Since the launch of the World Health Organization Action Plan for Non-Communicable Diseases (NCDs) in 2013, there has been global progress in the proportion of countries with a national NCD action plan and dedicated NCD units.34 However, CKD is only incorporated into NCD strategies in approximately one-half of countries.4 Policies are required to integrate kidney care within essential health packages under universal health coverage (Fig. 4).30 Multisectoral policies must also address the social determinants of health, which are major amplifiers of CKD risk and severity, limiting people's opportunities to improve their health.3 Lack of investment in kidney health promotion, along with primary and secondary prevention of kidney disease, hinders progress.14

Fig. 4.

Depiction of the spectrum of factors impacting implementation of timely and quality kidney care. CKD, chronic kidney disease; NCD, noncommunicable disease; UHC, universal health coverage.

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Two major goals of universal health coverage are to achieve coverage of essential health services and reduce financial hardship imposed by health care. However, universal health coverage alone is insufficient to ensure adequate access to kidney care.3 Health systems must be strengthened and quality of care must also be prioritized, as poor quality care contributes to more deaths than lack of access in low-resource settings.35 Quality care requires a well-trained health care workforce, sustainable availability of accurate diagnostics, reliable infrastructure, and medication supplies and should be monitored in an ongoing process of quality improvement (Fig. 4). The quality of medications, especially in LMICs, may be an additional barrier to successful management of CKD.36 Regulation and monitoring of drug manufacturing and quality standards are important to ensure safe and effective therapies. Strategies to support regulation and quality assurance will need to be developed in local contexts and guidance, as outlined elsewhere.37

Establishing a credible case for CKD detection and management based on risks, interventions and outcomes, and costs, based on real-world data, will help to translate theoretical cost-effectiveness (currently established primarily in high-income countries with minimal data from elsewhere) into economic reality.30,38 Screening should include evaluation of risk factors for CKD, eliciting a family history, recognizing potential symptoms (usually advanced—fatigue, poor appetite, edema, itching etc.), and measuring blood pressure, serum creatinine, urinalysis, and urine albumin/protein to creatinine ratios, as outlined in established guidelines.19,39 Addressing CKD upstream beginning in primary care should lower costs over time by reducing CKD complications and KF. Medications required for kidney care are already included in the World Health Organization Essential Medication List (Table 1). These must be provided at national levels under universal health coverage.40 Pharmaceutical companies should provide these at affordable prices.

A shortage of primary care professionals is compounded by inconsistent access to specialists and allied health professionals in both high-income countries and LMICs. Defining roles and responsibilities for kidney care is essential. Solutions may include multidisciplinary team care (primary care physicians, pharmacists, advanced practitioners, nurses, therapists, educators, nutritionists, and mental health professionals) with well-established mechanisms of collaboration of all elements and promptly available communication technologies within health systems and between professionals to support care and decision-making.41,42 Brain drain in low-resource settings is complex and must be tackled.

Mobilization of community health workers yields cost savings in infectious disease programs in LMICs, and may facilitate early detection, diagnosis, and management of NCDs.43 Protocolized CKD management, possibly supported by electronic decision-support systems, lends itself well to interventions at the community level, with integration of primary care physicians and backup from nephrology and other professionals.44,45 In some environments, pharmacists, for example, could identify people with diabetes or hypertension, at risk of CKD, based on their prescriptions, and could offer testing on site and reference if needed.46 Pharmacists can also provide medication reconciliation and medication advice for safety, effectiveness, and adherence. Social workers and pharmacists can help patients with medications access programs.46

Clinical “inertia,” commonly blamed for low prescribing rates, has many facets (Fig. 4).47 Many knowledge gaps regarding CKD exist among primary care clinicians.48 Such gaps are remediable with focused public and professional education. Additional factors include fear of medication adverse effects, misaligned incentives within the health system, excessive workload, formulary restrictions, and clinician burnout.47 Furthermore, discrepancies in guideline recommendations from different professional organizations may add to confusion. A major impediment to optimal care is the time constraints imposed on individual clinicians. The average primary care practitioner in the United States would require ≈26.7h per day to implement guideline-recommended care for a 2500 patient panel.49 Innovation is required to support guideline implementation, especially for primary care practitioners who must implement many different guidelines to meet the needs of various patients. Electronic health records, reminders, team-based nudges, and decision support tools offer a promising support for quality kidney care in busy clinical practices.50 The extra time and effort spent negotiating preauthorizations or completing medication assistance program requests, along with need for frequent monitoring of multiple medications, however, also hinder appropriate prescribing.25 Many primary care practitioners have only a few minutes allocated per patient because of institutional pressure or patient volume. “Inertia” can hardly be applied to clinicians working at this pace. The number of health professionals must increase globally.

Visits for patients with CKD are complex as multimorbidity is high. Patients are often managed by multiple specialists, leading to fragmentation of care, lack of holistic oversight, and diffusion of responsibility for treatment. Multidisciplinary care improved transition to kidney replacement therapy and lowered mortality in single and combined outcomes analyses.51 Novel models of “combined clinics” with on-site collaboration and coparticipation (nephrologist–cardiologist–endocrinologist) may prove to be of substantial benefit for patients, in terms of reduced fragmentation of care, logistics, and cost saving.

Self-care is the most important aspect of kidney care. A patient's ability to understand his/her health needs, make healthy choices, and feel safe and respected in the health system, and psychosocial support are important to promote health decision-making (Fig. 4). Communication should start from good communication that requires quality information and importantly confirmation of “understanding” on the side of the patient and often family. Electronic apps and reminders may become useful tools to support patients by improving disease knowledge, promoting patient empowerment, and improving self-efficacy, although it is unlikely that one size will fit all.52 Insufficient patient health information, poor communication, and mistrust, among other elements, are important barriers, especially in marginalized and minoritized communities, where CKD is common.30 Patients may also be confused by contradictory recommendations for care between health care professionals, as well as conflicting messaging in lay media. Innovative platforms to improve communication between patients and clinicians about CKD are promising and may promote optimal prescribing and adherence.53,54

To overcome barriers and promote equity, patient perspectives are essential to designing and testing better health strategies. Collaborative care models must include patients, families, community groups, diverse health care professionals, health systems, government agencies, and payers.38 Advocacy organizations and local community groups and peer navigators, having trusted voices and relationships, can be conduits for education and may provide input for development of patient tools and outreach programs.55 Most important, patients must be at the center of their care.

In high-income countries, people without health insurance and those with high copays paradoxically pay the most for even essential medications.38 Across LMICs, kidney disease is the leading cause of catastrophic health expenditure because of reliance on out-of-pocket payments.56 Across 18 countries, 4 cardiovascular disease medications (statins, ACEIs, aspirin, and β-blockers), all often indicated in CKD, were more available in private than in public settings, mostly unavailable in rural communities, and unaffordable for 25% of people in upper middle-income countries and 60% of people in low-income countries.57 Newer therapies may be prohibitively expensive worldwide, especially where generics may not yet be available. In the United States, the retail price for a 1-month supply of an SGLT2 inhibitor or finerenone is ≈$500–$700; and for glucagon-like peptide-1 receptor agonists, ≈$800–$1200 per month.38 Reliance on out-of-pocket payment for vital, life-saving basic medications is unacceptable (Fig. 4).

Given that we know how to treat CKD based on a rigorous evidence base, we must now optimize implementation.60 Implementation research aims to identify effective solutions by understanding how evidence-based practices, often developed in high-income countries, can be integrated into care pathways in lower-resource settings. The management of CKD lends itself to implementation research: optimal therapeutic strategies are known, outcomes are easily measurable, and essential diagnostics and medications should already be in place. Eliciting local patient preferences and understanding challenges are crucial components of such research. Ministries of health should commit to overcoming identified barriers and scaling up successful and sustainable programs.

Polypills are attractive on multiple levels: fixed doses of several guideline-recommended medications are present within 1 tablet (Table 1); lower price; reduced pill burden; and simplicity of the regimen.61 Polypills have been shown to prevent cardiovascular disease, and to be cost-effective for patients with CKD.62 More studies are needed, but given the alternatives of costly kidney replacement therapy or early death, it is likely that polypills will prove cost-effective to reduce CKD progression.

Integration of telehealth and other types of remotely delivered care can improve efficiency and reduce costs.63 Electronic health records and registries can support monitoring of quality of care and identify gaps to guide implementation and improve outcomes within learning health care systems. Artificial intelligence may also be harnessed to risk stratify and personalize medication prescribing and adherence.64 The use of telenephrology for communication between primary care and subspecialists may also prove of use and benefit for patient treatment.65