Diabetes and hypertension are the most common conditions associated with chronic kidney disease (CKD) and end stage renal disease (ESRD). In contrast to diabetes, regular screening for CKD among non- diabetic hypertensive adults in the U.S. is not universally recommended or implemented. The vast majority of persons with CKD and their providers are unaware of the disease. Therefore, identification of persons with CKD among non-diabetic adults with hypertension represents an important opportunity to translate evidence- based approaches into clinical practice to reduce the burden of CKD. Our prior work has shown that a """"""""triple- marker approach"""""""" to detect CKD using creatinine, cystatin C and the urinary albumin-to-creatinine ratio greatly enhanced identification of persons at highest risk for complications, compared with creatinine alone. Control of BP remains the mainstay of CKD management;and programs led by nurses and pharmacists have been the most effective at improving BP control in clinical practice. Therefore, the goal of this proposal is to evaluate to strategies to improve BP control among non-diabetic hypertensive persons with unrecognized CKD, We propose a pragmatic, cluster-randomized clinical trial to improve BP control for non-diabetic, hypertensive adults with screen-detected CKD in primary care. The first intervention will evaluate the efficacy of a nurse-led screen-and-educate strategy that utilizes a """"""""triple-marker"""""""" CKD screening approach, coupled with both patient and provider education, compared with usual care. The second intervention will evaluate whether a screen, educate, and intensify treatment program co-led by both a nurse and a clinical pharmacist can improve BP management among persons with highest risk CKD, compared with the screen-and-educate strategy and with usual care. Based on the Chronic Care Model for primary care, this project is specifically designed to leverage an existing multi-disciplinary team to improve BP levels and increase appropriate use of inhibitors of the renin-angiotensin system (ACE/ARB). We will also evaluate the feasibility and process implementation of these programs using the Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) framework. If successful, these interventions could help to reduce the burden of CKD and its associated complications.

Public Health Relevance

Most people with chronic kidney disease (CKD) are not aware of its presence. We aim to improve blood pressure control among persons who have hypertension and no diabetes, and who have unrecognized CKD. Control of BP could significantly reduce CKD complications.

National Institute of Health (NIH)
National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK)
Planning Grant (R34)
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Special Emphasis Panel (ZDK1)
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Narva, Andrew
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Northern California Institute Research & Education
San Francisco
United States
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Peralta, Carmen A; Frigaard, Martin; Rubinsky, Anna D et al. (2017) Implementation of a pragmatic randomized trial of screening for chronic kidney disease to improve care among non-diabetic hypertensive veterans. BMC Nephrol 18:132
de Boer, Ian H; Kovesdy, Csaba P; Navaneethan, Sankar D et al. (2016) Pragmatic Clinical Trials in CKD: Opportunities and Challenges. J Am Soc Nephrol 27:2948-2954