New proposals for kidney and cardiovascular protection, alongside established CKD treatment.
CKD treatment increasingly combines medicines that protect the kidneys and cardiovascular system. The KDIGO 2027 focused update concentrates on SGLT2 inhibitors, nonsteroidal mineralocorticoid receptor antagonists (nsMRAs) and GLP-1-based therapies, including proposed use in selected people without diabetes.
These treatments sit alongside ACE inhibitors/ARBs, blood pressure and lipid management, and treatment of CKD complications. This article summarises the principal drug groups without attempting to replace their individual prescribing protocols.
Scope: the focused update excludes dialysis patients and kidney transplant recipients. It contains no formal pediatric recommendations. eGFR units are mL/min/1.73 m²; uACR is in mg/g. Grades: 1 = strong, 2 = conditional; A–D = high to very low evidence certainty. Practice points are ungraded.
1. SGLT2 inhibitors: eligibility across albuminuria groups
The draft proposes treatment for adults with CKD and type 2 diabetes or heart failure irrespective of albuminuria. Other groups are defined by eGFR and uACR.
| Adult CKD profile | Draft recommendation | Grade |
|---|---|---|
| Type 2 diabetes or heart failure | SGLT2 inhibitor irrespective of albuminuria* | 1A |
| uACR >200; eGFR ≥20 | SGLT2 inhibitor | 1A |
| uACR 30–200; eGFR 20–45 | SGLT2 inhibitor | 1B |
| uACR <30; eGFR 20–45 | SGLT2 inhibitor suggested | 2B |
*The T2D/HF clause specifies no eGFR threshold. Supporting text discusses initiation below 20; this should not be simplified into unrestricted prescribing at any eGFR or assumed to override product authorisation.
Practical points: continue after eGFR falls below 20; the supporting text discusses continuation until kidney replacement therapy. An early eGFR dip alone is not a reason to stop. Withhold during prolonged fasting, major surgery or critical illness when ketosis or hypovolaemia risk rises; restart after clinical stability and adequate oral intake. Routine extra laboratory testing solely for initiation is usually unnecessary. Previous UTI alone is not a contraindication.
Benefits should not automatically be extrapolated to polycystic kidney disease, which was excluded from the large CKD trials.
2. Nonsteroidal MRAs: proposals beyond type 2 diabetes
Eligibility depends on diabetes status, albuminuria, kidney function, potassium and background RAS inhibition.
| Population | Draft eligibility | Grade |
|---|---|---|
| Type 2 diabetes | nsMRA with proven kidney/CV benefit; eGFR ≥25, normal potassium and albuminuria on maximum tolerated RAS inhibitor | 1A |
| Type 1 diabetes | Same conditions; nsMRA with proven kidney/CV benefit | 2C |
| Without diabetes | Finerenone specifically; GFR ≥25, normal potassium, uACR ≥200, taking a RAS inhibitor and preferably an SGLT2 inhibitor | 2B |
The evidence differs: the type 1 diabetes proposal is conditional with low certainty. The non-diabetic proposal names finerenone, rather than endorsing all MRAs interchangeably.
Algorithm 1: Proposed nsMRA review
Do not combine steroidal and nonsteroidal MRAs.
For selected adults with T2D, persistent albuminuria and normal potassium while taking a RAS inhibitor, the draft permits simultaneous SGLT2 inhibitor and nsMRA initiation. This is an option, not a universal requirement.
3. GLP-1-based therapy: protection beyond glycaemia
| Clinical profile | Draft indication | Grade |
|---|---|---|
| T2D and CKD | High risk of major cardiovascular or kidney events, or individualised glycaemic targets unmet | 1A |
| CKD without diabetes | Established ASCVD and overweight or obesity | 2B |
Choose agents with documented cardiovascular or kidney benefit. Without diabetes, the proposal requires both ASCVD and overweight/obesity; it does not cover every person with CKD and excess weight.
Support resistance training and individualised nutrition to preserve muscle and function. Address reduced intake, nutritional deficiencies and gastrointestinal effects. Body composition changes can affect creatinine and cystatin C independently of filtration, complicating interpretation of eGFR trends.
4. ACE inhibitors and ARBs remain foundational
The draft retains RAS inhibition in comprehensive care. Established KDIGO 2024 guidance for CKD G1–G4 recommends ACEi/ARB for A3 albuminuria without diabetes (1B), suggests it for A2 without diabetes (2C), and recommends it for A2–A3 with diabetes (1B). A1 may warrant treatment for hypertension or HFrEF.
Use the highest approved tolerated dose. Check BP, creatinine and potassium within 2–4 weeks of initiation/titration. A creatinine rise >30% within four weeks warrants investigation and reassessment. Manage hyperkalaemia where possible before withdrawal. Consider reducing/stopping for symptomatic hypotension, uncontrolled hyperkalaemia despite treatment, or selected kidney-failure symptoms. eGFR <30 alone is not a stopping indication. Avoid combined ACEi/ARB/direct-renin-inhibitor therapy.
5. Other antihypertensives and cardiovascular medicines
Established guidance uses dihydropyridine calcium-channel blockers and/or diuretics to meet individualised BP targets. Steroidal MRAs have a role in selected resistant hypertension, with potassium and kidney-function monitoring. The standardised-office SBP target is <120 mmHg when tolerated, with individualisation for frailty, falls or hypotensive symptoms.
Statin-based therapy remains central to cardiovascular prevention. Low-dose aspirin is recommended for secondary prevention in established ischaemic cardiovascular disease; CKD alone does not establish a routine primary-prevention indication.
6. Other glucose-lowering medicines and CKD complications
| Treatment area | What to retain in comprehensive care |
|---|---|
| Metformin | The draft’s Figure 15 places it in T2D with eGFR ≥30 when targets remain unmet despite SGLT2/GLP-1-based therapies, or those medicines cannot be used. |
| Other glucose-lowering drugs | Individualise additional treatment using diabetes guidance, renal dosing and hypoglycaemia risk. This focused draft does not comprehensively revise every drug class. |
| Calcium, phosphate and vitamin D | Separate CKD-MBD guidance bases decisions on serial calcium, phosphate and PTH. Treat persistent/progressive hyperphosphataemia, avoid hypercalcaemia and limit calcium-based binders. Calcitriol/active vitamin D are not routine in non-dialysis adults; reserve for selected severe progressive hyperparathyroidism. |
| Anaemia | Investigate causes and iron status; use iron and, where indicated, erythropoiesis treatment under dedicated anaemia guidance. No new detailed anaemia regimen is supplied here. |
| Acidosis and potassium abnormalities | Address clinically significant acidosis and potassium disturbances using established guidance; individualise diet, contributing medicines and corrective treatment. |
7. Combining treatment without a fixed sequence
Algorithm 2: Individualised treatment review
Both algorithms are editorial summaries, not dosing protocols. Treatment can overlap; the sequence is not mandatory. The draft supports timely combinations where safety and individual circumstances permit.
Pregnancy planning also matters: review ACEi/ARB, SGLT2 inhibitors, GLP-1-based therapies and nsMRAs before conception. The draft advises prompt discontinuation when pregnancy is suspected or confirmed, with clinician-led transition to appropriate alternatives.
Clinical perspective
The proposed advances broaden organ-protective therapy, including selected non-diabetic CKD. They complement established RAS inhibition, BP control, cardiovascular prevention and complication management. Eligibility and evidence grades must remain visible: the new draft proposals should not be presented as final recommendations.
Sources
- KDIGO. 2027 CKD Guideline: Medications Management. Public Review Draft, October 2026; recommendations, practice points and Figures 12–15. Original guideline page.
- KDIGO. 2024 Clinical Practice Guideline for the Evaluation and Management of CKD. Sections 3.4, 3.6, 3.10 and 3.15. Full guideline.
- KDIGO. 2017 CKD-MBD Guideline Update. Sections 4.1–4.2. Full guideline.