Overcoming barriers to implementing new guideline-directed therapies for chronic kidney disease.

For the first time in many years, guideline-directed drug therapies have emerged that offer substantial cardiorenal benefits, improved quality of life and longevity in patients with chronic kidney disease (CKD) and type 2 diabetes. These treatment options include sodium-glucose cotransporter-2 inhibitors, nonsteroidal mineralocorticoid receptor antagonists and glucagon-like peptide-1 receptor agonists. However, despite compelling evidence from multiple clinical trials, their uptake has been slow in routine clinical practice, reminiscent of the historical evolution of angiotensin-converting enzyme inhibitor and angiotensin II receptor blocker use.

Racial and Socioeconomic Disparities in CKD in the Context of Universal Health Care Provided by the Military Health System.

Rationale & Objective: Health-impeding social determinants of health-including reduced access to care-contribute to racial and socioeconomic disparities in chronic kidney disease (CKD). The Military Health System (MHS) provides an opportunity to assess a large, diverse population for CKD disparities in the context of universal health care.

Study Design: Cross-sectional study.

CKD Prevalence in the Military Health System: Coded Versus Uncoded CKD.

Rationale & Objective: Chronic kidney disease (CKD) is common but often goes unrecorded.

Study Design: Cross-sectional.

Setting & Participants: Military Health System (MHS) beneficiaries aged 18 to 64 years who received care during fiscal years 2016 to 2018.

Development and Validation of a Pragmatic Electronic Phenotype for CKD.

Background And Objectives: Poor identification of individuals with CKD is a major barrier to research and appropriate clinical management of the disease. We aimed to develop and validate a pragmatic electronic (e-) phenotype to identify patients likely to have CKD.

Design, Setting, Participants, & Measurements: The e-phenotype was developed by an expert working group and implemented among adults receiving in- or outpatient care at five healthcare organizations.

Need for a Judicious Use of Nonsteroidal Anti-inflammatory Drugs to Avoid Community-Acquired Acute Kidney Injury.

Millions of Americans use over-the-counter analgesics on a daily basis, and nearly 100 million nonsteroidal anti-inflammatory drug (NSAID) prescriptions are filled per year. In high-risk patients, these medications can disrupt kidney hemodynamics and precipitate community-acquired acute kidney injury (CA-AKI). The risk of NSAID-associated CA-AKI increases 3- to 5-fold in patients taking renin-angiotensin system inhibitors and diuretics concurrently.

Personalizing Longitudinal Care Coordination for Patients with Chronic Kidney Disease.

Chronic care coordination efforts often focus on the needs of the healthcare team and not on the individual needs of each patient. However, developing a personalized care plan for patients with Chronic Kidney Disease (CKD) requires individual patient engagement with the health care team. We describe the development of a CKD e-care plan that focuses on patient specific needs and life goals, and can be personalized according to provider needs.

Population Health for CKD and Diabetes: Lessons From the Indian Health Service.

Despite extensive clinical guidelines, innovative efforts to improve care, and well-funded efforts to raise awareness, limited progress has been made in reducing the burden of kidney disease in the United States, and the prevalence continues to increase worldwide. The Indian Health Service and the Centers for Disease Control and Prevention recently reported a 54% decrease in the incidence of kidney failure among American Indian and Alaska Native people with diabetes. This decrease in end-stage renal disease incidence was associated with a population health approach to diabetes care based in the community and the primary clinical setting.

Standardization of Urine Albumin Measurements: Status and Performance Goals.

Background: Urine albumin is a key laboratory test used for classification, assessment of risk, and monitoring treatment of patients with chronic kidney disease. Urine albumin measurement results are not standardized among different measurement procedures. Consequently, clinical guidelines using fixed decision values for urine albumin cannot be applied consistently.

Managing CKD by Telemedicine: The Zuni Telenephrology Clinic.

Telemedicine has significant potential to extend nephrology consultation to rural and isolated communities. We describe a telenephrology clinic that has delivered ongoing consultative care from a nephrologist based at the National Institutes of Health in Bethesda, MD, to the Zuni Comprehensive Health Center in western New Mexico. Over the past 9 years, the clinic has conducted 1870 patient visits managing patients using a collaborative approach engaging a nurse case manager, nephrologist, primary clinicians, pharmacists, and community health nurses.

CE: Improving Outcomes for Patients with Chronic Kidney Disease: Part 2.

: Coping with chronic kidney disease (CKD) is challenging for many people, since symptoms often don't appear until the disease is advanced and the patient is close to requiring dialysis. This two-part article aims to provide nurses with the basic information necessary to assess and manage patients with CKD. Part 1, which appeared last month, offered an overview of the disease, described identification and etiology, and discussed ways to slow disease progression.

CE: Improving Outcomes for Patients with Chronic Kidney Disease: Part 1.

: The burden of chronic kidney disease (CKD) is rising both in this country and worldwide. An estimated 10% to 15% of U.S.

Vital Signs: Decrease in Incidence of Diabetes-Related End-Stage Renal Disease among American Indians/Alaska Natives - United States, 1996-2013.

Background: American Indians and Alaska Natives (AI/AN) have the highest diabetes prevalence among any racial/ethnic group in the United States. Among AI/AN, diabetes accounts for 69% of new cases of end-stage renal disease (ESRD), defined as kidney failure treated with dialysis or transplantation. During 1982-1996, diabetes-related ESRD (ESRD-D) in AI/AN increased substantially and disproportionately compared with other racial/ethnic groups.

Social Determinants of Racial Disparities in CKD.

Significant disparities in CKD rates and outcomes exist between black and white Americans. Health disparities are defined as health differences that adversely affect disadvantaged populations, on the basis of one or more health outcomes. CKD is the complex result of genetic and environmental factors, reflecting the balance of nature and nurture.

Educating Patients about CKD: The Path to Self-Management and Patient-Centered Care.

Patient education is associated with better patient outcomes and supported by international guidelines and organizations, but a range of barriers prevent widespread implementation of comprehensive education for people with progressive kidney disease, especially in the United States. Among United States patients, obstacles to education include the complex nature of kidney disease information, low baseline awareness, limited health literacy and numeracy, limited availability of CKD information, and lack of readiness to learn. For providers, lack of time and clinical confidence combine with competing education priorities and confusion about diagnosing CKD to limit educational efforts.

Association of Erythropoietin Dose and Route of Administration with Clinical Outcomes for Patients on Hemodialysis in the United States.

Background And Objectives: Recombinant human erythropoietin (epoetin) is used routinely to increase blood hemoglobin levels in patients with ESRD and anemia. Although lower doses of epoetin are required to achieve equivalent hemoglobin responses when administered subcutaneously rather than intravenously, standard practice has been to administer epoetin to patients on hemodialysis intravenously. Randomized trials of alternative epoetin treatment regimens in patients with kidney failure have shown that risks of cardiovascular complications and death are related to the dose levels of epoetin used.

Laboratory Assessment of Diabetic Kidney Disease.

IN BRIEF Regardless of etiology, chronic kidney disease (CKD) is identified by two laboratory tests: 1) estimated glomerular filtration rate (eGFR), a measure of kidney function, and 2) urine albumin-to-creatinine ratio (UACR), a measure of kidney damage. It is crucial for all health professionals to understand the significance and limitations of these tests to appropriately identify CKD patients, guide therapy, and determine prognosis. This article provides information that will enable diabetes educators and other clinicians to properly interpret eGFR and UACR laboratory results in the identification and management of CKD.

CKD as a Model for Improving Chronic Disease Care through Electronic Health Records.

Electronic health records have the potential to improve the care of patients with chronic medical conditions. CKD provides a unique opportunity to show this potential: the disease is common in the United States, there is significant room to improve CKD detection and management, CKD and its related conditions are defined primarily by objective laboratory data, CKD care requires collaboration by a diverse team of health care professionals, and improved access to CKD-related data would enable identification of a group of patients at high risk for multiple adverse outcomes. However, to realize the potential for improvement in CKD-related care, electronic health records will need to provide optimal functionality for providers and patients and interoperability across multiple health care settings.

Early chronic kidney disease: diagnosis, management and models of care.

Chronic kidney disease (CKD) is prevalent in many countries, and the costs associated with the care of patients with end-stage renal disease (ESRD) are estimated to exceed US$1 trillion globally. The clinical and economic rationale for the design of timely and appropriate health system responses to limit the progression of CKD to ESRD is clear. Clinical care might improve if early-stage CKD with risk of progression to ESRD is differentiated from early-stage CKD that is unlikely to advance.

Diabetic kidney disease: a report from an ADA Consensus Conference.

The incidence and prevalence of diabetes mellitus have grown significantly throughout the world, due primarily to the increase in type 2 diabetes. This overall increase in the number of people with diabetes has had a major impact on development of diabetic kidney disease (DKD), one of the most frequent complications of both types of diabetes. DKD is the leading cause of end-stage renal disease (ESRD), accounting for approximately 50% of cases in the developed world.

Diabetic kidney disease: a report from an ADA Consensus Conference.

The incidence and prevalence of diabetes mellitus have grown significantly throughout the world, due primarily to the increase in type 2 diabetes. This overall increase in the number of people with diabetes has had a major impact on development of diabetic kidney disease (DKD), one of the most frequent complications of both types of diabetes. DKD is the leading cause of end-stage renal disease (ESRD), accounting for approximately 50% of cases in the developed world.

The last mile: translational research to improve CKD outcomes.

The National Institute of Diabetes and Digestive and Kidney Diseases-supported Kidney Research National Dialogue asked the scientific community to formulate and prioritize research objectives that would enhance understanding of kidney function and disease and improve clinical outcomes. An engaged and growing group of investigators working in type 2 translation (from clinical evidence to implementation in the community) identified barriers to improving patient care in CKD and suggested research priorities to test translational strategies that have been effective for other chronic diseases.