Practice Guidelines

Chronic Kidney Disease: Evaluation and Treatment Guidelines from the VA/DoD

 

Am Fam Physician. 2020 Sep 15;102(6):378-379.

Author disclosure: No relevant financial affiliations.

Key Points for Practice

• When screening for or staging CKD, consider assessing function with urine albumin-to-creatinine ratio and serum cystatin-C measurement.

• ACE inhibitors are the best treatment for nondiabetic CKD, whereas ACE inhibitors and ARBs are beneficial in diabetic CKD. Combination ACE inhibitor and ARB therapy should be avoided.

• Treating type 2 diabetes with metformin in CKD reduces mortality and can be continued until eGFR drops to 30 mL per minute per 1.73 m2. SGLT-2 inhibitors and GLP-1 receptor agonists also improve outcomes in CKD.

From the AFP Editors

Chronic kidney disease (CKD) affects 15% of the U.S. population, although fewer than one in 10 with the disease is aware of their diagnosis. The U.S. Department of Veterans Affairs and Department of Defense (VA/DoD) have updated recommendations for evaluation and treatment of CKD.

Diagnosis

Screening for CKD does not improve outcomes in any population, and the VA/DoD recommend screening based on clinical risk and shared decision-making. CKD is staged based on estimated glomerular filtration rate (eGFR) as shown in Table 1, which is most often calculated from serum creatinine. If screening or stratifying CKD risk, physicians should use urine albumin-to-creatinine ratio testing with eGFR to improve risk prediction. The recommendations suggest a single eGFR based on a cystatin-C measurement, if available, because it is less affected by age, sex, and muscle mass than creatinine in patients with an eGFR less than 60 mL per minute per 1.73 m2. Doing so may reduce the misclassification of CKD in up to 40% of patients and may result in a higher classification stage for 25% of those with CKD.

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TABLE 1.

Chronic Kidney Disease Staging

StageeGFR (mL per minute per 1.73 m2)Description

1

≥ 90

Normal or increased GFR

2

60 to 89

Mildly decreased GFR

3a

45 to 59

Mildly to moderately decreased GFR

3b

30 to 44

Moderately to severely decreased GFR

4

15 to 29

Severely decreased GFR

5

< 15 or dialysis

End-stage renal disease


Note: Diagnosis of chronic kidney disease based on eGFR < 60 mL per minute per 1.73 m2 for three months or any of the following: albuminuria (urine albumin-to-creatinine ratio > 30); proteinuria (urine protein-to-creatinine ratio > 0.2); hematuria or abnormal findings on urinalysis; structural renal abnormalities, including solitary kidney; history of abnormal renal histology; or history of renal transplantation.

eGFR = estimated glomerular filtration rate.

Adapted from U.S. Department of Veterans Affairs. Va/DoD clinical practice guideline for the management of chronic kidney disease. September 2019. Accessed July 2, 2020. https://www.healthquality.va.gov/guidelines/CD/ckd/

TABLE 1.

Chronic Kidney Disease Staging

StageeGFR (mL per minute per 1.73 m2)Description

1

≥ 90

Normal or increased GFR

2

60 to 89

Mildly decreased GFR

3a

45 to 59

Mildly to moderately decreased GFR

3b

30 to 44

Moderately to severely decreased GFR

4

15 to 29

Severely decreased GFR

5

< 15 or dialysis

End-stage renal disease


Note: Diagnosis of chronic kidney disease based on eGFR < 60 mL per minute per 1.73 m2 for three months or any of the following: albuminuria (urine albumin-to-creatinine ratio > 30); proteinuria (urine protein-to-creatinine ratio > 0.2); hematuria or abnormal findings on urinalysis; structural renal abnormalities, including solitary kidney; history of abnormal renal histology; or history of renal transplantation.

eGFR = estimated glomerular filtration rate.

Adapted from U.S. Department of Veterans Affairs. Va/DoD clinical practice guideline for the management of chronic kidney disease. September 2019. Accessed July 2, 2020. https://www.healthquality.va.gov/guidelines/CD/ckd/

Nephrology Referral

Using a risk prediction model, such as the Kidney Failure Risk Calculator (https://www.mdcalc.com/kidney-

Coverage of guidelines from other organizations does not imply endorsement by AFP or the AAFP.

This series is coordinated by Michael J. Arnold, MD, contributing editor.

A collection of Practice Guidelines published in AFP is available at https://www.aafp.org/afp/practguide.

 

 

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