Laboratory Engagement Initiative (LEI)

Low recognition of chronic kidney disease (CKD) is a serious public health problem. An estimated 37 million Americans have CKD but only 10% are aware of their condition. Increasing early diagnosis with two routine lab tests and clear, actionable test results is a health care imperative involving the primary care clinician, the patient, and the clinical laboratory. When appropriate testing occurs and an earlier CKD diagnosis is made, primary care clinicians  and their patients can  take action to protect both kidney and cardiovascular health, which are tightly linked.

CKD diagnosis involves two independent and complementary tests – estimated GFR (eGFR) and albumin-creatinine ratio, urine (uACR). Both are required to assess kidney function and kidney damage. However, considerable room for improvement exists to ensure patients at high risk for CKD, particularly those with hypertension, diabetes, or both, receive this testing.

To understand and address factors causing low and incomplete testing, the National Kidney Foundation convened the Laboratory Engagement Initiative (LEI) - a unique, multidisciplinary team of professionals from leading laboratories, hospital health systems and professional laboratory societies.   The LEI conducted a thorough, end-to-end review of the challenges that impede complete testing and thus early recognition of CKD in the primary care setting.

An important outcome of the LEI review has been the establishment and advocacy of the Kidney Profile, which combines into a single, orderable unit the guideline-concordant tests recommended for CKD diagnosis– eGFR and uACR.   Endorsed by the NKF and leaders of the pathology and laboratory community, the Kidney Profile makes it easier for clinicians to order both the uACR and eGFR and helps eliminate the possibility of overlooking one of the recommended tests.

The LEI review also uncovered confusion around the names used for albuminuria testing and the units for results reporting.  In response, the LEI standardized the test name to albumin-creatinine ratio, urine or uACR and the results reporting units to milligrams per gram (mg/g).

The NKF-ASN Task Force took the lead in scrutinizing the use of race in medical algorithms.  Outcomes from this work added important insights that strongly discourage use of race in assessing eGFR. Race is a social, not biological construct, and its use in calculating eGFR does not improve test accuracy or kidney disease management.  In fact, it perpetuates kidney health inequity and adversely impacts diagnosis and treatment particularly in advanced kidney disease.

Following is an overview of the NKF – ASN Task Force Recommendations:

• Immediate implementation of the CKD-EPI 2021 creatinine equation refit without the race variable in all US laboratories.
• National efforts to facilitate increased, routine, and timely use of cystatin C, especially to confirm eGFR in adults who are at risk for or have chronic kidney disease. 
• Research on GFR estimation with new endogenous filtration markers and on interventions to eliminate race and ethnic disparities should be encouraged and funded.

Outcomes from surveys conducted during the fall of 2022 indicate national commercial laboratories have implemented these changes; however, there are likely many academic, hospital health system, and physician laboratories that have not done so.  If your organization is interested in implementing these recommendations, please consider the materials that we have created to assist you.

• College of American Pathologists (CAP) Recommendations to Aid in Adoption of New eGFR Equation
• Position Statement: U.S Pathology & Laboratory Society Leadership Endorse Use of CKD-EPI 2021 Race-free Equations for eGFR
• eGFR Summary with eGFR/uACR CKD Prognostic Heat Map for Ordering Clinicians
• Continuing medical education available through July 11,2024, Not by Muscle, Race or Ethnicity: Practical use of Cystatin C to estimate GFR
• Original article, New England Journal of Medicine, New Creatinine- and Cystatin C–Based Equations to Estimate GFR without Race
•  NKF-ASN Force Final Report, A Unifying Approach for GFR Estimation: Recommendations of the NKF-ASN Task Force on Reassessing the Inclusion of Race in Diagnosing Kidney Disease
• Frequently Asked Questions About GFR Estimates
• Laboratory guidance for implementation of the CKD-EPI 2021 race-free equations, National Kidney Foundation Laboratory Engagement Working Group Recommendations for Implementing the CKD-EPI 2021 Race-Free Equations for Estimated Glomerular Filtration Rate: Practical Guidance for Clinical Laboratories 

• Estimated Glomerular Filtration Rate (eGFR)
• Download the NKF Fact Sheet: eGFR
• Download Kidney Numbers and the CKD Heat Map

Watch some short, animated videos and learn about: 

• the importance of knowing your kidney numbers
• how your kidney numbers are used to see how well your kidneys are working
• tips that may help improve your kidney health

Our full playlist of videos is here.

CKDIntercept is a groundbreaking initiative from the National Kidney Foundation to improve chronic kidney disease testing, recognition and management in primary care.

• Kidney Evaluation Health Measure
• CKD Change Package
• Improving Patient Education
• Ending Disparities in Chronic Kidney Disease: NKF Leadership Summits
• Community Health Workers
• CKD Data Analysis Summary
• Laboratory Engagement Initiative 
• Chronic Kidney Disease Learning Collaborative

1. Alfego et al. Chronic kidney disease testing among at-risk adults in the U.S. remains low: Real-world evidence from a national laboratory database. Diabetes Care 2021;44:1–8.
2.  https://www.cdc.gov/kidneydisease/basics.html
3. Matsushita et al. Estimated glomerular filtration rate and albuminuria for prediction of cardiovascular outcomes: a collaborative meta-analysis of individual participant data. Lancet Diabetes Endocrinol 2015
4. 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):268-288.e1. (In eng). DOI: 10.1053/j.ajkd.2021.08.003.
5. Inker LA, Eneanya ND, Coresh J, et al. New Creatinine- and Cystatin C–Based Equations to Estimate GFR without Race. New England Journal of Medicine 2021;385(19):1737-1749. DOI: 10.1056/NEJMoa2102953.