Approximately 15% of adult Americans have chronic kidney disease (CKD) – representing over 35 million Americans. This equates to more than 1 million people with CKD living in Michigan, where kidney disease is also the 8th leading cause of death. There exist many barriers to optimal management of CKD, including the fact that most patients are asymptomatic and unaware of their kidney condition. Yet fundamentally much of kidney disease is preventable by patient actions thus, intervening early to increase patient engagement with providers and prevent progression of CKD is critically important.
CKD is a heterogeneous disease. While some kidney conditions require targeted therapy (e.g. immunosuppression regimen for glomerulonephritis), in most cases, CKD is caused by upstream modifiable factors, e.g. Diabetes Mellitus and high blood pressure. As such, there are mainstays of preventing kidney disease and its progression for many that include controlling blood pressure; risk factor modification (e.g. glycemic control in diabetes); preferential use of angiotensin converting enzyme inhibitors (ACEI) or angiotensin receptor blockers (ARB); and avoidance of nephrotoxic exposures.
Despite available guidelines, the most recent Medicare data show that only 71% of patients with diabetes and CKD are on an ACEI or ARB, and little significant improvement has been made over the past decade. In addition, use of some nephrotoxins (e.g. NSAIDs) in patients who have CKD has been on the rise.
This important kidney centric CQI will specifically address opportunities to improve care for patients with chronic kidney disease who have type 2 diabetes, with the goal of slowing progression and preventing new onset of CKD. Further, it will set the stage for optimizing provider recognition and equipping providers with support tools so that they have what they need to deliver evidence-based, best practices seamlessly at the time of care delivery.
Areas of Impact
Our overall goal is to reduce the incidence and progression of kidney disease among residents of Michigan. To achieve this goal, we will focus initially on the following areas:
Increase awareness around kidney disease by promoting testing for urine albumin in at-risk patients. Elevated urine albumin is a well-established risk factor for adverse outcomes including kidney disease progression, yet is often not assessed. We will work with partners to address potential barriers to testing.
Increase use of newer treatments for diabetic kidney disease, such as SGLT2 inhibitors and GLP-1 agonists. We will provide educational support and resources to partners, and help to increase accessibility to newer therapies.
Worldwide, the US ranks among the top five countries for incidence of End Stage Kidney disease.  Chronic Kidney Disease is a poster child for disparities by race, ethnicity, geography and socioeconomic status. Despite its high burden (~15% of the adult population of the US; i.e., more common than diabetes mellitus), awareness of kidney disease is low at 10%.  This means that while 1 in 7 US adults have CKD, on average, only 1 in 10 of those who have it by laboratory criteria, are even aware of it.  Infrequent urine testing for albuminuria is common even among those identified with major risk factors such as diabetes and hypertension.  CKD is predominantly a disease of older adults, although a significant problem among young people and children. The race/ethnicity groups in the US with the highest incidence of CKD and ESKD include African Americans, Native Hawaiian and Pacific Islanders and Hispanics [3-6]. Multiple hotspots of the disease exist in the US and in the state of Michigan. Social determinants of health (poverty, racism, food insecurity, etc.), and environmental factors (e.g., air pollution, heat and toxin exposure) may play a significant role in perpetuating disparities in kidney disease.
United States Renal Data System. 2020 USRDS Annual Data Report: Epidemiology of kidney disease in the United States. National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, MD, 2020.
Centers for Disease Control and Prevention. Chronic Kidney Disease Surveillance System—United States. website: https://nccd.cdc.gov/CKD/
Crews DC, Bello AK, Saadi G; World Kidney Day Steering, Committee. Burden, access, and disparities in kidney disease. J Nephrol. 2019 Feb;32(1):1-8. doi: 10.1007/s40620-019-00590-6. PMID: 30707401.
Laster M, Shen JI, Norris KC. Kidney Disease Among African Americans: A Population Perspective. Am J Kidney Dis. 2018 Nov;72(5 Suppl 1):S3-S7. doi: 10.1053/j.ajkd.2018.06.021. PMID: 30343720; PMCID: PMC6200351.
Xiang J, Morgenstern H, Li Y, Steffick D, Bragg-Gresham J, Panapasa S, Raphael KL, Robinson BM, Herman WH, Saran R. Incidence of ESKD Among Native Hawaiians and Pacific Islanders Living in the 50 US States and Pacific Island Territories. Am J Kidney Dis. 2020 Sep;76(3):340-349.e1. doi: 10.1053/j.ajkd.2020.01.008. Epub 2020 May 5. PMID: 32387021.
Albertus P, Morgenstern H, Robinson B, Saran R. Risk of ESRD in the United States. Am J Kidney Dis. 2016 Dec;68(6):862-872. doi: 10.1053/j.ajkd.2016.05.030. Epub 2016 Aug 28. PMID: 27578184; PMCID: PMC5123906.