Effects of proactive population-based nephrologist oversight on progression of chronic kidney disease: a retrospective control analysis

Electronic Health Record Population Health Management for Chronic Kidney Disease Care: A Cluster Randomized Clinical Trial

Importance

Large gaps in clinical care in patients with chronic kidney disease (CKD) lead to poor outcomes.

Objective

To compare the effectiveness of an electronic health record-based population health management intervention vs usual care for reducing CKD progression and improving evidence-based care in high-risk CKD.

Design, Setting, and Participants

The Kidney Coordinated Health Management Partnership (Kidney CHAMP) was a pragmatic cluster randomized clinical trial conducted between May 2019 and July 2022 in 101 primary care practices in Western Pennsylvania. It included patients aged 18 to 85 years with an estimated glomerular filtration rate (eGFR) of less than 60 mL/min/1.73m2 with high risk of CKD progression and no outpatient nephrology encounter within the previous 12 months.

Interventions

Multifaceted intervention for CKD comanagement with primary care clinicians included a nephrology electronic consultation, pharmacist-led medication management, and CKD education for patients. The usual care group received CKD care from primary care clinicians as usual.

Main Outcomes and Measures

The primary outcome was time to 40% or greater reduction in eGFR or end-stage kidney disease.

Results

Among 1596 patients (754 intervention [47.2%]; 842 control [52.8%]) with a mean (SD) age of 74 (9) years, 928 (58%) were female, 127 (8%) were Black, 9 (0.6%) were Hispanic, and the mean (SD) estimated glomerular filtration rate was 36.8 (7.9) mL/min/1.73m2. Over a median follow-up of 17.0 months, there was no significant difference in rate of primary outcome between the 2 arms (adjusted hazard ratio, 0.96; 95% CI, 0.67-1.38; P = .82). Angiotensin-converting enzyme inhibitor/angiotensin receptor blocker exposure was more frequent in intervention arm compared with the control group (rate ratio, 1.21; 95% CI, 1.02-1.43). There was no difference in the secondary outcomes of hypertension control and exposure to unsafe medications or adverse events between the arms. Several COVID-19-related issues contributed to null findings in the study.

Conclusion and Relevance

In this study, among patients with moderate-risk to high-risk CKD, a multifaceted electronic health record-based population health management intervention resulted in more exposure days to angiotensin-converting enzyme inhibitors/angiotensin receptor blockers but did not reduce risk of CKD progression or hypertension control vs usual care.

Trial Registration

ClinicalTrials.gov Identifier: NCT03832595.

Minimisation of dialysis risk in hospital patients with chronic kidney disease (MinDial): study protocol for a multicentre, stepped-wedge, cluster-randomised controlled trial

BACKGROUND

Early identification of patients with chronic kidney disease (CKD) and advancing kidney insufficiency, followed by specialist care, can decelerate the progression of the disease. However, awareness of the importance and possible consequences of kidney insufficiency is low among doctors and patients. Since kidney insufficiency can be asymptomatic even in higher stages, it is often not even known to those belonging to risk groups. This study aims to clarify whether, for hospitalised patients with advanced chronic kidney disease, a risk-based appointment with a nephrology specialist reduces disease progression.

METHODS

The target population of the study is hospitalised CKD patients with an increased risk of end-stage renal disease (ESRD), more specifically with an ESRD risk of at least 9% in the next 5 years. This risk is estimated by the internationally validated Kidney Failure Risk Equation (KFRE). The intervention consists of a specific appointment with a nephrology specialist after the hospital stay, while control patients are discharged from the hospital as usual. Eight medical centres include participants according to a stepped-wedge design, with randomised sequential centre-wise crossover from recruiting patients into the control group to recruitment to the intervention. The estimated glomerular filtration rate (eGFR) is measured for each patient during the hospital stay and after 12 months within the regular care by the general practitioner. The difference in the change of the eGFR over this period is compared between the intervention and control groups and considered the primary endpoint.

DISCUSSION

This study is designed to evaluate the effect of risk-based appointments with nephrology specialists for hospitalised CKD patients with an increased risk of end-stage renal disease. If the intervention is proven to be beneficial, it may be implemented in routine care. Limitations will be examined and discussed. The evaluation will include further endpoints such as non-guideline-compliant medication, economic considerations and interviews with contributing physicians to assess the acceptance and feasibility of the intervention.

TRIAL REGISTRATION

German Clinical Trials Register DRKS00029691 . Registered on 12 September 2022.

Primary care clinician perspectives on automated nephrology e-consults for diabetic kidney disease: a pre-implementation qualitative study

BACKGROUND

Many patients with diabetic kidney disease (DKD) do not receive evidence-based, guideline-recommended treatment shown to reduce DKD progression and complications. Proactive electronic consultations (e-consults) are an emerging intervention strategy that could potentially allow nephrologists to provide timely and evidence-based guidance to primary care providers (PCPs) engaged in early DKD care.

METHODS

The objective of this study was to explore perspectives about potential barriers and facilitators associated with a proactive e-consult program to improve DKD care delivery. We conducted semi-structured qualitative interviews with PCPs across three different health systems. Interview transcripts were reviewed in a rapid qualitative analysis approach to iteratively identify, refine, and achieve consensus on a final list of themes and subthemes.

RESULTS

A total of 18 interviews were conducted. PCPs across all sites identified similar challenges to delivering guideline-recommended DKD care. PCPs were supportive of the proactive e-consult concept. Three major themes emerged surrounding (1) perceived potential benefits of proactive e-consults, including educational value and improved specialist access; (2) concerns about the proactive nature of e-consults, including the potential to increase PCP workload and the possibility that e-consults could be seen as documenting substandard care; and (3) leveraging of care teams to facilitate recommended DKD care, such as engaging clinic-based pharmacists to implement specialist recommendations from e-consults.

CONCLUSION

In this pre-implementation qualitative study, PCPs noted potential benefits and identified concerns and implementation barriers for proactive e-consults for DKD care. Strategies that emerged for promoting successful implementation included involving clinic support staff to enact e-consult recommendations and framing e-consults as a system improvement effort to avoid judgmental associations.

Electronic health record based population health management to optimize care in CKD: Design of the Kidney Coordinated HeAlth Management Partnership (K-CHAMP) trial

Primary care physicians (PCPs) provide the majority of medical care to patients with non-dialysis dependent CKD. However, PCPs report numerous limitations to providing expert CKD care, including poor patient education, inadequate diagnostic evaluation, suboptimal use of medications, and time limitations. The Kidney Coordinated HeAlth Management Partnership (Kidney CHAMP) trial is a cluster randomized controlled trial to evaluate the effectiveness of a novel centralized electronic health records (EHR)-delivered population health management (PHM) strategy for high-risk CKD patients on patient care, safety, and other outcomes of interest to patients, providers, and payors. Over a 42-month period, the trial will compare the effectiveness of a multifaceted intervention that combines early identification of high-risk patients, timely nephrology guidance, pharmacist-led medication management services, and CKD patient education to usual care and enroll 1650 high-risk CKD patients from 100 primary care practices. The primary outcome will be ≥40% decline in estimated glomerular filtration rate (eGFR) or end stage kidney disease. Key secondary outcomes will include blood pressure, renin-angiotensin aldosterone system inhibitors use, and exposure to potentially unsafe medications. If successful, our treatment approach could improve CKD care delivery and safety, resource allocation, and adoption of evidence-based CKD guideline-concordant care.

Systematic CKD Care Approaches: A Potential Solution for the Costly ESRD Program

Care of patients with advanced kidney disease includes dialysis, kidney transplant, vascular access, primary care, and other specialist care, which are often siloed among multiple physicians, dialysis clinics, vascular access centers, and health system or hospital-based transplant programs. Other than the patient themselves, no one provider has holistic patient visibility or responsibility. Given that hospitals often lose money on Medicare patients who require dialysis services, momentum from innovation in advanced kidney care management, new technology with the potential for reduced costs, expansion of Medicare Advantage, and Medicare incentives for home dialysis could be leveraged by health systems to ultimately reduce the nearly $50 billion annual Federal spending on patients with kidney failure in the United States. Health systems, which offer many primary and specialty care services, may be uniquely positioned to leverage the more favorable economics associated with these changes to move kidney care from siloed, provider-centric care to integrated, patient-centric care. With 60% of patients initiating dialysis through an unplanned hospitalization, a holistic health system approach that includes offerings of kidney care management and kidney replacement therapy could move financial incentives away from the interests of any single provider and toward better addressing the total needs and the goals of the patient.

Screening for chronic kidney disease in a hypertensive primary care cohort

BACKGROUND

Screening rates for chronic kidney disease (CKD) in primary care settings remain low. Although primary care providers are well positioned to offer this testing, there are many barriers that contribute to low screening rates.

PURPOSE

The purpose of this study was to examine both practice and contextual factors that relate to screening for CKD in a cohort of primary care patients with hypertension.

METHODS

A mixed-methods, single-embedded, convergent parallel design was used for this organizational case study. The Chronic Care Model served as the framework. Electronic medical record data, resource walk-through, and provider surveys were collected from selected primary care clinics within one large academic medical center in the Pacific Northwest. Analyses included regression models, descriptive statistics, narrative content analysis, and pattern matching for organizational case creation.

RESULTS

Screening rates were low in the cohort, but patients with more risk factors for CKD were more likely to receive orders for screening. Organizational and community support was deemed necessary for primary care providers to effectively translate guidelines into practice.

IMPLICATIONS FOR PRACTICE

The results of this study offer support for a wholistic approach to guideline translation into practice. Participants in the study were open to increased screening for CKD but needed support in multiple ways from the organization. Guidelines alone were not deemed the ideal vehicles for translation of research into practice.

Developing quality indicators for Chronic Kidney Disease in primary care, extractable from the Electronic Medical Record. A Rand-modified Delphi method

BACKGROUND

Chronic kidney disease (CKD) is a common chronic condition and a rising public health issue with increased morbidity and mortality, even at an early stage. Primary care has a pivotal role in the early detection and in the integrated management of CKD which should be of high quality. The quality of care for CKD can be assessed using quality indicators (QIs) and if these QIs are extractable from the electronic medical record (EMR) of the general physician, the number of patients whose quality of care can be evaluated, could increase vastly. Therefore the aim of this study is to develop QIs which are evidence based, EMR extractable and which can be used as a framework to automate quality assessment.

METHODS

We used a Rand-modified Delphi method to develop QIs for CKD in primary care. A questionnaire was designed by extracting recommendations from international guidelines based on the SMART principle and the EMR extractability. A multidisciplinary expert panel, including patients, individually scored the recommendations for measuring high quality care on a 9-point Likert scale. The results were analyzed based on the median Likert score, prioritization and agreement. Subsequently, the recommendations were discussed in a consensus meeting for their in- or exclusion. After a final appraisal by the panel members this resulted in a core set of recommendations, which were then transformed into QIs.

RESULTS

A questionnaire composed of 99 recommendations was extracted from 10 international guidelines. The consensus meeting resulted in a core set of 36 recommendations that were translated into 36 QIs. This final set consists of QIs concerning definition & classification, screening, diagnosis, management consisting of follow up, treatment & vaccination, medication & patient safety and referral to a specialist. It were mostly the patients participating in the panel who stressed the importance of the QIs concerning medication & patient safety and a timely referral to a specialist.

CONCLUSION

This study provides a set of 36 EMR extractable QIs for measuring the quality of primary care for CKD. These QIs can be used as a framework to automate quality assessment for CKD in primary care.

Diagnosis Patterns of CKD and Anemia in the Japanese Population

INTRODUCTION

Although early intervention for chronic kidney disease (CKD) and renal anemia are desirable, these conditions are often asymptomatic during their early stages and may be underdiagnosed.

METHODS

We retrospectively analyzed Japanese administrative claims data for general and hospital populations. The data period for the general and hospital data ranged from January 2011 to December 2016 and from April 2008 to July 2017, respectively. CKD stage was determined by estimated glomerular filtration rate (eGFR). Anemia was defined per Japanese guidelines using hemoglobin (Hb) values. The proportion of patients who had eGFR-defined stages G3-G5 CKD without a CKD diagnosis, and Hb-defined anemia without an anemia diagnosis or treatment records, was estimated.

RESULTS

Among 16,779 (general) and 68,161 (hospital) patients, a high proportion of G3 CKD patients did not have a CKD-related diagnosis (general: G3a, 95.0%; G3b, 68.4%; hospital: G3a, 89.2%; G3b, 67.9%); however, some patients were treated with antihypertensives. Among anemic patients, 75.7% (G3a) and 66.7% (G3b) of the general population, and 56.2% (G3a) and 47.5% (G3b) of the hospital population, did not have an anemia-related diagnosis or treatment. CKD and anemia were more likely to be diagnosed in patients with G4 and G5 CKD.

CONCLUSION

A high proportion of G3 CKD patients did not have a CKD-related diagnosis. Likewise, many anemic patients with G3 CKD did not have an anemia-related diagnosis. Despite the lack of a CKD-related diagnosis, some patients received appropriate treatment (e.g., antihypertensives). Further outreach to CKD and anemia patients at earlier stages may be warranted.

Health Care Utilization Among Adults With CKD and Psychological Distress

Rationale & Objective

Despite extensive research on health care access for individuals with chronic kidney disease (CKD), there is little research on the relationship between health care access barriers and psychological distress.

Study Design

An observational study based on the publicly available 2013 to 2017 US National Health Interview Survey data.

Setting & Participants

3,923 respondents 18 years or older who self-reported a diagnosis of CKD in the preceding 12 months.

Predictor(s) and Outcome(s)

Psychological distress was measured using the Kessler Psychological Distress Scale (K6). Barriers to health care access included lack of health insurance coverage, lack of a usual source of health care, and financial barriers to accessing/obtaining health care, including medical specialist services, prescription drugs, mental health counseling, and dental care.

Analytical Approach

Multinomial logistic regression with 3 levels of K6 scores (no distress, mild to moderate distress, and serious distress) as the dependent variable.

Results

15% of respondents reported mild to moderate and 11% reported serious psychological distress. Compared with those with no distress, those with mild to moderate and serious distress were younger but less likely to have worked in the preceding year, had more chronic medical conditions, and visited an emergency department more frequently. Multivariable regression models show that each financial barrier to health care access (likely due to lack of health insurance) was significantly associated with mild to moderate and serious distress.

Limitations

CKD diagnosis was self-reported and CKD stage was unknown. Because this is a cross-sectional study, associations cannot be assumed to imply causal relationships.

Conclusions

Access to sick and preventive/routine care should be improved. People with CKD should be assessed for psychological distress, treated as needed, and offered case management and social services to help them navigate the health care system and alleviate personal stressors.

Barriers to Achieving Economies of Scale in Analysis of EHR Data. A Cautionary Tale

Signed in 2009, the Health Information Technology for Economic and Clinical Health Act infused $28 billion of federal funds to accelerate adoption of electronic health records (EHRs). Yet, EHRs have produced mixed results and have even raised concern that the current technology ecosystem stifles innovation. We describe the development process and report initial outcomes of a chronic kidney disease analytics application that identifies high-risk patients for nephrology referral. The cost to validate and integrate the analytics application into clinical workflow was $217,138. Despite the success of the program, redundant development and validation efforts will require $38.8 million to scale the application across all multihospital systems in the nation. We address the shortcomings of current technology investments and distill insights from the technology industry. To yield a return on technology investments, we propose policy changes that address the underlying issues now being imposed on the system by an ineffective technology business model.

Risk-Based Triage for Nephrology Referrals Using the Kidney Failure Risk Equation

BACKGROUND

In some jurisdictions, routine reporting of the estimated glomerular filtration rate (eGFR) has led to an increase in nephrology referrals and wait times.

OBJECTIVE

We describe the use of the Kidney Failure Risk Equation (KFRE) as part of a triage process for new nephrology referrals for patients with chronic kidney disease stages 3 to 5 in a Canadian province.

DESIGN

A quasi-experimental study design was used.

SETTING

This study took place in Manitoba, Canada.

MEASUREMENTS

Demographics, laboratory values, referral numbers, and wait times were compared between periods.

METHODS

In 2012, we adopted a risk-based cutoff of 3% over 5 years using the KFRE as a threshold for triage of new referrals. Referrals who did not meet other prespecified criteria (such as pregnancy, suspected glomerulonephritis, etc) and had a kidney failure risk of <3% over 5 years were returned to primary care with recommendations based on diabetes and hypertension guidelines. The average wait time and number of consults seen between the pretriage (January 1, 2011, to December 31, 2011) and posttriage period (January 1, 2013, to December 31, 2013) were compared using a general linear model.

RESULTS

In the pretriage period, the median number of referrals was 68/month (range: 44-76); this increased to 94/month (range: 61-147) in the posttriage period. In the posttriage period, 35% of referrals were booked as urgent, 31% as nonurgent, and 34% of referrals were not booked. The median wait times improved from 230 days (range: 126-355) in the pretriage period to 58 days (range: 48-69) in the posttriage period.

LIMITATIONS

We do not have long-term follow-up on patients triaged as low risk. Our study may not be applicable to nephrology teams operating under capacity without wait lists. We did not collect detailed information on all referrals in the pretriage period, so any differences in our pretriage and posttriage patient groups may be unaccounted for.

CONCLUSIONS

Our risk-based triage scheme is an effective health policy tool that led to improved wait times and access to care for patients at highest risk of progression to kidney failure.

User Requirements for a Chronic Kidney Disease Clinical Decision Support Tool to Promote Timely Referral

BACKGROUND

Timely referral of patients with CKD has been associated with cost and mortality benefits, but referrals are often done too late in the course of the disease. Clinical decision support (CDS) offers a potential solution, but interventions have failed because they were not designed to support the physician workflow. We sought to identify user requirements for a chronic kidney disease (CKD) CDS system to promote timely referral.

METHODS

We interviewed primary care physicians (PCPs) to identify data needs for a CKD CDS system that would encourage timely referral and also gathered information about workflow to assess risk factors for progression of CKD. Interviewees were general internists recruited from a network of 14 primary care clinics affiliated with Brigham and Women's Hospital (BWH). We then performed a qualitative analysis to identify user requirements and system attributes for a CKD CDS system.

RESULTS

Of the 12 participants, 25% were women, the mean age was 53 (range 37-82), mean years in clinical practice was 27 (range 11-58). We identified 21 user requirements. Seven of these user requirements were related to support for the referral process workflow, including access to pertinent information and support for longitudinal co-management. Six user requirements were relevant to PCP management of CKD, including management of risk factors for progression, interpretation of biomarkers of CKD severity, and diagnosis of the cause of CKD. Finally, eight user requirements addressed user-centered design of CDS, including the need for actionable information, links to guidelines and reference materials, and visualization of trends.

CONCLUSION

These 21 user requirements can be used to design an intuitive and usable CDS system with the attributes necessary to promote timely referral.

Insights from Screening a Racially and Ethnically Diverse Population for Chronic Kidney Disease

BACKGROUND

The value of chronic kidney disease (CKD) screening in the general population remains unclear but may be beneficial in populations with high disease prevalence. We examined risk factors for albuminuria among participants in a state-wide CKD screening program in Hawaii.

METHODS

The National Kidney Foundation of Hawaii Kidney Early Detection Screening (NKFH-KEDS) program held 19 CKD screening events from 2006 to 2012. Participants rotated through 5 stations during which sociodemographic, blood glucose, urine albumin-to-creatinine ratio (ACR), and spot urine albumin data were collected. Multivariate logistic regression analyses (adjusted for age, sex, race/ethnicity, body mass index [BMI]) were used to identify clinical predictors of abnormal ACR (≥30 μg/mg) and abnormal spot urine albumin (>20 mg/L) levels.

RESULTS

Among 1,190 NKFH-KEDS participants who met eligibility criteria, 13 and 49% had abnormal ACR and urine albumin levels, respectively. In multivariate logistic regression analyses, participants of older age (>65 years), Asian and Pacific Islander race/ethnicity, BMI ≥30 kg/m2, and with hypertension had higher risk of abnormal ACR. Being of older age; Asian, Pacific Islander, and Mixed race/ethnicity; and having diabetes was associated with higher risk of abnormal urine albumin levels in adjusted analyses.

CONCLUSIONS

NKFH-KEDS participants of older age; Asian and Pacific Islander race/ethnicity; and with obesity, hypertension, and diabetes had higher risk of kidney damage defined by elevated ACR and urine albumin levels. Further studies are needed to determine whether targeted screening programs can result in timely identification of CKD and implementation of interventions that reduce cardiovascular disease, death, and progression to end-stage renal disease.

Nephrology co-management versus primary care solo management for early chronic kidney disease: a retrospective cross-sectional analysis

Background

Primary care physicians (PCPs) typically manage early chronic kidney disease (CKD), but recent guidelines recommend nephrology co-management for some patients with stage 3 CKD and all patients with stage 4 CKD. We sought to compare quality of care for co-managed patients to solo managed patients.

Methods

We conducted a retrospective cross-sectional analysis. Patients included in the study were adults who visited a PCP during 2009 with laboratory evidence of CKD in the preceding two years, defined as two estimated glomerular filtration rates (eGFR) between 15–59 mL/min/1.73 m² separated by 90 days. We assessed process measures (serum eGFR test, urine protein/albumin test, angiotensin converting enzyme inhibitor or angiotensin receptor blocker [ACE/ARB] prescription, and several tests monitoring for complications) and intermediate clinical outcomes (mean blood pressure and blood pressure control) and performed subgroup analyses by CKD stage.

Results

Of 3118 patients, 11 % were co-managed by a nephrologist. Co-management was associated with younger age (69 vs. 74 years), male gender (46 % vs. 34 %), minority race/ethnicity (black 32 % vs. 22 %; Hispanic 13 % vs. 8 %), hypertension (75 % vs. 66 %), diabetes (42 % vs. 26 %), and more PCP visits (5.0 vs. 3.9; p < 0.001 for all comparisons). After adjustment, co-management was associated with serum eGFR test (98 % vs. 94 %, p = <0.0001), urine protein/albumin test (82 % vs 36 %, p < 0.0001), and ACE/ARB prescription (77 % vs. 69 %, p = 0.03). Co-management was associated with monitoring for anemia and metabolic bone disease, but was not associated with lipid monitoring, differences in mean blood pressure (133/69 mmHg vs. 131/70 mmHg, p > 0.50) or blood pressure control. A subgroup analysis of Stage 4 CKD patients did not show a significant association between co-management and ACE/ARB prescription (80 % vs. 73 %, p = 0.26).

Conclusion

For stage 3 and 4 CKD patients, nephrology co-management was associated with increased stage-appropriate monitoring and ACE/ARB prescribing, but not improved blood pressure control.

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. The diagnostic tests that are currently used for CKD exhibit key limitations; therefore, additional research is required to increase awareness of the risk factors for CKD progression. Systems modelling can be used to evaluate the impact of different care models on CKD outcomes and costs. The US Indian Health Service has demonstrated that an integrated, system-wide approach can produce notable benefits on cardiovascular and renal health outcomes. Economic and clinical improvements might, therefore, be possible if CKD is reconceptualized as a part of primary care. This Review discusses which early CKD interventions are appropriate, the optimum time to provide clinical care, and the most suitable model of care to adopt.

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. Although incidence rates for ESRD attributable to DKD have recently stabilized, these rates continue to rise in high-risk groups such as middle-aged African Americans, Native Americans, and Hispanics. The costs of care for people with DKD are extraordinarily high. In the Medicare population alone, DKD-related expenditures among this mostly older group were nearly $25 billion in 2011. Due to the high human and societal costs, the Consensus Conference on Chronic Kidney Disease and Diabetes was convened by the American Diabetes Association in collaboration with the American Society of Nephrology and the National Kidney Foundation to appraise issues regarding patient management, highlighting current practices and new directions. Major topic areas in DKD included 1) identification and monitoring, 2) cardiovascular disease and management of dyslipidemia, 3) hypertension and use of renin-angiotensin-aldosterone system blockade and mineralocorticoid receptor blockade, 4) glycemia measurement, hypoglycemia, and drug therapies, 5) nutrition and general care in advanced-stage chronic kidney disease, 6) children and adolescents, and 7) multidisciplinary approaches and medical home models for health care delivery. This current state summary and research recommendations are designed to guide advances in care and the generation of new knowledge that will meaningfully improve life for people with DKD.