Proactive Engagement of Patients With Advanced Chronic Kidney Disease to Reduce Clinical Complications: The Kaiser Permanente Northern California Experience.

INTRODUCTION

Chronic kidney disease (CKD) affected > 35 million US adults in 2023. Effective therapies exist to reduce CKD progression and risk of cardiovascular events. However, whether population-level management strategies are effective is not known. The authors evaluated a program that proactively identified and referred high-risk patients to a structured CKD management approach aimed at improving guideline-direct care.

METHODS

Within a large, integrated health care delivery system, the authors enrolled adults with high-risk CKD identified from electronic health records between June 2021 and March 2022 who were not receiving nephrology care into a structured CKD management program based on a multidisciplinary, nephrologist-led model of care. These patients were compared to a matched cohort of high-risk patients with CKD receiving usual care. The authors evaluated feasibility and differences in targeted process measures over a 3-month follow-up period.

RESULTS

Among 120 eligible patients with CKD enrolled in the program and 120 matched patients with CKD receiving usual care, mean (standard deviation) age was 73.9 (8.4) years, 57.8% were women, and demographic characteristics and comorbidity burden were well matched. Despite the COVID-19 pandemic, implementing the structured CKD management program was feasible. During the 3-month follow-up period, those enrolled in the CKD management program experienced a higher rate of estimated glomerular filtration (58% vs 43%, P = .02) and urinary protein (38% vs 11%, P < .0001) testing.

CONCLUSION

Proactive referral to structured CKD management was feasible and led to increased short-term surveillance of kidney function. Future studies should assess whether engagement at earlier stages of CKD and longer systematic care and follow-up can improve outcomes and inform broader implementation of population-level CKD management strategies.