The timely and rational institution of therapy is a key step towards reducing the global burden of chronic kidney disease (CKD). CKD is a heterogeneous entity with varied aetiologies and diverse trajectories, which include risk of kidney failure but also cardiovascular events and death. Developments in the past decade include substantial progress in CKD risk prediction, driven in part by the accumulation of electronic health records data. In addition, large randomized clinical trials have demonstrated the effectiveness of sodium–glucose co-transporter 2 inhibitors, glucagon-like peptide 1 receptor agonists and mineralocorticoid receptor antagonists in reducing adverse events in CKD, greatly expanding the options for effective therapy. Alongside angiotensin-converting enzyme inhibitors and angiotensin receptor blockers, these classes of medication have been proposed to be the four pillars of CKD pharmacotherapy. However, all of these drug classes are underutilized, even in individuals at high risk. Leveraging prognostic estimates to guide therapy could help clinicians to prescribe CKD-related therapies to those who are most likely to benefit from their use. Risk-based CKD management thus aligns patient risk and care, allowing the prioritization of absolute benefit in determining therapeutic selection and timing. Here, we discuss CKD prognosis tools, evidence-based management and prognosis-guided therapies.

及时合理的治疗是减轻慢性肾病 （CKD） 全球负担的关键一步。CKD 是一种异质性疾病，具有不同的病因和不同的发展轨迹，包括肾衰竭的风险，但也包括心血管事件和死亡的风险。过去十年的发展包括 CKD 风险预测的重大进展，部分原因是电子健康记录数据的积累。此外，大型随机临床试验已证明钠-葡萄糖协同转运蛋白 2 抑制剂、胰高血糖素样肽 1 受体激动剂和盐皮质激素受体拮抗剂在减少 CKD 不良事件方面的有效性，大大扩展了有效治疗的选择。与血管紧张素转换酶抑制剂和血管紧张素受体阻滞剂一起，这类药物被认为是 CKD 药物治疗的四大支柱。然而，所有这些药物类别都没有得到充分利用，即使在高危个体中也是如此。利用预后估计来指导治疗可以帮助临床医生为最有可能从使用 CKD 相关疗法的人开具 CKD 相关疗法。因此，基于风险的 CKD 管理使患者风险和护理保持一致，从而在确定治疗选择和时机时优先考虑绝对益处。在这里，我们讨论了 CKD 预后工具、循证管理和预后指导疗法。