CKD Population Health

CKD Change Package Main Page
Engage a broad, multi-disciplinary team in the development of a chronic kidney disease strategy for the institution. This team may include representatives from primary care, nephrology, quality, data analysis [populytics or population health], accountable care, EMR design/development, nursing, etc. For integrated institutions it is also recommended to include representatives from emergency medicine, nutrition, etc. Include IT resources in the conversation to leverage technology to make the process as dynamic as possible.
Build internal consensus regarding the CKD metrics to be evaluated in primary care
  • Annual CKD testing and risk stratification in at-risk populations (eGFR and ACR)7,10,27
  • Blood pressure control11-14
  • A1c control19,20
  • Use of ACE Inhibitor or Angiotensin Receptor Blocker15-18
  • Use of Statins28
  • Medical Nutrition Therapy Referral21,22,29
  • NSAIDs Avoidance counseling23-25,30
  • Appropriate collaboration with nephrology (see below)26
  • Use of a risk prediction model (i.e., the Kidney Failure Risk Equation)31
Tools and Resources
Implement a program that supports CKD recognition in its earliest stages. Start by running a small trial before widening to the entire practice or network. Align the strategies proposed with appropriate practice resources. Make the program design flexible to allow for variation within the practices.
Engage the practice team in tailoring the intervention to work best with their own practice workflows.
Use Data to Drive Improvements in CKD care
Implement parameters for nephrology referral and co-management of CKD