The standards for treating chronic kidney disease are evolving. The 2025 VA/DoD (U.S. Department of Veterans Affairs and Department of Defense) clinical practice guideline establishes prevention as the primary priority. This shift is vital for millions of people, as kidney damage often progresses “silently,” without manifest symptoms.
The new recommendations are based on the latest scientific achievements from 2018–2024. The guideline emphasizes the necessity of screening for high-risk groups, including individuals with diabetes, arterial hypertension, cardiovascular pathologies, or those over the age of 60.
Early Diagnosis
Two primary indicators are used to evaluate kidney status: eGFR (estimated Glomerular Filtration Rate), which determines filtration capacity, and UACR (Urine Albumin-to-Creatinine Ratio), which detects the presence of protein. The latter is the earliest indicator of organ damage.
Pharmacotherapy
A major portion of the guideline addresses pharmacotherapy, specifically new-generation drugs: SGLT2 inhibitors and GLP-1 agonists. Although originally developed for the treatment of diabetes, they have proven to be “reno-protective” as well. Their use reduces the risk of kidney failure by more than 30%, offering many patients a genuine opportunity to avoid dialysis.
Since high blood pressure is a leading cause of kidney damage, the new guideline mandates strict control using specific protective medications: ACE inhibitors or ARBs. Concurrently, statins (cholesterol-lowering medications) are recommended for all patients not on dialysis to reduce cardiovascular complications.
A significant update includes the use of potassium-binding agents, which allow physicians to safely continue treatment without the development of adverse side effects (hyperkalemia).
Changes have also been made to the preparation process for contrast-enhanced imaging (e.g., CT scans). For years, N-acetylcysteine was considered a reliable method for preventing contrast-induced acute kidney injury; however, the 2025 guideline has reversed this approach. Two large-scale randomized trials confirmed that this agent provides no real benefit. It was found that it neither protects kidney function nor has a positive impact in the long term. Consequently, according to the new recommendations, its use is no longer advisable. Intravenous fluids remain the primary protective measure.
The guideline also places special importance on the principle of “Shared Decision-Making.” This means the treatment plan must be developed through active collaboration between the physician and the patient. Especially in the elderly, a person’s quality of life and priorities are considered as important as clinical outcomes.
Ultimately, the management of chronic kidney disease is now a team responsibility. For optimal results, the involvement of a multidisciplinary team—including primary care physicians, nephrologists, pharmacists, and dietitians—is essential to coordinate care and stop the progression of the disease in a timely manner.
წყარო: Annals of internal medicine
