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

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VA/Dod Clinical Practice Guideline for Management of Chronic Kidney Disease in Primary Care The VA/DoD Clinical Practice Guideline for Management of Chronic Kidney Disease in Primary Care VA/DoD CLINICAL PRACTICE GUIDELINE FOR MANAGEMENT OF CHRONIC KIDNEY DISEASE IN PRIMARY CARE Department of Veterans Affairs Department of Defense GUIDELINE SUMMARY Key Elements Addressed by the Guideline 1. Diagnostic criteria and identification of early disease. 2. Identification of susceptibility factors (adult patients at increased risk for developing CKD). 3. Identification of progression factors (adult patients at high risk for worsening kidney damage and subsequent loss of kidney function). 4. Evaluation of patients with kidney disease (estimate of GFR, blood pressure, and assessment of proteinuria as a marker of kidney damage). 5. Slowing the progression of CKD and prevention of conditions that exacerbate chronic disease. 6. Management of comorbidities. 7. Indication for consultation and referral to a nephrologist. 8. Outline of patient education and preparation for kidney replacement therapy. Key Changes in the Update to the 1999 VA/DoD Guideline for ESKD The revised guideline recommendations continue to support the approach initially advocated in the 1999 version of the VA/DoD guideline for ESKD; however, a goal of the current update is to provide guidance to primary care providers in the management of CKD in the primary care setting. The emphasis of the current guideline has thus shifted away from the management of severe CKD (eGFR <30 ml/min/1.73m2) and toward the management of earlier stage CKD (eGFR > 30 ml/min/1.73m2). In addition, the evidence published from randomized trials in recent years allowed the Working Group to make firmer recommendations in the following areas: • Diagnostic Workup: o Classification of CKD based on eGFR rather than levels of serum creatinine. • A unified approach to management of common aspects of kidney disease that is not dependent on the underlying etiology of the CKD: o Complications of CKD (anemia, cardiovascular disease, dyslipidemia). o Strategies to slow the decline of eGFR. Page 1 The VA/DoD Clinical Practice Guideline for Management of Chronic Kidney Disease in Primary Care Scope of Guideline 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. Audiences: 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. Evidence Evidence Rating System A A strong recommendation that the clinicians provide the intervention to eligible patients. Good evidence was found that the intervention improves important health outcomes and concludes that benefits substantially outweigh harm. B A recommendation that clinicians provide (the service) to eligible patients. At least fair evidence was found that the intervention improves health outcomes and concludes that benefits outweigh harm. C No recommendation for or against the routine provision of the intervention is made. At least fair evidence was found that the intervention can improve health outcomes, but concludes that the balance of benefits and harms is too close to justify a general recommendation. D Recommendation is made against routinely providing the intervention to asymptomatic patients. At least fair evidence was found that the intervention is ineffective or that harms outweigh benefits. I The conclusion is that the evidence is insufficient to recommend for or against routinely providing the intervention. Evidence that the intervention is effective is lacking, or poor quality, or conflicting, and the balance of benefits and harms cannot be determined. Lack of Evidence – Consensus of Experts Where existing literature was ambiguous or conflicting, or where scientific data were lacking on an issue, recommendations were based on the clinical experience of the Working Group. These recommendations are indicated in the evidence tables as based on “Working Group Consensus.” This Guideline is the product of many months of diligent effort and consensus-building among knowledgeable individuals from the VA, DoD, and academia, and a guideline facilitator from the private sector. An experienced moderator facilitated the multidisciplinary Working Group. The draft document was discussed in 3 face-to-face group meetings. The content and validity of each section was thoroughly reviewed in a series of conference calls. The final document is the product of those discussions and has been approved by all members of the Working Group. Page 2 The VA/DoD Clinical Practice Guideline for Management of Chronic Kidney Disease in Primary Care Guideline Update Working Group Guideline Update Working Group* DoD VA Arianna M. Aoun MS, RD, CSR Kevin Abbott, MD Magna Brito, RD Angela V. Klar, MSN, RN, ANP-CS Peter G. Carson, MD Parnell C. Mattison, DO John Dooley, MD Eric Sawyers, MD, LCDR USN Elaine M. Furmaga, PharmD Mark Stephens, MD, MS, FAAFP James S. Kaufman, MD, Co-Chair Fred Yeo, MD Mary Ellen Nugent, RN, MSN Ann M. O’Hare, MA, MD, Co-Chair Carlos E. Palant, MD Christine Pasquariello, MD Thakor G. Patel, MD, MACP Kevin T. Stroupe, PhD FACILITATOR Oded Susskind, MPH RESEARCH TEAM – EVIDENCE APPRAISAL HEALTHCARE QUALITY INFORMATICS, INC. RTI INTERNATIONAL NORTH CAROLINA Martha D’Erasmo, MPH Linda Lux, MPA Rosalie Fishman, RN, MSN, CPHQ Meera Viswanathan, PhD Joanne Marko, MS, SLP Kathleen Lohr, PhD * Bolded names are members of the Editorial Panel. Additional contributor contact information is available in Appendix J of the full guideline. The complete list of participants is included in Appendix J of the full guideline. Page 3 The VA/DoD Clinical Practice Guideline for Management of Chronic Kidney Disease in Primary Care Algorithm and Annotations Table of Contents Page 1. DEFINITION OF CHRONIC KIDNEY DISEASE ...................................................................................................... 7 1.1. Patient with Suspected or Confirmed Chronic Kidney Disease (CKD) ..................................................... 7 1.2. CKD Classification .............................................................................................................................. 7 2. EARLY DETECTION OF KIDNEY DISEASE ............................................................................................................ 8 2.1. Case Identification/Screening ............................................................................................................ 8 3. EVALUATION OF PATIENTS WITH CKD ............................................................................................................... 9 3.1. Medical History ................................................................................................................................... 9 3.2. Physical Examination ....................................................................................................................... 10 3.3. Laboratory Tests .............................................................................................................................. 10 4. ASSESSMENT OF KIDNEY FUNCTION.............................................................................................................. 10 4.1. Measuring Disease Progression ....................................................................................................... 10 4.2. Estimating GFR ................................................................................................................................ 11 4.3. Assessing Proteinuria ...................................................................................................................... 12 4.4. Imaging the Kidney .......................................................................................................................... 13 5. URGENT/EMERGENT CONDITIONS ................................................................................................................ 14 6. REVERSIBLE CONDITIONS ............................................................................................................................. 14 7. PRIMARY ETIOLOGY OF KIDNEY DISEASE ....................................................................................................... 14 8. CONSULTATION WITH/REFERRAL TO NEPHROLOGY ........................................................................................ 15 9. MANAGEMENT OF CKD – PROMOTION OF GENERAL HEALTH ........................................................................... 15 10. STRATEGIES TO SLOW THE PROGRESSION OF THE DISEASE ............................................................................ 17 10.1. Control of Hypertension ................................................................................................................... 17 10.2. Use of an ACEI or ARB ...................................................................................................................... 18 10.3. Protein Restriction ........................................................................................................................... 18 10.4. Control of Hyperglycemia in Patients with Diabetes ..........................................................................
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