Updated VA/DoD guidelines for CKD highlight SGLT2 inhibitors, GLP-1 RAs, and statins for risk reduction

The U.S. Department of Veterans Affairs (VA) and U.S. Department of Defense (DoD) updated their 2019 clinical practice guideline (CPG) for the management of chronic kidney disease (CKD), emphasizing early detection, risk stratification, and expanded pharmacologic options.

Of the 23 recommendations included, 21 are new or updated from the 2019 CPG, including treatment with a sodium–glucose cotransporter 2 inhibitor (SGLT2i) or a glucagon-like peptide 1 receptor agonist (GLP-1 RA) in patients with type 2 diabetes and albuminuria. A summary of recommendations most relevant for primary care physicians is published in Annals of Internal Medicine.

To inform the 2025 updated CPG, the VA and DoD compiled a multidisciplinary work group with expertise in nephrology, internal medicine, and other specialties. The work group used a systematic review of peer-reviewed literature published from 14 September 2018 to 30 June 2024 to develop recommendations.

Key recommendations include the use both estimated glomerular filtration rate (eGFR) and urine albumin-to-creatinine ratio (UACR) for diagnosis and risk prediction; the use of a validated kidney failure risk prediction model for management of patients with G3 to G5 CKD; shared decision-making for kidney replacement therapy; and an interdisciplinary care team and early referral to nephrology for patients with progressive CKD.

11 recommendations concerned pharmacological management, including strong recommendations for use of statins in patients with CKD not on dialysis; use of either an angiotensin-converting enzyme inhibitor (ACE-I) or an angiotensin II receptor blocker (ARB) in patients with hypertension and albuminuria; and referral of patients with autosomal-dominant polycystic kidney disease (ADPKD) to nephrology to consider tolvaptan.