Managing Chronic Kidney Disease: A Work In Progress
August 19, 2025 · Becky Kolinski
Chronic kidney disease (CKD) affects nearly 36 million adults in the U.S., yet it remains underdiagnosed and undertreated. NCQA convened an expert panel of clinicians and patient advocates to discuss current challenges and future opportunities associated with the assessment, diagnosis and management of CKD.
The discussion focused on three goals:
- Identify quality gaps in CKD care related to screening, prevention, monitoring, management and slowing progression.
- Recommend solutions for closing quality gaps and improving outcomes related to CKD.
- Inform a framework for expanding the evaluation of quality of care, experience and outcomes related to CKD, while also considering how CKD contributes to cardiovascular-kidney-metabolic (CKM) syndrome.
NCQA developed a white paper based on the convening—Advancing Care for Chronic Kidney Disease: Using Care Gaps to Inform a Quality Framework—that encompasses the latest insights and advice from the brightest minds in CKD care, and is a must-read for anyone interested in improving outcomes for people with CKD.
Key Takeaways
The white paper covers a wide range of topics, from CKD prevention, screening and management to recommendations for closing gaps in care. Below are some key findings; download the paper for a complete picture.
- Experts need to align. There is ongoing expert debate on CKD care: who should be screened; how—and how often—kidney function testing should occur; what tests should be performed; when patients should be referred to nephrology.
- Early detection is key. One area where experts agree is that early identification of CKD is critical because it allows patients and their care teams to quickly initiate a treatment plan to address the increased risk of cardiovascular disease and slow CKD progression.
- Screening guidelines are hotly debated. Because CKD is largely asymptomatic in the early stages, risk assessment and screening are essential. Reliable lab tests are available to identify CKD, but experts disagree on the preferred approach: population-level screening or case finding among high-risk individuals.
- Team-based care is best. Once CKD is identified, there should be seamless coordination among primary care, nephrology, endocrinology, cardiology, nutrition and pharmacy professionals, based on the patient’s clinical profile. But lack of access to specialty care hinders these efforts.
- You can’t treat CKD in isolation. Because CKD, cardiovascular disease, diabetes and obesity share common risk factors and respond to similar treatments, a holistic, patient-centered approach is needed.
- Community engagement matters. Local venues like barbershops and faith-based organizations can harness the influence of trusted, community-based messengers to deliver health information on CKD risk factors and encourage screening and management of CKD.
The Future of Quality Measurement of CKD
The white paper outlines concepts for potential quality measures that could be developed in the near term in the areas of prevention, case finding, measuring and monitoring CKD. Other topics, such as the appropriate interval for screening people with established CKD, are not currently aligned across stakeholders, and would require additional research prior to developing a measure.
Learn More
- Download Advancing Care for Chronic Kidney Disease: Using Care Gaps to Inform a Quality Framework.
- Listen to our podcast, Chronic Kidney Disease Is a Quality Priority.
- Learn about our recent panel on CKM syndrome.
Thanks to our panel of experts for sharing their knowledge and insights. This research, and the resulting white paper, are made possible with support from Boehringer Ingelheim and Novo Nordisk.
