Management of Chronic Kidney Disease
Publication Date: April 1, 2020
Last Updated: March 14, 2022
Recommendations
Diagnosis Assessment and Lab Monitoring
In the general population, there is insufficient evidence to recommend for or against periodic evaluation for chronic kidney disease. ()
315659
When screening or stratifying risk for chronic kidney disease, we recommend including urine albumin-to-creatinine ratio testing in addition to estimated glomerular filtration rate to optimize the diagnosis and staging of chronic kidney disease. (Strong for)
315659
In patients with an estimated glomerular filtration rate <60 mL/minute/1.73 m², we suggest one-time cystatin C-based estimated glomerular filtration to confirm diagnosis and/or refine staging of chronic kidney disease. (Weak for)
315659
We suggest the use of a validated risk prediction model as a clinical decision support aid in the management of patients with chronic kidney disease. (Weak for)
315659
When assessing the risk of progression to end-stage renal disease, there is insufficient evidence to recommend a specific risk prediction calculator. ()
315659
General Management Strategies
Team Management and Education
There is currently insufficient evidence to recommend a specific threshold of risk, renal function, or proteinuria to refer patients for a nephrology evaluation and management of chronic kidney disease. ()
315659
We suggest interdisciplinary care (including dietitians, pharmacists, and social workers in addition to physicians and nurses) for patients with later-stage chronic kidney disease. (Weak for)
315659
When providing patient education, there is insufficient evidence to recommend for or against a particular health education program, mode, or modality to prevent chronic kidney disease progression. ()
315659
For patients who are at high risk for requiring hemodialysis/renalreplacement and need long-term venous access, we suggest against peripherally inserted central catheter (PICC) lines to optimize future dialysis vascular access options, while considering patient values and preferences. (Weak against)
315659
Indication for Referral to Nephrology for Renal Replacement Therapy Including Dialysis and Renal Transplant
We suggest utilizing shared decision making regarding renal replacement therapy (versus conservative management) in part to improve patient satisfaction. (Weak for)
315659
In patients with high comorbidities/low functional status approaching the need for renal replacement therapy and for whom prolongation of life is the priority, we suggest evaluation for renal replacement therapy with sufficient time for comprehensive preparation. (Weak for)
315659
In patients with high comorbidities/low functional status approaching the need for renal replacement therapy and for whom avoiding hospitalization, death in hospitals, or intensive procedures is the priority, we suggest offering conservative management over dialysis. (Weak for)
315659
In patients with high comorbidities/low functional status approaching the need for renal replacement therapy and for whom prolongation of life may not be the priority, there is insufficient evidence to recommend for or against dialysis to improve quality of life. ()
315659
Non-pharmacological Management of CKD
We suggest the use of dietary sodium restriction as a self-management strategy to reduce proteinuria and improve blood pressure control in patients with chronic kidney disease. (Weak for)
315659
In selected patients with stage 3 and 4 chronic kidney disease, we suggest offering a dietary protein intake of 0.6 to 0.8 g/kg/day as it may slow the decline in estimated glomerular filtration rate and progression to end-stage renal disease. (Weak for)
315659
Pharmacologic Management of CKD & Associated Conditions
Diabetes Medications
We suggest offering metformin as a first-line therapy for the treatment of type 2 diabetes in patients with stage 1 to 3 chronic kidney disease to reduce all-cause mortality. (Weak for)
315659
We recommend offering sodium-glucose co-transporter 2 inhibitors as an option for add-on therapy for the treatment of type 2 diabetes in patients with stage 1 to 3 chronic kidney disease to reduce chronic kidney disease progression and the risk of cardiovascular events. (Strong for)
315659
We suggest offering liraglutide or dulaglutide (glucagon-like peptide1 receptor agonists) as an option for add-on therapy for the treatment of type 2 diabetes in patients with chronic kidney disease to reduce chronic kidney disease progression. (Weak for)
315659
In patients with chronic kidney disease and type 2 diabetes, there is insufficient evidence to recommend for or against the use of thiazolidinediones or dipeptidyl peptidase-4 inhibitors to decrease progression of chronic kidney disease or mortality. ()
315659
Hypertension Medications
We suggest intensive blood pressure management (insufficient evidence to recommend a specific target) beyond a target of less than 140/90 mmHg, to reduce mortality in patients with estimated glomerular filtration rate below 60 mL/minute/1.73 m². (Weak for)
315659
In patients with non-diabetic chronic kidney disease, hypertension, and albuminuria, we recommend the use of an angiotensin-converting enzyme inhibitor to prevent progression of chronic kidney disease. Angiotensin II receptor blockers may be substituted for patients with an angiotensin-converting enzyme-inhibitor-induced cough. (Strong for)
315659
In patients with chronic kidney disease, diabetes, hypertension, and albuminuria, we recommend the use of an angiotensin-converting enzyme inhibitor or angiotensin II receptor blockers to slow the progression of chronic kidney disease, unless there is documentation of intolerance. (Strong for)
315659
We recommend against the use of combination renin-angiotensin-aldosterone system blockade (an angiotensin-converting enzyme inhibitor and angiotensin II receptor blocker, or an angiotensin-converting enzyme inhibitor or angiotensin II receptor blocker with a direct renin inhibitor) in patients with chronic kidney disease. (Strong against)
315659
Anemia Medications
We suggest initiation of oral iron therapy to support iron requirements in patients with chronic kidney disease. (Weak for)
315659
We recommend against initiating erythropoiesis-stimulating agents in patients with chronic kidney disease for the purpose of achieving a hemoglobin target above 11.5 g/dL due to increased risk of stroke and hypertension. (Strong against)
315659
We recommend against initiating erythropoiesis-stimulating agents at a hemoglobin level greater than 10 g/dL. (Strong against)
315659
Bone Health Medications
We suggest against offering calcitriol or active vitamin D analogs to patients with stage 3 and 4 chronic kidney disease and elevated parathyroid hormone levels. (Weak against)
315659
We suggest against offering calcimimetics to patients with stage 3 and 4 chronic kidney disease and elevated parathyroid hormone levels. (Weak against)
315659
There is insufficient evidence to recommend for or against the use of phosphate binders to reduce mortality, progression of chronic kidney disease, or major cardiovascular outcomes in patients with stage 2 to 5 chronic kidney disease. ()
315659
Other Medications to Slow CKD Progression
We suggest the use of bicarbonate supplementation in chronic kidney disease patients with metabolic acidosis to slow the progression of chronic kidney disease. (Weak for)
315659
In patients with chronic kidney disease and asymptomatic hyperuricemia, there is insufficient evidence to recommend for or against the use of urate-lowering therapy for the purpose of slowing progression of chronic kidney disease. ()
315659
In patients at risk for rapidly progressing autosomal dominant polycystic kidney disease, we suggest offering tolvaptan in consultation with a nephrologist to slow decline in estimated glomerular filtration rate. (Weak for)
315659
Contrast-Associated Kidney Injury Management
For patients at increased risk for iodinated contrast-associated acute kidney injury, we recommend volume expansion with intravenous isotonic saline prior to and following iodinated contrast administration. (Strong for)
315659
We recommend against the administration of N-acetylcysteine for prevention of iodinated contrast-associated acute kidney injury. (Strong against)
315659
We recommend against the use of renal replacement therapy for iodinated contrast-associated acute kidney injury prophylaxis. (Strong against)
315659
Recommendation Grading
Overview
Title
Management of Chronic Kidney Disease
Authoring Organization
Veterans Health Administration / Department of Defense
Publication Month/Year
April 1, 2020
Last Updated Month/Year
February 5, 2024
Supplemental Implementation Tools
Document Type
Guideline
External Publication Status
Published
Country of Publication
US
Inclusion Criteria
Female, Male, Adult, Older adult
Health Care Settings
Operating and recovery room, Outpatient
Intended Users
Dietician nutritionist, epidemiology infection prevention, nurse, nurse practitioner, physician, physician assistant
Scope
Management, Treatment
Diseases/Conditions (MeSH)
D003920 - Diabetes Mellitus, D006973 - Hypertension, D000740 - Anemia, D016030 - Kidney Transplantation, D007676 - Kidney Failure, Chronic
Keywords
chronic kidney disease, Kidney Dialysis, glomerular filtration rate (GFR)
Source Citation
Https://www.healthquality.va.gov/guidelines/CD/ckd/index.asp
Supplemental Methodology Resources
Methodology
Number of Source Documents
244
Literature Search Start Date
December 1, 2013
Literature Search End Date
September 27, 2018