Department of Veterans Affairs

Department of Defense

VA/DoD Clinical Practice Guideline

for 

The management of Chronic Kidney Disease 

in Primary care

Guideline Summary

Prepared by:

The Chronic Kidney Disease

Working Group

With support from:

The Office of Quality, Safety and Value, VA, Washington, DC

and

Quality Performance Assurance Directorate, United States Army MEDCOM

Full guideline available at:

http://www.healthquality.va.gov or https://www.qmo.amedd.army.mil

QUALIFYING STATEMENTS

The Department of Veterans Affairs (VA) and The Department of Defense (DoD) guidelines are based upon the best 

information available at the time of publication. They are designed to provide information and assist decision-making. 

They are not intended to define a standard of care and should not be construed as one. Neither should they be interpreted 

as prescribing an exclusive course of management.

Variations in practice will inevitably and appropriately occur when providers take into account the needs of individual 

patients, available resources, and limitations unique to an institution or type of practice. Every health care professional 

making use of these guidelines is responsible for evaluating the appropriateness of applying them in the setting of any 

particular clinical situation. 

Version 3.0 – 2014
2 | Guideline Summary – 2014

DISCLAIMER

This Clinical Practice Guideline is based on a systematic review of both clinical and epidemiological evidence. 

Developed by a panel of multidisciplinary experts (all practicing clinicians), it provides a clear explanation of the logical 

relationships between various care options and health outcomes while rating both the quality of the evidence and the 

strength of the recommendations.

These guidelines are not intended to represent TRICARE policy. Further, inclusion of recommendations for specific 

testing and/or therapeutic interventions within these guidelines does not guarantee coverage of civilian sector care. 

Additional information on current TRICARE benefits may be found at www.tricare.mil or by contacting your regional 

TRICARE Managed Care Support Contractor.

TABLE OF CONTENTS

SUMMARY........................................................................................................................................................................ 3

ALGORITHM...................................................................................................................................................................... 6

RECOMMENDATIONS.....................................................................................................................................................10

PHARMACOLOGICAL AGENTS ......................................................................................................................................13

REFERENCES ...................................................................................................................................................................15
Management of Chronic Kidney Disease | BACKGROUND | 3

SUMMARY

Chronic kidney disease (CKD) is one of the most common serious medical conditions affecting adults in the United 

States (US). The Centers for Disease Control and Prevention (CDC) estimate that more than 10% of adults in the US—

over 20 million people—have CKD, [1] which is defined as having an estimated glomerular filtration rate (eGFR) of <60 

mL/min/1.73m2 or albuminuria (albumin excretion rate [AER] of ≥30 mg/24 hours or albumin:creatinine ratio [ACR] of 

≥30 mg/g), kidney transplantation, or any of several other less common reasons (e.g., urine sediment abnormalities, 

electrolytes and other abnormalities due to tubular disorders, histologic abnormalities, structural abnormalities 

identified by imaging). [2] Patients may suffer from mild illness without symptoms to severe illness associated with 

increased risk of death or progression to end-stage renal disease (ESRD) requiring dialysis or kidney transplantation. 

The risk of developing CKD increases among people over 50 years of age and peaks after 70 years of age. [1] In many 

patients the disease is caused by, or associated with, other conditions including diabetes, hypertension, cardiovascular 

disease, malnutrition, and anemia. Early intervention and management is important to stabilize, or at least slow down, 

progressive kidney damage, which worsens the prognosis of patients with CKD. The stages of CKD are described in 

Table 1 below. For a given stage of CKD, the categories A1-A3 will increase the risk of CKD progression.

Table 1 Stages of CKD [2-4]

Stage

Stages eGFR 

(mL/min/1.73 m2) Description

G1 ≥ 90 Kidney damage with normal or increased GFR

G2 60-89 Kidney damage with mildly decreased GFR

G3a 45-59 Mildly to moderately decreased GFR

G3b 30-44 Moderately to severely decreased GFR

G4 15-29 Severely decreased GFR

G5 <15 or dialysis Kidney failure

Albuminuria

Category Range 

(mg albumin/g creatinine) Description

A1 <30 mg/g Normal to mildly increased

A2 30-300 mg/g Moderately increased

A3 >300 mg/g Severely increased 

The Department of Veterans Affairs (VA) and Department of Defense (DoD) have an obligation to ensure that all 

patients with CKD receive a full range of high quality care. This clinical practice guideline (CPG) is designed to 

assist primary care providers in managing patients with CKD Stages 1-4. Additionally, the CPG provides evaluation 

considerations and treatment options, including pharmacological and non-pharmacological interventions.

Topics discussed in this CPG include:

• Evaluation for CKD

• Strategies for acute kidney injury (AKI) avoidance

• Self-management strategies

• Clinical management strategies
4 | Guideline Summary – 2014

Evaluation for CKD

Factors that need to be considered prior to screening for an asymptomatic disease include if, a) a simple accurate test 

is available and b) there are treatments that improve patient outcomes. For CKD, there are currently no randomized 

controlled trials that demonstrate an improvement in patient outcomes associated with CKD screening. Given the lack of 

evidence for CKD screening, the Work Group does not encourage screening asymptomatic individuals for the presence 

of kidney disease. The Work Group recommends periodic evaluation of CKD in patients at high risk for CKD and further 

evaluation of CKD in those with elements of abnormal kidney tests, such as those with albuminuria or abnormal imaging 

tests.

For every newly discovered patient with kidney disease and those with acute worsening of CKD, the history, physical 

examination, and basic laboratory evaluation remain the cornerstone for establishing etiology and ruling out reversible 

causes. Clinical assessment will help identify the clinical markers that indicate kidney disease and outline basic diagnostic 

testing required in all patients.

A targeted history to detect the presence and possible contribution of conditions present in a patient with new or 

established CKD includes:

• History of diabetes or kidney disease

• Hypertension

• Cardiovascular disease

• Significant end-organ disease (liver disease)

• Lower urinary tract symptoms suggestive of urinary obstruction

• Systemic illness (e.g., hepatitis B or C, human immunodeficiency virus [HIV])

• Symptoms suggestive of a systemic vasculitis (e.g., rash, arthritis, serositis)

• Chronic pain syndrome (raising suspicion for analgesic abuse)

• Genito-urinary malignancy

• History of abdominal/pelvic surgery or radiation

• Exposure to environmental toxins or nephrotoxins

Acute Kidney Injury Avoidance

Acute kidney injury is being increasingly recognized as a forerunner of CKD. Additionally, CKD is both a consequence of 

and a risk factor for AKI. Prevention of AKI may help reduce progression of CKD; thus, AKI avoidance should be a goal of 

care. Risk factors for AKI are increasingly described; however, the most well-described risk factor of AKI is the parenteral 

administration of iodinated radiocontrast agents. Contrast-induced nephropathy (CIN) is a potentially preventable form 

of AKI.

Self-Management Strategies

The role of the patient in management of CKD is being increasingly emphasized. We reviewed the literature for evidence 

of self-management strategies that might reduce CKD progression. The guideline panel suggests the use of dietary 

sodium restriction and dietary protein restriction as these interventions may slow CKD progression. The guideline 

panel also encourages weight loss, exercise, health education and smoking cessation interventions for patients with 

CKD as these are useful strategies to improve overall patient health. More broadly, evidence suggests that patient selfmanagement plays an essential role in the management of any chronic disease.
Management of Chronic Kidney Disease | BACKGROUND | 5

Additional Resources for Smoking Cessation

The VA smoking quit line, 1-855-QUIT-VET, offers callers counseling, help building a quit plan, and strategies 

to prevent relapse. SmokefreeVET is a free mobile text messaging service that sends tips, support, and 

encouragement for up to eight weeks during the quitting process. Veterans can sign up by visiting 

http://smokefree.gov/VET, or texting the word VET to 47848.

Clinical Management Strategies

Complementing patient self-management strategies are numerous effective clinical management strategies that may be 

employed to reduce the adverse outcomes of CKD. Blood pressure control, appropriately tailored to patient tolerance, 

and preferential use of an angiotensin-converting enzyme inhibitor (ACEI) or angiotensin II receptor blocker (ARB) in 

patients with hypertension and CKD with albuminuria are essential to limit progression of CKD to ESRD. Monitored 

dietary interventions including sodium and protein restriction in patients with CKD, and bicarbonate supplementation 

in patients with metabolic acidosis may also be useful in limiting progression to kidney failure. For patients with diabetes 

and CKD, the risks and benefits of intensive glycemic control need to be discussed with the patient and balanced to 

achieve patient-centered goals of care.

Prevention of cardiovascular disease and infection is paramount in this at-risk population; thus, the directed use of statins 

and administration of prophylactic immunizations should be built into the routine care of patients with CKD.

In light of the increased possibility for adverse drug events in patients with CKD, vigilance is required to appropriately 

dose-adjust all medications for the patient’s level of kidney function, avoid potentially hazardous combinations of 

medications, and limit the patient’s exposure to potentially nephrotoxic agents.

Additional Resources for Reduction of Cardiovascular Risk

• Framingham (cohort age range 40-74):

http://cvdrisk.nhlbi.nih.gov/

• ASCVD Pooled Risk Calculator from the 2013 ACC/AHA Lipid Guideline (cohort age range 40-79):

http://clincalc.com/Cardiology/ASCVD/PooledCohort.aspx

• Cardiovascular Risk/Benefit Calculator (combines Framingham and ACC/AHA cohorts):

http://bestsciencemedicine.com/chd/calc2.html

• Mayo Statin Decision Aid:

http://statindecisionaid.mayoclinic.org/index.php/site/index

Patient safety must also be considered and prudence applied when using medications to treat the complications of 

progressive kidney disease (e.g., iron, erythropoiesis-stimulating agents [ESAs] to treat anemia, and oral phosphate 

binders, vitamin D analogs, and calcimimetics in the management of CKD bone and mineral disorders).

Lastly, the use of a multidisciplinary model of care and timely engagement of nephrology specialty care is suggested to 

more effectively meet the myriad needs of patients with CKD.
6 | Guideline Summary – 2014

STRENGTH OF RECOMMENDATIONS

This CPG uses the GRADE methodology to assess the quality of the evidence base and assign a grade for the strength 

for each recommendation. The GRADE system uses the following four domains to assess the strength of each 

recommendation: [6]

• Balance of desirable and undesirable outcomes

• Confidence in the quality of the evidence

• Values and preferences

• Other implications, as appropriate, e.g.,

- Resource Use

- Equity

- Acceptability

- Feasibility

- Subgroup considerations

The framework below was used by the VA/DoD HTN Work Group to guide discussions on each domain.

Table 1. Evidence to Recommendation Framework

Decision Domain Judgment

Balance of desirable and undesirable outcomes

Given the best estimate of typical values and preferences, 

are you confident that the benefits outweigh the harms and 

burden or vice versa?

Are the desirable anticipated effects large? Are the 

undesirable anticipated effects small?

Are the desirable effects large relative to undesirable effects?

Benefits outweigh harms/burden 

Benefits slightly outweigh harms/burden 

Benefits and harms/burden are balanced 

Harms/burden slightly outweigh benefits 

Harms/burden outweigh benefits

Confidence in the quality of the evidence

Is there high or moderate quality evidence that answers this 

question?

What is the overall certainty of this evidence?

High 

Moderate 

Low

Very low

Values and preferences

Are you confident about the typical values and preferences 

and are they similar across the target population?

What are the patient’s values and preferences?

Are the assumed or identified relative values similar across 

the target population?

Similar values 

Some variation 

Large variation

Other implications (e.g., resource use, equity, acceptability, feasibility, subgroup considerations):

Are the resources worth the expected net benefit from the 

recommendation?

What are the costs per resource unit? Is this intervention 

generally available?

Is this intervention and its effects worth withdrawing or not 

allocating resources from other interventions?

Is there lots of variability in resource requirements across 

settings?

Various considerations

The strength of a recommendation is defined as the extent to which one can be confident that the desirable effects 

of an intervention outweigh its undesirable effects, and is based on the framework above, which combines the four 

domains. [6]
Management of Chronic Kidney Disease | BACKGROUND | 7

The GRADE of a recommendation is based on the following elements:

• Four decision domains used to determine the strength and direction (described above)

• Relative strength (Strong or Weak)

• Direction (For or Against)

The relative strength of the recommendation is based on a binary scale, “Strong” or “Weak.” A strong recommendation 

indicates that the Work Group is highly confident that desirable outcomes outweigh undesirable outcomes. If the 

Work Group is less confident of the balance between desirable and undesirable outcomes, they present a weak 

recommendation.

Similarly, a recommendation for a therapy or preventive measure indicates that the desirable consequences outweigh 

the undesirable consequences. A recommendation against a therapy or preventive measure indicates that the 

undesirable consequences outweigh the desirable consequences.

Using these elements, the grade of each recommendation is presented as part of a continuum:

• Strong For (or “We recommend offering this option ...”)

• Weak For (or “We suggest offering this option ...”)

• Weak Against (or “We suggest not offering this option ...”)

• Strong Against (or “We recommend against offering this option ...”)

GUIDELINE WORKING GROUP

VA DoD

Susan T. Crowley, MD, FASN* (Co-Chair) LT Col. Eric Barnes, DO, FASN*(Co-Chair)

Suzanne Watnick, MD* (Co-Chair) Lt Col. Heidi Clark, MS, RD*

Christopher Barrett Bowling, MD Corinne K.B. Devlin, MSN, RN, FNP-BC*

Sarah Campoy, DNP, ANP-BC* MAJ Khayanga Namasaka, MD

Nicole Cheran, RD Annie T. Nguyen, PharmD*

Elaine Furmaga, PharmD* D. Nick Patterson, PharmD, BCPS*

Adriana Hung, MD, MPH* LCDR Robert Selvester, MD

Areef Ishani, MD*

Michelle Kasenfang, RN

Gaurang Shah, MD, FACP, FASN*

Douglas Slotkoff, MD*

Janette Williams-Smith, LCSW

Office of Quality, Safety and Value 

Veterans Health Administration

Office of Evidence Based Practice

US Army Medical Command

Eric Rodgers, PhD, FNP, BC Ernest Degenhardt, COL USA (Ret.) MSN, RN, ANP, FNP

Rene Sutton, BS, HCA Corinne K. B. Devlin, MSN, RN, FNP-BC

Lewin Group ECRI Institute

Cliff Goodman, PhD James Reston, PhD

Christine Jones, MS, MPH Nancy Sullivan, BA

Hillary Kleiner, MPH Edmond Baganizi, MB BCh, MPH

Erin Gardner, BS Jeff Oristaglio, PhD

Sneha Rangarao, MPH Sigma Health Consulting, LLC

Mariam Siddiqui, BS Fran Murphy, MD, MPH

Anjali Jain, MD

*Indicates members of the core editing panel.
8 | Guideline Summary – 2014

Algorithm Management of Chronic Kidney Disease

2

3

7

4

5

10 9

11

12

6

8

1

Yes

Yes

Yes

Yes

Yes

No

No

No

Does patient have an urgent or 

emergent condition?

(see Sidebar B)

Does patient have evidence 

of CKD?

(see Sidebar C)

Are there indications for 

nephrology consultation?

(see Sidebar F)

Complete clinical assessment 

Determine stage of CKD

(see Sidebar D)

Consult nephrology

Evaluate at-risk patients for CKD:

obtain SCr, eGFR, urinalysis, & spot urine UAER

(see Sidebar A)

Refer to emergency department to 

manage or stabilize

No further evaluation for 

kidney disease

Patient at risk for CKD

Adjust treatment plan:

optimize care of comorbid conditions ** 

(e.g., CVD, diabetes), address vaccination status, 

& evaluate medication and supplement use

Follow-up – frequency varies depending upon 

rate of progression, comorbid conditions, 

symptoms & complications 

Obtain initial clinical information: 

medical history (including risk factors for kidney disease), 

physical examination and review existing laboratory results

Establish primary etiology of CKD and treatment 

plan to slow progression

(see Sidebar E)

ACEI=angiotensin-converting enzyme inhibitor

ARB= angiotensin II receptor blocker

CHF=chronic heart failure

CVD=cardiovascular disease

DM=diabetes mellitus

eGFR=estimated glomerular filtration rate

RRT=renal replacement therapy

SCr=serum creatinine

UAER=urinary albumin excretion rate

** As appropriate, refer to VA/DoD Clinical Practice 

Guidelines for management of other chronic conditions
Management of Chronic Kidney Disease | ALGORITHMS | 9

Algorithm Management of Chronic Kidney Disease

Sidebar E: Strategies to Slow Progression

• Control of hypertension with preferential

use of either an ACEI or an ARB in 

patients with proteinuria

• Individualized control of hyperglycemia

• Dietary protein restriction in patients with

stage 3 and 4 CKD (consider consultation 

with nephrologist or renal dietitian)

• Correction of metabolic acidosis

• Avoid nephrotoxic agents

Sidebar F: Indication for Nephrology Consultation *#

• eGFR < 30 ml/min/1.73m2

• Rapid decline of eGFR (>5 ml/min/1.73m2 per year)

• Complication of CKD (e.g., anemia, calcium

or phosphorus abnormalities)

• Nephrotic range of proteinuria (>3.5 grams/24 hours)

• Underlying cause of CKD or proteinuria is unclear

• Patient’s level of disease exceeds the level of

comfort of the primary care provider

Sidebar A: At-Risk Population

• Diabetes, hypertension, other end organ disease (e.g.,

CHF), or personal or family history of kidney disease

• Systemic illness (e.g., human immunodeficiency virus

(HIV), systemic lupus erythematous, multiple myeloma)

• History of acute kidney injury (AKI) (e.g., acute tubular

necrosis, urinary tract obstruction, interstitial nephritis)

• Elderly patients

• Races and ethnicities associated with increased risk (e.g.,

African Americans, Hispanics, Native Americans)

Sidebar B: Urgent/Emergent Conditions

• Acute unexplained decline in kidney function

• Heart failure/volume overload

• Hyperkalemia (potassium ≥6 mEq/L)

• Signs or symptoms of uremia

Sidebar C: Criteria for Confirmed CKD

CKD is defined as sustained abnormality for > 3 

months of 

either:

• eGFR < 60 ml/min/1.73m2

Or any of the following:

• Albuminuria

• Urine sediment abnormality

• Abnormal renal histology

• Structural renal abnormality by imaging

• History of renal transplantation

Sidebar D: Stages of CKD

Stages

eGFR

(mL/min/1.73 

m2) Description

G1 ≥ 90 Kidney damage with normal or increased GFR

G2 60-89 Kidney damage with mildly decreased GFR

G3a 45-59 Mildly to moderately decreased GFR

G3b 30-44 Moderately to severely decreased GFR

G4 15-29 Severely decreased GFR

G5 <15 or dialysis Kidney failure

Albuminuria

Category

Range

(mg albumin/

g creatinine) Description

A1 <30 mg/g Normal to mildly increased

A2 30-300 mg/g Moderately increased

A3 >300 mg/g Severely increased 

* NB: Referral should be made following

shared decision making with patient that 

ensures the referral focus is consistent 

with the patient values & preferences

# This list is not exhaustive, consult the 

discussion of Recommendation 16 in 

the full CPG for more information
10 | Guideline Summary – 2014

Recommendations

Evaluation for Chronic Kidney Disease (CKD)

1. While there is insufficient evidence to associate exposure to depleted uranium and solvents such as

hydrocarbons with CKD, we suggest that clinicians take a detailed occupational and non-occupational history.

[Weak For]

2. We suggest that periodic evaluation for CKD be considered in patients with the following:

a. Diabetes, hypertension, other end organ disease (e.g., chronic heart failure [CHF]), or a personal or family

history of kidney disease

b. Systemic illness (e.g., human immunodeficiency virus [HIV], systemic lupus erythematosus, multiple

myeloma)

c. History of acute kidney injury (AKI) (e.g., acute tubular necrosis, urinary tract obstruction, interstitial

nephritis)

d. Elderly patients

e. Races and ethnicities associated with increased risk (e.g., African Americans,Hispanics, Native

Americans) [Weak For]

(Carryover modified from the 2008 CPG )* * 

Acute Kidney Injury Avoidance 

Prevention of Contrast-induced Nephropathy (CIN) in Patients with CKD

3. We suggest that patients at increased risk for CIN receive volume expansion with intravenous (IV) isotonic

crystalloid solutions (saline or sodium bicarbonate) prior to and following iodinated contrast administration.

[Weak For]

4. We suggest offering oral hydration to patients in which IV hydration is not feasible for CIN prophylaxis. [Weak

For]

5. Given inconsistent evidence, we do not recommend for or against the routine administration of N-acetylcysteine

(NAC) for CIN prophylaxis. [Weak For]

6. We recommend against the use of renal replacement therapy (RRT) for CIN prophylaxis. [Strong Against]

7. We suggest not initiating statin therapy for the purpose of CIN prophylaxis in patients undergoing elective

angiography. [Weak Against]

8. We suggest not offering theophylline therapy for CIN prophylaxis for patients undergoing elective coronary

angiography [Weak Against]
 Management of Chronic Kidney Disease | RECOMMENDATIONS | 11

Management of Chronic Kidney Disease

Self-Management Strategies

9. We suggest the use of dietary sodium restriction as a self-management strategy to reduce proteinuria and

improve blood pressure control in patients with CKD. [Weak For]

10. In patients with stage 3 and 4 CKD, we suggest a protein diet of 0.6 to 0.8 g/kg/day as it may slow the decline in

glomerular filtration rate (GFR) and progression to end-stage renal disease (ESRD). [Weak For]

(Carryover modified from the 2008 CPG).

11. There is insufficient evidence to recommend for or against weight loss in obese patients as an intervention

to reduce proteinuria or to slow progression of CKD. However, we suggest weight loss interventions in obese

patients as part of an overall health improvement strategy. [Weak For]

12. There is insufficient evidence to recommend for or against exercise with or without lifestyle intervention to

reduce ESRD, mortality, change in GFR, or change in urinary protein. However, we suggest regular exercise as

part of an overall health improvement strategy. [Weak For]

13. There is insufficient evidence to recommend for or against health education to reduce time to dialysis initiation

or to reduce mortality. However, we suggest CKD health education because it supports the aim of maximizing

patient-centered care. [Weak For]

14. There is insufficient evidence to recommend smoking cessation to halt progression of CKD, however, we suggest

tobacco cessation for cardiovascular risk reduction in patients with CKD. [Weak For]

Clinical Management Strategies

15. We suggest offering multidisciplinary care, if available, for patients with CKD to reduce non-fatal stroke, slow

progression from micro- to macroalbuminuria, and reduce all-cause mortality. [Weak For]

16. Although there is insufficient evidence to recommend for or against referral to a nephrology specialist for

patients with stage 3 CKD for slowing CKD progression, we suggest consultation with a nephrologist to assist in

the diagnosis and treatment of patients with any of the following conditions: [Weak For]

a. eGFR <30 mL/min/1.73 m2 to facilitate education and planning for renal replacement therapy (dialysis or

kidney transplant)

b. Kidney function that is rapidly worsening without obvious cause

c. Metabolic complications of CKD (e.g., anemia, secondary hyperparathyroidism)

d. CKD of unclear etiology after initial work-up, or has a known or suspected kidney condition requiring

specialized care

e. Nephrotic range proteinuria

f. Nephrolithiasis

17. We recommend that treatment with the following vaccinations be considered for patients with CKD as a

measure to prevent infections: [Strong For]

a. Influenza vaccine*

b. Tdap vaccine

c. Pneumococcal polysaccharide vaccine (i.e., PCV 13 and PPSV23)

d. Hepatitis B vaccine

e. Zoster /shingles vaccine*

f. Varicella vaccine*

g. MMR vaccine*

(*Note: Live vaccines, including nasal influenza (LAIV), may be contraindicated in patients with CKD and severe immunodeficiency 

including treatment with immunosuppressive agents) (Carryover modified from the 2008 CPG)
12 | Guideline Summary – 2014

18. We recommend that clinicians avoid or limit the use of nephrotoxic medications for patients with CKD. [Strong

For]

(Carryover modified from the 2008 CPG) 

19. In patients with CKD, we suggest that medications should be reviewed and their dosing modified, where

appropriate, according to the level of the patient’s kidney function. [Weak For]

(Carryover modified from the 2008 CPG) [See Table 2 for a list of select medications]

20. We suggest the use of bicarbonate supplementation in CKD patients with metabolic acidosis to slow the

progression of CKD. [Weak For]

21. In adult patients with stages 1-4 CKD, we recommend that blood pressure targets should be less than 140/90

mmHg. [Strong For]

(Carryover modified from the 2008 CPG)

22. In patients with non-diabetic CKD, hypertension, and albuminuria, we recommend the use of an angiotensinconverting-enzyme inhibitor (ACEI) to prevent progression of CKD. Angiotensin II receptor blockers (ARBs) may

be substituted for patients with an ACEI-induced cough. [Strong For]

(Carryover modified from the 2008 CPG) [See Table 3 for recommended dosage for ACEIs and ARBs]

23. In patients with diabetes, hypertension, and albuminuria, we recommend the use of an ACEI or ARB to slow the

progression of CKD, unless there is documentation of intolerance. [Strong For]

(Carryover modified from the 2008 CPG)

24. We recommend against the use of combination renin-angiotensin-aldosterone system (RAAS) blockade (ACEI

and ARB, or an ACEI or ARB with a direct renin inhibitor) in patients with CKD. [Strong Against]

25. We recommend that all patients with CKD who are not on dialysis and have no known history of coronary artery

disease be assessed for 10-year CVD risk using a validated risk calculator for primary prevention. If at risk (as

defined in the VA/DoD Management of Dyslipidemia guideline), we recommend use of at least a low dose statin.

[Strong For]

26. We suggest against the use of statins prescribed with the intent of slowing eGFR decline or preserving kidney

function. [Weak Against]

27. We recommend against intensive glycemic control to patients with stage 3 or worse CKD due to the lack of

benefit on renal or cardiovascular outcomes and potential for significant harm. [Strong Against]

(Carryover modified from the 2008 CPG)

28. We suggest initiation of oral iron therapy (in preference to parenteral) to support iron requirements in patients

with CKD stages 3 and 4. [Weak For]

29. We recommend against offering erythropoiesis-stimulating agents (ESAs) to patients with CKD for the purpose

of achieving a hemoglobin target above 11.5 g/dL due to increased risk of stroke and hypertension. [Strong

Against]

30. We recommend against initiating ESAs at a hemoglobin level greater than 10 g/dL. [Strong Against]

31. We suggest offering supplemental vitamin D to correct vitamin D deficiency in patients with CKD stages 3 or 4.

[Weak For]

32. We suggest not offering active vitamin D analogs or calcitriol to patients with stage 3 and 4 CKD with elevated

parathyroid hormone (PTH) levels due to lack of evidence for kidney, bone, or cardiovascular benefit and

increased potential of harm from hypercalcemia. (Any use of active vitamin D analogs should be managed by a

nephrologist.) [Weak Against]

33. We suggest not offering phosphate binders to patients with stage 3 and 4 CKD with normal serum phosphorous.

[Weak Against]

(Carryover modified from the 2008 CPG) 

34. We suggest not offering calcimimetics to patients with stage 3 and 4 CKD due to lack of evidence for kidney or

cardiovascular benefit and increased risk of harm from hypocalcemia. [Weak Against]
 Management of Chronic Kidney Disease | RECOMMENDATIONS | 13

Table 2: Select Medications Requiring Dose Adjustments or to be Used with Caution in Patients 

with CKD * †

• Most antibiotics (macrolides,

clindamycin, and metronidazole are 

exceptions) and antiviral agents

• Multiple anti-cancer therapies

(cytotoxic drugs,targeted 

agents, biologics)

• Hypoglycemic agents

• Acarbose

• Miglitol

• Glyburide

• Chlorpropamide

• Insulin

• Metformin

• Exenatide

• Repaglinide

• Alogliptin

• Saxagliptin

• Sitagliptin

• Canagliflozin

• Dapagliflozin

• Empagliflozin

• Cardiovascular agents

• Atenolol

• Sotalol

• Digoxin

• Dofetilide

• Potassium-sparing diuretics

• RAAS blockers

• ACEIs

• ARBs

• Aliskiren

• Eplerenone, spironolactone

• Anticoagulants

• Apixaban

• Dabigatran

• Rivaroxaban

• Low Molecular Weight Heparins

• Opioid analgesics

• Codeine

• Fentanyl

• Hydrocodone

• Hydromorphone

• Meperidine

• Methadone

• Morphine

• Oxycodone

• Oxymorphone

• Tapentadol

• Tramadol

• NSAIDs

• Gabapentin

• Levetiracetam

• Lithium

• Memantine

• Risperidone, Paliperidone

• Antidepressants

• Bupropion

• Citalopram

• Desipramine

• Duloxetine

• Mirtazapine

• Paroxetine

• Venlafaxine

• Bisphosphonates

• Gout agents

• Allopurinol

• Colchicine

• H2-blockers

• PDE5 inhibitors

• Sildenafil

• Tadalafil

• Statins

• Fluvastatin

• Lovastatin

• Pitavastatin

• Pravastatin

• Rosuvastatin

• Simvastatin

• Fibric acid derivatives

• Fenofibrate

• Gemfibrozil

* Note this is not a comprehensive list; consult individual product information or alternate sources such as the American Hospital Formulary Service (AHFS) 

Drug Information, Lexicomp Online, or UpToDate for dosing information and/or precautions in patients with kidney function impairment.

† See recommendation 19.
14 | Guideline Summary – 2014

Refer to www.pbm.va.gov for a current list of medications on the VA National Formulary

a Adapted from VA/DoD Clinical practice guideline for management of chronic kidney disease in primary care. Washington DC: Department 

of Veteran Affairs and Department of Defense; Version 2.0 - 2007.

b Facts & Comparisons® eAnswers http://www.factsandcomparisons.com/online-products/. Accessed 2014 Apr 25.

c One hour before meals, on an empty stomach.

† See Recommendation 22

Table 3. Recommended Dosage for ACEIs and ARBs in Patients with CKD a,b †

Drug Usual Dose Range Comments/Cautions

Angiotensin-Converting Enzyme Inhibitors (ACEIs)

Benazepril

• Start with lower or less frequent doses in patients with CKD (except 

fosinopril as partial compensation by hepatobiliary elimination) or in 

patients currently being treated with a diuretic.

• Use with caution in patients with renal artery stenosis.

• Monitor potassium and kidney function (e.g., one-to-two weeks after 

initiation or dose adjustment)

• Concomitant therapy with potassium-sparing diuretics,potassium 

supplements, and/or additional RAAS blockers may result in hyperkalemia.

• Boxed Warning: due to the potential risk for fetal morbidity and mortality in 

patients taking an ACEI during pregnancy, it is recommended that therapy 

be discontinued as soon as a woman becomes pregnant;alternate therapy 

should be considered.

• Contraindicated in patients with a history of angioedema on an ACEI.

Captopril c

Enalapril

Fosinopril

Lisinopril

Moexipril c

Perindopril

Quinapril

Ramipril

Trandolapril

10-40 mg divided once or twice daily

25-150 mg divided 2-3 times daily

5-40 mg divided once or twice daily

10-40 mg once daily

10-40 mg once daily

7.5-30 mg divided once or twice daily

4 - 8 mg divided once or twice daily

10-40 mg divided once or twice daily

2.5-20 mg divided once or twice daily

1 - 4 mg once daily

Angiotensin II Receptor Blockers (ARBs)

Azilsartan • Consider lower doses in patients with intravascular volume depletion (e.g., 

patients currently being treated with a diuretic).

• Use with caution in patients with renal artery stenosis.

• Monitor potassium and renal function after initiation.

• Concomitant therapy with potassium-sparing diuretics,potassium 

supplements, and/or additional RAAS blockers may result in hyperkalemia.

• Boxed Warning: due to the potential risk for fetal morbidity and mortality in 

patients taking an ARB during pregnancy, it is recommended that therapy 

be discontinued as soon as a woman becomes pregnant;alternate therapy 

should be considered.

• Use with caution in patients with a history of angioedema on an ACEI.

• An ARB may be considered in patients unable to tolerate an ACEI due to 

cough.

Candesartan

Eprosartan

Irbesartan

Losartan

Olmesartan

Telimisartan

Valsartan

80 mg once daily

8-32 mg once daily

400-800 mg divided once or twice daily

150-300 mg once daily

25-100 mg divided once or twice daily

20-40 mg once daily

20-80 mg once daily

80-320 mg once daily
 Management of Chronic Kidney Disease | PHARMACOLOGICAL AGENTS | 15

REFERENCES

1. U.S. Department of Health and Human Services Centers for Disease Control and Prevention. National chronic kidney 

disease fact sheet. Atlanta,GA: 2014. http://www.cdc.gov/diabetes/pubs/pdf/kidney_factsheet.pdf. Accessed February 

24, 2014.

2. Kidney Disease: Improving Global Outcomes CKD Work Group. KDIGO clinical practice guideline for the evaluation 

and management of chronic kidney disease. Kidney inter., Suppl. 01//print 2013;3(1):1-150.

3. International Society of Nephrology. KDIGO guidelines. Chapter 2: Definition, identification, and prediction of CKD 

progression. Kidney inter., Suppl. 01//print 2013;3(1):63-72.

4. National Kidney Foundation. K/DOQI clinical practice guidelines for chronic kidney disease: Evaluation, classification, 

and stratification. Am J Kidney Dis. Feb 2002;39(2 Suppl 1):S1-266.

5. Andrews J, Guyatt G, Oxman AD, et al. GRADE guidelines: 14. Going from evidence to recommendations: The 

significance and presentation of recommendations. J Clin Epidemiol.Jul 2013; 66(7):719-725.
16 | Guideline Summary – 2014

NOTES

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