VA/DoD recommendations updated for primary care management of chronic kidney disease

In a clinical practice guideline (CPG) issued by the U.S. Department of Veterans Affairs (VA) and U.S. Department of Defense (DoD) and published online Dec. 30 in the Annals of Internal Medicine, updated recommendations are presented for the primary care management of chronic kidney disease (CKD).

Amy R. Schwartz, M.D., from the VA Connecticut Healthcare System in West Haven, and colleagues updated the 2019 VA/DoD CPG for primary care management of CKD. Twelve key questions were developed to guide the evidence review.

The guidelines encompass 23 recommendations for the diagnosis, assessment, and monitoring of CKD; general management strategies; pharmacologic management of CKD and associated conditions; and contrast-associated acute kidney injury management. The guidelines include a strong recommendation for using urine albumin-to-creatinine ratio and estimated glomerular filtration rate for predicting CKD progression. Use of either an angiotensin-converting enzyme inhibitor (ACE-I) or an angiotensin II receptor blocker (ARB) is strongly recommended to slow progression of CKD in patients with hypertension and albuminuria.

In patients with CKD who have one or more of type 2 diabetes, albuminuria, or heart failure, sodium-glucose cotransporter 2 inhibitors are strongly recommended in addition to maximally tolerated ACE-Is or ARBs to reduce the risk for major adverse cardiovascular events (MACE), heart failure, progression of kidney disease, and mortality. To reduce CKD progression, MACE, and all-cause mortality, the addition of a glucagon-like peptide-1 receptor agonist to an ACE-I or ARB is strongly recommended in patients with type 2 diabetes and albuminuric CKD.

“The VA/DoD CPG provides primary care clinicians with up-to-date practical recommendations for accurately staging CKD, predicting progression to kidney failure, and using pharmacotherapies to prevent progression to kidney failure and reduce the risk for MACE,” the authors write.

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