For decades, chronic kidney disease (CKD) care has largely been reactive. Patients often aren’t referred to a nephrologist until kidney function has significantly declined, and often only months before dialysis becomes inevitable.
Investigators in the Renal-Electrolyte Division are working to change that.
Through Kidney CHAMP (Coordinated HeAlth Management Partnership), researchers, including Manisha Jhamb, Melanie Weltman, and Linda-Marie Lavenburg, have developed and tested an innovative population health model designed to identify high-risk patients earlier, support primary care clinicians, and deliver evidence-based kidney care long before patients reach kidney failure.
The work reflects a broader shift in how health systems are approaching CKD, moving beyond specialty clinics to improve care where most patients are actually treated.
“Traditional kidney care is largely reactive and centered around individual clinic visits,” said Dr. Jhamb. “A population health approach proactively identifies patients at highest risk, stratifies them based on need, and delivers targeted interventions across an entire population. Rather than waiting for patients to be referred or develop complications, health systems can ensure that the right patients receive the right intervention at the right time.”
That shift is becoming increasingly important as CKD becomes more common. Approximately one in seven U.S. adults has chronic kidney disease, yet many remain unaware they have it until the disease has progressed. Despite the availability of evidence-based therapies, significant gaps persist between guideline-recommended care and what patients receive in routine practice.
“Many people assume that CKD care primarily occurs in nephrology clinics, but the reality is that most patients with CKD are cared for entirely in primary care settings,” said Dr. Lavenburg. “Unfortunately, there are still substantial gaps in diagnosis, risk stratification, patient education, and use of kidney-protective therapies.”
Because the overwhelming majority of CKD care occurs in primary care practices, improving outcomes depends on supporting front-line clinicians. Yet primary care physicians face limited time during office visits, competing priorities, increasingly complex patients, and rapidly evolving treatment guidelines.
Kidney CHAMP was designed to bridge that gap by leveraging electronic health record data to identify high-risk patients and connect primary care teams with nephrologists and pharmacists through e-consults, medication reviews, and clinical decision support, bringing specialty expertise upstream before irreversible kidney damage occurs.
The approach addresses a longstanding challenge in kidney care. Nearly two-thirds of patients who ultimately begin dialysis have received less than one year of nephrology care before dialysis initiation, representing missed opportunities to slow disease progression.
Among the program’s successes has been its ability to deliver multidisciplinary expertise at scale while expanding access to specialty care for rural patients. The model achieved high completion rates for nephrology e-consults and pharmacist medication reviews, with nearly one-quarter of participating patients living in rural communities. Clinicians also reported that e-consults helped overcome barriers such as long wait times for specialty appointments, uncertainty about referral decisions, and difficulty engaging patients in nephrology care.
The timing of Kidney CHAMP also coincides with a transformative period in CKD treatment. For nearly two decades, ACE inhibitors and ARBs were the primary therapies available to slow kidney disease progression. Today, newer therapies, such as SGLT2 inhibitors, GLP-1 receptor agonist, and a non-steroidal mineralocorticoid receptor antagonists, not only slow CKD progression but also reduce cardiovascular events.
“These advances have given clinicians powerful new tools to delay or even prevent kidney failure for many patients,” said Dr. Jhamb.
Patient interviews revealed another critical challenge: awareness.
“One thing that surprised us was how little many patients knew about their kidney disease, even after years of receiving medical care,” said Dr. Weltman. “Many patients were unaware they had CKD or did not appreciate its seriousness.”
Because CKD is often called a “silent disease,” many patients experience few or no symptoms until kidney function is substantially impaired. As a result, nearly 90% of people with CKD are unaware they have the disease.
Those conversations also reshaped the team’s approach to patient education.
“Effective patient education requires meeting patients where they are, understanding their goals and concerns, and tailoring discussions to their health literacy, cultural background, and readiness to change,” Weltman said. “Patients benefit from clear, simple explanations focused on what they can do to preserve kidney function rather than solely discussing laboratory values or disease stages.”
Looking ahead, the investigators envision kidney care becoming increasingly proactive, personalized, and team-based. Advances in predictive analytics, artificial intelligence, machine learning, remote monitoring, and digital health will help health systems identify patients at highest risk earlier, allowing interventions before substantial kidney function is lost.
Building on Kidney CHAMP’s success, the team translated the model into a larger clinical initiative called Kidney CARE, which provided nephrology co-management for more than 3,000 patients across more than 100 primary care practices in 13 counties throughout western Pennsylvania. Dr. Jhamb is leading a recently NIH funded grant that will evaluate the clinical- and cost-effectiveness of this approach, which will help health systems and policy makers to make informed decisions on whether models like Kidney CHAMP should become standard practice.
But, health systems will need stronger incentives for value-based kidney care, along with integrated risk prediction tools, clinical decision support embedded within electronic health records, sustainable reimbursement for team-based care, and continued collaboration between primary care and nephrology.
Ultimately, the team’s goal is straightforward: identify patients earlier, deliver evidence-based therapies sooner, and prevent avoidable kidney failure, cardiovascular events, and hospitalizations.
“I hope this work helps ensure that patients with CKD are identified earlier, receive evidence-based therapies sooner, and avoid preventable complications such as kidney failure, cardiovascular events, and hospitalizations,” said Dr. Jhamb. ” More broadly, I hope it provides a blueprint for health systems to deliver equitable, high-quality kidney care at scale so that where a patient lives or whether they see a nephrologist does not determine their outcomes.”