Follow-up monitoring of patients with chronic kidney disease by primary care physicians. Guidelines

The high and steadily increasing prevalence of chronic kidney disease (CKD) is a significant medical and social problem. CKD complications significantly reduce quality of life and increase the risk of disability, hospitalization, and death. Timely identification and correction of modifiable risk factors for CKD progression underpins secondary prevention measures.

These guidelines describe the management of follow-up monitoring for CKD patients by a general practitioner and incorporate modern approaches to diagnosing disease severity and complications (clinical and paraclinical methods), as well as disease treatment and complication prevention. Application of these guidelines will enable physicians to make informed clinical decisions based on the presented diagnostic algorithm (examinations, consultations). These guidelines are intended for general practitioners, family doctors, and for nursing staff working with these physicians, for paramedics performing the doctor functions of managing follow-up monitoring. These guidelines are also intended for healthcare executives, heads of primary care facilities, and their departments.

1. Yarnoff BO, Hoerger TJ, Simpson SK, et al. The cost-effectiveness of using chronic kidney disease risk scores to screen for early-stage chronic kidney disease. BMC Nephrol. 2017;18(1):85. doi:10.1186/s12882-017-0497-6.

2. Drapkina OM, Kobalava ZhD, Shestakova MV, et al. Cardiovascular risk and chronic kidney disease: strategies for cardiac and renal protection. Interdisciplinary consensus. Cardiovascular Therapy and Prevention. 2025;24(6):4466. (In Russ.) doi:10.15829/1728-8800-2025-4466. EDN: MIARUF.

3. Milovanov YuS, Milovanova LYu, Kozlovskaya LV. Nephrogenic Anemia: Impact on the Cardiovascular System and Progression of Chronic Kidney Disease. Clinical Nephrology. 2010;6:7-18. (In Russ.) EDN: NEFTSF.

4. Shilov EM, Yesayan AM, Shilova MM, Kotenko ON. Possible structure of stages of chronic kidney disease in the Russian Federation. Clinical nephrology. 2021;4. (In Russ.) doi: 10.18565/nephrology.2021.4.6-7. EDN: ZTSZJZ.

5. Astanina SYu, Kalinina AM, Shepel RN, Drapkina OM. Methodological recommendations for training doctors to conduct brief preventive counseling. Moscow: LLC "Silicea-Poligraf", 2023. (In Russ.) doi:10.15829/ROPNIZ-a2-2023. EDN: NBSIVZ.

6. Gorbunov VM, Smirnova MI, Kurekhyan AS, Drapkina OM Assessment of Clinical and Ambulatory Blood Pressure in the Practical Work of a Primary Health Care Physician. Methodological Recommendations. Cardiovascular Therapy and Prevention. 2023;22(7):3666. (In Russ.) doi:10.15829/1728-8800-2023-3666. EDN: YRHRNI.

7. Boytsov SA, Pogosova NV, Ansheles AA, et al. Cardiovascular prevention 2022. Russian national guidelines. Russian Journal of Cardiology. 2023;28(5):5452. (In Russ.) doi:10.15829/1560-4071-2023-5452. EDN: EUDWYG.

8. Drapkina OM, Drozdova LYu, Kalinina AM, et al. Organization of Preventive Medical Examinations and Dispensary Examinations of Certain Groups of the Adult Population. Guidelines, 2nd Edition. Moscow: Federal State Budgetary Institution "National Medical Research Center for Preventive Medicine" of the Ministry of Health of the Russian Federation, 2020. 232 p. (In Russ.) ISBN: 978-5-6043991-1-8.

9. Drapkina OM, Shilov EM, Kamkin EG, et al. "School" for patients with chronic kidney disease. Guidelines. Primary Health Care (Russian Federation). 2025;2(1S):79-92. (In Russ.) doi: 10.15829/3034-4123-2025-109. EDN: ZKKSHO.

10. Shilov EM, Sigitova ON. Chronic Kidney Disease in the Practice of Primary Care Physicians. Therapy. 2023;3(65):106-13. (In Russ.) doi:10.18565/therapy.2023.3.106-112. EDN: GOYBQB.

11. Delgado C, Baweja M, Crews DC, et. al. A Unifying Approach for GFR Estimation: Recommendations of the NKF-ASN Task Force on Reassessing the Inclusion of Race in Diagnosing Kidney Disease. Am J Kidney Dis. 2022;79(2):268-88. doi:10.1053/j.ajkd.2021.08.003.

12. Inker LA, Eneanya ND, Coresh J, et al. Chronic Kidney Disease Epidemiology Collaboration. New Creatinine- and Cystatin C-Based Equations to Estimate GFR without Race. N Engl J Med. 2021;385(19):1737-49. doi:10.1056/NEJMoa2102953.

13. Lukina YV, Kutishenko NP, Martsevich SY, et al. The questionnaire survey method in medicine on the example of treatment adherence scales. Rational Pharmacotherapy in Cardiology. 2020;17(4):576-83. (In Russ.) doi:10.20996/1819-6446-2021-08-02.

14. Bogdanova AR, Khasanova MI. Chronic kidney disease: an educational and methodical manual. Kazan: Kazan Publishing House. University, 2024. 40 p. (In Russ.) URI: https://dspace.kpfu.ru/xmlui/handle/net/183114.

15. Kobalava ZhD, Konradi AO, Nedogoda SV, et al. 2024 Clinical practice guidelines for Hypertension in adults. Russian Journal of Cardiology. 2024;29(9):6117. (In Russ.) doi:10.15829/1560-4071-2024-6117. EDN: GUEWLU.

16. Dedov I, Shestakova M, Sukhareva O, et al. Standards of Specialized Diabetes Care. Edited by Dedov I.I., Shestakova M.V., Sukhareva O.Yu. 12th Edition. Diabetes mellitus. 2025;28(5S):1-175. (In Russ.) doi:10.14341/DM20255S.

17. Drapkina OM, Boytsov SA, Ageev FT, et. al. Outpatient follow-up of patients with chronic heart failure by a general practitioner in primary health care. Guidelines. Primary Health Care (Russian Federation). 2025;2(1):53-114. (In Russ.) doi:10.15829/3034-4123-2025-39. EDN: FBLCHN.

18. Drapkina OM, Boytsov SA, Golukhova EZ, et al. Outpatient follow-up of patients with atrial fibrillation and flutter by a primary care physician. Guidelines. Primary Health Care (Russian Federation). 2024;1(1):134-78. (In Russ.) doi:10.15829/3034-4123-2024-24.

19. Golukhova EZ, Golitsyn SP, Mikhailov EN, et al. 2025 Clinical practice guidelines for Atrial fibrillation and flutter. Russian Journal of Cardiology. 2025;30(11):6668. (In Russ.) doi:10.15829/1560-4071-2025-6668. EDN: MGXGON.

20. Drapkina OM, Briko NI, Namazova-Baranova LS, et al. Immunoprophylaxis. Guidelines (second edition). Primary Health Care (Russian Federation). 2025;2(3):135-262. (In Russ.). doi: 10.15829/3034-4123-2025-76. EDN: DBKJIQ.

21. Avdeev SN, Alyeva MH, Baranov AA, et al. Federal Clinical Guidelines on Vaccination of pneumococcal infection in children and adults. Russian Journal of Preventive Medicine. 2023;26(9-2):3-23. (In Russ.) doi:10.17116/profmed2023260923.

22. Ridda I, Yin JK, King C, et al. The importance of pertussis in older adults: a growing case for reviewing vaccination strategy in the elderly. Vaccine. 2012;30(48):6745-52. doi:10.1016/j.vaccine.2012.08.079.

23. Kostinov MP. Adult vaccination — from strategy to tactics. A guide for doctors. Moscow: MDV Group, 2020. 248 p. (In Russ.) ISBN: 978-5-9704-7962-9.