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  • Review Article
  • Published:

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

Nature Reviews Nephrology volume 11, pages 491–502 (2015)Cite this article

Subjects

Key Points

  • Chronic kidney disease (CKD) is associated with early-onset cardiovascular disease, end-stage renal disease and premature death

  • Patients with mild-to-moderate reductions in estimated glomerular filtration rates often have comorbidities that are more relevant to their current and future well-being than a CKD diagnosis

  • An integrated care pathway is required for patients with CKD

  • A growing number of experiences from different countries have shown that primary care models can lead to improvements in cardiovascular and renal health outcomes among CKD patients

  • More research into early identification, screening, monitoring and management strategies for CKD is required; this research should include the establishment of CKD registries to permit health–economic analyses

Abstract

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.

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Figure 1: Prevalence of CKD by stage in the USA between 1988 and 2012.
Figure 2: Breakdown of chronic kidney disease (CKD) by stage (1–5) in selected countries with data available from the 2000s.9,18,19,20,21,22,23
Figure 3: Comparison of CKD prevalence as determined using different formulae to estimate glomerular filtration rate (CKD–EPI creatinine versus the four-variable MDRD study) in the USA between 1999 and 2004.
Figure 4: An integrated care continuum for CKD that is consistent with the chronic care model.

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Acknowledgements

We would like to thank Dr Shari Ling and Dr Kimberly Smith (Centers for Medicare and Medicaid Services, Baltimore, MD, USA) for their useful comments on early versions of this manuscript.

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Authors and Affiliations

  1. LSE Health, Cowdray House, London School of Economics and Political Science, Houghton Street, London, WC2A 2AE, UK

    Olivier J. Wouters & Panos G. Kanavos

  2. Department of Renal Medicine, Salford Royal NHS Foundation Trust, Stott Lane, Salford, M6 8HD, UK

    Donal J. O'Donoghue & James Ritchie

  3. National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, 31 Center Drive, Bethesda, 20892-2560, MD, USA

    Andrew S. Narva

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  1. Olivier J. Wouters
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  4. Panos G. Kanavos
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  5. Andrew S. Narva
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O.J.W., D.J.O., and J.R. wrote the article. All authors researched the data for the article, provided substantial contributions to discussions of its content, and undertook review and/or editing of the manuscript before submission.

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Correspondence to Donal J. O'Donoghue.

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Wouters, O., O'Donoghue, D., Ritchie, J. et al. Early chronic kidney disease: diagnosis, management and models of care. Nat Rev Nephrol 11, 491–502 (2015). https://doi.org/10.1038/nrneph.2015.85

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