Chronic kidney disease (CKD) happens when the kidneys become damaged over time. Patients with CKD have an estimated glomerular filtration rate (eGFR) of less than 60 mL/min/1.73m2 or may have a normal eGFR if other signs of kidney disease are present for more than 3 months. CKD is a progressive condition that increases the risk of cardiovascular disease and death. To further complicate the issue, many adults with CKD have no symptoms and about 40% are unaware that they have advanced kidney disease. Treatment focuses on reducing morbidity and mortality by preventing worsening kidney damage and complications of CKD.

In this Guidelines Side-by-Side, we have compared the latest clinical practice guidelines from the Department of Veterans Affairs/Department of Defense (VA/DOD) and Kidney Disease Improving Global Outcomes (KDIGO) on chronic kidney disease. We chose to look more closely at medications for the management of CKD and its complications. Both of these societies also address other facets of patient care. We encourage you to review the full guidelines found on our website for more helpful information on this topic.

Guidelines for Comparison

ItemVA/DOD CLINICAL PRACTICE GUIDELINE FOR THE PRIMARY CARE MANAGEMENT OF CHRONIC KIDNEY DISEASEKDIGO 2024 CLINICAL PRACTICE GUIDELINE FOR THE EVALUATION AND MANAGEMENT OF CHRONIC KIDNEY DISEASE
Authoring OrganizationDepartment of Veterans Affairs/Department of DefenseKidney Disease Improving Global Outcomes (KDIGO)
Publication DateMay 2025March 2024
Graded RecommendationsYesYes
Uses GRADEYesYes
LinksSummary
Full Text		Summary
Full Text

Key Takeaways

In general the VA/DOD increases emphasis on the importance of shared decision making and collaboration of an interdisciplinary team. Their recommendations are intended for adults 18 years of age and older who are eligible for veterans benefits.

KDIGO approaches their recommendations with the goal of providing a comprehensive evidence based practice guide. They give both graded recommendations and ungraded practice points which include lifestyle modifications in combination with medical therapy and special considerations for children and adolescents, older adults, and based on sex/gender, and fertility/pregnancy.

Below are some of the key similarities and differences with regards to medications recommended for patients with CKD. 

  • Angiotensin Converting Enzyme Inhibitor (ACEi)/Angiotensin II Receptor Blocker (ARB)
    • Both societies recommend using either an ACEi or ARB in certain patients with hypertension to slow the progression of chronic kidney disease. The VA/DOD recommends this based on measurements of urine albumin-to-creatinine ratio (UACR) while KDIGO uses categories of the severity of albuminuria and GFR and whether or not the patient has diabetes to make this decision. 
    • Both societies agree that patients on an ACEi or ARB may continue treatment even if eGFR falls below 30.
    • KDIGO advises avoiding any combination of ACEi, ARB, and direct renin inhibitor (DRI) therapy in people with CKD, with or without diabetes which is not addressed by the VA/DOD guidelines.
  • Thiazide diuretics/Calcium Channel Blockers (CCB)
    • The VA/DOD has a new recommendation that is not addressed by KDIGO suggesting the use of a thiazide diuretic or a CCB to lower blood pressure in patients with CKD and hypertension that is not controlled with an ACEi or ARB. 
  • Sodium-Glucose Cotransporter 2 Inhibitors (SGLT2i)
    • SGLT2is are recommended by both societies with some differences in who they recommend them for. 
    • The VA/DOD recommends this for patients who have maximized an ACEi or ARB and have either type 2 diabetes (T2D), albuminuria based on UACR, or heart failure.
    • KDIGO recommends this for patients with T2D based on eGFR and UACR.
  • Glucagon-Like-Peptide-1 Receptor Agonists (GLP-1 RA)
    • The VA/DOD recommends adding a GLP-1 RA to an ACEi or ARB in patients with T2D and albuminuric CKD.
    • KDIGO recommends a long acting GLP-1 RA for adults with T2D and CKD who have not achieved glycemic targets with metformin and an SGLT2i or patients who cannot take those medications.
  • Sacubitril/Valsartan
    • The VA/DOD has a new recommendation that is not addressed by KDIGO suggesting sacubitril/valsartan as an alternative to monotherapy with an ACEi or ARB. 
  • Mineralocorticoid Receptor Antagonist (MRA)
    • Both societies suggest using an MRA in patients with T2D on a maximally tolerated ACEi or ARB based on albuminuria, eGFR, and potassium levels.
  • Statins
    • The VA/DOD recommends statins for patients with CKD who are not on dialysis.
    • KDIGO recommends treatment with a statin or statin/ezetimibe combination for patients with CKD not on dialysis or being treated with a kidney transplant based on age, eGFR, comorbidities, and estimated 10 -year risk of coronary death or myocardial infarction.
  • Potassium Binding Agents
    • The VA/DOD suggests using potassium binders for patients with CKD who have persistent, non-life threatening hyperkalemia. This is not addressed by KDIGO.

Comparison of Recommendations

MedicationVA/DODKDIGO
ACEi/ARBIn patients with hypertension and albuminuria (i.e., urine albumin-to-creatinine ratio [UACR] >30 mg/g), guideline recommends the use of either an angiotensin-converting enzyme inhibitor or angiotensin II receptor blocker to slow the progression of chronic kidney disease. Recommends starting renin-angiotensin-system inhibitors (RASi) (angiotensin converting enzyme inhibitor [ACEi] or angiotensin II receptor blocker [ARB]) for people with CKD and severely increased albuminuria (G1–G4, A3) without diabetes.
Recommends starting RASi (ACEi or ARB) for people with CKD and moderately-to severely increased albuminuria (G1–G4, A2 and A3) with diabetes.
Suggests starting RASi (ACEi or ARB) for people with CKD and moderately increased albuminuria (G1–G4, A2) without diabetes.
In patients with advanced chronic kidney disease (estimated glomerular filtration rate [eGFR] <30 mL/min/1.73 m2) currently on an angiotensin-converting enzyme inhibitor or angiotensin II receptor blocker, guideline suggests continuing therapy, unless there is drug intolerance or adverse event.Practice Point: Continue ACEi or ARB in people with CKD even when the eGFR falls below 30 ml/min per 1.73 m2.
Not AddressedRecommends avoiding any combination of ACEi, ARB, and direct renin inhibitor (DRI) therapy in people with CKD, with or without diabetes.
Thiazide Diuretic/CCBSuggests the addition of a thiazide diuretic or calcium channel blocker to reduce blood pressure in patients with chronic kidney disease and hypertension not controlled on an angiotensin-converting enzyme inhibitor or angiotensin II receptor blocker.Not Addressed
SGLT2iRecommends the addition of sodium-glucose co-transporter 2 inhibitors to maximally tolerated angiotensin-converting enzyme inhibitors or angiotensin II receptor blockers, in patients with chronic kidney disease who have one or more of the following:  • Type 2 diabetes  • Albuminuria (UACR >200 mg/g)• Heart failure  to reduce the risk of major adverse cardiovascular events, heart failure, progression of kidney disease, and mortality, and continuing sodium-glucose co-transporter 2 inhibitors until the start of dialysis.Recommends treating patients with type 2 diabetes (T2D), CKD, and an eGFR greater than or equal to 20 ml/min per 1.73 m2 with an SGLT2i.
Recommends treating adults with CKD with an SGLT2i for the following (1A):eGFR of ≥ 20 ml/min per 1.73 m2 with urine ACR ≥ 200 mg/g ( ≥ 20 mg/mmol), orheart failure, irrespective of level of albuminuria.
Suggests treating adults with eGFR 20 to 45 ml/min per 1.73 m2 with urine ACR <200 mg/g (<20 mg/mmol) with an SGLT2i.
GLP-1 RARecommends adding a glucagon-like peptide-1 receptor agonist to an angiotensinconverting enzyme inhibitor or angiotensin II receptor blocker in patients with type 2 diabetes and albuminuric chronic kidney disease to reduce the progression of chronic kidney disease, major adverse cardiovascular events, and all-cause mortality.In adults with T2D and CKD who have not achieved individualized glycemic targets despite use of metformin and SGLT2 inhibitor treatment, or who are unable to use those medications, guideline recommends a long-acting GLP-1 RA.
Sacubitril/ValsartanIn patients with chronic kidney disease and heart failure, guideline suggests sacubitril/valsartan as an alternative to monotherapy with angiotensin-converting enzyme inhibitors or angiotensin II receptor blockers.Not Addressed
MRASuggests the addition of a non-steroidal mineralocorticoid receptor antagonist (e.g., finerenone) in individuals on maximally tolerated angiotensin-converting enzyme inhibitor or angiotensin II receptor blocker who meet all the following criteria:• Type 2 diabetes• Albuminuria >30 mg/g• eGFR ≥25 mL/min/1.73 m2• Potassium <4.8 mEq/Lfor the purpose of decreasing major adverse cardiovascular events and slowing progression of chronic kidney disease.Suggests a nonsteroidal mineralocorticoid receptor antagonist with proven kidney or cardiovascular benefit for adults with T2D, an eGFR >25 ml/min per 1.73 m2, normal serum potassium concentration, and albuminuria (>30 mg/g [>3 mg/mmol]) despite maximum tolerated dose of RAS inhibitor (RASi).
StatinsIn patients with chronic kidney disease not on dialysis, guideline recommends the initiation of statins to reduce major adverse cardiovascular events and mortality.In adults aged ≥ 50 years with eGFR <60 ml/min per 1.73 m2 but not treated with chronic dialysis or kidney transplantation (GFR categories G3a–G5), guideline recommends treatment with a statin or statin/ezetimibe combination.
In adults aged ≥ 50 years with CKD and eGFR ≥ 60 ml/min per 1.73 m2 (GFR categories G1–G2), guideline recommends treatment with a statin.
In adults aged 18–49 years with CKD but not treated with chronic dialysis or kidney transplantation, guideline suggests statin treatment in people with one or more of the following (2A):known coronary disease (myocardial infarction or coronary revascularization), diabetes mellitus, prior ischemic stroke, or estimated 10-year incidence of coronary death or nonfatal myocardial infarction >10%.
Potassium BindersIn patients with chronic kidney disease, guideline suggests using potassium binders in the management of persistent, non-life-threatening hyperkalemia.Not Addressed

This concludes our Guidelines Side-by-Side on Chronic Kidney Disease. Don’t forget to sign up for alerts to stay informed on the latest published guidelines and articles.

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