Impact of VA/DoD CKD Guideline Updates on Nephrology Practice

The VA/DoD CKD guideline update consolidates risk stratification and expands pharmacotherapy recommendations, emphasizing combined risk markers and targeted agents to slow progression and reduce cardiovascular events.

The changes affect screening, medication selection, and referral thresholds across primary care and nephrology and will alter workup and triage workflows.

Screening now prioritizes concurrent assessment of albuminuria and estimated glomerular filtration rate rather than eGFR alone, clarifying prior ambiguity around early detection. The guideline treats urine albumin and eGFR as complementary predictors with additive prognostic value; initial workups should document both eGFR and albuminuria category in the problem list and encounter note to guide monitoring cadence and treatment selection.

Staging is explicit: albuminuria categories match A1 (<30 mg/g), A2 (30–300 mg/g), and A3 (>300 mg/g), while eGFR follows G1–G5 bands, with progressive risk below 60 mL/min/1.73 m2 (G3a and lower). For practical triage, patients with A2–A3 albuminuria or eGFR <60 mL/min/1.73 m2 should be flagged for intensified follow-up and medication review. The guideline also underscores routine measurement of the urine albumin-to-creatinine ratio as part of CKD staging.

The guideline strongly endorses renin–angiotensin system blockade; ACE inhibitors or ARBs remain first-line for patients with hypertension and albuminuria to slow progression. In patients with type 2 diabetes and albuminuric CKD, SGLT2 inhibitors are recommended, and GLP-1 receptor agonists are noted to reduce cardiovascular events and mortality when added to maximally tolerated ACEi or ARB.

Agent selection should reflect comorbidities, renal function, and glycemic needs; clinicians are advised to monitor serum creatinine and potassium after initiating or titrating RAAS blockade and to anticipate a modest initial eGFR dip after starting an SGLT2 inhibitor followed by stabilization. Medication sequencing in practice generally prioritizes RAAS blockade, then SGLT2 therapy for eligible patients, with GLP-1 agonists considered for additional glycemic or cardiovascular benefit.

Referral triggers are clearly defined: rapid eGFR decline, persistently high albuminuria despite optimized therapy, sustained eGFR <30 mL/min/1.73 m2, and complex electrolyte or acid–base disturbances merit nephrology consultation. Practices should expect more referrals for patients with persistent A2–A3 albuminuria and for patients started on novel agents who require early co-management; updating triage workflows and prioritization rules will be necessary to preserve referral appropriateness and capacity. Serial eGFR and albuminuria trends should be recorded in problem lists and referral templates to support guideline-aligned escalation.

Guideline-driven risk stratification, broader adoption of SGLT2s and GLP-1s, and clearer referral gatekeeping align with CMS value-based incentives for population management and reduced cardiovascular and renal events, with operational and financial implications for nephrology practices.

Next steps include aligning referral pathways, monitoring protocols, and formulary/access strategies with the guideline to support coordinated, measurable CKD care.

Key Takeaways:

• Combined eGFR and albuminuria assessment plus endorsement of ACEi/ARB with SGLT2 and GLP-1 use for eligible patients tighten staging and pharmacotherapy algorithms.
• Primary care clinicians, nephrologists, and patients with CKD—especially those with type 2 diabetes or A2–A3 albuminuria—will see changes in screening, medication initiation, and referral timing.
• Update workflow templates, referral criteria, monitoring protocols, and formulary-access plans to capture quality metrics and enable timely nephrology co-management.