Chronic Kidney Disease Change Package

Chronic kidney disease (CKD): An Unrecognized Public Health Issue

Of the estimated thirty million American adults with CKD, over 80% are unaware of the condition that increases risk for cardiovascular events and progression to kidney failure and death.1 Almost 90% of adults with type-2 diabetes and CKD are not currently diagnosed,2 and as many as 50% of patients with advanced CKD (Stage G4) remain undiagnosed in primary care populations.3 While CKD is recognized for the costs associated with progression to kidney failure and dialysis, recent data illustrate that unrecognized CKD has significant impact on outcomes and healthcare utilization, beginning with the earliest stages.4
Two tests assess for CKD: estimated glomerular filtration rate (eGFR) and urine albumin-creatinine ratio (ACR). Current guidelines for CKD testing recommend that adults with diabetes and/or hypertension be evaluated at least annually for albuminuria. Less than 10% of those with hypertension and less than 40% of those with diabetes are appropriately assessed.5 Two large studies have shown that people with both low eGFR and high ACR have increased risk of cardiovascular events and death.6,7
Early recognition and management of CKD allows clinicians more opportunities to protect kidney health. A population health model for CKD including regular assessment, diagnosis, and early intervention has been shown to favorably impact CKD progression and downstream incidence of ESRD.8

In Brief: CKD Diagnosis and Management

Chronic kidney disease is defined as estimated glomerular filtration rate (eGFR) < 60 ml/min/1.73m2 and/or markers of kidney damage for at least three months.9 In clinical practice, the most common tests for chronic kidney disease include glomerular filtration rate estimated from the serum creatinine concentration (eGFR) using the CKD-EPI (CKD Epidemiology Collaboration) equation and albuminuria from the urinary albumin-creatinine ratio (ACR).9
Assessment of estimated glomerular filtration rate and albuminuria should be performed for persons with diabetes and/or hypertension but is not recommended for the general population.10
Management of chronic kidney disease includes reducing the patient’s risk of CKD progression and risk of associated complications such as cardiovascular disease, acute kidney injury (AKI), CKD anemia, CKD metabolic acidosis, as well as CKD mineral and bone disorder.
Prevention of chronic kidney disease progression requires individualized blood pressure target that considers < 130/90 mm Hg or higher goals,11-14 use of ACE inhibitors (ACEi) or angiotensin receptor blockers (ARB) for patients with albuminuria and hypertension,15-18 hemoglobin A1c ≤ 7% for patients with diabetes,19,20 and referral for medical nutrition therapy.21,22
To reduce patient safety hazards from medications, the level of estimated glomerular filtration rate should be considered when prescribing and nephrotoxins should be generally be avoided such as prolonged use of nonsteroidal anti-inflammatory drugs (NSAIDs).23-25
The main reasons to refer to nephrology specialists are estimated glomerular filtration rate < 30 ml/min/1.73m2, severe albuminuria, undetermined CKD etiology and acute kidney injury.26
Risk of Chronic Kidney Disease Progression and Frequency of Assessment

What is the CKD Change Package?

The contents of this document represent a list of suggested process improvements that ambulatory care can utilize to improve chronic kidney disease (CKD) screening, recognition and management. This also includes discussion of these change concepts and change ideas taken directly from interviews with teams that have integrated CKD care into ambulatory care settings.
This document follows the format of the Million Hearts Hypertension Change Package in compiling change concepts, change ideas, evidence- or practice-based tools and resources:
“Change concepts are general notions that are useful in the development of more specific ideas for changes that lead to improvement. Change ideas are actionable, specific ideas for changing a process. Change ideas can be rapidly tested on a small scale to determine whether they result in improvements in the local environment.”
Interviews were conducted in January/February 2018 with clinical teams that have implemented CKD processes of care in ambulatory care.
Most of the language included in this document arises directly from statements shared during the interview process. It reflects an aggregate of the comments from the teams interviewed.

Implement the CKD Change Package

Read more about how to implement a CKD Population Health program in your care setting: