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VA/Dod CLINICAL PRACTICE GUIDELINE for the MANAGEMENT of CHRONIC KIDNEY DISEASE

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VA/Dod CLINICAL PRACTICE GUIDELINE for the MANAGEMENT of CHRONIC KIDNEY DISEASE VA/DoD CLINICAL PRACTICE GUIDELINE FOR THE MANAGEMENT OF CHRONIC KIDNEY DISEASE Department of Veterans Affairs Department of Defense QUALIFYING STATEMENTS The Department of Veterans Affairs and the Department of Defense 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. This Clinical Practice Guideline is based on a systematic review of both clinical and epidemiological evidence. Developed by a panel of multidisciplinary experts, 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 recommendation. Variations in practice will inevitably and appropriately occur when clinicians take into account the needs of individual patients, available resources, and limitations unique to an institution or type of practice. Every healthcare professional making use of these guidelines is responsible for evaluating the appropriateness of applying them in the setting of any particular clinical situation. These guidelines are not intended to represent Department of Veterans Affairs or 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. Version 4.0 – 2019 VA/DoD Clinical Practice Guideline for the Management of Chronic Kidney Disease Prepared by: The Management of Chronic Kidney Disease Work Group With support from: The Office of Quality, Safety and Value, VA, Washington, DC & Office of Evidence Based Practice, U.S. Army Medical Command Version 4.0 – 2019 Based on evidence reviewed through November 2018 September 2019 Page 2 of 159 VA/DoD Clinical Practice Guideline for the Management of Chronic Kidney Disease Table of Contents I. Introduction ..................................................................................................................................... 6 II. Background...................................................................................................................................... 6 A. Description of Chronic Kidney Disease ............................................................................................... 6 B. Epidemiology and Impact in the General Population ........................................................................ 7 C. CKD in the Department of Defense and the Department of Veterans Affairs Populations .............. 7 III. About this Clinical Practice Guideline ............................................................................................... 7 A. Methods ............................................................................................................................................... 8 a. Grading Recommendations ......................................................................................................... 9 b. Reconciling 2014 Clinical Practice Guideline Recommendations ............................................. 10 c. Peer Review Process .................................................................................................................. 11 B. Summary of Patient Focus Group Methods and Findings ................................................................ 11 C. Potential Conflicts of Interest ............................................................................................................ 12 D. Scope of this Clinical Practice Guideline ........................................................................................... 13 E. Highlighted Features of this Clinical Practice Guideline ................................................................... 13 F. Patient-centered Care ....................................................................................................................... 14 G. Shared Decision Making .................................................................................................................... 14 H. Co-occurring Conditions .................................................................................................................... 14 I. Implementation ................................................................................................................................. 15 IV. Guideline Work Group ................................................................................................................... 16 V. Algorithm ...................................................................................................................................... 17 A. Module A: Screening for CKD and Initial Assessment ...................................................................... 18 B. Module B: Evaluation for AKI or New Decline in Renal Function .................................................... 20 C. Module C: Evaluation for CKD ........................................................................................................... 22 D. Module D: Management of Patients with CKD Requiring Iodinated Contrast ................................ 25 VI. Recommendations ......................................................................................................................... 27 A. Diagnosis Assessment and Lab Monitoring ...................................................................................... 30 B. General Management Strategies ...................................................................................................... 38 a. Team Management and Education .......................................................................................... 38 b. Indication for Referral to Nephrology for Renal Replacement Therapy Including Dialysis and Renal Transplant................................................................................................................. 43 C. Non-pharmacologic Management of CKD ........................................................................................ 47 a. Nutrition ..................................................................................................................................... 47 September 2019 Page 3 of 159 VA/DoD Clinical Practice Guideline for the Management of Chronic Kidney Disease D. Pharmacologic Management of CKD and Associated Conditions.................................................... 49 a. Diabetes Medications ................................................................................................................ 49 b. Hypertension Medications ........................................................................................................ 53 c. Anemia Medications .................................................................................................................. 59 d. Bone Health Medications .......................................................................................................... 63 e. Other Medications to Slow CKD Progression ............................................................................ 65 E. Contrast-Associated Kidney Injury Management ............................................................................. 68 VII. Future Research ............................................................................................................................. 75 Appendix A: Evidence Review Methodology ....................................................................................... 77 A. Developing the Key Questions .......................................................................................................... 77 B. Conducting the Systematic Review ................................................................................................... 85 C. Convening the Face-to-face Meeting ................................................................................................ 90 D. Grading Recommendations ............................................................................................................... 91 E. Recommendation Categorization ..................................................................................................... 94 F. Drafting and Submitting the Final Clinical Practice Guideline.......................................................... 96 Appendix B: Patient Focus Group Methods and Findings .................................................................... 98 A. Methods ............................................................................................................................................. 98 B. Findings .............................................................................................................................................. 98 Appendix C: Evidence Table ............................................................................................................. 101 Appendix D: 2014 Recommendation Categorization Table ................................................................ 106 Appendix E: Participant List .............................................................................................................. 112 Appendix F: Literature Review Search Terms and Strategy
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