Chronic kidney disease, commonly referred to as CKD, is a growing public health concern in the United States. According to national estimates, approximately 14 percent of U.S. adults are affected by some stage of CKD, yet a significant proportion remain unaware of their condition. Early identification and effective management are critical, as CKD is strongly associated with cardiovascular disease, increased mortality, and progression to kidney failure.
In December 2025, the U.S. Department of Veterans Affairs and the U.S. Department of Defense released an updated Clinical Practice Guideline for the Primary Care Management of Chronic Kidney Disease. Published in Annals of Internal Medicine, this guideline reflects major advances in CKD diagnosis, risk stratification, and pharmacologic treatment since the previous 2019 version. The guideline is specifically designed for primary care clinicians, recognizing that most patients with early and moderate CKD are managed outside of nephrology practices.
This article provides a comprehensive overview of the 2025 VA and DoD CKD guideline, highlights key updates, explains implications for primary care, and summarizes evidence based recommendations that can improve kidney and cardiovascular outcomes.
The management of chronic kidney disease has evolved rapidly in recent years. New therapies such as sodium glucose cotransporter 2 inhibitors and glucagon like peptide 1 receptor agonists have demonstrated significant benefits in slowing kidney disease progression and reducing cardiovascular events. As a result, primary care clinicians now play a central role in implementing therapies that were once considered specialty level interventions.
The VA and DoD guideline is unique because it focuses on real world primary care settings and emphasizes practical strategies for early detection, ongoing monitoring, and shared decision making. It also aligns with modern principles of patient centered care and evidence based medicine.
The 2025 VA and DoD CKD guideline was developed by the VA and DoD Evidence Based Practice Work Group. A multidisciplinary panel was assembled, including experts in nephrology, internal medicine, family medicine, pharmacy, dietetics, nursing, and social work. Patient perspectives were also incorporated through focus groups.
The guideline followed the National Academy of Medicine standards for trustworthy clinical practice guidelines. Evidence was reviewed from peer reviewed English language studies published between September 2018 and June 2024. Recommendations were graded using the GRADE framework, which evaluates evidence quality, balance of benefits and harms, patient values, and feasibility.
A total of 23 evidence based recommendations were issued, with 21 being new or modified from the 2019 guideline.
The guideline suggests screening for CKD in adults with one or more major risk factors, including:
Screening typically includes measurement of estimated glomerular filtration rate and urine albumin to creatinine ratio. While evidence remains limited on population wide screening, targeting high risk groups captures most individuals who would benefit from early intervention.
The guideline strongly recommends using both eGFR and UACR to assess kidney function and predict disease progression. These two measures independently predict the risk of kidney failure and cardiovascular events. Importantly, they also help identify patients who may benefit from kidney protective therapies.
For patients with an eGFR below 60 mL per minute per 1.73 m², the guideline suggests using a combined creatinine and cystatin C equation for improved accuracy in risk prediction.
For patients with stage G3 to G5 CKD, the guideline suggests using a validated kidney failure risk prediction model such as the Kidney Failure Risk Equation. These tools help clinicians estimate the likelihood of progression to kidney failure and guide decisions regarding nephrology referral and patient counseling.
Risk prediction models support shared decision making and improve communication about prognosis, especially when planning long term care strategies.
The guideline suggests interdisciplinary care for patients with CKD, involving clinicians, nurses, pharmacists, dietitians, social workers, and palliative care professionals when appropriate. Evidence suggests that team based care can reduce hospitalizations, improve adherence, and support smoother transitions to advanced kidney care.
Although evidence is insufficient to recommend a specific education program, the guideline emphasizes the importance of patient education and shared decision making. This is especially critical when discussing kidney replacement therapy versus conservative management in advanced CKD.
For patients with significant comorbidities or limited functional status, dialysis may offer limited survival benefit and may negatively impact quality of life. Conservative management focused on symptom control may align better with patient values in some cases.
The guideline encourages timely referral to nephrology for patients with progressive CKD, uncertain diagnosis, or approaching kidney failure. Early referral allows for better preparation, vascular access planning, and comprehensive education.
The guideline also suggests avoiding peripherally inserted central catheter lines in patients at high risk for future dialysis, as these can compromise future vascular access.
Hypertension is highly prevalent in CKD and is a major driver of cardiovascular risk. The guideline suggests intensive blood pressure management to reduce mortality and major adverse cardiovascular events in patients with an eGFR below 60 mL per minute per 1.73 m².
However, the guideline does not specify a single blood pressure target due to variability in trial data. Instead, clinicians are encouraged to individualize treatment while balancing cardiovascular benefits and potential adverse effects.
The guideline strongly recommends using either an angiotensin converting enzyme inhibitor or an angiotensin II receptor blocker in patients with hypertension and albuminuria. These agents slow CKD progression and reduce cardiovascular risk.
Importantly, the guideline suggests continuing ACE inhibitor or ARB therapy even in advanced CKD, unless contraindicated by intolerance or adverse effects. Evidence shows that continuation may delay progression to kidney failure.
One of the most significant updates in the 2025 guideline is the strong recommendation to add SGLT2 inhibitors in patients with CKD who have type 2 diabetes, significant albuminuria, or heart failure. These medications reduce the risk of kidney disease progression, heart failure hospitalization, major cardiovascular events, and mortality.
The guideline supports initiating SGLT2 inhibitors at lower eGFR thresholds and continuing therapy until dialysis initiation.
For patients with type 2 diabetes and albuminuric CKD, the guideline strongly recommends adding a GLP 1 receptor agonist to ACE inhibitor or ARB therapy. Evidence demonstrates benefits in slowing CKD progression, reducing cardiovascular events, and lowering all cause mortality.
When both SGLT2 inhibitors and GLP 1 receptor agonists are indicated, the guideline prioritizes SGLT2 inhibitors due to stronger kidney specific evidence.
Finerenone, a nonsteroidal mineralocorticoid receptor antagonist, is suggested for select patients with type 2 diabetes, albuminuria, and preserved potassium levels. While benefits exist, the guideline emphasizes careful patient selection due to hyperkalemia risk and higher costs.
The guideline strongly recommends initiating statin therapy in patients with CKD who are not on dialysis. Statins reduce major cardiovascular events and mortality regardless of baseline cholesterol levels. Evidence does not support initiating statins once dialysis has started.
Hyperkalemia is common in CKD and can limit the use of kidney protective medications. The guideline suggests using potassium binders such as patiromer or sodium zirconium cyclosilicate for persistent, non life threatening hyperkalemia. This approach helps maintain safe potassium levels and allows continuation of ACE inhibitors, ARBs, and other beneficial therapies.
For patients with autosomal dominant polycystic kidney disease, the guideline strongly recommends referral to nephrology to evaluate appropriateness for tolvaptan therapy. Tolvaptan can slow kidney function decline but requires careful monitoring due to side effects and liver toxicity risks.
The guideline reaffirms that medically indicated imaging using iodinated contrast should not be withheld solely due to CKD. For patients at increased risk, intravenous isotonic fluid administration is strongly recommended to reduce the risk of contrast associated acute kidney injury.
The guideline strongly recommends against the use of N acetylcysteine, as high quality trials show no benefit.
The VA and DoD guideline aligns closely with recommendations from the American Diabetes Association, Kidney Disease Improving Global Outcomes, and the American Heart Association. Differences exist in blood pressure targets and sequencing of pharmacologic therapies, but overall consensus supports aggressive cardiovascular and kidney risk reduction.
The 2025 VA and DoD CKD guideline reinforces the expanding role of primary care in kidney disease management. Early screening, accurate staging, risk prediction, and timely initiation of evidence based therapies can significantly improve patient outcomes.
By integrating these recommendations into routine practice, primary care clinicians can slow CKD progression, reduce cardiovascular events, and improve quality of life for millions of patients.
The 2025 VA and DoD Clinical Practice Guideline for the Primary Care Management of Chronic Kidney Disease represents a major advancement in kidney care. With updated evidence, new pharmacologic options, and a strong emphasis on patient centered care, the guideline equips primary care clinicians with practical tools to manage CKD effectively.
Early detection, interdisciplinary care, and judicious use of therapies such as ACE inhibitors, SGLT2 inhibitors, GLP 1 receptor agonists, and statins can transform outcomes for patients with chronic kidney disease.
This content is for informational and educational purposes only and does not constitute medical advice. Always consult a qualified healthcare professional for diagnosis and treatment decisions.
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