Who "Owns" CKD? Making the Case for Co-Management and Patient Empowerment

In this National Kidney Foundation (NKF) panel, moderator Andrew Bzowyckyj, PharmD, BCPS, CDCES, senior scientific director and learning consultant at NKF, talks with 3 clinicians from different practice settings:

• Michelle Estrella, MD, a nephrologist, professor of medicine at the University of California, San Francisco, and renal section chief at the San Francisco VA Medical Center;
• Venita Schandorf, DNP, ARNP, a board-certified family nurse practitioner at MultiCare Covington Family Practice in Washington State’s Puget Sound area;
• and Mark Loafman, MD, MPH, a family medicine physician and systems chair for family and community medicine at Cook County Health in Chicago, Illinois.

Because the cardiovascular-kidney-metabolic (CKM) framework brings several specialties together, “ownership” of a chronic kidney disease (CKD) diagnosis and of overlapping therapies can become unclear; however, CKM framework creates an opportunity to move from isolated silos to co-management.

Estrella described a risk-based approach to coordinating between primary care and nephrology. E-consults handle quick questions, a 1-time evaluation suits patients with stage IIIa CKD and severe albuminuria, and patients with stage IV or V CKD are referred for full nephrology management. Rather than strict rules about who “owns” each medication, she relies on open communication, such as notifying colleagues of medication changes and tagging them in notes.

Schandorf stated that the patient ultimately owns the CKD diagnosis. Using a football analogy, she described the patient as the “quarterback” and clinicians across specialties as a “coaching staff” that shares responsibility for common Centers for Medicare & Medicaid Services quality measures. Clinically, she said primary care can manage early-stage CKD with mild albuminuria and should escalate care when comorbidities accumulate.

Loafman noted that, unlike other specialties, nephrology lacks a clear referral trigger short of a crisis. He said that 85% to 90% of progressing CKD is preventable and called for electronic medical records to display the change in estimated glomerular filtration rate (eGFR) over time, so that declining kidney function prompts action. Bzowyckyj added that newer guidelines are increasingly considering the rate of eGFR decline alongside fixed referral thresholds. Loafman also observed that patients often become more engaged in treatment once they hear their kidneys are failing.

Schandorf and Loafman both emphasized that clinical pharmacists are underused. Co-managed visits allow pharmacists to review each medication for safe dosing and coordinate recommendations across specialties. Loafman said he secured a part-time clinical pharmacist by converting an anticoagulation clinic to chronic disease management as patients moved from warfarin to direct oral anticoagulants, and by streamlining refill management to free up pharmacist time without adding staff.

Learn more about the National Kidney Foundation at kidney.org and at this link.