The new KDIGO update widens the diagnostic and therapeutic arsenal of chronic kidney failure, with a more global and personalized approach to delay progression to the terminal stage.
In 2022, the Kdigo Scientific Committee (Kidney Disease Improving Global Outcomes) has published a major update of its recommendations on the evaluation and management of chronic renal insufficiency (IRC) in adults and children not requiring renal supply treatment. Based on an exhaustive analysis of the English -speaking medical literature until July 2023, these new recommendations have 28 graduated recommendations and 141 non -graduated clinical practice.
This updating covers the entire patient route. The recommendations emphasize personalized management taking into account age and sex specificities, as well as disparities in access to healthcare according to national resources.
The multidisciplinary working group has integrated the prospects of low, intermediate and high income countries, highlighting the global inequalities in access to care while establishing the basics of best practices.
It all starts with the evaluation
The IRC assessment is based on the measurement of the glomerular filtration rate (DFG) and the Albuminuria on Creatinuria (UACR). In case this dosage requiring access to a laboratory is difficult, it is possible to use a test at the care point. This recommendation is strong, type 1 A, and is aimed at Patients in GRAD G3 to G5.
In individuals at risk of IRC, if the dosage of the cystatin C is achievable, the estimate of the DFG must best include the combination of the measurement of the creatinemia and that of the Cystatin C (EDFG-CYST), of greater informative value. Indeed, many factors can affect the dosage of creatinine: extreme muscle mass, malnutrition, quality and quantity of food intakes, drugs influencing its tubular secretion … Nevertheless, certain factors can affect the dosage of cytatin C: smoking, chronic inflammation, cancer, chemotherapy, corticosteroid therapy …
The use of a risk prediction equation, such as the Kidney Failure Risk Equationincluding Sex, Age, UACR and EDFG provides a good estimate of the need for kidney supplementary in 2 to 5 years.
Delay the progress of the IRC and manage complications
In order to delay progression and treat associated complications, type 2 renal insufficient diabetics with an EDFG still greater than 20 ml/min/1.73 m2it is recommended to use an inhibitor of the Sodium-Glucose co-transporter of the ISGLT2 type (strong recommendation, 1A). This recommendation can be extended to non -diabetic renal insufficiency with a UACR greater than 20 mg/mmol (recommendation 1A).
In a meta-analysis that included 13 randomized clinical trials against placebo, more than 90,000 patients, taking ISGLT2 reduced the risk of increase in nephropathy by 37 %, and 23 % that of acute kidney failure, regardless of diabetes. In case of less worrying EDFG, between 20 and 45 ml/1.73 m2And a UACR less than 20 mg/mmol, this recommendation is less strong (2b). The benefit of this therapeutic class is also very clear on the cardiovascular prognosis and the risk of hospitalization, regardless of the importance of albuminuria. In the event of previous prescription, ISGLT2 must be maintained when the EDFG increases to less than 20 ml/min/1.73 m2except in the event of poor tolerance or initiation of a kidney supply.
Furthermore, renal insufficiency with symptomatic hypericosemia should be treated by a hypouricemant agent (recommendation 1C), this recommendation being, however, not valid if the hyperuricemia is asymptomatic.
Finally, due to the increased risk of cardiovascular disease in the event of IRC, treatment with statins or by a statine-ezetimibe combination is recommended in subjects aged 50 or over, in the absence of kidney supply, with an EDFG less than 60 ml/min/1.73 m2in category G3 to G5 (strong recommendation, 1A). This attitude can also be adopted in the case of higher EDFG (recommendation 1B). In people with IRC, the same principles should be used to manage atherosclerical risk as in people without IRC. Thus, statins are recommended in patients aged 18 to 49 with IRC not treated with chronic dialysis or renal transplantation and with coronaryaropathy, meal diabetes, a history of ischemic stroke or whose risk of cardiovascular death at 10 years exceeds 10 % (recommendation 2A). These effective treatments are often underused in people with IRC with acute coronary syndrome
In total, these recommendations emphasize the value of the dosage of the Cystatin C, which improves the precision of the simple calculation of the EDFG. They recall the interest of start-up of an inhibitory treatment of the co-transformer 2 sodium-glucose in renal insufficiency, diabetics or not, both for its beneficial effects on nephropathy, whatever its origin, but also on the cardiovascular system. The preventive role in taking statins in cardiovascular prevention in the event of IRC is also recalled. However, the cost of these new diagnostic and therapeutic measures, in particular the high cost of dosage of cystatin C, may seem prohibitive. It must be balanced with short -term induced budget expenses and long -term profit.
These recommendations nevertheless have certain limits, in particular concerning the definition of optimal diagnostic strategies, the choice of the most effective therapeutic associations and the timing appropriate for their initiation. Future research will have to include populations systematically excluded from current therapeutic trials: young people, pregnant women, and conversely, patients with a very advanced IRC.
In conclusion, this KDIGO 2024 update significantly widens the diagnostic and therapeutic arsenal of the IRC. Beyond the measures already mentioned, it also recommends the use of hypo-users in the event of symptomatic hyperuricemia, thus supplementing a global approach aimed at delaying progression to terminal renal failure.
