2023 CKD Change Package References

Stage of Change 1 References

  • 12. Alfego D, Ennis J, Gillespie B 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 Sept;44(9):2025-2032.
  • 13. United States Renal Data System. www.usrds.org
  • 14. CDC CKD Surveillance System. https://nccd.cdc.gov/CKD/
  • 15. Jankowski J, Floege J, Fliser D et al. Cardiovascular disease in chronic kidney disease: pathophysiological insights and therapeutic options. Circulation. 2021 Mar 16;143(11):1157-1172.
  • 16. Go AS, Chertow GM, Fan D et al. Chronic kidney disease and the risks of death, cardiovascular events, and hospitalization. N Engl J Med 2004 Sep 23;351(13):1296-305.
  • 17. Nichols GA, Ustyugova A, Anouk DL et al. Health care costs by type of expenditure across eGFR stages among patients with and without diabetes, cardiovascular disease, and heart failure. J Am Soc Nephrol. 2020 Jul;31(7):1594–1601.
  • 18. National Kidney Foundation. K/DOQI Clinical practice guide- lines for chronic kidney disease: evaluation, classification and stratification. Am J Kidney Dis 2002;39:S1-S26.
  • 19. Vassalotti JA, Centor, Turner BJ et al. Practical approach to detection and management of chronic kidney disease for the primary care clinician. Am J Med 2016 Feb;129(2):153-162.e7.
  • 20. Whelton PK, Carey RM, Aronow WS et al. 2017 ACC/AHA/ AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA guide- line for the prevention, detection, evaluation, and manage- ment of high blood pressure in adults: a report of the American College of Cardiology/American Heart Association Task Force on clinical practice guidelines. Hypertension.  2018; 71(6): p. e13-e115.
  • 21.  Chobanian AV, Bakris GL, Black HR et al. Seventh report of the joint national committee on prevention, detection, evaluation, and treatment of high blood pressure. Hypertension. 2003;42:1206-1252.
  • 22. James PA, Oparil S, Carter BL et al., 2014 evidence-based guideline for the management of high blood pressure in adults: report from the panel members appointed to the eighth joint national committee (JNC 8). JAMA. 2014. 311(5):507-520.
  • 23. Taler SJ, Agarwal R, Bakris GL et al. KDOQI US commentary on the 2012 KDIGO clinical practice guideline for Management of Blood Pressure in CKD. Am J Kidney Dis. 2013;62(2):201-213.
  • 24. KDOQI Clinical Practice Guideline for Diabetes and CKD: 2012 Update. Am J Kidney Dis. 2012 Nov;60(5):850-86.
  • 25. Inker LA, Astor BC, Fox CH et al. KDOQI US commentary on the 2012 KDIGO clinical practice guideline for the evaluation and management of CKD. Am J Kidney Dis. 2014;63(5):713-735.
  • 26. Friedewald, V.E., Bennett JS, Christo JP et al. Editor’s consensus: selective and nonselective nonsteroidal anti-inflammatory drugs and cardiovascular risk. Am J of Cardiol, 2010. 106(6):873-884.
  • 27. Leonard CE, Freeman CP, Newcomb CW et al., Proton pump inhibitors and traditional nonsteroidal anti-inflam matory drugs and the risk of acute interstitial nephritis and acute kidney injury. Pharmacoepidemiol Drug Saf, 2012. 21(11):1155-1172.
  • 28. Academy of Nutrition and Dietetics. Chronic Kidney Disease (CKD) Evidence-Based Nutrition Practice Guideline. https:// www.andeal.org/files/files/CKD/CKD2020_Comparison_ Table_20200820.pdf. Accessed October 10, 2023.
  • 29. Kramer H, Jimenez EY, Brommage D et al. Medical nutri- tion therapy for patients with non-dialysis dependent chronic kidney disease: barriers and solutions. J Acad Nutr Diet. 2018 Oct;118(10):1958-1965.
  • 30. Chan MR, Dall AT, Fletcher KE, et al. Outcomes in Patients with Chronic Kidney Disease Referred Late to Nephrologists: A Meta-analysis. Am J Med 2007;120:1063-70.e2.
  • 31. Vassalotti JA, DeVinney R, Lukasik S et al. CKD quality improvement intervention with PCMH integration: health plan results. Am J Manag Care. 2019 Nov 1;25(11):e326-e333.

Stage of Change 2 References

N/A

Stage of Change 3 References

  • 12. Alfego D, Ennis J, Gillespie B 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 Sept;44(9):2025-2032
  • 31. Vassalotti JA, DeVinney R, Lukasik S et al. CKD quality improvement intervention with PCMH integration: health plan results. Am J Manag Care. 2019 Nov 1;25(11):e326-e333.
  • 32. Scholle SH, Ontad K, Hart A, Hwee T. Chronic kidney disease disparities: educational guide for primary care. Prepared for the Centers for Medicare and Medicaid Services (CMS) by the National Committee for Quality Assurance (NCQA). 2021 April:1-19.
  • 33. Tummalapalli SL, Powe NR, Keyhani S. Trends in quality of care for patients with CKD in the United States. Clin J Am Soc Nephrol. 2019 Aug 7;14(8):1142-1150.
  • 34. Norton J, Moxey-Mims MM, Eggers PW et al. Social determinants of racial disparities in CKD. J Am Soc Nephrol. 2016 Sep;27(9):2576-95.
  • 35. Crews DC and Novick TK. Social determinants of CKD hotspots. Semin Nephrol. 2019 May;39(3):256-262.
  • 36. Tucker KJ. Social justice as a tool to eliminate inequities in kidney disease. Semin Nephrol. 2021 May;41(3):203-210.
  • 37. Crews DC, Pfaff T, Powe NR. Socioeconomic factors and racial disparities in kidney disease outcomes. Semin Nephrol. 2013 Sep;33(5):468-75.
  • 38. Sevin C, Moore G, Shepherd J et al. Transforming care teams to provide the best possible patient-centered, collaborative care. J Ambul Care Manage. 2009 Jan-Mar;32(1):24-31.

Stage of Change 4 References

  • 6. Kidney Disease: Improving Global Outcomes (KDIGO) Diabetes Work Group. KDIGO 2022 clinical practice guideline for diabetes management in chronic kidney disease. Kidney Int. 2022 Nov;102(5S):S1-S127.
  • 19. Vassalotti JA, Centor, Turner BJ et al. Practical approach to detection and management of chronic kidney disease for the primary care clinician. Am J Med 2016 Feb;129(2):153-162.e7.
  • 25. Inker LA, Astor BC, Fox CH et al. KDOQI US commentary on the 2012 KDIGO clinical practice guideline for the evaluation and management of CKD. Am J Kidney Dis. 2014;63(5):713-735.
  • 39. Tuot DS and Powe NR. Chronic kidney disease in primary care: an opportunity for generalists. J Gen Intern Med 2011 Feb; 26(4):356–8.
  • 40. Neumiller JJ, Shubrook JH, Manley T et al. Optimizing use of SGLT2 inhibitors and other evidence-based therapies to improve outcomes in patients with type 2 diabetes and chronic kidney disease: An opportunity for pharmacists. Am J Health Syst Pharm. 2022 Jan 1;79(1):e65-e70.
  • 41. Strand MA, DiPietro MNA, Hall L et al. Pharmacy contributions to improved population health: expanding the public health roundtable. Prev Chronic Dis 2020 17:200350.
  • 42. Norton JM, Kaltun A, Jurkovitz CT et al. Development and validation of a pragmatic electronic phenotype for CKD. Clin J Am Soc Nephrol. 2019 Sep 6;14(9):1306-1314.
  • 43. Shang N, Khan A, Polubriaginof F et al. Medical records- based chronic kidney disease phenotype for clinical care and “big data” observational and genetic studies. npj Digital Medicine 2021 4:70.
  • 44. van der Scheer JW, Woodward M, Ansari A et al. How to specify healthcare process improvements collaboratively using rapid, remote consensus-building: a framework and a case study of its application. BMC Med Res Methodol. 2021 21:103:1-16.
  • 45. Moise N, Cene CW, Tabak RG et al. Leveraging implementation science for cardiovascular health equity: a scientific statement from the American Heart Association. Circulation. 2022;146:e260–e278.
  • 46. ElSayed NA, Allepo G, Aroda VR et al. 11. Chronic kidney disease and risk management: standards of care in diabetes—2023. Diabetes Care 2023;46(Supplement_1):S191–S202.
  • 47. Inker LA, Astor BC, Fox CH et al. KDOQI US Commentary on the 2012 KDIGO Clinical Practice Guideline for the Evaluation and Management of CKD. Am J Kidney Dis. 2014;63(5):713-735.
  • 48. Handelsman Y, Anderson JE, Bakris G et al. DCRM Multispecialty Practice Recommendations for the management of diabetes, cardiorenal, and metabolic diseases. J Diabetes Complications. 2022;36(2):1-22.
  • 49. Navaneethan SD, Zoungas S, Caramori ML et al. Diabetes management in chronic kidney disease: synopsis of the KDIGO 2022 clinical practice guideline update. Ann Intern Med. 2023;176:381-387.
  • 50. KDIGO 2021 Clinical Practice Guideline for the Management of Blood Pressure in Chronic Kidney Disease. Kidney Int. 2021 99:S1–S87.
  • 51. Taler SJ, Afarwal R, Bakris GL et al. KDOQI US commentary on the 2012 KDIGO clinical practice guideline for management of blood pressure in CKD. Am J Kidney Dis. 2013; Aug; 62(2):201–213.
  • 52. de Boer IH, Khunti K, Sadusky T, et al. Diabetes management in chronic kidney disease: a consensus report by the American Diabetes Association (ADA) and Kidney Disease: Improving Global Outcomes (KDIGO). Kidney Int. 2022 Nov;102(5):974-989.
  • 53. Yau K, Dharia A, Alrowiyti I et al. Prescribing SGLT2 inhibitors in patients with CKD: expanding indications and practical considerations. Kidney Int Rep (2022) 7:1463–1476.
  • 54. Tuttle KR, Brosius FC, Cavender, MA et al. SGLT2 inhibition for CKD and cardiovascular disease in type 2 diabetes: report of a scientific workshop sponsored by the National Kidney Foundation. Am J Kidney Dis. 2021 Jan;77(1):94-109.
  • 55. Arnett DK, Blumenthal RS, Albert MA et al. 2019 ACC/AHA guideline on the primary prevention of cardiovascular disease: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. J Am Coll Cardiol. 2019 Sep, 74 (10) e177–e232.
  • 56. Wanner C, Tonelli M and the Kidney Disease: Improving Global Outcomes (KDIGO) Lipid Guideline Development Work Group Members KDIGO Clinical Practice Guideline for Lipid Management in CKD: summary of recommendation statements and clinical approach to the patient. Kidney Int. (2014) 85, 1303–1309.
  • 57. Ikizler TA, Burrowes JD, Byham-Gray LD et al. KDOQI clinical practice guideline for nutrition in CKD: 2020. Am J Kidney Dis. 2020;76(3)(suppl 1):S1-S107.
  • 58. Pai AB. Keeping kidneys safe: The pharmacist’s role in NSAID avoidance in high-risk patients. J Am Pharm Assoc (2003). 2015 Jan-Feb;55(1):e15-23.update. 
  • 59. Keohane DM, Dennehy T, Keohane KP et al. Reducing inappropriate non-steroidal anti-inflammatory prescription in primary care patients with chronic kidney disease. Int J Health Care Qual Assur. 2017 Aug 14;30(7):638-644.
  • 60. Baker M and Perazella MA. NSAIDs in CKD: are they safe? Am J Kidney Dis. 2020 Oct;76(4):546-557.
  • 61. Plantinga L, Grubbs V, Sarkar U et al. Nonsteroidal anti-inflammatory drug use among persons with chronic kidney disease in the United States. Ann Fam Med. 2011 Sep-Oct;9(5):423-30.
  • 62. Tuot DS, Plantinga LC, Judd SE et al. Healthy behaviors, risk factor control and awareness of chronic kidney disease. Am J Nephrol (2013) 37 (2): 135–143.
  • 63. Tangri N, Stevens LA, Griffith J et al. A predictive model for progression of chronic kidney disease to kidney failure. JAMA 2011 Apr 20;305(15):1553-9.
  • 64. EH De Marchis, Brown E, Aceves BA et al. SCREEN Report: state of the science executive summary on social screening in healthcare settings. Summer 2022.
  • 65. National Association of Community Health Centers, Inc., Association of Asian Pacific Community Health Organizations, and the Oregon Primary Care Association. March 2019.
  • 66. Chronic Kidney Disease Prevention, Early Recognition, and Management. Department of Veterans Affairs, Veterans Health Administration, Washington, DC 20420. March 17, 2020.
  • 67. Moulin JC, Dickson KS, Stadnick NA et al. Ten recommendations for using implementation frameworks in research and practice. Implement Sci Commun. 2020 1:42.
  • 68. Kaplan HC and Walsh KE. Context in implementation science. Pediatrics 2022 (149);Supplement 3.
  • 70. Damschroder LJ, Reardon CM, Opra Widerquist MA et al. The updated consolidated framework for implementation research based on user feedback. Implement Sci. 2022 Oct 29: 2-16.

Stage of Change 5 References

  • 71. R. Rubin. It takes an average of 17 years for evidence to change practice-the burgeoning field of implementation science seeks to speed things up. Medical News & Perspectives. JAMA 2023;329(16):1333-1336.
  • 72. Mendu ML, Ahmed S, Maron JK et al. Development of an electronic health record-based chronic kidney disease registry to promote population health management. BMC Nephrol 2019 20:72.
  • 73. Litvin CB, Hyer M and Ornstein SM. Use of clinical decision support to improve primary care identification and management of chronic kidney disease (CKD). J Am Board Fam Med. 2016 Sep-Oct;29(5):604-12.
  • 74. Mendu ML, Schneider LI, Aizer AA et al. Implementation of a CKD checklist for primary care providers. Clin J Am Soc Nephrol. 2014 Sep 5;9(9):1526-35.
  • 75. The role of faith-based models in community outreach and patient care. Symposium Recap. Am J Manag Care. April 2023.
  • 76. Cutts T, Gunderson G, Carter D et al. From the Memphis model to the North Carolina way: lessons learned from emerging health system and faith community partnerships. NC Med J. 78 (4): 267–72.

Stage of Change 6 References

  • 77. Bullock A, Burrows NR, Narva AS et al. Vital Signs: decrease in incidence of diabetes-related end-stage renal disease among American Indians/Alaska Natives—United States, 1996–2013. MMWR 2017 (66)1:26-32.
  • 78. Fernandez ME, Ten Hoor GA, van Lieshout S et al. Implementation mapping: using intervention mapping to develop implementation strategies. Front. Public Health 2019 7:158.
  • 79. Damschroder LJ, Reardon CM, Opra Widerquist MA et al. The updated consolidated framework for implementation research based on user feedback. Implement Sci. 2022 Oct 29:2-16.