Table 3.

Research recommendations for general management of patients with CKD G4+

1. Risk-based assessment and management

Implementation and evaluation of prognostic models in clinical care to guide risk-based management approaches. Researchers should consider clinical impact analyses of tools that link prognostic information on kidney failure to specific guidance for common CKD management decisions and evaluate the impact on measures of appropriateness, timeliness, patient-centeredness, and efficiency of CKD care.

Derivation, validation, and impact analyses of prognostic models for other outcomes in addition to kidney failure. In addition to CVD events, kidney failure, and death, models should consider patient-centered outcomes including quality of life, functional status, cognitive impairment and hospitalization. Prognostic models that help patients and providers weigh the relative benefits and risk of common medical therapies, radiologic procedures (e.g., angiography), and surgery for patients with CKD should also be investigated.

2. Incorporating patient preferences and values

Development and evaluation of tools and resources to elicit patient values and preferences for management options throughout CKD G4+. Such studies should evaluate the impact of tools to facilitate shared decision-making on patient-reported outcomes and experience measures, including measures of knowledge transfer and the quality of decision-making processes in CKD management.

3. Models of care

Evaluation of the impact of clinic structures and processes on patient experience, outcome measures, and costs of providing care. Specific structural interventions that require further evaluation include financial incentives to support longitudinal patient care rather than episodic health care contacts; novel strategies to address multi-morbidity; technology-based strategies to enhance communication; and transition of care interventions addressing gaps between hospital and community, as well as between phases of pre-dialysis, dialysis, and transplant care.

4. Uncertainties about targets and therapies

Evaluation of novel, emerging, and existing pharmacotherapeutic strategies in randomized controlled trials specifically in populations with CKD G4+. Promising therapies include bicarbonate therapy and treatment of asymptomatic hyperuricemia to slow progression in the later stages of CKD, as well as aspirin for primary prevention of cardiovascular events. Inclusion of patients with CKD G4+ should also be a priority for future trials of blood pressure control, glycemic targets, and comparative effectiveness studies of medication safety.

CKD, chronic kidney disease; CVD, cardiovascular disease.