Principles Supporting CKD Management in Primary Care

Introduction To support evidence-based care for CKD in primary care, the US Department of Veterans Affairs (VA) and Department of Defense (DoD) convened a workgroup to synthesize new evidence published since the last review in 2019. The 2025 VA/DoD Clinical Practice Guideline (CPG) for Primary Care Management of CKD contains 23 evidence-based recommendations, five algorithms, and 11 appendices to guide primary care providers (PCPs), accessible at https://www.healthquality.va.gov/guidelines/cd/ckd/index.asp. Advances in the conceptualization of cardiovascular-kidney-metabolic (CKM) syndrome and an expansion of therapeutic options offer opportunities to slow progression of CKD and reduce cardiovascular morbidity.1 The updated CPG is intended to capitalize on these developments by enhancing consistency and quality of CKD management in diverse primary care settings. Guideline Development and Scope In parallel with its evidence review,2 the CPG workgroup outlined core principles to guide primary care management of CKD across the continuum of care (Figure 1A). These principles reflect deliberations on the reach, expertise, capacity, and strategic role of PCPs versus those of nephrology providers, prioritizing areas where each has the greatest potential to influence outcomes. Guided by these principles, we describe the application of evidence-based recommendations for CKD.Figure 1: Guideline recommendations structure CKD management across the care continuum and guide pharmacologic therapy. (A) VA/DoD CKD guideline recommendation topics grouped according to the principles of CKD management and continuum of care. (B) Pharmacologic management of CKD in patients not on dialysis. The Work Group recommends stepwise addition of pharmacotherapies to slow progression of CKD and reduce MACE, noting that trials of SGLT2i, GLP-1 RA, and finerenone were each conducted on a background of ACEI/ARB therapy; however, the benefits of various combinations are unknown. *Strongest evidence for kidney protection with ACEI/ARB is in UACR >300 mg/g. **In patients with heart failure, sacubitril/valsartan may be used as an alternative to ACEI/ARB. †See VA/DOD HTN CPG. ‡Depending on co-occurring conditions. §See VA/DOD Diabetes CPG. ACEI, angiotensin-converting enzyme inhibitor; ADPKD, autosomal dominant polycystic kidney disease; ARB, angiotensin II receptor blocker; CCB, calcium channel blocker; CPG, clinical practice guideline; CV, cardiovascular; DM, diabetes mellitus; DoD, Department of Defense; g, gram; GLP-1 RA, glucagon-like peptide-1 receptor agonists; HF, heart failure; HTN, hypertension; L, liter; MACE, major adverse cardiovascular events; mEq, milliequivalent; mg, milligram; nsMRA, nonsteroidal mineralocorticoid receptor antagonist; PICC, peripherally inserted central catheter; SGLT2i, sodium-glucose cotransporter 2 inhibitor; UACR, urine albumin-to-creatinine ratio; VA, Veterans Affairs.Principles of CKD Management in Primary Care Principle 1: Early Detection and Risk Stratification PCPs are well-positioned to identify CKD because they interact with a broad population of patients with or at risk for CKM syndrome. The guidelines make five recommendations concerning testing for CKD, staging CKD with measurement of urine albumin-to-creatinine ratio and eGFR, estimating GFR with the combined creatinine-cystatin C formula to predict risk for progression, and referral for polycystic kidney disease. CKD is undetected in up to two thirds of adults with diabetes or hypertension due to lack of testing for albuminuria.3 The CPG's recommendations are consistent with the American Heart Association Advisory on Cardiovascular-Kidney-Metabolic Health and the American Diabetes Association guidance for annual urine albumin-to-creatinine ratio and eGFR measurements in those with metabolic risk factors or CKD.1,4 In patients with stages G3–G5 CKD, the workgroup recommends estimating GFR with a combined creatinine-cystatin C formula for risk prediction at least once and the use of a validated CKD progression risk model to counsel patients, guide treatment selection, optimize referrals for those at high risk of progression, and enhance provider confidence in managing low-risk patients. Principle 2: Management of Cardiovascular-Kidney-Metabolic Syndrome PCPs deliver care for most patients with early CKD. Treatments for CKM, such as sodium-glucose cotransporter 2 inhibitors (SGLT2is) and glucagon-like peptide-1 receptor agonists (GLP-1 RAs), fall within PCPs' expertise and are covered by the VA and DoD health systems. The CPG makes eight recommendations to promote uptake of pharmacologic treatments for CKM syndrome. The workgroup recommends statin use and suggests treating hypertension to a systolic BP goal more intensive than