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Background Chronic kidney disease (CKD) is a common condition with adverse health outcomes addressable by early disease management. The impact of the COVID-19 pandemic on care utilization for the CKD population is unknown. Objective To examine pandemic CKD care and identify factors associated with a high care deficit. Design Retrospective observational study Participants 248,898 insured individuals (95% Medicare Advantage, 5% commercial) with stage G3–G4 CKD in 2018 Main Measures Predicted (based on the pre-pandemic period of January 1, 2019–February 28, 2020) to observed per-member monthly face-to-face and telehealth encounters, laboratory testing, and proportion of days covered (PDC) for medications, evaluated during the early (March 1, 2020–June 30, 2020), pre-vaccine (July 1, 2020–December 31, 2020), and late (January 2021–August 2021) periods and overall. Key Results In-person encounters fell by 24.1% during the pandemic overall; this was mitigated by a 14.2% increase in telehealth encounters, resulting in a cumulative observed utilization deficit of 10% relative to predicted. These reductions were greatest in the early pandemic period, with a 19.8% cumulative deficit. PDC progressively decreased during the pandemic (range 9–20% overall reduction), with the greatest reductions in hypertension and diabetes medicines. CKD laboratory monitoring was also reduced (range 11.8–43.3%). Individuals of younger age (OR 1.63, 95% CI 1.16, 2.28), with commercial insurance (1.43, 95% CI 1.25, 1.63), residing in the Southern US (OR 1.17, 95% CI 1.14, 1.21), and with stage G4 CKD (OR 1.21, 95% CI 1.17, 1.26) had greater odds of a higher care deficit overall. Conclusions The early COVID-19 pandemic resulted in a marked decline of healthcare services for individuals with CKD, with an incomplete recovery during the later pandemic. Increased telehealth use partially compensated for this deficit. The downstream impact of CKD care reduction on health outcomes requires further study, as does evaluation of effective care delivery models for this population.

The United States Preventive Services Task Force has no current recommendation to guide primary care physician screening for chronic kidney disease (CKD). This is misaligned with the scope of the CKD public health emergency, recommendations from clinical practice guidelines, health spending on CKD, the changing landscape of CKD detection and treatment, and the focus by policymakers on identifying tangible approaches to improving health equity. This review summarizes patient, clinician, health equity, and health system perspectives in support of screening adults with risk factors for CKD. This review concludes with the assessment that the United States Preventive Services Task Force should revisit targeted CKD screening specifically for adults with diabetes and/or hypertension.

Recognizing that race is a social and not a biological construct, healthcare professionals and the public have called for removal of race in clinical algorithms. In response, the National Kidney Foundation and the American Society of Nephrology created the Task Force on Reassessing the Inclusion of Race in Diagnosing Kidney Diseases to examine the issue and provide recommendations. The final report from the Task Force recommends calculating estimated glomerular filtration rate (eGFR) without a race coefficient using the recently published CKD-EPI 2021 creatinine (cr) and creatinine-cystatin C (cr-cys) equations. The Task Force recommends immediately replacing older eGFRcr equations (MDRD Study and CKD-EPI 2009) with the new CKD-EPI 2021 equation. In a 2019 survey by the College of American Pathologists, 23% of 6200 laboratories reporting eGFRcr used an incorrect equation that is not suitable for use with standardized creatinine measurements, 34% used the CKD-EPI 2009 equation and 43% used the MDRD Study 2006 equation re-expressed for standardized creatinine measurement. Rapid transition to using the CKD-EPI 2021 equation is an opportunity for laboratories to standardize to a single equation to eliminate differences in eGFRcr due to different equations used by different laboratories, and to report eGFR without use of race. We provide guidance to laboratories for implementing the CKD-EPI 2021 equations for both eGFRcr and eGFRcr-cys.

Estimated glomerular filtration rate (eGFR) and albuminuria, the current standard-of-care tests that predict risk of kidney function decline in early-stage diabetic kidney disease (DKD), are only modestly useful. We evaluated the decision-making impact of an artificial intelligence-enabled prognostic test, KidneyIntelX, in the management of DKD by primary care physicians (PCPs).This was a prospective web-based survey administered among PCPs in the United States.We used conjoint analysis with multivariable logit models to estimate PCP preferences. The survey included hypothetical patient profiles with 6 attributes: albuminuria, eGFR, age, blood pressure (BP), hemoglobin A1c (HbA1c), and KidneyIntelX result. Each PCP viewed 8 patient profiles randomly selected from 42 unique profiles having 1 level from each attribute. For each patient, PCPs were asked to indicate whether they would prescribe a sodium-glucose cotransporter-2 (SGLT2) inhibitor, increase angiotensin receptor blocker (ARB) dose, and/or refer to a nephrologist.A total of 401 PCPs completed the survey (response rate, 8.8%). The relative importance of the top 2 attributes for each decision were HbA1c (52%) and KidneyIntelX result (23%) for prescribing SGLT2 inhibitors, BP (62%) and KidneyIntelX result (13%) for increasing ARB dose, and eGFR (42%) and KidneyIntelX result (27%) for nephrologist referral. A high-risk KidneyIntelX result was associated with significantly higher odds of PCPs prescribing SGLT2 inhibitors (odds ratio [OR], 1.64; 95% CI, 1.29-2.08), increasing ARB dose (OR, 1.49; 95% CI, 1.17-1.89), and referring to a nephrologist (OR, 2.47; 95% CI, 1.99-3.08) compared with no test.The KidneyIntelX test had greater relative importance than albuminuria and eGFR to PCPs in making treatment decisions and was second only to eGFR for nephrologist referrals. Because of its significant impact on decision-making, KidneyIntelX has high clinical utility in DKD management.

Over the past 65 years, kidney transplantation has evolved into the optimal treatment for patients with kidney failure, dramatically reducing suffering through improved survival and quality of life. However, access to transplant is still limited by organ supply, opportunities for transplant are inequitably distributed, and lifelong transplant survival remains elusive. To address these persistent needs, the National Kidney Foundation convened an expert panel to define an agenda for future research. The key priorities identified by the panel center on the needs to develop and evaluate strategies to expand living donation, improve waitlist management and transplant readiness, maximize use of available deceased donor organs, and extend allograft longevity. Strategies targeting the critical goal of decreasing organ discard that warrant research investment include educating patients and clinicians about potential benefits of accepting nonstandard organs, use of novel organ assessment technologies and real-time decision support, and approaches to preserve and resuscitate allografts before implantation. The development of personalized strategies to reduce the burden of lifelong immunosuppression and support "one transplant for life" was also identified as a vital priority. The panel noted the specific goal of improving transplant access and graft survival for children with kidney failure. This ambitious agenda will focus research investment to promote greater equity and efficiency in access to transplantation, and help sustain long-term benefits of the gift of life for more patients in need.

Aim Predicting progression in diabetic kidney disease (DKD) is critical to improving outcomes. We sought to develop/validate a machine-learned, prognostic risk score (KidneyIntelX™) combining electronic health records (EHR) and biomarkers. Methods This is an observational cohort study of patients with prevalent DKD/banked plasma from two EHR-linked biobanks. A random forest model was trained, and performance (AUC, positive and negative predictive values [PPV/NPV], and net reclassification index [NRI]) was compared with that of a clinical model and Kidney Disease: Improving Global Outcomes (KDIGO) categories for predicting a composite outcome of eGFR decline of ≥5 ml/min per year, ≥40% sustained decline, or kidney failure within 5 years. Results In 1146 patients, the median age was 63 years, 51% were female, the baseline eGFR was 54 ml min−1 [1.73 m]−2, the urine albumin to creatinine ratio (uACR) was 6.9 mg/mmol, follow-up was 4.3 years and 21% had the composite endpoint. On cross-validation in derivation (n = 686), KidneyIntelX had an AUC of 0.77 (95% CI 0.74, 0.79). In validation (n = 460), the AUC was 0.77 (95% CI 0.76, 0.79). By comparison, the AUC for the clinical model was 0.62 (95% CI 0.61, 0.63) in derivation and 0.61 (95% CI 0.60, 0.63) in validation. Using derivation cut-offs, KidneyIntelX stratified 46%, 37% and 17% of the validation cohort into low-, intermediate- and high-risk groups for the composite kidney endpoint, respectively. The PPV for progressive decline in kidney function in the high-risk group was 61% for KidneyIntelX vs 40% for the highest risk strata by KDIGO categorisation (p event for the high-risk group was 41% (p Conclusions KidneyIntelX improved prediction of kidney outcomes over KDIGO and clinical models in individuals with early stages of DKD. Graphical abstract

BACKGROUND Patient awareness of chronic kidney disease (CKD) is low in part due to suboptimal testing for CKD among those at risk and lack of discussions about kidney disease between patients and clinicians. To bridge these gaps, the National Kidney Foundation developed The Kidney Score Platform, which is a web-based series of tools that includes resources for health care professionals as well as an interactive, dynamic patient-facing component that includes a brief questionnaire about risk factors for kidney disease, individualized assessment of risk for developing CKD, and self-management tools to manage one’s kidney disease. OBJECTIVE To perform usability testing of the patient-component of The Kidney Score platform among Veterans with and at risk for kidney disease and clinicians working as primary care providers in Veterans Affairs administration. METHODS Think-aloud exercises were conducted, during which participants (Veterans and clinicians) engaged with the platform while verbalizing their thoughts and making their perceptions, reasonings, and decision points explicit. A Usability Facilitator observed participants’ behaviors and probed selectively to clarify their comprehension of the tool’s instructions, content, and its overall functionality. Thematic analysis on the audio-recording transcripts was performed, focusing on positive attributes, negative comments, and areas that required Facilitator involvement. RESULTS Veterans (n=20) were 78% male with a mean age of 58.1 years. Two-thirds were of non-white race/ethnicity, 28% had laboratory evidence of CKD without a formal diagnosis and 50% carried a diagnosis of hypertension or diabetes. Clinicians (n=19) were 29% male, 30% of non-white race/ethnicity and had a mean of 17 (range 4-32) years of experience. Veterans and clinicians easily navigated the on-line tool and appreciated the personalized results page as well as the inclusion of infographics to deliver key educational messages. Three major themes related to content and communication about risk for CKD emerged from the think aloud exercises: (1) tension between lay and medical terminology when discussing kidney disease and diagnostic tests; (2) importance of linking general information to concrete self-management actions; (3) usefulness of the tool as an adjunct to the office visit to prepare for patient-clinician communication. Importantly, these themes were consistent among interviews involving both Veterans and clinicians. CONCLUSIONS Veterans and clinicians both thought that the Kidney Score Platform would successfully promote communication and discussion about kidney disease in primary care settings. Tension between using medical terminology that is used regularly by clinicians versus lay terminology to promote CKD awareness was a key challenge that can inform the development of future CKD educational materials.

There are limited data evaluating chronic nonsteroidal anti-inflammatory drug (NSAID) exposure and decline in kidney function in primary care practice where rates of NSAID prescribing are high (1,2). The majority of published observational studies have evaluated the association of prescription NSAID use with AKI using claims data in focused geographic areas outside of the United States (1). It is estimated that >36 million Americans use over-the-counter (OTC) NSAIDs and data suggest that many users, regardless of age, exceed the recommended dose (1,3,4). Education materials for prescription ( e.g ., Food and Drug Administration Medication Guide) and OTC (label) NSAIDs have also been noted to have content that is not aligned with the universal precautions for health literacy. Poor literacy around NSAID education materials has been documented among primary care patients with CKD (5). This study sought to evaluate eGFR changes associated with chronic NSAID exposure in a large, geographically vast, primary care cohort using data from the DARTNet Practice Performance Registry receiving prescription and OTC NSAIDs (6). This project was determined to not require oversight by the University of Michigan Institutional Review Board. This determination was based on the fact that the data set analyzed had no protected health information. Eligible patients were ≥18 years old and had at least two eGFR measurements (between 29 ml/min per 1.73 m2) at least 3 months apart. Baseline was defined as the first qualifying eGFR during the study period of January 1, …

Multiple clinical guidelines recommend an ACE (angiotensin-converting enzyme) inhibitor or angiotensin II receptor blocker (ARB) in patients with elevated albuminuria, which can be measured through urine albumin-to-creatinine ratio (ACR), protein-to-creatinine ratio, or dipstick. However, how albuminuria test results relate to the prescription of ACE inhibitor/ARB is uncertain. We identified individuals with an ACR measurement between January 1, 2004, and June 30, 2018, and no contraindications or allergy to ACE inhibitor/ARB. We performed multivariable logistic regression analyses to evaluate the association between ACR level and prescription of ACE inhibitor/ARB within 6 months after the test. We applied similar methods to investigate the association of protein-to-creatinine ratio and dipstick measurement results with the prescription of ACE inhibitor/ARB. Among 67 237 individuals with an ACR measurement, 47.7% were already taking an ACE inhibitor or ARB at the time of first ACR measurement. Among the 35 138 individuals who were not on ACE inhibitor/ARB, those with higher ACR levels were more likely to be prescribed ACE inhibitor/ARB in the following 6 months, with steep increases in prescriptions until ACR 300 mg/g, after which the association plateaued. The majority (80.9%) of ACE inhibitor/ARB prescriptions were made by family medicine and internal medicine. A similar pattern held in the cohorts tested by protein-to-creatinine ratio and dipstick measurement. Our study provides evidence that albuminuria test results change patient care, suggesting that adherence to albuminuria testing is a key step in optimal medical management.

BackgroundHyperkalemia is a potentially life-threatening electrolyte abnormality that often requires urgent treatment. Clinicians should distinguish true hyperkalemia from pseudohyperkalemia and reverse pseudohyperkalemia (RPK). RPK has exclusively been described in case reports of patients with hematologic malignancies (HMs) and extreme leukocytosis [white blood cell (WBC) count >200 × 103/mL].MethodsThis single-center retrospective study analyzed laboratory data from the Mount Sinai Data Warehouse between 1 January 2010 and 31 December 2016 for plasma potassium and serum potassium samples drawn within 1 h of each other, with plasma potassium ≥1 mEq/L of the serum potassium. Only plasma potassium ≥5 mEq/L were included. Samples that were documented to be hemolyzed or contaminated were excluded. Clinical history and laboratory data were collected from the identified cases.ResultsAfter applying the inclusion/exclusion criteria to 485 potential cases, the final cohort included 45 cases from 41 patients. There were 24 men and 17 women with a mean age of 52 years. The median plasma potassium was 6.1 mEq/L and serum potassium was 4.4 mEq/L. The median WBC count was 9.35 × 103/mL (interquartile range 6.5–19.7 × 103/mL). Only 44% of the samples had leukocytosis, defined as WBC >11 × 103/mL.Seven patients had a HM and comprised 11 of the cases (24%) with a median WBC of 181.8 × 103µL. There was no difference in their plasma and serum potassium levels when compared with the total cohort, despite a higher median WBC count. Thirty-eight percent of the cases required medical management.ConclusionsThe literature on RPK is limited to case reports and series associated with extreme leukocytosis. This is the first study characterizing RPK predominantly associated with normal leukocyte counts. Further investigation is required to more precisely characterize factors associated with RPK and to elucidate RPK mechanisms.

Introduction Albuminuria is a sign of kidney disease and associated with adverse outcomes. However, most individuals with albuminuria are unaware of it. The Kidney Disease Screening and Awareness Program (KDSAP) aims for early detection and raising awareness of albuminuria, targeting underserved populations in communities. This study will assess the prevalence and awareness of albuminuria and identify associated risk factors among KDSAP participants. Methods KDSAP participants ≥18 years old without a history of dialysis or kidney transplant were included. Albuminuria was identified by dipstick urinalysis. Individuals with albuminuria who answered yes to either of the following 2 questions were defined as being aware: (i) Have you ever had protein in the urine? (ii) Do you have kidney disease? Results Among 2304 participants, 461 (20.0%) had albuminuria: 16.3% with trace or 1+ (low degree) and 3.7% with 2+ or more (high degree). Correlating factors of albuminuria included young age, male sex, African American descent, self-reported diabetes, hypertension, family history of kidney disease, and smoking. Overall albuminuria awareness was 15.8%, but awareness inversely correlated to younger age groups: 7.0% for ages 18–39 years, 13.5% for ages 40–59 years, and 24.0% for ages ≥60 years (P < 0.001). A high degree of albuminuria (vs. low, odds ratio: 5.04, P < 0.001) and concurrent hematuria (odds ratio: 2.12, P=0.024) were both associated with higher awareness; conversely, risk factors for low awareness included African American and better self-assessments of health. Conclusions There was a high albuminuria prevalence among KDSAP participants, yet low awareness. KDSAP can potentially be a useful model for detecting albuminuria and raising awareness in communities., Graphical abstract

Rationale & Objective Patients experience various symptoms during hemodialysis. We aimed to assess the frequency and severity of symptoms during hemodialysis and whether intradialytic symptoms are associated with recovery time postdialysis. Study Design An online questionnaire was sent to 10,000 patients in a National Kidney Foundation database. Setting & Participants Adult patients receiving in-center hemodialysis 3 times weekly for 3 or more months. Exposure Online questionnaire. Analytic Approach Tabulation of frequency and severity of events and recovery time as percent of respondents, construction of a total symptom score, followed by rank correlation analysis of symptom characteristics with total recovery time. Outcomes Patient-reported intradialytic symptoms and recovery time postdialysis. Results 359 patients met screening criteria and completed the questionnaire. Mean age was 62.5 ± 13.8 years, 207 (58%) were men, 74 (21%) were black/African American, 132 (37%) had diabetes, 252 (70%) had hypertension, and 102 (28%) had a history of myocardial infarction, heart surgery, or stent placement. 311 (87%) patients had symptoms during dialysis in the previous week, with mean severity of 2.7 (range for each symptom, 1-5). The most common symptoms were fatigue/feeling washed out (62%), cramps (44%), and symptoms of low blood pressure (42%). Median time to recovery was 3 (range, 0-24) hours, and this correlated with the incidence and severity of intradialytic symptoms (P < 0.0001). 40% of patients had time to recovery times of 4 hours or longer. 1 in 3 patients reported having stopped dialysis early for intradialytic symptoms and 6% reported skipping dialysis at least once because of intradialytic symptoms. Limitations Recall-based self-reported data with a relatively low response rate. Conclusions A majority of patients receiving in-center hemodialysis experience symptoms such as feeling washed out, fatigue, and cramping; these may be severe and are correlated with longer recovery time following hemodialysis, as well as shortened and skipped hemodialysis sessions., Graphical abstract

Introduction The uptake of the Kidney Disease: Improving Global Outcomes (KDIGO) 2012 chronic kidney disease (CKD) Guideline is not fully described in real-world nephrology practice across the world. Methods We used baseline data from the CKD Outcomes and Practice Patterns Study (2013–2017), a 4-country cohort of patients with estimated glomerular filtration rate, Graphical abstract

Despite the high prevalence and economic burden of chronic kidney disease (CKD) in the United States, federal funding for kidney-related research, prevention, and education activities under the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) remains substantially lower compared to other chronic diseases. More federal support is needed to promote critical research that will expand knowledge of kidney health and disease, develop new and effective therapies, and reduce health disparities. In 2021, the National Kidney Foundation (NKF) convened 2 Research Roundtables (preclinical and clinical research), comprising nephrology leaders from prominent US academic institutions and the pharmaceutical industry, key bodies with expertise in research, and including individuals with CKD and their caregivers and kidney donors. The goal of these roundtables was to identify priorities for preclinical and clinical kidney-related research. The research priorities identified by the Research Roundtables and presented in this position statement outline attainable opportunities for groundbreaking and critically needed innovations that will benefit patients with kidney disease in the next 5-10 years. Research priorities fall within 4 preclinical science themes (expand data science capability, define kidney disease mechanisms and utilize genetic tools to identify new therapeutic targets, develop better models of human disease, and test cell-specific drug delivery systems and utilize gene editing) and 3 clinical science themes (expand number and inclusivity of clinical trials, develop and test interventions to reduce health disparities, and support implementation science). These priorities in kidney-related research, if supported by additional funding by federal agencies, will increase our understanding of the development and progression of kidney disease among diverse populations, attract additional industry investment, and lead to new and more personalized treatments.

OBJECTIVE An estimated 37 million Americans have chronic kidney disease (CKD). Nearly 90% do not know about their condition because of low awareness about the importance of CKD testing and diagnosis among practitioners and people at risk for CKD. This study uses data from a national clinical laboratory to identify guideline-recommended CKD testing rates across the U.S. RESEARCH DESIGN AND METHODS Patients with Laboratory Corporation of America Holdings (Labcorp) testing between 2013 and 2019 were defined as at risk for CKD if they had any testing ordered with diagnosis codes for diabetes and/or hypertension. Guideline-concordant CKD assessment was defined by estimated glomerular filtration rate (eGFR) and urine albumin-to-creatinine ratio (uACR) testing within the study year. RESULTS We identified 28,295,982 at-risk patients (mean age 60.6 ± 14.8 years; 53.6% women): 16.2% had diabetes, 63.8% had hypertension, and 20.1% had both comorbidities. Of these, 80.3% did not receive guideline-concordant assessment during the study period. Furthermore, only 21.0% had uACR testing versus 89.6% with eGFR. CKD assessment occurred at least once in 28.7% of patients with diabetes, 10.5% of patients with hypertension, and 41.4% of patients with both conditions. In a state-by-state comparison, annual testing rates ranged from 5 to 30%. The nationwide rate increased modestly each year between 2013 and 2018 (from 10.7% to 15.2%). CONCLUSIONS Despite guideline recommendations, testing for CKD with uACR and eGFR in U.S. adults with diabetes and hypertension is low in routine clinical care. These data highlight the need for strategies to improve routine CKD assessment nationwide.

Objective: Clinical guidelines for people with diabetes recommend chronic kidney disease (CKD) testing at least annually using estimated glomerular filtration rate (eGFR) and urinary albumin-creatinine ratio (uACR). We aimed to understand CKD testing among people with type 2 diabetes in the United States. Research Design and Methods: Electronic health record data were analyzed from 513,165 adults with type 2 diabetes, receiving primary care from 24 health care organizations and 1,164 clinical practice sites. We assessed the percentage of patients with both ≥1 eGFR and ≥1 uACR, and each test individually, in the 1, 2, and 3 years ending September 2019, by health care organization and clinical practice site. Elevated albuminuria was defined by uACR ≥30 mg/g. Results: The 1-year median testing rate across organizations was 51.6% for both uACR and eGFR, 89.5% for eGFR, and 52.9% for uACR. uACR testing varied (10th–90th percentile) from 44.7% to 63.3% across organizations and from 13.3% to 75.4% across sites. Over 3 years, the median testing rate for uACR across organizations was 73.7%. Overall, the prevalence of detected elevated albuminuria was 15%. The average prevalence of detected elevated albuminuria increased linearly with uACR testing rates at sites, with estimated prevalence of 6%, 15%, and 30%, at uACR testing rates of 20%, 50%, and 100%. Conclusions: While eGFR testing rates are uniformly high among people with type 2 diabetes, testing rates for uACR are suboptimal and highly variable across and within the organizations examined. Guideline-recommended uACR testing should increase detection of CKD.

The primary laboratory tests for diagnosis of chronic kidney disease (CKD)9 are serum/plasma/blood creatinine with calculation of estimated glomerular filtration rate (eGFR) and urine albumin–creatinine ratio (UACR). Cystatin C is becoming a secondary test for estimating eGFR in some clinical situations. Urine total protein and the protein–creatinine ratio are also used to monitor patients with more advanced CKD. The US Renal Data System 2018 reports that data from the National Health and Nutrition Examination Survey provide an estimate that 15% of the US population meet the laboratory criteria for CKD based on the Kidney Disease Improving Global Outcomes (KDIGO) 2012 Clinical Practice Guideline definition of GFR 30 mg/g (3 mg/mmol). In the years from 2010 to 2018, 80%–90% of laboratories in the US have reported eGFR along with creatinine, yet patient awareness of having CKD continues to be poor. In the 2013–2016 US National Health and Nutrition Examination Survey data, only 8% of people with eGFR 30 mg/g (3 mg/mmol) were aware of having CKD. In this Q&A, a panel of experts in laboratory medicine and in nephrology examine laboratory ordering, testing, and reporting practices and recommend how those practices can be improved to better serve patients with CKD. What is a kidney profile and when should it be ordered? Joseph Vassalotti: The American Diabetes Association, KDIGO, and the National Kidney Foundation (NKF)'s Kidney Disease Outcomes Quality Initiative recommend eGFR and UACR as the tests for CKD targeted for the major risk groups, including diabetes and hypertension. The combination of eGFR and UACR guides therapeutic interventions and predicts risk for CKD progression as well as cardiovascular events, and mortality. The UACR is …

Background A majority of diabetic kidney disease (DKD) patients receive medical care in the primary care setting, making it an important opportunity to improve patient management. There is limited evidence evaluating whether primary care physicians (PCPs) are equipped to effectively manage these patients in routine clinical practice. The present study was undertaken to identify gaps in primary care and unmet needs in the diagnosis and monitoring of DKD in type 2 diabetes (T2D) patients among PCPs. Methods This was a qualitative analysis based on 30–45-min interviews with PCPs treating T2D patients. PCPs were recruited via email and were board-certified, in practice for more than 3 years, spent most of their time in direct clinical care, and provided care for more than three T2D patients in a week. Descriptive data analysis was conducted to identify and examine themes that were generated by interviews. Two reviewers evaluated interview data to identify themes and developed consensus on the priority themes identified. Results A total of 16 PCPs satisfying the inclusion criteria were recruited for qualitative interviews. Although the PCPs recognized kidney disease as an important comorbidity in T2D patients, testing for kidney disease was not consistently top of mind, with 56% reportedly performing kidney function testing in their T2D patients. PCPs most frequently reported using estimated glomerular filtration rate (eGFR) alone to monitor and stage DKD; only 25% PCPs reported testing for albuminuria. Most PCPs incorrectly believed that a majority of DKD patients are diagnosed in early stages. Also, early stages of DKD emerged as ambiguous areas of decision-making, wherein treatments prescribed greatly varied among PCPs. Lastly, early and accurate risk stratification of DKD patients emerged as the most important unmet need; which, if it could be overcome, was consistently identified by PCPs as a key to monitoring, appropriate nephrologist referrals, and intervening to improve outcomes in patients with DKD. Conclusions Our study highlights important unmet needs in T2D DKD testing, staging, and stratification in the PCP setting that limit effective patient care. Health systems and insurers in the U.S. should prioritize the review and approval of new strategies that can improve DKD staging and risk stratification.

Chronic kidney disease (CKD) causes substantial global morbidity and increases cardiovascular and all-cause mortality. Unlike other chronic diseases with established strategies for screening, there has been no consensus on whether health systems and governments should prioritize early identification and intervention for CKD. Guidelines on evaluating and managing early CKD are available but have not been universally adopted in the absence of incentives or quality measures for prioritizing CKD care. The burden of CKD falls disproportionately upon persons with lower socioeconomic status, who have a higher prevalence of CKD, limited access to treatment, and poorer outcomes. Therefore, identifying and treating CKD at the earliest stages is an equity imperative. In 2019, Kidney Disease: Improving Global Outcomes (KDIGO) held a controversies conference entitled "Early Identification and Intervention in CKD." Participants identified strategies for screening, risk stratification, and treatment for early CKD and the key health system and economic factors for implementing these processes. A consensus emerged that CKD screening coupled with risk stratification and treatment should be implemented immediately for high-risk persons and that this should ideally occur in primary or community care settings with tailoring to the local context.

OBJECTIVE Clinical guidelines for people with diabetes recommend chronic kidney disease (CKD) testing at least annually using estimated glomerular filtration rate (eGFR) and urinary albumin-to-creatinine ratio (uACR). We aimed to understand CKD testing among people with type 2 diabetes in the U.S. RESEARCH DESIGN AND METHODS Electronic health record data were analyzed from 513,165 adults with type 2 diabetes receiving primary care from 24 health care organizations and 1,164 clinical practice sites. We assessed the percentage of patients with both one or more eGFRs and one or more uACRs and each test individually in the 1, 2, and 3 years ending September 2019 by health care organization and clinical practice site. Elevated albuminuria was defined as uACR ≥30 mg/g. RESULTS The 1-year median testing rate across organizations was 51.6% for both uACR and eGFR, 89.5% for eGFR, and 52.9% for uACR. uACR testing varied (10th–90th percentile) from 44.7 to 63.3% across organizations and from 13.3 to 75.4% across sites. Over 3 years, the median testing rate for uACR across organizations was 73.7%. Overall, the prevalence of detected elevated albuminuria was 15%. The average prevalence of detected elevated albuminuria increased linearly with uACR testing rates at sites, with estimated prevalence of 6%, 15%, and 30% at uACR testing rates of 20%, 50%, and 100%, respectively. CONCLUSIONS While eGFR testing rates are uniformly high among people with type 2 diabetes, testing rates for uACR are suboptimal and highly variable across and within the organizations examined. Guideline-recommended uACR testing should increase detection of CKD.

Rationale & Objective The Kidney Disease Outcome Quality Initiative (KDOQI) and Kidney Disease: Improving Global Outcomes (KDIGO) chronic kidney disease (CKD) classification systems published in 2002 and 2012, respectively, are recommended worldwide and based on strong epidemiologic data. However, their impact on CKD recognition and management is not well evaluated in clinical practice, and we therefore investigated whether they help physicians recognize and appropriately care for patients with CKD. Study Design Randomized vignette experiment with fractional factorial design based on 6 kidney-related scenarios and 3 laboratory presentation methods reflecting the CKD guidelines. Participants evaluated 1 of 3 subsets of the 18 vignettes (ie, 6 vignettes each with 4 answer alternatives). Setting & Participants 249 interns, general practitioners, and residents/fellows attending postgraduate meetings and courses in Norway and the United States. Intervention Kidney-related results (serum creatinine level and urinary albumin excretion) were presented as the “minimal data” (high/low levels), KDOQI-2002 (estimated glomerular filtration rate [eGFR] reported automatically), or KDIGO-2012 (eGFR + albuminuria categorization + risk for complications) laboratory report. Outcome CKD management choice by physicians. Results When kidney laboratory data were presented as the KDOQI-2002 report (automatic eGFR calculation), there was a significantly higher odds for correct patient management decisions compared with the minimal data report (OR, 1.57; P < 0.001). Additional significant improvement was obtained with the KDIGO-2012 report (OR, 2.28 for correct answer vs minimal data report [P < 0.001]; OR, 1.45 compared to KDOQI-2002 report [P = 0.005]). The KDIGO classification system improved physician management in 4 of the 6 clinical scenarios covering a wide range of kidney-related topics. Interaction analysis showed that general practitioners and those with 1 to 3 years of internal medicine experience had the greatest improvements with the new presentation techniques. Limitations Physicians’ management was evaluated by theoretical scenarios rather than direct patient care. Conclusions Automatic GFR estimation, albuminuria categorization, and notification of the associated risk for complications improve most physicians` recognition and management of a wide range of CKD clinical scenarios., Graphical abstract

BACKGROUND Patient awareness, clinician detection, and management of chronic kidney disease remain suboptimal, despite clinical practice guidelines and diverse education programs. OBJECTIVE This protocol describes a study to develop and investigate the impact of the National Kidney Foundation Kidney Score Platform on chronic kidney disease awareness, communication, and management, by leveraging the Behavior Change Wheel, an implementation science framework that helps identify behavioral intervention targets and functions that address barriers to behavior change. METHODS We interviewed 20 patients with chronic kidney disease and 11 clinicians to identify patient and clinician behaviors suitable for intervention and barriers to behavior change (eg, limited awareness of chronic kidney disease clinical practice guidelines within primary care settings, limited data analytics to highlight chronic kidney disease care gaps, asymptomatic nature of chronic kidney disease in conjunction with patient reliance on primary care clinicians to determine risk and order kidney testing). Leveraging the Behavior Change Wheel, the Kidney Score Platform was developed with a patient-facing online Risk Calculator and a clinician-facing Clinical Practice Toolkit. The Risk Calculator utilizes risk predictive analytics to provide interactive health information tailored to an individual’s chronic kidney disease risk and health status. The Clinical Practice Toolkit assists clinicians in discussing chronic kidney disease with individuals at risk for and with kidney disease and in managing their patient population with chronic kidney disease. The Kidney Score Platform will be tested in 2 Veterans Affairs primary health care settings using a pre–post study design. Outcomes will include changes in patient self-efficacy for chronic kidney disease management (primary outcome), quality of communication with clinicians about chronic kidney disease, and practitioners’ knowledge of chronic kidney disease guidelines. Process outcomes will identify usability and adoption of different elements of the Kidney Score Platform using qualitative and quantitative methods. RESULTS As of September 2020, usability studies are underway with veterans and clinicians to refine the patient-facing components of the Kidney Score Platform before study initiation. Results and subsequent changes to the Kidney Score Platform will be published at a later date. The study is expected to be completed by December 2021. CONCLUSIONS Results of this study will be used to inform integration of the Kidney Score Platform within primary care settings so that it can serve as a central component of the National Kidney Foundation public awareness campaign to educate, engage, and empower individuals at risk for and living with chronic kidney disease. INTERNATIONAL REGISTERED REPORT PRR1-10.2196/22024

ImportanceDiabetic kidney disease (DKD) is the leading cause of kidney failure in the United States and predicting progression is necessary for improving outcomes.ObjectiveTo develop and validate a machine-learned, prognostic risk score (KidneyIntelX™) combining data from electronic health records (EHR) and circulating biomarkers to predict DKD progression.DesignObservational cohort studySettingTwo EHR linked biobanks: Mount Sinai BioMe Biobank and the Penn Medicine Biobank.ParticipantsPatients with prevalent DKD (G3a-G3b with all grades of albuminuria (A1-A3) and G1 & G2 with A2-A3 level albuminuria) and banked plasma.Main outcomes and measuresPlasma biomarkers soluble tumor necrosis factor 1/2 (sTNFR1, sTNFR2) and kidney injury molecule-1 (KIM-1) were measured at baseline. Patients were divided into derivation [60%] and validation sets [40%]. The composite primary end point, progressive decline in kidney function, including the following: rapid kidney function decline (RKFD) (estimated glomerular filtration rate (eGFR) decline of ≥5 ml/min/1.73m2/year), ≥40% sustained decline, or kidney failure within 5 years. A machine learning model (random forest) was trained and performance assessed using standard metrics.ResultsIn 1146 patients with DKD the median age was 63, 51% were female, median baseline eGFR was 54 ml/min/1.73 m2, urine albumin to creatinine ratio (uACR) was 61 mg/g, and follow-up was 4.3 years. 241 patients (21%) experienced progressive decline in kidney function. On 10-fold cross validation in the derivation set (n=686), the risk model had an area under the curve (AUC) of 0.77 (95% CI 0.74-0.79). In validation (n=460), the AUC was 0.77 (95% CI 0.76-0.79). By comparison, the AUC for an optimized clinical model was 0.62 (95% CI 0.61-0.63) in derivation and 0.61 (95% CI 0.60-0.63) in validation. Using cutoffs from derivation, KidneyIntelX stratified 46%, 37% and 16.5% of validation cohort into low-, intermediate- and high-risk groups, with a positive predictive value (PPV) of 62% (vs. PPV of 37% for the clinical model and 40% for KDIGO; p < 0.001) in the high-risk group and a negative predictive value (NPV) of 91% in the low-risk group. The net reclassification index for events into high-risk group was 41% (pConclusions and RelevanceA machine learned model combining plasma biomarkers and EHR data improved prediction of progressive decline in kidney function within 5 years over KDIGO and standard clinical models in patients with early DKD.

Background Kidney transplantation remains the optimal therapy for patients with end stage kidney disease (ESKD), though a small fraction of patients on dialysis are on organ waitlists. An important barrier to both preemptive kidney transplantation and successful waitlisting is timely referral to a kidney transplant center. We implemented a quality improvement strategy to improve outpatient kidney transplant referrals in a single center academic outpatient nephrology clinic. Methods Over a 3 month period (July 1–September 30, 2016), we assessed the baseline kidney transplantation referral rate at our outpatient nephrology clinic for patients 18–75 years old with an estimated glomerular filtration rate (eGFR) of less than 20 mL/min/1.73m2 (2 values over 90 days apart). Charts were manually reviewed by two reviewers to look for kidney transplant referrals and documentation of discussions about kidney transplantation. We then performed a root cause analysis to explore potential barriers to kidney transplantation. Our intervention began on July 1, 2017 and included the implementation of a column in the electronic medical record (EMR) which displayed the patient’s last eGFR as part of the clinic schedule. In addition, physicians were given a document listing their patients to be seen that day with an eGFR of 2. Annual education sessions were also held to discuss the importance of timely kidney transplant referral. Results At baseline, 54 unique patients with eGFR ≤20 ml/min/1.73 m2 were identified who were seen in the Clinic between July 1, 2016 and September 30, 2016. 29.6% (16) eligible patients were referred for kidney transplantation evaluation. 69.5% (37) of these patients were not referred for kidney transplant evaluation. 46.3% (25) did not have documentation regarding kidney transplant in the EMR. nephrologist’s most recent note. Following the intervention, 66 unique patients met criteria for eligibility for kidney transplant evaluation. Kidney transplant referrals increased to 60.6% (p Conclusions Our pilot implementation study of a strategy to improve outpatient kidney transplant referrals showed that a free, simple, scalable intervention can significantly improve kidney transplant referrals in the outpatient setting. This intervention targeted the nephrologist’s role in the transplant referral, and facilitated the process of patient recognition and performing the referral itself without significantly interrupting the workflow. Next steps include further investigation to study the impact of early referral to kidney transplant centers on preemptive and living donor kidney transplantation as well as successful waitlisting.

ImportancePreliminary reports indicate that acute kidney injury (AKI) is common in coronavirus disease (COVID)-19 patients and is associated with worse outcomes. AKI in hospitalized COVID-19 patients in the United States is not well-described.ObjectiveTo provide information about frequency, outcomes and recovery associated with AKI and dialysis in hospitalized COVID-19 patients.DesignObservational, retrospective study.SettingAdmitted to hospital between February 27 and April 15, 2020.ParticipantsPatients aged ≥18 years with laboratory confirmed COVID-19ExposuresAKI (peak serum creatinine increase of 0.3 mg/dL or 50% above baseline).Main Outcomes and MeasuresFrequency of AKI and dialysis requirement, AKI recovery, and adjusted odds ratios (aOR) with mortality. We also trained and tested a machine learning model for predicting dialysis requirement with independent validation.ResultsA total of 3,235 hospitalized patients were diagnosed with COVID-19. AKI occurred in 1406 (46%) patients overall and 280 (20%) with AKI required renal replacement therapy. The incidence of AKI (admission plus new cases) in patients admitted to the intensive care unit was 68% (553 of 815). In the entire cohort, the proportion with stages 1, 2, and 3 AKI were 35%, 20%, 45%, respectively. In those needing intensive care, the respective proportions were 20%, 17%, 63%, and 34% received acute renal replacement therapy. Independent predictors of severe AKI were chronic kidney disease, systolic blood pressure, and potassium at baseline. In-hospital mortality in patients with AKI was 41% overall and 52% in intensive care. The aOR for mortality associated with AKI was 9.6 (95% CI 7.4-12.3) overall and 20.9 (95% CI 11.7-37.3) in patients receiving intensive care. 56% of patients with AKI who were discharged alive recovered kidney function back to baseline. The area under the curve (AUC) for the machine learned predictive model using baseline features for dialysis requirement was 0.79 in a validation test.Conclusions and RelevanceAKI is common in patients hospitalized with COVID-19, associated with worse mortality, and the majority of patients that survive do not recover kidney function. A machine-learned model using admission features had good performance for dialysis prediction and could be used for resource allocation.Key PointsQuestionWhat is incidence and outcomes of acute kidney injury (AKI) in patients hospitalized with COVID-19?FindingsIn this observational study of 3,235 hospitalized patients with COVID-19 in New York City, AKI occurred in 46% of patients and 20% of those patients required dialysis. AKI was associated with increased mortality. 44% of patients discharged alive had residual acute kidney disease. A machine learned predictive model using baseline features for dialysis requirement had an AUC Of 0.79.MeaningAKI was common in patients with COVID-19, associated with increased mortality, and nearly half of patients had acute kidney disease on discharge.

Author(s): Harding, Kimberly; Mersha, Tesfaye B; Pham, Phuong-Thu; Waterman, Amy D; Webb, Fern A; Vassalotti, Joseph A; Nicholas, Susanne B | Abstract: BackgroundThe persistent challenges of bridging healthcare disparities for African Americans (AAs) in need of kidney transplantation continue to be unresolved at the national level. This healthcare disparity is multifactorial: stemming from limited kidney donors suitable for AAs; inconsistent care coordination and suboptimal risk factor control; social determinants, low socioeconomic status, reduced access to care; and mistrust of clinicians and the healthcare system.SummaryThere are numerous opportunities to significantly lessen the disparities in kidney transplantation for AAs through the following measures: the adoption of new care and patient engagement models that include education, enhanced practice-level cultural sensitivity, and timely referral as well as increased research on the impact of the environment on genetic risk, and implementation of new transplantation-related policies. Key Messages: This systematic review describes pretransplant concerns related to access to kidney transplantation, posttransplant complications, and policy interventions to address the challenging issues associated with kidney transplantation in AAs.

To execute a chronic kidney disease (CKD) intervention to assess feasibility and preliminary outcomes for a health plan.This CKD quality improvement study was incorporated into an existing CareFirst primary care patient-centered medical home cohort with a pre- and postintervention assessment from July 1, 2015, to June 30, 2017.The study targeted the population at risk for CKD with diabetes and/or hypertension by implementing a care plan according to the stratification by estimated glomerular filtration rate (eGFR) and urinary albumin-creatinine ratio (uACR) or CKD heat map class.The population included 7420 individuals (51.8% female) with a mean age of 55.9 years; 19.1% had diabetes only, 42.2% had hypertension only, and 38.2% had both conditions. Overall, there was no change in eGFR testing among risk groups (84.8%), but a small significant increase in uACR testing occurred (from 31.3% to 33.0%; P = .0020). Reductions in admissions per 1000 patients were from 362.5 to 249.0 for class 3, 311.7 to 219.2 for class 4, and 590.9 to 323.5 for class 5. Lastly, there were reductions in 30-day readmissions per 1000 patients, from 51.9 to 13.7 for class 4 and 45.5 to 0 for class 5. Although there were increases in many of the per-member per-month costs assessed pre- versus post intervention, net savings in medical costs were $276.80 and $480.79 for CKD classes 3 and 5, respectively.This scalable CKD intervention demonstrated feasibility. For advanced CKD, decreased hospitalization and a reduction in several important costs were observed. These preliminary results support the stratification of laboratory data for CKD population health innovation in commercial health plans.

BACKGROUND: Effective co-management of patients with chronic kidney disease (CKD) between primary care physicians (PCPs) and nephrologists is increasingly recognized as a key strategy to ensure the delivery of efficient and high-quality CKD care. However, the co-management of patients with CKD remains suboptimal. OBJECTIVE: We aimed to identify PCPs’ perceptions of key barriers and facilitators to effective co-management of patients with CKD at the PCP-nephrology interface. STUDY DESIGN: Qualitative study SETTING AND PARTICIPANTS: Community-based PCPs in four US cities: Baltimore, MD; St. Louis, MO; Raleigh, NC; and San Francisco, CA APPROACH: We conducted four focus groups of PCPs. Two members of the research team coded transcribed audio-recorded interviews and identified major themes. KEY RESULTS: Most of the 32 PCPs (59% internists and 41% family physicians) had been in practice for > 10 years (97%), spent ≥ 80% of their time in clinical care (94%), and practiced in private (69%) or multispecialty group practice (16%) settings. PCPs most commonly identified barriers to effective co-management of patients with CKD focused on difficulty developing working partnerships with nephrologists, including (1) lack of timely adequate information exchange (e.g., consult note not received or CKD care plan unclear); (2) unclear roles and responsibilities between PCPs and nephrologists; and (3) limited access to nephrologists (e.g., unable to obtain timely consultations or easily contact nephrologists with concerns). PCPs expressed a desire for “better communication tools” (e.g., shared electronic medical record) and clear CKD care plans to facilitate improved PCP-nephrology collaboration. CONCLUSIONS: Interventions facilitating timely adequate information exchange, clear delineation of roles and responsibilities between PCPs and nephrologists, and greater access to specialist advice may improve the co-management of patients with CKD.

This analysis assessed healthcare costs associated with progression of chronic kidney disease (CKD) in patients with type 2 diabetes (T2D). Adults (90 days later. Non-progression required an eGFR indicating same stage within 12 months and eGFR confirmation of same stage >12 months post-index. Per-patient per-month (PPPM) healthcare costs evaluated from index to the earliest of end of eligibility or data were compared between progressors and non-progressors by baseline CKD Stage, and adjusted costs were compared using multivariate linear regressions. Of the 204,767 patients selected, 4.8% progressed ≥1 CKD Stage within a year. Progressors were older (72.5 vs. 64.5 years), more likely to be female (55.6% vs. 51.2%) and had a higher Diabetes Complications Severity Index (2.12 vs. 1.17) compared to non-progressors. Healthcare costs PPPM for progressors vs. non-progressors were $2,685 vs. $1,659 for baseline normal eGFR, $3,131 vs. $2,003 for G3a, $5,138 vs. $2,396 for G3b and $14,400 vs. $3,475 for G4. Among patients with confirmed progression status, progressors represented 4.1%, 8.5%, 5.5% and 4.2% of those from normal eGFR, G3a, G3b and G4, respectively. Controlling for baseline characteristics, the adjusted incremental post-index healthcare costs associated with progressors were $674 for baseline normal eGFR, $947 for G3a, $2,625 for G3b, and $10,704 for G4. All comparisons tested at p Disclosure L. Blonde: Consultant; Self; Gilead Sciences, Inc., Janssen Pharmaceuticals, Inc., Merck & Co., Inc., Novo Nordisk Inc., Sanofi US. Research Support; Self; Janssen Pharmaceuticals, Inc., Lexicon Pharmaceuticals, Inc., Merck & Co., Inc., Novo Nordisk Inc., Sanofi US. Speaker's Bureau; Self; Janssen Pharmaceuticals, Inc., Novo Nordisk Inc., Sanofi US. J.A. Vassalotti: Advisory Panel; Self; Merck & Co., Inc. Consultant; Self; Janssen Pharmaceuticals, Inc., KPMG. D. Pilon: Other Relationship; Self; Janssen Scientific Affairs, LLC., Novartis Pharmaceuticals Corporation. W. Wynant: Consultant; Self; AbbVie Inc., Bristol-Myers Squibb Company, Daiichi Sankyo Company, Limited, Genentech, Inc., GlaxoSmithKline plc., Janssen Scientific Affairs, LLC., Novartis Pharmaceuticals Corporation, Novartis Pharmaceuticals Corporation, Taiho Pharmaceutical Co., Ltd. M. Zhdanava: Other Relationship; Self; Janssen Scientific Affairs, LLC., Novartis Pharmaceuticals Corporation. P. Lefebvre: Research Support; Self; Janssen Scientific Affairs, LLC. J. Voelker: Consultant; Self; Janssen Scientific Affairs, LLC. R. Bailey: Employee; Self; Janssen Scientific Affairs, LLC. Stock/Shareholder; Self; Johnson & Johnson. M. Durkin: Employee; Self; Janssen Scientific Affairs, LLC. Funding Janssen Scientific Affairs, LLC

CKD progression is introduced broadly, including definitions to distinguish related conditions (such as rapid CKD progression from AKI), common pathways for loss of kidney function, as well as validated ESRD prediction models to risk stratify patients and populations. Interventions to slow CKD progression are hypertension control in the context of current blood pressure target controversies, use of RAAS blockade for hypertension with albuminuria (A3) or proteinuria, glycemic control in diabetes, diabetic kidney disease therapy with a focus on recent and ongoing interventional trials and alkali therapy for CKD metabolic acidosis. Other less evidenced-based treatments (retrospective and observational trials, as well as secondary outcomes of RCT) to slow CKD progression are also discussed. These include the folic acid supplementation in the deficient population, SGLT-2 inhibitors for type-2 diabetes, intervention for obstructive sleep apnea, prevention of AKI, early nephrology referral and implementation of the multi-disciplinary approach to slowing CKD progression.