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Chronic kidney disease

What's new

The U.S. Department of Veterans Affairs (VA) and Department of Defense (DoD) have released an updated guideline for the primary care management of chronic kidney disease (CKD). The recommendations have been amended from the previous edition and are aligned with KDIGO guidelines, with several newly added recommendations. The addition of a nonsteroidal mineralocorticoid receptor antagonist, such as finerenone, is suggested for patients receiving maximally tolerated renin-angiotensin system (RAS) inhibitors who meet all of the following criteria: type 2 diabetes, albuminuria >30 mg/g, estimated glomerular filtration rate (eGFR) ≥25 mL/min/1.73 m², and serum potassium <4.8 mEq/L. Thiazide diuretics and calcium channel blockers are suggested for patients with hypertension not controlled on a RAS inhibitor. SGLT2 inhibitors are recommended for patients with type 2 diabetes, albuminuria, and/or heart failure. GLP-1 receptor agonists are recommended for patients with type 2 diabetes and albuminuric CKD. .

Background

Overview

Definition
CKD is defined as the presence of kidney damage persisting for > 3 months, which is manifested by decreased kidney function or albuminuria, measured by eGFR.
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Pathophysiology
The most common causes of CKD include diabetes and hypertension. Other causes include infectious glomerulonephritis, renal vasculitis, ureteral obstruction, genetic alterations, and autoimmune diseases.
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Disease course
CKD may be asymptomatic or result in vague symptoms, such as excessive tiredness, itching, sleep disturbance, lack of concentration, bone/joint pain, loss of appetite, loss of muscle strength, dyspnea, muscle spasm, and restless legs. Disease progression may lead to ESRD with uremic symptoms, and death.
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Prognosis and risk of recurrence
The mortality of patients ≤ 60 years and > 60 years with CKD requiring hospital admission is 13.9% and 41.0%, respectively.
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Guidelines

Key sources

The following summarized guidelines for the evaluation and management of chronic kidney disease are prepared by our editorial team based on guidelines from the American Diabetes Association (ADA 2025,2024), the Diabetes Canada (DC 2025,2018), the United States Department of Defense (DoD/VA 2025), the British Medical Journal (BMJ 2024), the European Society for Clinical Nutrition and Metabolism (ESPEN 2024), the European ...
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Screening and diagnosis

Indications for screening, asymptomatic patients: as per ACP 2013 guidelines, do not obtain screening for CKD in asymptomatic adults without risk factors for CKD.
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  • Indications for screening (patients at risk)

  • Diagnostic criteria

Classification and risk stratification

Classification: as per KDIGO 2024 guidelines, classify CKD based on cause, GFR category, and albuminuria category.
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  • Risk prediction

Diagnostic investigations

Initial evaluation, choice of test
As per DoD/VA 2025 guidelines:
Obtain urine albumin-to-creatinine ratio and eGFR to predict CKD progression.
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Consider estimating GFR with a combined creatinine and cystatin C formula for risk prediction in patients with an eGFR < 60 mL/min/1.73 m².
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  • Initial evaluation (point-of-care testing)

  • Initial evaluation (assessment of chronicity)

  • Renal ultrasound

  • Evaluation of albuminuria

  • Evaluation of hypertension

  • Evaluation of dyslipidemia

  • Evaluation of mineral and bone disorders

  • Evaluation for etiology

  • Screening for anemia

  • Screening for HCV infection

  • Nutritional assessment (clinical assessment)

  • Nutritional assessment (body composition assessment)

  • Nutritional assessment (calorimetry)

Medical management

General principles: as per DoD/VA 2025 guidelines, consider ensuring interdisciplinary care, including dietitians, pharmacists, social workers, providers, nurses, and palliative care, for patients with CKD.
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  • Drug dose adjustments

  • RAAS inhibitors (ACEis/ARBs)

  • RAAS inhibitors (mineralocorticoid receptor antagonists)

  • SGLT-2 inhibitors

  • Uric acid-lowering agents

  • Management of hypertension (BP targets)

  • Management of hypertension (lifestyle modifications)

  • Management of hypertension (sodium intake)

  • Management of hypertension (RAAS inhibitors)

  • Management of hypertension (diuretics and CCBs)

  • Management of hypertension (SGLT-2 inhibitors)

  • Management of hypertension (kidney transplant recipients)

  • Management of hypertension (pediatric patients)

  • Management of hypertension (patients with nephrosclerosis and renal artery stenosis)

  • Management of electrolyte derangements

  • Management of hyperphosphatemia

  • Management of hyperparathyroidism

  • Management of anemia (iron therapy)

  • Management of anemia (ESA therapy, initiation)

  • Management of anemia (ESA therapy, choice of agent)

  • Management of anemia (ESA therapy, route of administration)

  • Management of anemia (ESA therapy, dosing)

  • Management of anemia (ESA therapy, maintenance)

  • Management of anemia (ESA therapy, RBC transfusion)

  • Management of dyslipidemia

  • Symptomatic management

Nonpharmacologic interventions

Weight loss: as per KDIGO 2024 guidelines, consider advising/encouraging weight loss and achieving an optimal BMI in patients with CKD and obesity.
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  • Physical activity

  • Smoking cessation

  • Alcohol intake

  • Salt and water intake

  • Nutritional support (dietary advice)

  • Nutritional support (timing)

  • Nutritional support (route of administration)

  • Nutritional support (energy intake)

  • Nutritional support (protein intake)

  • Nutritional support (carbohydrate and lipid intake)

  • Nutritional support (electrolyte intake)

  • Nutritional support (glucose control)

  • Nutritional support (supplements with no evidence for benefit)

Therapeutic procedures

RRT, indications
As per KDIGO 2024 guidelines:
Initiate dialysis based on a composite assessment of patient's symptoms, signs, QoL, preferences, level of GFR, and laboratory abnormalities.
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Initiate dialysis in the presence ≥ 1 of the following, often but not invariably occurring in the glomerular filtration range of 5-10 mL/min/1.73 m²:
symptoms or signs attributable to kidney failure, such as neurological signs and symptoms attributable to uremia, pericarditis, anorexia, medically resistant acid-based or electrolyte abnormalities, intractable pruritus, serositis, and acid-base or electrolyte abnormalities
inability to control volume status or BP
progressive deterioration in nutritional status refractory to dietary intervention, or cognitive impairment
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  • RRT (counseling)

  • RRT (evaluation of fistula malfunction)

  • RRT (management of fistula malfunction)

  • RRT (management of intradialytic hypotension)

Surgical interventions

Kidney transplantation: as per KDIGO 2024 guidelines, consider planning for preemptive kidney transplantation and/or dialysis access in adult patients with a GFR < 15-20 mL/min/1.73 m² or when the risk of RRT is > 40% over 2 years.
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Specific circumstances

Pediatric patients, screening: as per JSN 2019 guidelines, consider obtaining urinary screening at 3 years of age and throughout school age to detect CKD at an early stage, thus, facilitating early management and improving the renal prognosis in pediatric populations.
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  • Pediatric patients (risk assessment)

  • Pediatric patients (evaluation)

  • Pediatric patients (indications for referral)

  • Pediatric patients (physical activity)

  • Pediatric patients (protein intake)

  • Pediatric patients (salt intake)

  • Pediatric patients (immunizations)

  • Pediatric patients (management of hypertension)

  • Pediatric patients (management of mineral and bone disorder)

  • Pediatric patients (management of growth stunting)

  • Pediatric patients (RRT)

  • Pediatric patients (kidney transplantation)

  • Pediatric patients (patients with HIV infection)

  • Elderly patients (evaluation)

  • Elderly patients (prognostic scores)

  • Elderly patients (physical activity)

  • Elderly patients (nutritional support)

  • Elderly patients (glycemic targets)

  • Elderly patients (renal adjustment of medications)

  • Elderly patients (BP targets)

  • Elderly patients (lipid-lowering therapy)

  • Elderly patients (RRT)

  • Elderly patients (management of anemia)

  • Elderly patients (management of hyperphosphatemia)

  • Elderly patients (management of hyperparathyroidism)

  • Pregnant patients

  • Patients with diabetes mellitus (primary prevention)

  • Patients with diabetes mellitus (general principles of management)

  • Patients with diabetes mellitus (team-based care)

  • Patients with diabetes mellitus (self-management programs)

  • Patients with diabetes mellitus (indications for specialist referral)

  • Patients with diabetes mellitus (treatment goals)

  • Patients with diabetes mellitus (glycemic monitoring)

  • Patients with diabetes mellitus (monitoring of renal function)

  • Patients with diabetes mellitus (weight loss)

  • Patients with diabetes mellitus (physical activity)

  • Patients with diabetes mellitus (dietary modifications)

  • Patients with diabetes mellitus (protein intake)

  • Patients with diabetes mellitus (sodium intake)

  • Patients with diabetes mellitus (smoking cessation)

  • Patients with diabetes mellitus (metformin)

  • Patients with diabetes mellitus (renin-angiotensin system inhibitors)

  • Patients with diabetes mellitus (mineralocorticoid receptor antagonists)

  • Patients with diabetes mellitus (beta-blockers)

  • Patients with diabetes mellitus (SGLT-2 inhibitors)

  • Patients with diabetes mellitus (GLP-1 receptor agonists)

  • Patients with diabetes mellitus (statin therapy)

  • Patients with diabetes mellitus (antiplatelet therapy)

  • Patients with diabetes mellitus (RRT)

  • Patients with diabetes mellitus (kidney transplantation)

  • Patients with coronary artery disease

  • Patients with AF

  • Patients with osteoporosis (bisphosphonates)

  • Patients with HCV infection (liver testing)

  • Patients with HCV infection (screening for other infections)

  • Patients with HCV infection (antiviral regimens)

  • Patients with HCV infection (management of glomerular disease)

  • Patients with HCV infection (kidney transplantation)

  • Patients with HCV infection (kidney transplant recipients)

  • Patients with HCV infection (follow-up)

  • Patients with HIV infection (monitoring of renal function)

  • Patients with HIV infection (evaluation for kidney disease)

  • Patients with HIV infection (antiretroviral therapy)

  • Patients with HIV infection (RAAS blockers)

  • Patients with HIV infection (statins)

  • Patients with HIV infection (aspirin)

  • Patients with HIV infection (BP targets)

  • Patients with HIV infection (corticosteroids)

  • Patients with HIV infection (RRT)

  • Patients with HIV infection (kidney transplantation)

  • Patients with HIV infection (pediatric patients)

Patient education

Education programs
As per KDIGO 2024 guidelines:
Incorporate education programs that also involve care partners where appropriate to promote informed, proactive patients with CKD.
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Consider using telehealth technologies such as web-based platforms, mobile applications, virtual visits, and wearable devices in the provision of education and care.
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Preventative measures

Use of contrast media, iodine-containing
As per DoD/VA 2025 guidelines:
Administer isotonic crystalloids for IV volume expansion in patients with CKD undergoing imaging with iodinated contrast media who are at increased risk for iodinated contrast-associated AKI.
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Do not use N-acetylcysteine for the prevention of iodinated contrast-associated AKI.
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  • Use of contrast media (gadolinium-containing)

Follow-up and surveillance

Indications for specialist referral
As per DoD/VA 2025 guidelines:
Consider referring patients with high co-occurring conditions and low functional status to nephrology with sufficient time for comprehensive preparation for conservative management or dialysis for treatment of kidney failure.
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Refer patients with autosomal dominant polycystic kidney disease to a nephrology provider for evaluation and assessment of appropriateness of treatment with tolvaptan.
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  • Monitoring for disease progression

Quality improvement

Requirements for laboratories: as per KDIGO 2024 guidelines, implement the following laboratory standards of care to ensure precision and reliability in GFR assessment using creatinine and cystatin C:
report eGFR in addition to the serum concentrations of filtration markers using validated equations
report eGFR rounded to the nearest whole number and relative to a body surface area of 1.73 m² in adults using the units mL/min/1.73 m²
flag reported eGFR levels < 60 mL/min/1.73 m² as low
report serum creatinine concentration rounded to the nearest whole number when expressed as standard IUs (mcmol/L) and rounded to the nearest 100th of a whole number when expressed as conventional units (mg/dL), and serum cystatin C concentration rounded to the nearest 100th of a whole number when expressed as conventional units (mg/L)
measure filtration markers using a specific, precise (coefficient of variation < 2.3% for creatinine and < 2.0% for cystatin C) assay with calibration traceable to the international standard reference materials and desirable bias (< 3.7% for creatinine and < 3.2% for cystatin C) compared with reference methodology (or appropriate international standard reference method group target in external quality assessment for cystatin C)
use an enzymatic method to assay creatinine, where possible
separate serum/plasma from RBCs by centrifugation within 12 hours of venipuncture
measure creatinine on the same sample used to measure cystatin C to enable calculation of eGFR by creatinine and cystatin C.
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