TY - JOUR
AU - P. Jones
AU - H. O'Keeffe
AU - R. W. Major
AU - J. Ritchie
AU - N. Sanganee
AU - S. Sinha
AU - J. O. Burton
A1 - 
AB - Chronic kidney disease (CKD) is a common condition and important cardiovascular risk factor. However, CKD remains underdiagnosed and evidence-based medicines underutilized. In most healthcare systems, most CKD is managed in primary care. Optimal management in this setting can only be achieved with integration of care including early identification, prioritization, and use of the tools and skill mix available. This narrative review focuses on the importance of screening and identification in primary care, looking at innovative solutions and methods from other long-term conditions, particularly cardio-renal-metabolic conditions. Integrated care virtual multidisciplinary reviews, have demonstrated clinical and economic benefits, improved medication optimization, and reduced unnecessary referrals. However, implementation remains inconsistent, and prescribing of both established and novel therapies remains sub-optimal. Optimizing CKD care requires a system-wide approach that reinforces primary-secondary care collaboration, prioritizes early detection, and facilitates timely, evidence-based interventions. The inclusion of urine albumin: creatinine ratio testing, integrated digital tools, and shared accountability frameworks must be urgently adopted to realize improved outcomes and reduce the burden of CKD on individuals and healthcare systems alike.
AD - Clinical Pharmacy Service, General Practice Alliance, Northampton, UK.; Donal O'Donoghue Renal Research Centre, Department of Renal Medicine, Northern Care Alliance NHS Foundation Trust, Salford, UK.; Manchester Academic Health Sciences Centre, University of Manchester, Manchester, UK.; Department of Population Health Sciences, University of Leicester, Leicester, UK.; Department of Renal Medicine, University Hospitals of Leicester NHS Trust, Leicester, UK.; Leicester, Leicestershire and Rutland Integrated Care Board, NHS England, Leicester, UK.; NIHR Leicester Biomedical Research Centre, University of Leicester, Leicester, UK.; Leicester British Heart Foundation Centre of Research Excellence, University of Leicester, Leicester, UK.
AN - 41608156
BT - Clin Kidney J
C5 - Healthcare Disparities
CP - 1
DA - Jan
DO - 10.1093/ckj/sfaf335
DP - NLM
ET - 20251104
IS - 1
JF - Clin Kidney J
LA - eng
N2 - Chronic kidney disease (CKD) is a common condition and important cardiovascular risk factor. However, CKD remains underdiagnosed and evidence-based medicines underutilized. In most healthcare systems, most CKD is managed in primary care. Optimal management in this setting can only be achieved with integration of care including early identification, prioritization, and use of the tools and skill mix available. This narrative review focuses on the importance of screening and identification in primary care, looking at innovative solutions and methods from other long-term conditions, particularly cardio-renal-metabolic conditions. Integrated care virtual multidisciplinary reviews, have demonstrated clinical and economic benefits, improved medication optimization, and reduced unnecessary referrals. However, implementation remains inconsistent, and prescribing of both established and novel therapies remains sub-optimal. Optimizing CKD care requires a system-wide approach that reinforces primary-secondary care collaboration, prioritizes early detection, and facilitates timely, evidence-based interventions. The inclusion of urine albumin: creatinine ratio testing, integrated digital tools, and shared accountability frameworks must be urgently adopted to realize improved outcomes and reduce the burden of CKD on individuals and healthcare systems alike.
PY - 2026
SN - 2048-8505 (Print); 2048-8505
SP - sfaf335
ST - Implementing a model of integrated CKD management between primary and secondary care
T1 - Implementing a model of integrated CKD management between primary and secondary care
T2 - Clin Kidney J
TI - Implementing a model of integrated CKD management between primary and secondary care
U1 - Healthcare Disparities
U3 - 10.1093/ckj/sfaf335
VL - 19
VO - 2048-8505 (Print); 2048-8505
Y1 - 2026
ER -