Integrated CKD Care Models Could Improve Early Detection and Outcomes

Key Takeaways

• Chronic kidney disease (CKD) affects approximately 10% of adults globally but remains substantially underdiagnosed and undertreated.
• Population health management strategies, including routine urine albumin-to-creatinine ratio (ACR) testing, risk stratification, and integrated primary-specialty care, may improve outcomes and reduce progression to kidney failure.
• Researchers argue that earlier identification and coordinated care are essential to reducing cardiovascular events, late-stage kidney disease, and health care costs.

CKD is projected to become 1 of the 5 leading noncommunicable causes of death worldwide by 2040, yet gaps in diagnosis and management continue to limit opportunities for early intervention.

In a narrative review examining population-based approaches to kidney care, investigators highlighted how integrated care models, risk stratification tools, and population health management programs may improve outcomes while reducing health care utilization and costs.

The review follows the World Health Assembly’s 2025 resolution recognizing kidney disease as a global health priority and calls attention to persistent shortcomings in CKD detection and treatment.

Early Detection Remains a Critical Opportunity

Although CKD affects an estimated 10% of adults, national data from England suggest that only about 4% of patients have a documented CKD diagnosis despite substantially higher estimated prevalence. The authors identified inadequate urine ACR testing as a major contributor to underdiagnosis.

Evidence from the multinational DEMAND study demonstrated that reliance on estimated glomerular filtration rate alone identified CKD in 22% of patients with type 2 diabetes. When albuminuria testing was incorporated, the proportion meeting diagnostic criteria increased to 58%.

The review noted that delayed CKD diagnosis has been associated with a 40% higher risk of disease progression, a 63% higher risk of kidney failure, and an 8% higher risk of major adverse cardiovascular events.

Population Health Management Offers a New Care Model

The authors advocate for population health management approaches that leverage electronic health records, risk prediction tools, and coordinated primary-specialty care.

Key elements include systematic identification of at-risk patients, routine albuminuria screening, use of the Kidney Failure Risk Equation for risk stratification, and targeted interventions for patients at greatest risk of progression.

The review also emphasized the growing importance of cardio-kidney-metabolic care models, which recognize the close relationship among kidney disease, diabetes, hypertension, and cardiovascular disease.

According to the authors, integrated care pathways can help address longstanding gaps in medication optimization, referral patterns, and cardiovascular risk management.

Implications for Managed Care

For managed care organizations, the findings underscore the value of proactive CKD identification and management programs.

The authors noted that most patients with CKD are more likely to experience cardiovascular complications than progress to end-stage kidney disease, making early intervention particularly important from both clinical and economic perspectives.

They also highlighted the potential role of quality incentives, population dashboards, and care coordination programs in improving adherence to evidence-based screening and treatment recommendations.

Looking Ahead

The authors conclude that effective CKD management requires stronger integration between primary care and nephrology services, supported by population health tools and systematic screening strategies.

As health systems increasingly shift toward value-based care, earlier detection and coordinated management of CKD may offer an important opportunity to improve patient outcomes while reducing long-term health care burden.

Reference

Jones P, O’Keeffe H, Major RW, et al. Implementing a model of integrated CKD management between primary and secondary care. Clin Kidney J. 2026;19(1):sfaf335. doi:10.1093/ckj/sfaf335