CARI Guidelines Commentary on the KDIGO Clinical Practice Guideline for the Management of Glomerular Diseases

The KDIGO 2021 Glomerular Disease Guidelines provide updated recommendations on the management of glomerular diseases (GD), with substantial advances made in diagnosis, treatment, and improvement of outcomes for people with GD.

The Caring for Australians and New Zealanders with kidney Impairment (CARI) Guidelines commentary contextualises the updated guidelines for the Australian and New Zealand setting.

Kidney biopsy remains central to diagnosis, with validated scoring systems available. However, genetic testing for suspected monogenic kidney disease is now accessible in Australia, enabling earlier diagnosis and management, particularly in situations where a kidney biopsy is considered high risk or contraindicated. The guideline emphasises timed urine collections for protein excretion over spot tests and we suggest the use of the CKiD u25 eGFR equation for people under 25. For IgA nephropathy (IgAN) and IgA vasculitis (IgAV), emerging therapies such as targeted-release budesonide and sparsentan demonstrate promise but await approval and public subsidy in our region. For membranous nephropathy, the guideline highlights the differences in adult and paediatric management. In nephrotic syndrome, tacrolimus is used as first-line therapy and rituximab as a second-line agent for steroid-dependent or frequently relapsing disease. Minimal change disease recommendations include glucocorticoid tapering after remission, while focal segmental glomerulosclerosis incorporates genetic classifications and advocates for next-generation sequencing.

Our commentary underscores the need for increased participation in clinical trials to validate regional applicability and improve long-term outcomes for people with GD in Australia and New Zealand. Clinical trials of new medications have led to more treatment options that are awaiting approval.