What management strategies are recommended for veterans with Chronic Kidney Disease (CKD) under the PACT Act?

CKD Management Under the PACT Act for Veterans

Veterans with CKD should receive comprehensive disease management that prioritizes early detection, aggressive cardiovascular risk reduction with SGLT2 inhibitors and statins, blood pressure control targeting <120 mmHg systolic, and coordinated multidisciplinary care to prevent progression and reduce mortality—all of which align with expanded VA healthcare access under the PACT Act.

Core Pharmacologic Strategy

Initiate SGLT2 inhibitors immediately for all veterans with CKD and eGFR ≥20 mL/min/1.73 m², regardless of diabetes status, as this represents the most significant advancement in preventing CKD progression and cardiovascular complications. 1, 2

• Start ACE inhibitor or ARB at maximum tolerated dose when albuminuria ≥30 mg/g or hypertension is present 1, 3, 2
• Prescribe moderate-to-high intensity statin (or statin/ezetimibe combination) for all veterans ≥50 years with eGFR <60 mL/min/1.73 m² 1, 3, 2
• Continue SGLT2 inhibitors until dialysis or transplant 1

Blood Pressure Targets

Target systolic blood pressure <120 mmHg for most veterans with CKD to maximize cardiovascular protection and slow progression. 1, 2

• For veterans without albuminuria: target BP <140/90 mmHg 4, 1, 3
• For veterans with albuminuria ≥30 mg/24h: target BP <130/80 mmHg 4, 1, 3, 2
• Use ACE inhibitor or ARB as first-line antihypertensive when albuminuria is present 4, 1

Monitoring Schedule

Establish risk-stratified monitoring intervals based on eGFR and albuminuria to detect progression early:

• eGFR ≥60 with normal albuminuria: annually 2
• eGFR 45-59 or UACR 30-299 mg/g: every 6 months 2
• eGFR 30-44 or UACR ≥300 mg/g: every 4 months 2
• eGFR <30: every 3 months 2

Monitor serum creatinine, eGFR, potassium, bicarbonate, UACR, hemoglobin, phosphorus, calcium, and PTH every 3-5 months as CKD advances 2

Lifestyle Modifications

Prescribe moderate-intensity physical activity for at least 150 minutes per week, adjusted to cardiovascular tolerance and frailty level. 4, 1, 3, 2

• Advise veterans to avoid sedentary behavior 4, 1, 3
• For veterans at higher risk of falls, provide specific guidance on exercise intensity (low, moderate, or vigorous) and type (aerobic vs. resistance) 4
• Encourage weight loss for veterans with obesity and CKD 4, 1, 3

Dietary Management

Advise a Mediterranean-style, plant-based diet with higher consumption of plant-based foods compared to animal-based foods and lower consumption of ultra-processed foods. 4, 1, 3, 2

• Maintain protein intake at exactly 0.8 g/kg body weight/day for CKD G3-G5 4, 1, 3, 2
• Avoid high protein intake (>1.3 g/kg body weight/day) in veterans at risk of progression 4, 1, 3
• Limit sodium intake to <2,300 mg/day (or <2 g/day for stricter control) 4, 2

Cardiovascular Disease Prevention

Prescribe oral low-dose aspirin (81 mg daily) for lifelong secondary prevention in veterans with CKD and established ischemic cardiovascular disease. 1, 3, 2

• Consider P2Y12 inhibitors when aspirin intolerance exists 1
• Use non-vitamin K antagonist oral anticoagulants (NOACs) in preference to warfarin for atrial fibrillation in veterans with CKD G1-G4 1, 3

Nephrology Referral Criteria

Refer veterans immediately to nephrology when eGFR <30 mL/min/1.73 m² (CKD G4-G5) or when eGFR <45 mL/min/1.73 m² with significant albuminuria. 2

Additional referral triggers include:

• ACR ≥30 mg/g or PCR ≥200 mg/g 1, 3
• Persistent hematuria 1, 3
• Any sustained decrease in eGFR 1, 3

Risk Assessment Tools

Use the Kidney Failure Risk Equation to identify veterans at high risk of progressive kidney disease and guide timing of specialist referral. 4, 1

• A 2-year kidney failure risk >10% warrants nephrology referral 4
• A 2-year kidney failure risk >40% triggers preparation for kidney replacement therapy including vascular access planning 4
• Estimate 10-year cardiovascular risk using validated tools that incorporate eGFR and albuminuria 4, 1

Medication Safety

Review all medications at every visit and adjust dosing based on eGFR for renally-cleared drugs. 1, 3

• Use validated eGFR equations using serum creatinine for drug dosing in most clinical settings 1, 3
• Perform thorough medication review at transitions of care to assess adherence, continued indication, and potential drug interactions 1, 3

Critical Medications to AVOID

Never prescribe NSAIDs in veterans with CKD due to acute kidney injury risk—use low-dose colchicine or glucocorticoids instead for inflammatory conditions like acute gout. 1, 2

• Discontinue NSAIDs immediately if currently prescribed 2
• Avoid metformin when eGFR <30 mL/min/1.73 m² due to lactic acidosis risk 2
• Do not use agents to lower serum uric acid in asymptomatic hyperuricemia 1

Management of ACE Inhibitor/ARB Therapy

Do not discontinue ACE inhibitors or ARBs due to modest increases in serum creatinine or potassium unless specific contraindications exist. 1

• Monitor for hyperkalemia (serum potassium >5.7 mEq/L), which occurs in approximately 2.2% of hypertensive patients and 4.8% of heart failure patients 5
• Risk factors for hyperkalemia include renal insufficiency, diabetes, and concomitant use of potassium-sparing diuretics or potassium supplements 5
• Expect modest increases in serum creatinine after ACE inhibitor/ARB initiation; these are usually reversible and do not indicate treatment failure 5
• Monitor renal function during the first few weeks of therapy, especially in veterans with pre-existing renal impairment 5

Symptom Management and Quality of Life

Incorporate regular global symptom screening using validated tools to address uremic symptoms, pain, depression, sleep disturbances, and restless legs syndrome. 4

• Depression affects 26.5% of CKD stages 1-4 patients and is associated with increased morbidity, hospitalization, and mortality 4
• Pain affects approximately 58% of CKD patients and is strongly associated with lower quality of life 4
• Use stepwise approach: first-line nonpharmacological interventions, then advance to pharmacologic therapy with careful attention to CKD-appropriate dosing 4

Target for Albuminuria Reduction

Achieve ≥30% reduction in UACR to slow CKD progression in veterans with UACR ≥300 mg/g. 2

• Reduction of proteinuria using RAAS interruption consistently slows progression of both diabetic and nondiabetic nephropathy 4
• Target hemoglobin A1c of 7% in diabetic veterans to reduce proteinuria and alleviate CKD progression 4

Acute Kidney Injury Awareness

Recognize that all veterans with CKD are at increased risk of acute kidney injury (AKI), which can accelerate CKD progression. 4

• CKD remains an independent risk factor for AKI even after adjustment for comorbidities 4
• AKI is a risk factor for both incident CKD and progression of existing CKD 4
• Avoid nephrotoxic exposures including contrast agents, NSAIDs, and aminoglycosides whenever possible 4