Implementing a model of integrated CKD management between primary and secondary care

TL;DR

This paper discusses improving chronic kidney disease management by integrating primary and secondary care through early detection and collaboration.

Contribution

The paper proposes system-wide integration and digital tools to enhance CKD care and outcomes.

Findings

Integrated care models improve medication optimization and reduce unnecessary referrals.

Early detection and urine albumin: creatinine ratio testing are critical for better CKD outcomes.

Collaboration between primary and secondary care is essential for effective CKD management.

Abstract

Chronic kidney disease (CKD) is a common condition and important cardiovascular risk factor. However, CKD remains underdiagnosed and evidence-based medicines underutilized. In most healthcare systems, most CKD is managed in primary care. Optimal management in this setting can only be achieved with integration of care including early identification, prioritization, and use of the tools and skill mix available. This narrative review focuses on the importance of screening and identification in primary care, looking at innovative solutions and methods from other long-term conditions, particularly cardio–renal–metabolic conditions. Integrated care virtual multidisciplinary reviews, have demonstrated clinical and economic benefits, improved medication optimization, and reduced unnecessary referrals. However, implementation remains inconsistent, and prescribing of both established and novel therapies remains sub-optimal. Optimizing CKD care requires a system-wide approach that reinforces primary–secondary care collaboration, prioritizes early detection, and facilitates timely, evidence-based interventions. The inclusion of urine albumin: creatinine ratio testing, integrated digital tools, and shared accountability frameworks must be urgently adopted to realize improved outcomes and reduce the burden of CKD on individuals and healthcare systems alike.

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