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Implementing a model of integrated CKD management between primary and secondary care

Philippa Jones1, Hannah O'Keeffe2,3, Rupert W Major4,5,6

  • 1Clinical Pharmacy Service, General Practice Alliance, Northampton, UK.

Clinical Kidney Journal
|January 29, 2026
PubMed

Insights

Early detection and integrated care are crucial for managing chronic kidney disease (CKD) in primary care. Optimizing medication use and collaboration can improve patient outcomes and reduce healthcare burdens.

Area of Science:

  • Nephrology
  • Primary Care Medicine
  • Cardiovascular Medicine

Background:

  • Chronic kidney disease (CKD) is prevalent and a significant cardiovascular risk factor.
  • CKD is frequently underdiagnosed, leading to underutilization of evidence-based treatments.
  • Primary care settings manage the majority of CKD patients, necessitating optimized care strategies.

Purpose of the Study:

  • To review the importance of screening and early identification of CKD in primary care.
  • To explore innovative solutions and methods for CKD management, drawing parallels with cardio-renal-metabolic conditions.
  • To highlight the need for integrated care models and system-wide approaches.

Main Methods:

  • This narrative review examines current practices and literature on CKD management in primary care.
  • It analyzes the potential of integrated care models, including virtual multidisciplinary reviews.
  • The review considers innovative solutions applied to other long-term conditions.

Main Results:

  • Integrated care virtual multidisciplinary reviews show promise for clinical and economic benefits, including improved medication optimization and reduced referrals.
  • Despite demonstrated benefits, implementation of integrated care and optimal prescribing of CKD therapies remain inconsistent.
  • Early detection through methods like urine albumin:creatinine ratio testing is vital.

Conclusions:

  • Optimizing CKD care requires a system-wide approach emphasizing primary-secondary care collaboration.
  • Prioritizing early detection and timely, evidence-based interventions is essential.
  • Adoption of urine albumin:creatinine ratio testing, digital tools, and shared accountability frameworks is urgently needed to improve outcomes.

Keywords:
chronic kidney diseasedashboardsintegrated caremedicine optimizationrisk stratification

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