ArticleThe Permanente journal2026
Proactive Engagement of Patients With Advanced Chronic Kidney Disease to Reduce Clinical Complications: The Kaiser Permanente Northern California Experience.
Article in The Permanente journal, 2026. The graph could read no effect estimate from its abstract, so it casts no vote on the map. Not yet cited in PubMed.
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7 authors.
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Abstract
introductionChronic kidney disease (CKD) affected > 35 million US adults in 2023. Effective therapies exist to reduce CKD progression and risk of cardiovascular events. However, whether population-level management strategies are effective is not known. The authors evaluated a program that proactively identified and referred high-risk patients to a structured CKD management approach aimed at improving guideline-direct care.
methodsWithin a large, integrated health care delivery system, the authors enrolled adults with high-risk CKD identified from electronic health records between June 2021 and March 2022 who were not receiving nephrology care into a structured CKD management program based on a multidisciplinary, nephrologist-led model of care. These patients were compared to a matched cohort of high-risk patients with CKD receiving usual care. The authors evaluated feasibility and differences in targeted process measures over a 3-month follow-up period.
resultsAmong 120 eligible patients with CKD enrolled in the program and 120 matched patients with CKD receiving usual care, mean (standard deviation) age was 73.9 (8.4) years, 57.8% were women, and demographic characteristics and comorbidity burden were well matched. Despite the COVID-19 pandemic, implementing the structured CKD management program was feasible. During the 3-month follow-up period, those enrolled in the CKD management program experienced a higher rate of estimated glomerular filtration (58% vs 43%,
conclusionProactive referral to structured CKD management was feasible and led to increased short-term surveillance of kidney function. Future studies should assess whether engagement at earlier stages of CKD and longer systematic care and follow-up can improve outcomes and inform broader implementation of population-level CKD management strategies.
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