021), the Canadian Cardiovascular Society (CCS 2022), the Kidney Disease: Improving Global Outcomes Foundation (KDIGO 2021; 2020; 2018; 2017; 2013; 2012; 2009; 2008), the United Kingdom Kidney Association (UKKA 2021; 2017; 2011), the Infectious Diseases Society of America (IDSA/AASLD 2020), the Japanese Society of Nephrology (JSN 2019), the Diabetes Canada Guidelines (Diabetes Canada 2018), the American College of Physicians (ACP 2016; 2013), the European Renal Best Practice Foundation (ERBP 2015), the Infectious Diseases Society of America (IDSA 2014), the Canadian Society of Nephrology (CSN 2014), the Japanese Society of Dialysis Therapy (JSDT 2013), the U.S. https://web.pathway.md/diseases/recIwpUFjFfYxzh1Y 1/32 6/29/23, 3:54 AM Chronic kidney disease Pathway Preventive Services Task Force (USPSTF 2012), and the American Society for Parenteral and Enteral Nutrition (ASPEN 2010). 1 2 3 4 5 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 Definition CKD is defined as the presence of kidney damage persisting for more than 3 months, which is manifested by decreased kidney function or albuminuria, measured by eGFR. 30 Epidemiology The most common causes of CKD include diabetes and hypertension. Other causes include infectious glomerulonephritis, renal vasculitis, ureteral obstruction, genetic alterations, and autoimmune diseases. 31 Disease course CKD may be asymptomatic or result in vague symptoms, such as excessive tiredness, itching, sleep disturbance, lack of concentration, bone/joint pain, loss of appetite, loss of muscle strength, dyspnea, muscle spasm, and restless legs. Disease progression may lead to end-stage renal disease with uremic symptoms, and death. 32 Prognosis and risk of recurrence The mortality of patients 60 years and > 60 years with CKD requiring hospital admission is 13.9% and 41.0%, respectively. 33 Calculator Diagnostic criteria for chronic ki Guidelines 1. Screening and diagnosis Indications for screening, asymptomatic patients: As per ACP 2013 guidelines, do not obtain screening for CKD in asymptomatic adults without risk factors for CKD. D As per USPSTF 2012 guidelines, insufficient evidence to assess the balance of benefits and harms of routine screening for CKD in asymptomatic adults. I Indications for screening, diabetic patients: As per ADA 2023 guidelines: https://web.pathway.md/diseases/recIwpUFjFfYxzh1Y 2/32 6/29/23, 3:54 AM Chronic kidney disease Pathway Assess urinary albumin (such as spot urinary albumin-to-creatinine ratio) and eGFR at least annually in all patients with T2DM regardless of treatment. B Monitor urinary albumin (such as spot urinary albumin-to-creatinine ratio) and eGFR 1-4 times per year depending on the stage of the disease in patients with established diabetic kidney disease. B As per Diabetes Canada 2018 guidelines, screen for CKD using a random urine albumin-to- creatinine ratio and a serum creatinine converted into an eGFR at diagnosis in patients with T2DM and 5 years after diagnosis in adult patients with T1DM, and yearly thereafter. B Indications for screening (pediatric patients): consider obtaining urinary screening at 3 years of age and throughout school age to detect CKD at an early stage, thus, facilitating early management and improving the renal prognosis in pediatric populations. C Diagnostic criteria: As per JSN 2019 guidelines, define CKD as the presence of either of the following conditions lasting for > 3 months: kidney damage findings (abnormal findings in blood or urinary tests, imaging studies or pathological evaluations), particularly evidence of urinary protein-to-creatinine ratio 0.15 g/g (urinary albumin-to-creatinine ratio 30 mg/g) GFR < 60 mL/min/1.73 m . A As per Diabetes Canada 2018 guidelines, establish a diagnosis of CKD on the basis of an eGFR < 60 mL/min/1.73 m and/or random urine albumin-to-creatinine ratio 2.0 mg/mmol on at least 2 of 3 samples over a 3-month period. B As per KDIGO 2013 guidelines, define CKD as abnormalities of kidney structure or function, present for > 3 months, with implications for health. 2. Classification and risk stratification Risk stratification: Identify the following variables in predicting risk for outcome of CKD: cause of CKD GFR category albuminuria category other risk factors and comorbid conditions. Show 2 more Classification: As per JSN 2019 guidelines, assess CKD severity based on cause, GFR category, and degree of proteinuria/albuminuria based on the CGA classification. A As per KDIGO 2013 guidelines, classify CKD based on cause, GFR category, and albuminuria category. B https://web.pathway.md/diseases/recIwpUFjFfYxzh1Y 3/32 6/29/23, 3:54 AM Chronic kidney disease Pathway 3. Diagnostic investigations Renal function tests: use serum creatinine and a GFR estimating equation for initial assessment. B Show 2 more Renal ultrasound: Obtain renal ultrasound as initial imaging for CKD to assess for small and/or scarred kidneys. B Obtain renal ultrasound as initial imaging for renal failure of unknown duration to detect hydronephrosis and evaluate renal size and morphology. B Evaluation of proteinuria: As per ACP 2013 guidelines, do not test for proteinuria in adult patients currently taking an ACEI or an ARB, with or without diabetes. D As per KDIGO 2013 guidelines: Consider one of the following tests to assess proteinuria, in descending order of preference: urine albumin-to-creatinine ratio urine protein-to-creatinine ratio reagent strip urinalysis for total protein with automated reading reagent strip urinalysis for total protein with manual reading. Test for speci c urine proteins (such as alpha-1 microglobulin, monoclonal heavy or light chains, known in some countries as Bence Jones proteins) if signi cant non-albumin proteinuria is suspected. Evaluation of albuminuria: Consider obtaining the following measurements for initial testing of proteinuria (in descending order of preference, preferring an early morning urine sample in all cases): urine albumin-to-creatinine ratio urine protein-to-creatinine ratio reagent strip urinalysis for total protein with automated reading reagent strip urinalysis for total protein with manual reading. Show 4 more Evaluation of hypertension: obtain standardized office BP measurement in preference to routine office BP measurement for the management of high BP in adult patients. B Show 4 more Evaluation of dyslipidemia: Obtain a lipid profile (total cholesterol, LDL cholesterol, HDL cholesterol, triglycerides) in adult and pediatric patients with newly identified CKD (including patients treated with chronic dialysis or kidney transplantation). B Do not obtain follow-up assessment of lipid levels in the majority of adult patients with CKD (including patients treated with chronic dialysis or kidney transplantation) Consider obtaining https://web.pathway.md/diseases/recIwpUFjFfYxzh1Y 4/32 6/29/23, 3:54 AM Chronic kidney disease Pathway annual measurements of fasting lipid levels in pediatric patients. Evaluation of mineral and bone disorders: As per KDIGO 2017 guidelines, consider measuring serum PTH or bone-specific ALP for the evaluation of bone disease in patients with CKD stages 3-5D as markedly high or low values predict underlying bone turnover. C Show 3 more As per JSDT 2013 guidelines, consider measuring serum phosphorus, calcium, albumin, PTH, and alkaline phosphate levels in the routine evaluation for CKD-mineral and bone disorder. C Show 4 more As per KDIGO 2013 guidelines, measure serum levels of calcium, phosphate, PTH, and ALP activity at least once in adult patients with GFR < 45 mL/min/1.73 m , in order to determine baseline values and inform prediction equations. B As per UKKA 2011 guidelines, consider monitoring serum levels of calcium, phosphate, ALP, PTH, and 25-hydroxyvitamin D in patients with CKD stages 3-5 and patients on dialysis, with a frequency based on stage, rate of progression, and whether specific therapies have been initiated. Evaluation for etiology: evaluate for the cause of CKD on the basis of presence or absence of systemic disease and the location within the kidney of observed or presumed pathologic-anatomic ndings. Screening for anemia: As per UKKA 2017 guidelines, consider measuring Hgb levels at least at following intervals to screen for anemia in patients with CKD: stage 3: once per year stage 4-5, non-dialysis: twice per year. C As per KDIGO 2012 guidelines, measure Hgb concentration in patients with CKD without anemia when clinically indicated and at least at the following intervals according to the stage of CKD: Situation Guidance Once per year Stage 3 Twice per year Stage 4-5, non-dialysis Every 3 months. Stage 5, on hemodialysis or peritoneal dialysis Screening for HCV infection: screen all patients for HCV infection at the time of initial evaluation of CKD. B Obtain an immunoassay followed by nucleic acid testing if the immunoassay is positive. B Show 8 more https://web.pathway.md/diseases/recIwpUFjFfYxzh1Y 5/32 6/29/23, 3:54 AM Chronic kidney disease Pathway Screening for peripheral artery disease: obtain regular assessment for signs of peripheral arterial disease in adult patients with CKD, and consider offering the usual approaches to therapy. B 4. Medical management General principles: manage people with progressive CKD in a multidisciplinary care setting. B Show 2 more Renal adjustment of medications: As per JSN 2019 guidelines, take into account kidney function and modify administration methods and doses of renally excreted drugs in patients with CKD to reduce the possibility of adverse events. B Show 2 more As per KDIGO 2013 guidelines: Take GFR into account when selecting drug dosing. B Calculate GFR using methods based upon cystatin C or via direct measurement: when more precise estimates renal function are required due to narrow therapeutic or toxic range when estimates may be unreliable (e.g., due to low muscle mass). B Sodium-glucose cotransporter-2 inhibitors: As per CCS 2022 guidelines, initiate SGLT-2 inhibitors to reduce the composite of significant decline in eGFR, progression to end-stage kidney disease, or kidney death, all-cause and cardiovascular mortality, nonfatal myocardial infarction, and hospitalization for HF in adult patients with CKD (urine albumin-to-creatinine ratio > 20 mg/mmol and eGFR 25 mL/min/1.73 m ). B Updated evidence: EMPA-KIDNEY In patients with CKD with an eGFR 20 and < 45 mL/min/1.73 m , or 45 and < 90 mL/min/1.73 m with a urinary albumin-to-creatinine ratio 200, empagliflozin was superior to placebo with respect to progression of kidney disease or death from cardiovascular causes. EMPA-KIDNEY Collaborative Group et al. N Engl J Med. 2023 Jan 12. As per UKKA 2021 guidelines: Consider monitoring bone parameters, including calcium, phosphate, and PTH, as appropriate for the CKD stage, in patients with CKD receiving SGLT-2 inhibitors. C Consider withholding SGLT-2 inhibitors for the duration of the fasting period in patients with CKD choosing to intermittently fast (such as for Ramadan). C Uric acid-lowering agents: https://web.pathway.md/diseases/recIwpUFjFfYxzh1Y 6/32 6/29/23, 3:54 AM Chronic kidney disease Pathway As per JSN 2019 guidelines, consider initiating uric acid-lowering therapy to slow the progression of renal dysfunction and reduce urinary protein excretion in patients with CKD and hyperuricemia. C As per KDIGO 2013 guidelines, insufficient evidence to support or refute the use of uric acid- lowering agents concentrations to delay progression of CKD. Management of microalbuminuria: consider ARBs or ACEIs in adults with diabetes, non- dialysis-dependent CKD, and urine albumin excretion of 30-300 mg/day or equivalent. C Management of hypertension (general principles): adapt antihypertensive therapy according age, comorbidities, and concomitantly administered medications in elderly patients with non- dialysis dependent CKD. Escalate treatment gradually and monitor closely for treatment-related adverse events, including electrolyte disorders, acute deterioration in kidney function, orthostatic hypotension and other drug side effects. Management of hypertension, BP targets: As per KDIGO 2021 guidelines, consider targeting systolic BP of < 120 mmHg, when tolerated, using standardized office BP measurement in adult patients with hypertension and CKD. C Show 2 more As per JSN 2019 guidelines, set a systolic BP reduction of no less than 110 mmHg in adult patients with hypertension and CKD, regardless of the CKD stage. B Show 3 more As per ERBP 2015 guidelines: Avoid applying lower BP targets in patients with diabetes and CKD stage 3b (eGFR < 45 mL/min/1.73 m ) than in the general population. D Consider offering all BP-lowering drugs equally to lower BP in patients with diabetes and CKD stage 3b (eGFR < 45 mL/min/ 1.73 m ) without proteinuria. C As per KDIGO 2013 guidelines, initiate BP-lowering agents if of ce BP is consistently > 140 mmHg systolic or > 90 mmHg diastolic in non-diabetic adults with non-dialysis-dependent CKD and urine albumin excretion < 30 mg/day. Target a BP < 140 mmHg systolic and < 90 mmHg diastolic. B Show 4 more Management of hypertension (physical activity): consider advising patients with CKD and hypertension to practice moderate-intensity physical activity for a cumulative duration of at least 150 minutes/week or to a level compatible with their cardiovascular and physical tolerance. C Show 2 more Management of hypertension (sodium intake): consider advising patients with CKD and hypertension to target a sodium intake of < 2 g of sodium per day (or < 90 mmol of sodium per day or < 5 g of sodium chloride per day). C Show 2 more Management of hypertension, RAAS blockers: https://web.pathway.md/diseases/recIwpUFjFfYxzh1Y 7/32 6/29/23, 3:54 AM Chronic kidney disease Pathway As per KDIGO 2021 guidelines, initiate RAAS inhibitors (ACEI or ARB) in patients with hypertension, CKD, and severely increased albuminuria (G1-G4, A3) without diabetes. B Show 10 more Updated evidence: STOP-ACEi In adult patients with advanced and progressive CKD, renin-angiotensin system inhibitor discontinuation was not superior to renin-angiotensin system inhibitor continuation with respect to eGFR at 3 years. Sunil Bhandari et al. N Engl J Med. 2022 Dec 1. As per JSN 2019 guidelines: Initiate ACEIs or ARBs in patients with CKD with diabetes mellitus (A1-A3 category) and without diabetes mellitus (A2-A3 category). B Initiate ACEIs or ARBs in patients with CKD without diabetes (A1 category). B As per ACP 2013 guidelines, initiate either an ACEI B or an ARB in patients with hypertension and CKD stage 1-3. A As per KDIGO 2013 guidelines: Consider initiating ACEIs or ARBs in non-diabetic adult patients with CKD and urine albumin excretion of 30-300 mg/24 hours (or equivalent) if treatment with BP-lowering drugs is indicated. C Initiate ACEIs or ARBs in non-diabetic adult patients with CKD and urine albumin excretion > 300 mg/24 hours (or equivalent) if treatment with BP-lowering drugs is indicated. B Management of hypertension (CCBs): initiate CCBs in patients with CKD without diabetes (A1 category). B Show 2 more Management of hypertension (diuretics): initiate thiazide diuretics in patients with CKD without diabetes (A1 category). B Management of hypertension, kidney transplant recipients: As per KDIGO 2021 guidelines: Set a target systolic BP of < 130 mmHg and diastolic BP of < 80 mmHg using standardized office BP measurement in adult kidney transplant recipients with hypertension. B Consider initiating a dihydropyridine CCB or an ARB as a first-line antihypertensive agent in adult kidney transplant recipients. C As per KDIGO 2013 guidelines, take into account the following factors when selecting a BP- lowering agent in adult kidney transplant recipients: time after transplantation concomitant use of calcineurin inhibitors presence of persistent albuminuria https://web.pathway.md/diseases/recIwpUFjFfYxzh1Y 8/32 6/29/23, 3:54 AM Chronic kidney disease Pathway other pertinent comorbid conditions. Management of hypertension, pediatric patients: As per KDIGO 2021 guidelines, consider lowering 24-hour mean arterial pressure by ambulatory BP monitoring to 50th percentile for age, sex, and height in pediatric patients with CKD. C Show 3 more As per KDIGO 2013 guidelines, initiate BP-lowering agents in children with non-dialysis- dependent CKD whose BP is consistently above the 90th percentile for age, sex, and height. B Show 2 more Management of hypertension (patients with cardiovascular disease): initiate ACEIs, ARBs, or -blockers as initial antihypertensive therapy in patients with CKD and coronary artery disease. A Show 7 more Management of hypertension (patients with nephrosclerosis and renal artery stenosis): avoid reducing BP strictly to a systolic pressure of < 120 mmHg in patients with CKD caused by nephrosclerosis with hypertension, especially in A1 category proteinuria due to the risk of AKI. Consider setting a target level of < 140/90 mmHg. D Show 3 more Management of dyslipidemia: As per JSN 2019 guidelines: Initiate lipid-lowering therapy with statins or statins plus ezetimibe in patients with CKD and dyslipidemia to inhibit the development and recurrence of CVD events, reduce urinary protein excretion, and slow the progression of renal dysfunction. B Consider initiating lipid-lowering therapy with fibrates to prevent the development and recurrence of CVD events in patients with CKD and dyslipidemia. Be careful when using fibrates in patients with moderate-to-severe renal dysfunction. C As per ACP 2013 guidelines, initiate statin therapy to manage elevated low-density lipoprotein in patients with CKD stage 1-3. B As per KDIGO 2013 guidelines, initiate statin therapy in 50 years old patients with eGFR 60 mL/min/1.73 m (GFR categories G1-G2). B Show 7 more Management of electrolyte derangements: As per JSN 2019 guidelines: Consider maintaining serum potassium levels in the range of 4.0-5.4 mEq/L for the reduction of mortality and CVD in patients with CKD. C Administer sodium bicarbonate or other such bases for the treatment of metabolic acidosis and prevention of hypertension, proteinuria, and CVD. Consider initiating treatment when the bicarbonate level is < 21 mmol/L. B https://web.pathway.md/diseases/recIwpUFjFfYxzh1Y 9/32 6/29/23, 3:54 AM Chronic kidney disease Pathway As per KDIGO 2013 guidelines, consider oral bicarbonate supplementation to maintain serum bicarbonate within the normal range, unless contraindicated, in patients with CKD and serum bicarbonate concentrations < 22 mmol/L. C Management of hyperphosphatemia: As per JSN 2019 guidelines: Consider administering phosphate binders to reduce the possibility of reducing progression to mortality in patients with non-dialysis CKD with hyperphosphatemia. C Consider administering non-calcium-containing phosphate binders to prevent progression to mortality and vascular calcification progression in patients with non-dialysis CKD with hyperphosphatemia. C As per KDIGO 2017 guidelines, consider lowering elevated phosphate levels toward the normal range in patients with CKD stages G3a-G5D. C Show 6 more As per JSDT 2013 guidelines, advise dietary phosphorus restriction in order to maintain appropriate serum phosphorus B and PTH levels. Show 5 more As per KDIGO 2013 guidelines, consider maintaining serum phosphate concentrations in the normal range according to local laboratory reference values in patients with CKD with a GFR < 45 mL/min/1.73 m . C Management of hyperparathyroidism: As per JSN 2019 guidelines, consider administering active vitamin D to lower PTH levels and reduce proteinuria in patients with non-dialysis CKD. Recognize that active vitamin D can cause hypercalcemia, thus, make therapeutic decisions on a case-by-case basis and start active vitamin D with small doses. Reduce or discontinue active vitamin D in case of hypercalcemia or worsening renal function. C As per KDIGO 2017 guidelines, consider evaluating patients with levels of intact PTH progressively rising or persistently above the ULN for modifiable factors, including hyperphosphatemia, hypocalcemia, high phosphate intake, and vitamin D deficiency. C Show 5 more As per JSDT 2013 guidelines, consider setting the target range of intact PTH between 60 and 240 pg/mL. C Show 8 more As per UKKA 2011 guidelines, consider initiating treatment for hyperparathyroidism in patients with CKD stages 3b-5 when serum PTH levels are progressively increasing and remain persistently higher than the upper reference limit for the assay, despite correction of modifiable factors. C As per KDIGO 2008 guidelines, consider evaluating for hyperphosphatemia, hypocalcemia, and vitamin D deficiency in patients with GFR < 45 mL/min/1.73 m in whom intact PTH is above the ULN. C Management of anemia, iron therapy: https://web.pathway.md/diseases/recIwpUFjFfYxzh1Y 10/32 6/29/23, 3:54 AM Chronic kidney disease Pathway As per JSN 2019 guidelines, consider administering iron therapy in patients with CKD and iron deficiency anemia. C As per KDIGO 2012 guidelines, balance the potential benefits of iron therapy (avoiding or minimizing blood transfusions, ESA therapy, and anemia-related symptoms) against potential risks of harm (anaphylactoid reactions, other unknown long-term risks) when prescribing iron therapy. Show 7 more Management of anemia, ESA therapy, initiation: As per UKKA 2017 guidelines, initiate ESAs in patients with anemia of CKD likely to benefit in terms of quality of life and physical function and to avoid blood transfusion, especially in patients deemed suitable for transplantation. B Show 2 more As per KDIGO 2012 guidelines, address all correctable causes of anemia including iron de ciency and in ammatory states before initiating ESAs. Show 6 more Management of anemia, ESA therapy, choice of agent: As per UKKA 2017 guidelines, decide on the choice of ESAs based on the local availability of ESAs. B As per KDIGO 2012 guidelines: Decide on the choice of an ESA based on the balance of pharmacodynamics, safety information, clinical outcome data, costs, and availability. B Consider choosing only ESAs approved by an independent regulatory agency. Choose true biosimilar products for 'copy' versions of ESAs. C Management of anemia, ESA therapy, route of administration: As per UKKA 2017 guidelines, consider determining the route of ESA administration by the CKD grade, treatment setting, efficacy, safety and class of ESA used. Prefer the SC route in non- dialysis patients and the IV route in hemodialysis patients because of convenience. C As per KDIGO 2012 guidelines: Consider using either IV or SC route of administration of ESAs in patients with CKD stage 5 on hemodialysis and in patients on hemofiltration or hemodia ltration therapy. C Consider using the SC route of administration of ESAs in patients with non-dialysis CKD and in patients with CKD stage 5 on peritoneal dialysis. C Management of anemia, ESA therapy, dosing: As per UKKA 2017 guidelines, determine the initial ESA dose based on the patient's Hgb level, target Hgb level, the observed rate of increase in Hgb level, and clinical circumstances. B Show 2 more As per KDIGO 2012 guidelines, determine the initial ESA dose based on the patient's Hgb concentration, body weight, and clinical circumstances. B Show 4 more https://web.pathway.md/diseases/recIwpUFjFfYxzh1Y 11/32 6/29/23, 3:54 AM Chronic kidney disease Pathway Management of anemia, ESA therapy, maintenance: As per JSN 2019 guidelines, consider reducing or terminating ESAs if the Hgb level is > 12 g/dL in patients with a past history or complication of severe CVD or any other medical indications. C As per UKKA 2017 guidelines, continue ESA therapy during acute illness, surgical procedures, or any other cause of hospitalization in ESA-dependent patients unless there is a clear contraindication, such as accelerated hypertension. B As per KDIGO 2012 guidelines, avoid using ESAs to maintain Hgb concentration > 11.5 g/dL in adult patients with CKD. D Show 2 more Management of anemia, ESA therapy, RBC transfusion: As per UKKA 2017 guidelines, avoid administering RBC transfusion where possible to minimize the risk of allosensitisation in patients with anemia of CKD, especially if renal transplantation is an option. D Show 2 more As per KDIGO 2012 guidelines, avoid administering red cell transfusions when possible to minimize the general risks related to their use when managing chronic anemia. D Show 4 more Treatments with no evidence for benefit: As per JSN 2019 guidelines, consider administering an oral spherical carbon adsorbent to delay CKD progression, recognizing that there is insufficient evidence regarding its therapeutic effect on end-stage kidney disease or death in patients with CKD. C As per KDIGO 2013 guidelines, avoid using androgens as adjuvants to ESAs. D End-of-life care: provide advance care planning in patients with a recognized need for end-of-life care, including those people undergoing conservative kidney care. 5. Nonpharmacologic interventions Weight loss: advise achieving or maintaining a healthy weight (BMI 20 to 25). B Physical activity: As per KDIGO 2021 guidelines, consider advising patients with CKD and hypertension to practice moderate-intensity physical activity for a cumulative duration of at least 150 minutes/week or to a level compatible with their cardiovascular and physical tolerance. C Show 2 more As per JSN 2019 guidelines, consider advising participation in aerobic exercise programs for weight loss and improvement of peak oxygen consumption in patients with CKD and obesity and/or metabolic syndrome. Estimate an adequate load of aerobic exercise training according to the clinical characteristics of each patient. C https://web.pathway.md/diseases/recIwpUFjFfYxzh1Y 12/32 6/29/23, 3:54 AM Chronic kidney disease Pathway As per KDIGO 2013 guidelines, encourage people with CKD to undertake physical activity compatible with cardiovascular health and tolerance (aiming for at least 30 minutes 5 times per week), and achieve a healthy weight. B Nutritional support: As per JSN 2019 guidelines, refer patients to a registered dietitian with specific training on medical guidance in CKD for nutritional interventions to prevent the progression of CKD stages. B As per KDIGO 2013 guidelines, refer individuals with CKD to an expert who can provide dietary advice tailored to severity of CKD, including the need to intervene on salt, phosphate, potassium, and protein intake where indicated. B As per ASPEN 2010 guidelines, obtain formal nutritional assessment, including evaluation of inflammation, and develop a nutrition care plan in patients with renal disease. B Show 4 more Salt and water intake: As per KDIGO 2021 guidelines, consider advising patients with CKD and hypertension to target a sodium intake of < 2 g of sodium per day (or < 90 mmol of sodium per day or < 5 g of sodium chloride per day). C Show 2 more As per JSN 2019 guidelines, advise restricting salt intake to < 6 g/day (but no less than 3 g/day because extreme salt restriction could be harmful) to prevent hypertension, proteinuria, and CVD. B As per KDIGO 2013 guidelines, advise patients with CKD to lower salt intake to < 90 mmol/day (< 2 g/day) of sodium, corresponding to < 5 g/day of sodium chloride, unless contraindicated. B Protein intake: As per JSN 2019 guidelines, offer individualized protein restriction in patients with CKD in accordance with their specific clinical condition, in addition to nutrition guidance consisting of a low protein diet under the management of a medical team with nephrologists and registered dietitians. B As per KDIGO 2013 guidelines, consider lowering protein intake to 0.8 g/kg/day in diabetic patients with CKD. C Show 2 more Alcohol intake: As per JSN 2019 guidelines, insufficient evidence to recommend an adequate amount of alcohol in adult patients with CKD. I As per KDIGO 2013 guidelines, consider limiting alcohol intake to 2 standard drinks per day for men and 1 standard drink per day for women. C Smoking cessation: As per JSN 2019 guidelines, advise smoking cessation in patients with CKD to reduce the progression of CKD and the risk of all-cause mortality. B https://web.pathway.md/diseases/recIwpUFjFfYxzh1Y 13/32 6/29/23, 3:54 AM Chronic kidney disease Pathway As per KDIGO 2013 guidelines, advise smoking cessation in patients with CKD. B 6. Therapeutic procedures Renal replacement therapy, indications: As per CSN 2014 guidelines, adopt an intent-to-defer over an intent-to-start-early approach for the initiation of chronic dialysis in adult patients with an eGFR < 15 mL/min/1.73 m . B As per KDIGO 2013 guidelines, refer patients with progressive CKD for RRT when the risk of kidney failure within 1 year is 10-20%, as determined by validated risk prediction tools. B Show 2 more Renal replacement therapy (evaluation of fistula malfunction): consider obtaining fluoroscopy fistulography or duplex ultrasound of the hemodialysis access in patients with suspected dysfunction of the upper or lower extremity hemodialysis access (arteriovenous fistula or graft), suggested by an abnormal clinical indicator or hemodynamic indicator (reduction in dialysis vascular access blood flow rate or kinetics). C Show 5 more Renal replacement therapy (management of fistula malfunction): guide interventional radiologic therapy by imaging. B Show 6 more 7. Surgical interventions Kidney transplantation: As per JSN 2019 guidelines, consider performing preemptive kidney transplantation in all suitable patients whenever a donor is available. C As per KDIGO 2013 guidelines, consider preemptive living donor transplantation in adult patients with a GFR < 20 mL/min/1.73 m , in whom there is evidence of progressive and irreversible CKD over a period of 6-12 months. 8. Specific circumstances Pediatric patients (screening): consider obtaining urinary screening at 3 years of age and throughout school age to detect CKD at an early stage, thus, facilitating early management and improving the renal prognosis in pediatric populations. C Pediatric patients (risk assessment): Recognize that low birth weight, preterm birth, and fetal growth retardation are risk factors for the future onset of CKD. B Recognize that CKD in pediatric patients is a risk factor for CVD. B https://web.pathway.md/diseases/recIwpUFjFfYxzh1Y 14/32 6/29/23, 3:54 AM Chronic kidney disease Pathway Pediatric patients (physical activity): advise practicing mild-to-moderate exercise to improve quality of life, motor function, and respiratory function in pediatric patients with CKD. B Pediatric patients (protein intake): avoid offering protein intake restrictions for preventive effects in pediatric patients with CKD. D Pediatric patients, immunizations: As per JSN 2019 guidelines, provide routine immunizations in pediatric patients with CKD as they are susceptible to infections likely to become severe. B As per KDIGO 2013 guidelines, follow to of cial international and regional recommedations for pediatric immunization schedules for pediatric patients with CKD. Pediatric patients, management of hypertension: As per KDIGO 2021 guidelines, consider lowering 24-hour mean arterial pressure by ambulatory BP monitoring to 50th percentile for age, sex, and height in pediatric patients with CKD. C Show 3 more As per JSN 2019 guidelines, consider initiating antihypertensive therapy along with lifestyle instruction and medication including RAAS inhibitors and calcium antagonists, on an individual basis and according to age, in pediatric patients with CKD and hypertension. C As per KDIGO 2013 guidelines, initiate BP-lowering agents in children with non-dialysis- dependent CKD whose BP is consistently above the 90th percentile for age, sex, and height. B Show 2 more Pediatric patients, management of mineral and bone disorder: As per JSN 2019 guidelines, treat CKD-mineral and bone disorder in pediatric patients with CKD to improve bone lesions and cardiovascular function. Consider maintaining the corrected serum levels of calcium and phosphorus within normal ranges in accordance with the patient's age. B As per JSN 2019 guidelines, treat CKD-mineral and bone disorder in pediatric patients with CKD to improve bone lesions and cardiovascular function. Consider maintaining the corrected serum levels of calcium and phosphorus within normal ranges in accordance with the patient's age. B As per KDIGO 2017 guidelines, consider maintaining serum calcium in the age-appropriate normal range in pediatric patients with CKD stages G3a-G5D. C Consider administering calcitriol and vitamin D analogs to maintain serum calcium levels in the age-appropriate normal range in pediatric patients. Show 3 more As per JSDT 2013 guidelines, consider starting monitoring of serum phosphorus, calcium, albumin, PTH, ALP, and bicarbonate ion concentration in stage 2 of CKD. C Show 4 more Pediatric patients (management of growth stunting): consider administering recombinant human GH in pediatric patients with CKD with growth stunting. B Pediatric patients (kidney transplantation): consider performing preemptive kidney transplantation in pediatric patients with CKD. C https://web.pathway.md/diseases/recIwpUFjFfYxzh1Y 15/32 6/29/23, 3:54 AM Chronic kidney disease Pathway Pediatric patients (patients with HIV infection): screen renal function with eGFR (using an estimating equation developed for children) when antiretroviral is initiated or changed, and at least twice yearly in pediatric and adolescent patients with human immunodeficiency virus without evidence of existing kidney disease. Monitor for kidney damage with urinalysis or a quantitative measure of proteinuria when antiretroviral therapy is initiated or changed, and at least annually in pediatric and adolescent patients with stable kidney function. Consider obtaining more frequent monitoring in patients with additional kidney disease risk factors. B Show 4 more Elderly patients (evaluation): use estimating equations correcting for differences in creatinine generation rather than plain serum creatinine measurements to assess kidney function in older patients. A Show 3 more Elderly patients (prognostic scores): use a simple score on a regular basis to assess functional status in older patients with CKD stage 3b-5d with the intention to identify patients who would benefit from a more in-depth geriatric assessment and rehabilitation. B Show 5 more Elderly patients (physical activity): advise exercising to improve the functional status in older patients with CKD stage 3b. B Offer exercise training in a structured and individualized manner to avoid adverse events. B Elderly patients (nutritional assessment): use the Subjective Global Assessment as the gold standard to assess the nutritional status in older patients with CKD stage 3b (eGFR < 45mL/min/1.73 m ). B Show 2 more Elderly patients (glycemic targets): implement strict glycemic therapy in 75 years old patients with CKD and diabetes mellitus as they are at risk of severe hypoglycemia. Consider deciding the target for glycemic control individually depending on the patient's health condition (age, cognitive function, physical function, comorbidity, risk of hypoglycemia, and time to live). B Elderly patients, renal adjustment of medications: As per JSN 2019 guidelines, pay attention to the control of doses of RAAS inhibitors, diuretics, vitamin D, and other frequently used drugs since metabolic and excretion rates decline in elderly patients with CKD. Consider checking the medication notebook to avoid polypharmacy. B As per ACP 2016 guidelines: Take into account kidney function when prescribing drugs whose active forms or metabolites are excreted renally. A Consider obtaining regular measurements of serum drug concentrations for drugs with a narrow toxic/therapeutic range. Consider using different target levels of total drug concentration because of the differences in protein binding in relation to uremia. C Elderly patients (BP targets): set a target BP < 150/90 mmHg (but no less than 110 mmHg of systolic BP) in elderly patients with hypertension and CKD. Set a target BP < 140/90 mmHg in https://web.pathway.md/diseases/recIwpUFjFfYxzh1Y 16/32 6/29/23, 3:54 AM Chronic kidney disease Pathway elderly patients with hypertension and CKD if antihypertensive agents are tolerated without any adverse events. B Elderly patients (lipid-lowering therapy): consider initiating lipid-lowering therapy (statin alone or a statin and ezetimibe combination) in 65-71 years old patients with CKD. Initiate lipid-lowering therapy in 75 years old patients for decreasing all-cause mortality and for primary or secondary prevention of CVD. C Elderly patients (renal replacement therapy): Use validated tools to project likely outcomes and help decide the appropriateness of discussing options for RRT. Discuss the option for conservative management during the shared decision-making process on different management options for end-stage renal disease. B Elderly patients (management of anemia): consider maintaining Hgb levels within the target range of 11-13 g/dL using ESAs and/or iron supplementation in elderly patients (aged 75 years) with non-dialysis CKD and anemia. Consider lowering the lower limit of the target range to 9 g/dL with respect to the mortality risk. Remove clinical factors associated with resistance to ESAs to avoid the use of high-dose ESAs. C Elderly patients (management of hyperphosphatemia): advise limiting dietary phosphate intake and/or consider offering phosphate binders to maintain serum phosphate levels within the normal range in elderly patients (aged 75 years) with non-dialysis CKD. Obtain close monitoring for adverse effects to prevent malnutrition since the phosphate-lowering therapies may cause loss of appetite. B Elderly patiants (management of hyperparathyroidism): consider lowering PTH levels within the normal range by treating abnormalities in serum phosphate and calcium levels before administering active vitamin D agents in elderly patients with non-dialysis CKD with secondary hyperparathyroidism. Avoid hypercalcemia when using active vitamin D agents. C Pregnant patients: As per KDIGO 2020 guidelines, advise contraception in female patients receiving ACEI or ARB therapy and discontinue these agents in patients considering pregnancy or becoming pregnant. B As per JSN 2019 guidelines: