Addressing Unmet Needs in the Management of Chronic Kidney Disease

Abstract

Chronic kidney disease (CKD), prevalent in more than 1 in 7 US adults, is a major noncommunicable disease that increases the risk of cardiovascular disease (CVD), stroke, and mortality. Type 2 diabetes and hypertension are the most common causes of CKD and kidney failure. Early identification and management are critical because CKD is asymptomatic in early stages. However, annual surveillance of high-risk patients is infrequent, and many patients with moderate to severe CKD remain undiagnosed. Barriers to effective CKD care and management include social determinants of health (SDoH), low CKD awareness, communication between patients and health care professionals, health literacy, and the complexity of caring for patients with CKD. SDoH-related factors negatively affect access to health care, increasing the risk of developing CKD and leading to poor health outcomes resulting from delays in diagnosis and treatment. Based on the experience and opinions of the authors, this narrative review of the literature aimed to explore the population-based unmet needs of patients with CKD, address potential solutions to SDoH-related issues, discuss the importance of multidisciplinary care, and offer strategies to overcome clinical inertia to increase screening for CKD and improve patient outcomes. Opportunities for improving the management of patients with CKD in both primary and specialty care include avoiding clinical inertia and optimizing guideline-directed therapy.

Plain Language Summary

Chronic kidney disease, or CKD, is a serious health issue that affects more than 1 in 7 American adults, particularly people with diabetes and/or high blood pressure. CKD increases the risk of heart disease, stroke, and death. Most people are not aware they have CKD until the later stages of the disease. Therefore, health care professionals must screen patients at the highest risk for CKD. However, many patients at high risk for CKD are not screened due to a variety of barriers and are undiagnosed. Some of the barriers to screening and managing CKD are social and economic factors that limit health care access, low public awareness about kidney disease, poor communication between patients and health care professionals, and the complexity of managing CKD. Another barrier is low health literacy, which refers to the ability to find, understand, and apply basic health information to make informed health care decisions. Undiagnosed CKD can lead to worse health outcomes because of delays in receiving treatment. This review discusses potential solutions to overcome barriers and increase screening, early detection, and treatment of CKD to prevent progression to a more advanced stage.

Graphical Abstract

Introduction

Chronic kidney disease (CKD) affects more than 1 in 7, or 14% of US adults, but is not uniform across patient populations; for example, prevalence is higher in non-Hispanic Black adults (20%) than in non-Hispanic Asian (14%), Hispanic (14%), and non-Hispanic White adults (12%).¹ Diabetes and hypertension are the leading causes of CKD and kidney failure.^2,3 CKD increases the risk of cardiovascular disease (CVD) and stroke, and premature death from these outcomes.^1,2,4 The differences in rates of mortality and CVD in people with CKD may be attributable to reasons other than race, such as biological, social, and cultural factors.⁵

Recognizing the epidemic nature of CKD, in May 2025, the World Health Organization approved a resolution highlighting the importance of early screening and elevating kidney disease as a major noncommunicable disease.⁶ CKD is often asymptomatic in its early stages, requiring measurement of creatinine to determine the estimated glomerular filtration rate (eGFR) and the urine albumin-to-creatinine ratio (UACR) to assess for albuminuria. Although most patients receive eGFR screening in the year after their diabetes diagnosis, only 50% or fewer receive annual UACR screening.⁷ Lack of diagnosis of CKD stage 3 is very high globally; according to an observational study of 5 countries, the prevalence of undiagnosed stage 3 CKD ranged from 62% to 96%.⁸

Many barriers to effective CKD care and management, including social determinants of health (SDoH), low awareness of CKD among patients and health care professionals (HCPs), and complexity of care, can lead to clinical inertia. Solutions to address these issues must occur at the individual (patients, caregivers, families), health care team, health system, community, and policy levels.⁹ SDoH significantly affect the diagnosis and treatment of CKD, leading to differences in outcomes, particularly among marginalized patient populations.¹⁰ Many factors increase the risk of developing CKD, delay diagnosis, and accelerate CKD progression, leading to worse patient outcomes. These factors include poverty, lack of education, unemployment, food insecurity, housing instability, inadequate social support, and limited access to health care (including telehealth and challenges related to travel distance/transportation), as well as racial/ethnic background, health literacy, and health insurance coverage.^9–12 Addressing these factors is crucial to improving kidney health in all patients with CKD or at risk of developing it.

Differences in outcomes for patients with CKD according to sex, gender, race, ethnicity, and sociocultural factors have been previously studied.^13–23 However, barriers to effective CKD management persist, including those related to screening, diagnosis, monitoring, and prescribing appropriate treatments for CKD and related complications (eg, diabetes, hypertension, CVD, and obesity). Further, the interactions among lack of CKD awareness, SDoH, the complexities of CKD care, and clinical inertia in CKD management have not been extensively explored. This review aims to provide an overview of population-based unmet needs among patients with CKD, address SDoH-related obstacles and potential solutions, highlight the critical role of coordinated care among HCPs, and outline strategies to overcome clinical inertia.

Methods

This is a narrative review of available published and grey literature (ie, government, policy, and technical documents), as well as the authors’ experiences and opinions. We conducted a non-systematic literature search across PubMed and other electronic databases from 2009 through January 2026 to identify guidelines, expert consensus statements, and systematic reviews on CKD management, with a focus on SDoH factors and clinical inertia.

Discussion

CKD Awareness and Communication

Language, cultural considerations, and a lack of understanding about the health implications of CKD are key barriers to effective CKD management (Figure 1). A substantial lack of awareness about CKD and the perceived individual risk of the disease among the general population, people at risk, patients with CKD, and HCPs may contribute to low rates of screening and treatment and increased rates of morbidity and mortality.^24–27 For example, a serial cross-sectional study from 2011 to 2020 found that few (12.3%) US adults with CKD were aware of the condition, including those with cardiometabolic conditions (13.2%).²⁸ Furthermore, a mixed-methods study of primary care physicians (PCPs) in 4 US cities identified patient, HCP, and systems-level barriers to managing CKD in primary care, including patients’ awareness of their disease, low treatment adherence, and low HCP knowledge of CKD and/or clinical practice guidelines.²⁹ Awareness and education are needed among patients at risk of CKD. To be effective, information needs to be delivered in a culturally sensitive manner in community settings, which can increase trust and improve early identification of CKD, particularly among minoritized people.³⁰

Figure 1.

Barriers to CKD awareness and communication.

Abbreviations: CKD, chronic kidney disease; HCP, health care professional.

Low health literacy is common, affecting approximately 25% of patients with CKD, particularly those with low socioeconomic status (SES) and nonwhite ethnicity.³¹ Low health literacy, which is associated with lower education, lower income levels, and greater comorbidity severity, is a barrier to awareness and understanding among people with CKD,^32–34 potentially leading to poorer outcomes.^34,35 HCPs play a crucial role in enhancing health literacy by effectively communicating, educating, and supporting their patients with CKD.^32,33 HCPs can informally assess health literacy by observing factors such as patients’ attendance at clinic visits and their ability to communicate their medication and health history effectively. Using plain language, repeating information, and assessing understanding can help overcome challenges to understanding complex medical information.^36,37

Communication between patients and HCPs contributes to patients’ awareness of CKD, and HCP awareness of CKD can improve communication and CKD management.³⁸ Relationship-building is crucial for patients who may mistrust advice in the health care environment, but it takes time and effort to develop trusting relationships with patients to encourage their acceptance of emerging therapies. Gaining the trust of patients and the community involves a cycle of listening, reflecting, acting, and revisiting.³⁹ Further, recommendations for lifestyle management and shared decision-making should be culturally appropriate and relevant.⁴⁰ We recommend providing literature/reading materials that are relatable, encouraging discussions to help patients overcome fear and/or denial, and suggesting that family or caregivers attend clinic visits with patients, especially when proposing newer therapies. Regular follow-up communication keeps patients engaged, ensures their questions are answered, and provides opportunities to offer additional resources or connect them with other clinical or nonclinical staff, as appropriate for their stage in the decision-making process.

SDoH and Access to CKD Care

Factors related to SDoH can prevent patients with CKD from accessing and participating in health care (including CV and nephrology care), adhering to treatment, and engaging in self-management activities.³⁴ Lack of access to HCPs negatively affects patients in rural areas, as can limited transportation or the distance required to receive health care, social stigma, and privacy concerns owing to small population sizes, which limit primary care and screening opportunities.⁴¹ Challenges associated with health insurance access, specifically, a lack of or limited insurance, include the affordability of medication and difficulty obtaining prescription approvals from insurance companies, even with nurse facilitators as a resource. Furthermore, specialists may be unaware of the number of undiagnosed or untreated patients in their community because patients with the opportunity for specialty care have already passed several levels of economic screening (eg, access to primary care for the initial referral, ability to pay for services rendered, and/or access to health insurance).

As health coverage changes, SDoH factors adjust accordingly, and changing policies will significantly affect vulnerable populations. Over the past couple of decades, access to health insurance has increased, driven by health policies such as the Affordable Care Act,⁴² but there is a large population under the age of 65 (ranging from 9% to 23%) without coverage, who are underinsured, or have had gaps in coverage;⁴³ new policies may reduce access to health insurance in the future. Lack of health insurance restricts access to preventive and chronic disease care,⁴⁴ causing more than half of underinsured adults to avoid health care due to cost.⁴³ Conversely, access to health coverage improves access to care, promotes appropriate health care utilization, and leads to better health outcomes.⁴⁵ Health care insurance access among people with CKD has improved since 2012, but between 2017 and 2020, the prevalence of lack of insurance was higher for individuals with CKD than for those without CKD (17.9% vs. 16.1%); the difference in prevalence rates was larger after age standardization for both groups (18.3% vs. 16.1%).⁴⁶ Moreover, patients with CKD and no or limited insurance coverage have a higher risk of kidney failure and mortality.³⁴

As seen in real-world examples, outreach and screening in underserved communities can help address the gap in CKD care. Community health workers, such as patient navigators, can serve as a bridge between clinicians and people at risk of CKD, particularly those in underserved or vulnerable populations.⁴⁷ People with CKD may more easily trust a community health worker who has a similar cultural and language background, especially if they also have experience with CKD.⁴⁷ Additionally, patients often form a relationship with their pharmacist; therefore, particularly for Black/African American individuals, this trusted relationship may improve adherence to CKD treatments by helping to identify financial challenges and connecting patients with assistance programs.⁴⁸

CKD Complexity and Management Challenges

As reported by PCPs participating in a cross-sectional study, difficulties in caring for patients with CKD include managing comorbidities, the belief that they cannot improve the patient’s condition, limited time for managing complex patients, staying current with clinical practice guidelines, reimbursement challenges, and other system issues, including electronic health records (EHR).²⁹ Although following CKD practice guidelines is significantly associated with improved kidney outcomes,⁴⁹ compliance with guideline recommendations, including the uptake of CV- and kidney-protective therapies, has been slow; for PCPs, this is at least partly due to low awareness.^50,51 Newer medications, including sodium-glucose cotransporter-2 inhibitors (SGLT2i), glucagon-like peptide-1 receptor agonists (GLP-1 RA), and nonsteroidal mineralocorticoid receptor antagonists (MRA), improve kidney function but have been underused for various reasons, such as accessibility and affordability, lack of early diagnosis and identification of at-risk individuals, and patients’ acceptance of additional treatment and subsequent adherence.⁵²

Nephrologists treat the most complex patients with CKD. Patients being treated in the specialty care setting are more likely to have comorbidities that are less well controlled, making the management of CKD more complicated. A large Canadian cohort study involving more than 2.5 million participants found that patients with kidney disease have the highest number of comorbidities (mean, 4.2) and the greatest medication burden (mean, 14.2).⁵³ CKD is challenging to manage regardless of the complexity of patients’ comorbidities; therefore, PCPs who treat most patients with CKD may find it challenging to manage the many facets of the disease. Managing CKD is complicated further by the bidirectional nature of common cardiometabolic conditions, such as type 2 diabetes (T2D), hypertension, CVD (including atherosclerotic cardiovascular disease [ASCVD]), and heart failure.^2,54–56 In addition to being associated with the development and progression of CKD, obesity increases the risk of CVD and mortality in patients with CKD.² Nutritional management in patients with CKD is challenging, owing to metabolic changes that affect nutrient absorption, particularly in patients who also have obesity.^57,58

CKD Screening, Monitoring, and Treatment

Screening is essential for identifying adults at risk of developing CKD (Figure 2). The American Diabetes Association (ADA) and Kidney Disease Improving Global Outcomes (KDIGO) recommend regular screening for CKD in patients with diabetes.^59,60 At least annually, UACR and eGFR should be assessed in individuals with type 1 diabetes (T1D) who have had the condition for at least 5 years, and in all individuals with T2D starting at the time of diagnosis, with a goal of reducing urinary albumin by at least 30% in people with albuminuria ≥300 mg/g.^59,60

Figure 2.

Summary of recommendations for CKD screening, monitoring, and treatment.

Abbreviations: CKD, chronic kidney disease; eGFR, estimated glomerular filtration rate; GLP-1 RA, glucagon-like peptide-1 receptor agonist; HbA1c, glycated hemoglobin; HCP, health care professional; MRA, mineralocorticoid receptor antagonist; RASi, renin-angiotensin system inhibitor; SGLT2i, sodium-glucose cotransporter-2 inhibitor; T1D, type 1 diabetes; T2D, type 2 diabetes; UACR, urine albumin-to-creatinine ratio.

Once patients are diagnosed with CKD, regular monitoring is necessary to assess its progression and adjust treatment appropriately (Figure 2). According to clinical practice guidelines, eGFR and UACR should be monitored 1–4 times per year, depending on the stage of CKD.^60,61 In patients with diabetes (T1D or T2D) and CKD, glycated hemoglobin (HbA1c) level should be used to monitor glycemic control twice per year for most patients, and as often as 4 times per year for patients with suboptimal glycemic target achievement.⁴⁰ In people with diabetes, glucose management and blood pressure control should be optimized to reduce the risk of CKD, slow its progression, and reduce the risk of CV events.⁶⁰

Adults with T2D and established or high risk of ASCVD should be treated with medications that reduce CVD and CKD risk, such as SGLT2i and/or GLP-1 RA, regardless of HbA1c level; SDoH should be considered when choosing glucose-lowering treatment for patients with T2D (Figure 2).⁶² Current treatment guidelines recommend that people with T2D and CKD receive treatments to improve glycemic control, slow the progression of CKD, and reduce the risk of CV events.⁶⁰ A nonsteroidal MRA with proven kidney and CV benefits is recommended for patients with eGFR ≥25 mL/min/1.73 m².⁶⁰ Renin-angiotensin system inhibitors (RASi), such as angiotensin-converting enzyme inhibitors or angiotensin receptor blockers, are recommended for patients with diabetes and hypertension who have moderately to severely increased albuminuria to prevent CKD progression and reduce CV events.⁶⁰ Additionally, SGLT2i and GLP-1 RA are recommended for patients with T2D and CKD to manage glycemia, slow the progression of CKD, reduce CVD risk, and reduce body weight (for patients with obesity).⁶² However, because glycemic control with SGLT2i is reduced in patients with eGFR <45 mL/min/1.73m², GLP-1 RA are preferred for treating people with T2D and advanced CKD (eGFR <45 mL/min/1.73m²).⁶² Moderate/high-intensity statins are also recommended for patients with CKD, with or without diabetes, focusing on lowering low-density lipoprotein cholesterol.^59,60 Although the clinical benefit of statins in reducing CVD decreases with advanced CKD,⁶³ a meta-analysis found that statins slowed the decline of eGFR in patients with CKD stage 3 or 4.⁶⁴

However, adoption of guidelines for managing patients with CKD is limited among HCPs, including nephrologists.⁶⁵ The management of CKD is highly variable, with differences by SES and race/ethnicity. A large database analysis of patients with diabetic kidney disease (DKD), a subset of CKD, in primary care in the United Kingdom found that those with lower SES were 2%–12% less likely to have their blood pressure measured in the previous year and to have their blood pressure and HbA1c below target; they were also 9% less likely to be prescribed RASi but 8% more likely to be prescribed statins.⁶⁶ A study of adults participating in the 1999–2006 National Health and Nutrition Examination Survey found that uninsured people with CKD were 40% and 55% less likely to be treated for hypertension and with angiotensin inhibitors, respectively, than those with insurance coverage.⁶⁷ An analysis of commercially insured patients with T2D found that use of SGLT2i was lower in Black patients, Asian patients, and patients with low household income, including those with CKD.⁶⁸ A retrospective cohort study of patients with CKD in a primary care setting in one US health system found that patients of Black non-Hispanic race/ethnicity or Hispanic ethnicity were significantly more likely to experience a care gap for SGLT2i, defined as not having an active prescription in the EHR.⁶⁹ Hispanic adults with diabetes and CKD were less likely to be prescribed newer glucose-lowering treatments, including SGLT2i and GLP-1 RA, than non-Hispanic White adults or non-Hispanic Black adults (8% vs. 20% and 20%, respectively).¹

There is a need for strategies to increase screening for CKD, especially in primary care practices, including screening during routine visits for patients with T2D (Figure 3). Additionally, using EHR reminders, clinical decision support tools, digital CKD risk progression scoring, health tracking tools, and new diagnostic tests with improved accuracy (when available) may increase screening and the timeliness of diagnosis.⁷⁰ Screening for SDoH factors in clinical practice may be one way to identify at-risk patients and connect them with support services.⁷¹ Increasing awareness and accessibility of clinical practice guidelines and treatment options may improve understanding and uptake among PCPs caring for patients with T2D and CKD.^51,70 Because CKD is asymptomatic in early stages, algorithms that incorporate laboratory testing and recommended actions can be helpful for early screening and diagnosis, particularly in primary care, endocrinology, or cardiology settings.⁵⁹

Figure 3.

Solutions to potentially increase screening for CKD.

Abbreviations: CKD, chronic kidney disease; SDoH, social determinants of health.

Beyond the clinical setting, pharmacists can play a crucial role in expanding access to care by offering additional screenings, blood pressure testing, and blood glucose testing, as well as discussing the affordability of medications and options with patients, including identifying patient assistance programs.⁴⁸ A secondary analysis of the STOP-DKD randomized clinical trial found that a telehealth intervention for behavioral and medication management of DKD led by pharmacists was effective in preserving kidney function in African American patients.⁷² Furthermore, point-of-care testing for serum creatinine and UACR in community pharmacies could aid in monitoring patients at high risk of CKD, such as those taking antihypertensive or glucose-lowering medications.⁴⁸

Overcoming Clinical Inertia and the Importance of Multidisciplinary Care

Clinical or therapeutic inertia is defined as the failure of HCPs to modify or intensify treatment when patients are not meeting treatment goals, which can negatively affect patient outcomes. Clinical inertia is common in CKD, typically manifesting as low uptake of new therapies despite their proven cardiovascular and kidney benefits.^73–75 Clinical inertia is often more pronounced in complex diseases like CKD, where care overlaps between PCPs and specialists, because HCPs are less likely to take individual responsibility for medical decision-making, including choosing to prescribe SGLT2i and GLP-1 RA.⁷⁶ Schernthaner et al suggest that various factors contribute to clinical inertia in managing CKD or CKD risk in patients with T2D, such as limited opportunities to reevaluate treatment options for patients, preference for treatments with which HCPs have more experience, other clinical priorities for individual patients, and lack of awareness of the benefits of cardiovascular and kidney therapies and supporting evidence (Figure 4).⁷⁴ Factors affecting clinical inertia include those at several levels of CKD management, including DKD. Patient factors contributing to clinical inertia include a lack of awareness or understanding of disease progression risk, concerns about treatment, and associated costs.⁷⁷ At the HCP level, factors include limited time and/or staff, limited knowledge of treatment options, and concerns about adherence to therapy; at the health care system level, factors include a lack of clinical guidelines/decision support, as well as a team-based approach to care.⁷⁷

Figure 4.

Factors leading to clinical inertia in CKD.

Abbreviations: CKD, chronic kidney disease; HCP, health care professional.

Team-based, coordinated, multidisciplinary care, including PCPs and specialists, is critical for effective CKD management, overcoming clinical inertia, and improving patient outcomes. Primary care HCPs are well-positioned to address inequities in CKD care; this involves multiple areas, including screening and diagnosis, integrating clinical practice guidelines for treatment and monitoring into the clinical workflow, educating patients and their families, using a patient-centered approach that leverages a larger health care team, and making referrals to specialists for additional care considerations.⁷⁸ However, a cross-sectional survey of PCPs treating patients with CKD and ASCVD found that, although PCPs personally diagnosed CKD in the majority of their patients, only about half identified as the coordinator of patients’ care for CKD and only about one-third of patients reported their HCP discussing their risk of developing CKD or ASCVD before they were diagnosed; of these patients, about half reported that their PCP was the one who communicated this information.⁷⁹ For patients at high risk of CKD progression, timely referrals to specialists improve patient outcomes by delaying the need for kidney replacement therapy and providing greater treatment options, whereas late referrals have a negative effect, including poorer CV and nutritional outcomes and higher hospitalization and mortality rates.⁵⁹ A large retrospective cohort study in the United States found that almost half of patients with CKD at high risk of progression to kidney failure did not receive care from a nephrologist within 1 year of being identified at high risk.⁸⁰ Reasons for referrals late in the disease process may include a perception that treatment options are limited; reasons for late referral for kidney replacement therapy include demographic, clinical, SDoH, and health care system–related factors.⁵⁹

KDIGO recommends a team-based integrated care framework for the care of patients with CKD and diabetes, which includes a variety of HCPs, such as physicians, nurses, nutritionists/dieticians, and pharmacists, as well as trained staff at the community and peer level; empowering patients in self-management is also a key component.⁴⁰ The multidisciplinary framework follows the chronic care model, which includes a system for communication between members of the care team; regular assessments of patients’ risk factors, lifestyle, stress, nutrition, and medication adherence; individualized treatment goals; and education/counseling.⁴⁰ The ADA recommends reassessing treatment every 3–6 months in patients with CKD and T2D, changing as needed, to avoid therapeutic inertia.⁶² Given the complexity of managing CKD and the likelihood of its progression, it is important that screening and treatment follow a multidisciplinary care model aligned with the stages of CKD (Figure 5).

Figure 5.

Transition of CKD stages and management strategies using a multidisciplinary team-based approach.^59,78 eGFR stages (mL/min/1.73m²). G1: normal or high eGFR, ≥90. G2: mildly decreased eGFR, 60–90. G3a: mildly to moderately decreased eGFR, 45–59. G3b: moderately to severely decreased eGFR, 30–44. G4: severely decreased eGFR, 15–29. G5: kidney failure, eGFR <15. Albuminuria categories (mm/g). A1: normal to mildly increased UACR, <30. A2: moderately increased UACR, 30–299. A3: severely increased UACR, ≥300.

Abbreviations: CKD, chronic kidney disease; CV, cardiovascular; eGFR, estimated glomerular filtration rate; KRT, kidney replacement therapy; PCP, primary care physician; SDoH, social determinants of health; UACR, urine albumin-to-creatinine ratio.

Educating and empowering patients can encourage self-management; however, regular communication is necessary to keep patients and HCPs engaged. Training of HCPs and staff is also needed to address behavioral and organizational aspects of CKD care that contribute to clinical inertia; clearly defining responsibilities for monitoring and adjusting treatment may help prevent gaps in care. Incorporating CKD risk equations into EHR systems can increase nephrology referral rates. KDIGO recommends using a validated risk equation to estimate kidney failure risk in patients with CKD who have moderately to severely decreased kidney function, which can guide referrals to a nephrologist and the timing of multidisciplinary care.⁵⁹ An objective risk calculator can identify patients with CKD at high risk of progression, thereby increasing the rate and timeliness of referrals to specialists, while PCPs can effectively manage patients at lower risk of CKD progression.⁵⁹

The Centers for Medicare and Medicaid Services offers suggested approaches to reduce CKD disparities in primary care, including practical methods to identify, treat, and monitor CKD progression.⁷⁸ The guidance also discusses how best to position the patient at the center of care, such as developing strategies for patient education about CKD, understanding patients’ SDoH, including patients’ social support system in educational efforts, and regularly assessing how patients understand their CKD and treatment plan.⁷⁸ Understanding that actions to mitigate CKD risk and manage existing CKD positively affect patients’ quality of life and health outcomes can motivate HCPs to actively screen and engage with their patients in treatment decision-making, using resources to support these activities (Table 1).

Table 1.

Resources for CKD Management in Primary Care

Organization and Resource	Summary (Text and Figure within Resource)	Website Link to Resource
American Academy of Family Physicians (AAFP) Diabetes and Chronic Kidney Disease Physician Fact Sheet	Brief overview of screening and treatment	https://www.aafp.org/assets/image/upload/v1769718965/uxf0z7b7ajvaq0ouuckw.pdf
Centers for Medicare & Medicaid Services (CMS) Chronic Kidney Disease Disparities: Educational Guide for Primary Care	Guidance for approaches to identifying CKD, treatment/monitoring of CKD progression, and patient-centered care, including a comprehensive resource list	https://www.cms.gov/files/document/chronic-kidney-disease-disparities-educational-guide-primary-care.pdf
CKD Prognosis Consortium	CKD risk models	https://www.ckdpc.org/risk-models.html
National Kidney Foundation	Podcast series on Hot Topics in Kidney Health	https://www.kidney.org/podcasts/hot-topics-kidney-health
“Best Practice Perspectives on Improving Early Detection and Management of Chronic Kidney Disease Associated With Type 2 Diabetes in Primary Care”	Plain language visual representation of the clinical data supporting guideline recommendations	The Data Behind the Treatment Recommendations for Persistent Albuminuria https://diabetesjournals.figshare.com/articles/figure/_b_Best_Practice_Perspectives_on_Improving_Early_Detection_and_Management_of_Chronic_Kidney_Disease_Associated_With_Type_2_Diabetes_in_Primary_Care_b_/24871611?file=43762452
American Heart Association (AHA) “The Link between CKD and CVD”	Podcast series covering topics such as eGFR and UACR testing to guide care, guideline-directed therapy and shared decision-making, strategies for testing/follow-up of patients with diabetes, and the connection between CKD and CVD Toolkit for HCPs for guiding collaboration and communication across the health care team Statements and guidelines to “Cardiovascular-Kidney-Metabolic Health: A Presidential Advisory From the American Heart Association”	1 & 2. https://professional.heart.org/en/education/the-link-between-ckd-and-cvd 3. https://www.ahajournals.org/doi/10.1161/cir.0000000000001184
“Chronic Kidney Disease and Cardiovascular Risk: Epidemiology, Mechanisms, and Prevention”	Pathophysiological interactions between the kidney and the heart in chronic kidney disease (Figure 5)	https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(13)60595-4/fulltext
National Kidney Foundation Kidney Disease Outcomes Quality Initiative (KDOQI)	“KDOQI US Commentary on the KDIGO 2024 Clinical Practice Guideline for the Evaluation and Management of CKD” “KDOQI Commentary on the KDIGO 2022 Update to the Clinical Practice Guideline for Diabetes Management in CKD”	1. https://www.ajkd.org/article/S0272-6386(24)00977-6/fulltext 2. https://www.ajkd.org/article/S0272-6386(23)00883-1/fulltext
Kidney Disease: Improving Global Outcomes (KDIGO) “KDIGO 2024 Clinical Practice Guideline for the Evaluation and Management of Chronic Kidney Disease”	Guide for effective patient education for people with CKD (Figure 53) Screening algorithm and staging of CKD in adults (Figure 3) Frequency of monitoring eGFR and albuminuria in people with CKD (Figure 13) Guide for referral of patients to specialist kidney care services (Figure 48) Key features of CKD care models (Table 40)	https://www.kidney-international.org/article/S0085-2538(23)00766-4/fulltext
Kidney Disease: Improving Global Outcomes (KDIGO) “KDIGO 2022 Clinical Practice Guideline for Diabetes Management in Chronic Kidney Disease”	Integrated care approach in patients with diabetes and CKD (Figure 33) Holistic approach for improving outcomes in patients with diabetes and CKD (Figure 2) Treatment algorithm for selecting glucose-lowering medications for patients with CKD and T2D and influence of patient factors (Figures 23 and 25) Presenting a culturally relevant healthy kidney diet (Figure 15)	https://www.kidney-international.org/article/S0085-2538(22)00507-5/fulltext
American Diabetes Association (ADA) “9. Pharmacologic Approaches to Glycemic Treatment: Standards of Care in Diabetes—2026” “11. Chronic Kidney Disease and Risk Management: Standards of Care in Diabetes—2026”	Guide to the use of glucose-lowering therapy in patients with T2D, including those with CKD Use of glucose-lowering medications in the management of type 2 diabetes (Figure 9.4) Guide to managing CKD in patients with diabetes Holistic approach for improving outcomes in people with diabetes and CKD (Figure 11.2)	1.https://diabetesjournals.org/care/article/49/Supplement_1/S183/163934/9-Pharmacologic-Approaches-to-Glycemic-Treatment 2. https://diabetesjournals.org/care/article/49/Supplement_1/S246/163914/11-Chronic-Kidney-Disease-and-Risk-Management

Abbreviations: CKD, chronic kidney disease; CVD, cardiovascular disease; eGFR, estimated glomerular filtration rate; T2D, type 2 diabetes; UACR, urinary albumin-to-creatinine ratio.

Limitations

In this narrative review, the objective was to explore population-based unmet needs among patients with CKD and to offer potential solutions informed by the authors’ experiences. Thus, this review does not quantitatively synthesize the literature. Selection bias is a potential limitation, as is the focus on the US population. Lastly, because we address the challenges to effective CKD care at the population level, there may be differences in barriers and solutions across low-, middle-, and high-income settings.

Future Directions

Diabetes is emerging in younger individuals (adolescents); about one-quarter of young patients with T2D already have hypertension or albuminuria.⁸¹ An observational study of patients with youth-onset T1D or T2D found that albuminuria progression was associated with clinical and demographic factors, including increased HbA1c, lack of private health insurance, and African American race.⁸² Thus, screening for CKD risk and SDoH factors and education of parents of children with diabetes may be an emerging need. Future research could explore the use of artificial intelligence as a potentially valuable tool for CKD risk assessments and prognosis.

Conclusion

Gaps in effective CKD management persist, and many at-risk patients are not screened and therefore are diagnosed with advanced disease. CKD is a complex condition requiring a multidisciplinary team-based approach to prevent or delay its development and progression. Overcoming clinical inertia resulting from SDoH factors, the complexity of patients with CKD, and low awareness is challenging, but it can improve and extend patients’ lives. Thoughtful engagement of patients with or at risk for CKD, use of community-level resources, and following clinical practice guidelines can improve the quality of CKD care. HCPs can help build trust and improve health literacy by providing education to patients and family members in a culturally sensitive manner. Pharmacists and patient navigators can provide other avenues for health information, risk screening, and assistance with health coverage or medication costs for underserved populations. To help slow the progression of CKD, it is essential that HCPs follow clinical practice guidelines, including regular screening and monitoring of at-risk patients, and use therapies with cardiovascular and kidney benefit, such as SGLT2i and GLP-1 RA. Along with clinical decision algorithms, risk-based calculators, and SDoH screening tools, a team-based approach to CKD care involving PCPs and specialists and using a chronic care model can improve patient outcomes.

Funding Statement

Medical writing support for this work was supported by Novo Nordisk Inc. The authors had complete editorial control over the manuscript’s contents. The authors did not receive financial support related to this work.

Use of Artificial Intelligence

No large language model-based artificial intelligence tools were used in the preparation of this manuscript. KJT Group, Inc. medical writers (disclosed in acknowledgments) provided editorial support and used Grammarly^® for routine review of sentence structure and punctuation only.

Data Sharing Statement

Data sharing not applicable – no new data was generated.

Author Contributions

All authors made a significant contribution to the work reported, whether that is in the conception, study design, execution, acquisition of data, analysis and interpretation, or in all these areas; took part in drafting, revising or critically reviewing the article; gave final approval of the version to be published; have agreed on the journal to which the article has been submitted; and agree to be accountable for all aspects of the work.

Disclosure

SER has received fees from Bayer, Travere, and Novo Nordisk for participation in scientific advisory boards, and has served on the steering committee for the FINE-ONE clinical trial, sponsored by Bayer. Her institution has received research funds from Bayer, AstraZeneca, and NIDDK. She is the Immediate Past President and National Board Member of the National Kidney Foundation. RB has served on the speaker bureau for Novo Nordisk and is a clinical investigator in several Novo Nordisk trials. DR has received funding from NIH and is the national leader for the ZEUS clinical trial sponsored by Novo Nordisk.