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Updated: Jan 11, 2026

Digital Home-Monitoring of Patients after Kidney Transplantation: The MACCS Platform
Published on: April 12, 2021
Building Capacity for Community-Based Kidney Health Screening: A Multi-Site Quality Improvement Initiative through
Amber B Paulus1,2,3, Imani Smith4, Angie Kurosaka5,6,7
1Associate Chief Nephrology Research & Data Analytics and Assistant Professor, Department of Internal Medicine, Division of Nephrology, School of Medicine, Virginia Commonwealth University, Richmond, VA.
Abstract:
Chronic kidney disease (CKD) disproportionately affects communities with limited access to screening and preventive care. While programs such as the Kidney Early Evaluation Program (KEEP) and the Kidney Disease Screening and Awareness Program (KDSAP) have demonstrated the feasibility of community-based kidney health initiatives, a gap remains in nurse-led models that explicitly leverage the expertise of registered nurses (RNs) and nurse practitioners (NPs) combined with quality improvement principles. The Community Kidney Health Network (CKHN) was piloted to evaluate the feasibility and scalability of American Nephrology Nurses Association (ANNA)-led kidney health screenings in structurally disadvantaged areas. Three ANNA chapters (Pacific Northwest - Seattle, Hazel Taylor - Birmingham, and Alamo City - San Antonio) partnered with local organizations to conduct screenings. Participants received point-of-care testing (hemoglobin A1C, serum creatinine/estimated glomerular filtration rate [eGFR], urine albumin-creatinine ratio) and assessments for blood pressure, body mass index (BMI), and waist circumference. The Kidney Health Score (KHS), based on six risk factors, categorized risk. Among 51 adults, nearly all were "At-Risk" or higher, with elevated blood pressure and BMI most prevalent. Average supply cost was $30.76/person. Sites reported strong engagement, operational feasibility, and readiness to expand. This pilot demonstrates the acceptability, scalability, and community health leadership potential of RN/NP-led kidney health screenings.
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