Chapter 27: 2024-2025 Practice Updates

SGLT2 Inhibitors: A Paradigm Shift in CKD

The landscape of chronic kidney disease management underwent a revolutionary change with the KDIGO 2024 guidelines now recommending SGLT2 inhibitors as first-line therapy for many CKD patients, with or without diabetes. This represents one of the most significant advances in nephrology in decades.

Key Takeaways for SGLT2i Use

Broad Indication: Recommended for CKD patients with eGFR ≥20 mL/min/1.73m² and albuminuria.
Proven Benefits: Reduce risk of CKD progression and cardiovascular death by ~30-40%.
The "eGFR Dip": Expect an initial, harmless drop in eGFR of 3-5 mL/min upon starting. This is a sign of beneficial hemodynamic changes and predicts long-term success. Do not stop the drug!

Finerenone: The Non-Steroidal MRA Revolution

Finerenone is the first non-steroidal mineralocorticoid receptor antagonist (MRA) demonstrating both cardiovascular and kidney benefits in diabetic kidney disease. It is used in patients with residual albuminuria despite maximum tolerated RAAS blockade.

Compared to spironolactone, finerenone has a significantly lower risk of causing hyperkalemia and has no hormonal side effects like gynecomastia, making it a safer option for many patients with CKD and diabetes.

Updated Approaches to AKI Management (2024)

Biomarkers: Novel biomarkers like urinary CXCL9 are emerging for non-invasive diagnosis of specific AKI etiologies like AIN.
Timing of RRT: The pendulum has swung away from early RRT initiation. A "watchful waiting" approach is now favored until absolute indications (AEIOU) are met.
Fluid Assessment: Point-of-care ultrasound (POCUS), particularly the VExUS (Venous Excess Ultrasound) protocol, is revolutionizing volume status assessment at the bedside.

Onco-Nephrology

This emerging subspecialty focuses on the complex interplay between cancer, its treatments, and kidney disease. Key areas include managing AKI from chemotherapy (especially immune checkpoint inhibitor nephritis), electrolyte disorders like tumor lysis syndrome, and paraprotein-related kidney diseases.

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