Reducing MACE and Renal Progression via Modern Pharmacotherapy in Albuminuric CKD

Article Impact Level: HIGH
Data Quality: STRONG
Summary of  ANNALS https://doi.org/10.7326/ANNALS-25-03499  
Dr. Amy R. Schwartz,  et al.

Points

The U.S. Department of Veterans Affairs and Department of Defense updated their clinical practice guidelines to provide primary care clinicians with twenty-three evidence-based recommendations for managing chronic kidney disease patients.
Clinicians are strongly advised to utilize the urine albumin to creatinine ratio alongside the estimated glomerular filtration rate to accurately predict disease progression and stage patients within the primary care setting.
The guideline advocates for the use of angiotensin converting enzyme inhibitors or angiotensin receptor blockers as a foundational therapy for patients presenting with both hypertension and significant albuminuria to slow progression.
Sodium glucose cotransporter two inhibitors are now strongly recommended for patients with type two diabetes or heart failure to reduce the risk of major adverse cardiovascular events and all-cause mortality.
Adding glucagon like peptide one receptor agonists to standard treatment regimens is suggested for patients with type two diabetes and albuminuria to further decrease the risk of kidney failure and death.

Summary

The 2025 VA/DoD Clinical Practice Guideline (CPG) provides a comprehensive update to the 2019 framework for the primary care management of chronic kidney disease (CKD). Developed by Amy R. Schwartz, M.D., and colleagues, the guidelines emerged from a systematic evidence review of twelve key questions. The final document comprises twenty-three specific recommendations regarding the diagnosis, assessment, and longitudinal monitoring of CKD, alongside pharmacologic strategies intended for implementation in the primary care setting.

The guidelines issue a strong recommendation for the concurrent use of urine albumin-to-creatinine ratio (uACR) and estimated glomerular filtration rate (eGFR) to accurately predict CKD progression. To mitigate renal decline in patients with hypertension and albuminuria, the foundational use of either an angiotensin-converting enzyme inhibitor (ACE-I) or an angiotensin II receptor blocker (ARB) is strongly advised. Furthermore, the addition of sodium-glucose cotransporter 2 (SGLT2) inhibitors is recommended for patients with type 2 diabetes, heart failure, or albuminuria to reduce the risk of major adverse cardiovascular events (MACE), heart failure hospitalization, and mortality.

For the specific population of patients with type 2 diabetes and albuminuric CKD, the guidelines strongly recommend integrating a glucagon-like peptide-1 (GLP-1) receptor agonist into a treatment regimen already containing an ACE-I or ARB. This triple-therapy approach is designed to further reduce the incidence of MACE and all-cause mortality while slowing the progression of kidney disease. By providing primary care clinicians with these updated staging and therapeutic protocols, the VA/DoD CPG aims to improve the prediction of kidney failure and optimize the use of modern pharmacotherapies across diverse patient populations.

Link to the article: https://www.acpjournals.org/doi/10.7326/ANNALS-25-03499

References

Schwartz, A. R., Sosnov, J., Brown, J., Delgado, C., Fried, L., Tamura, M. K., Morrison, J. W., Navaneethan, S. D., Palevsky, P. M., Rybacki, D., Sall, J., Verma, S., Watson, M., Wickham, J., & Nguyen, M. (2025). 2025 u. S. Department of veterans affairs and u. S. Department of defense clinical practice guideline for the primary care management of chronic kidney disease. Annals of Internal Medicine, ANNALS-25-03499. https://doi.org/10.7326/ANNALS-25-03499