United States Department of Veterans Affairs
VA/DoD Clinical Practice Guidelines

VA/DoD Clinical Practice Guideline for the Management of Chronic Kidney Disease in Primary Care

Citation: Chronic Kidney Disease Working Group. (2008). VA/DoD clinical practice guideline for the management of chronic kidney disease in primary care. Version 2.0. Washington, DC: Veterans Health Administration and Department of Defense.
Completion Date: 2007
Release Date: 2007
Source(s): Washington (DC): The Chronic Kidney Disease (CKD)Guideline was developed by and for clinicians from the Department of Veterans Affairs (VA) and the Department of Defense (DoD); 2007.
Adaptation:

The guideline was an update of the May, 2001 VA/DoD Clinical Practice Guideline for the Chronic Kidney Disease And Pre-ESKD in the Primary Care Setting.

Evidence-based guidelines referenced in this updated version of the VA/DoD Clinical Practice Guideline include:

  • The National Kidney Foundation Kidney Disease Outcomes Quality Initiative – which will be referred to throughout this guideline as KDOQI and can be accessed at http://www.kidney.org/professionals/KDOQI/guidelines.cfm.
  • The Joint Specialty Committee on Renal Medicine of the Royal College of Physicians and the Renal Association, and the Royal College of General Practitioners. Chronic kidney disease in adults: UK guidelines for identification, management and referral. London: Royal College of Physicians, 2006 – which will be referred to throughout this guideline as UK.
  • Caring for Australians with Renal Impairment - which will be referred to throughout this guideline as CARI and can be accessed at: http://www.cari.org.au/guidelines.php.
Guideline Status: This is the current version of the guideline. An update is targeted for 2013.
Previous Version:

There is only one previous version of this guideline.

  • Chronic Kidney Disease Working Group. (2008). VA/DoD clinical practice guideline for the management of chronic kidney disease and pre-ESKD in the primary care setting. Version 1.1. Washington, DC: Veterans Health Administration and Department of Defense.(Click here to access the previous version of the guideline)
Developer(s): Veterans Health Administration (VHA), Department of Veterans Affairs (VA) - Federal Government Agency [U.S.]
Department of Defense (DoD) - Federal Government Agency [US]
Funding Source: United States Government
Committee: The Management of Chronic Kidney Disease Working Group
Group Composition: Primary care providers (physicians and nurse practitioners), nephrologists, pharmacists, registered nurses, and registered dietitians.
Disease Condition: Chronic Kidney Disease (CKD)
Category: Assessment, Diagnosis, Treatment, Management
Intended Users: The guideline is relevant to all healthcare professionals who have direct contact with patients with CKD, and make decisions about their care. This version of the guideline was specifically tailored to provide what would be of greatest value to the primary care provider.
Target Population: Adult patients with CKD:This guideline applies to both patients presenting for the first time with CKD and to patients already being followed for CKD. In both instances, CKD is defined as the presence of decreased eGFR or proteinuria or structural renal damage as determined by radiologic imaging or kidney biopsy, which can occur together or independently.
Contact Person(s):
Carla L. Cassidy
Director, Evidence-Based Practice Program
Office of Quality, Safety and Value 10A4B2
1717H Street NW 4th Floor
Washington DC 20006
Office: 202-266-4502
Fax: 202-495-4969
carla.cassidy@va.gov 		 Ernest Degenhardt, COL USA (Ret.)
Chief, Evidence-Based Practice
Quality Management Division
U.S. Army MEDCOM
Office: 210-221-6527 or DSN 471-6527
ernest.degenhardt@us.army.mil 
Goals/Objectives: The intent of the guideline is to:
  • Reduce current practice variation and provide facilities with a structured framework to help improve patient outcomes.
  • Provide evidence-based recommendations to assist providers and their patients in the decision-making process for patients with CKD.
  • Identify outcome measures to support the development of practice-based evidence that can ultimately be used to improve clinical guidelines.  
Scope: Offers best practice advice on the care of adults who have a clinical working diagnosis of CKD.
  • Covers diagnostic criteria for CKD.
  • Focuses on identification of susceptibility factors (i.e., adult patients at increased risk for developing CKD).
  • Specifies key elements in the evaluation of patients with CKD (including assessment of disease progression).
  • Focuses on identification of risk factors for progression of CKD.
  • Addresses approaches to slowing the progression of CKD.
  • Addresses pharmacotherapy, nutrition, and management of comorbidities in patients with CKD.
  • Addresses indications for consultation and referral to a nephrologist.
  • Does not cover the management of patients with ESKD (i.e., hemodialysis, peritoneal dialysis, kidney transplantation), or detailed management of patients with severe CKD (eGFR < 30 ml/min/1.73m2), nor does it cover pediatric patients.
Interventions And Practices: The Guideline consists of two modules, which address management of CKD:
  • Algorithm A - Management of CKD
  • Algorithm B - Screening for CKD
This guideline also contains appendices that provide more information on the spectrum of treatment options, and give details on pharmacologic interventions, nutrition, and patient education.
  • Appendix A: Guideline Development Process
  • Appendix B: Assessment
  • Appendix C: Slowing Progression of CKD
  • Appendix D: Pharmacotherapy
  • Appendix E: Complications of Kidney Disease
  • Appendix F: Nutrition
  • Appendix G: Patient Education
  • Appendix H: Follow-up for Chronic Kidney Disease
  • Appendix I: Acronym List
  • Appendix J: Participant List
  • Appendix K: Bibliography
Outcomes Considered:
  1. Progressive loss of kidney
    1. Decrease in eGFR
    2. Increasing proteinuria
    3. Progression to ESKD
  2. Development/progression of cardiovascular disease
  3. Mortality
  4. Health Related-Quality of Life (HR-QOL)
  5. Utilization of healthcare (hospitalization)
  6. Control of metabolic implications (anemia, bone disease, acid base balance, malnutrition).
Major Recommendations: Presentation of the algorithms is intended to assist the clinician in reviewing and identifying key points that are comprehensively discussed in the guideline document.
Clinical Algorithms:
  • Algorithm A - Management of CKD
  • Algorithm B - Screening for CKD
Type Of Evidence: The guideline is supported by the literature in a majority of areas, with evidence-based tables and references throughout the document. The evidence consists of key clinical randomized controlled trials and longitudinal studies in the area of COPD. Where existing literature is ambiguous or conflicting, or where scientific data are lacking on an issue, recommendations are based on the expert panel's opinion and clinical experience. The guideline contains a bibliography and discussion of the evidence supporting each recommendation.
Guideline Development Process: The development process of this guideline follows a systematic approach described in "Guidelines-for-Guidelines." In addition Appendix A clearly describes the guideline development process. The literature was critically analyzed and evidence was graded using a standardized format. The evidence rating system for this document is based on the system used by the U.S. Preventative Services Task Force.
Review
Methods:		 Peer Review
Qualifying Statements: Clinical practice guidelines, which are increasingly being used in health care, are seen by many as potential solutions to inefficiency and inappropriate variations in care. Guidelines should be evidenced-based as well as based upon explicit criteria to ensure consensus regarding their internal validity. However, it must be remembered that the use of guidelines must always be in the context of a health care provider's clinical judgment in the care of a particular patient. For that reason, the guidelines may be viewed as an educational tool analogous to textbooks and journals, but in a more user-friendly format.
Guideline Availability: Electronic copies available from the OQSV website
Copyright Statement: No copyright restrictions apply.