Rethinking Early Detection of CKD: A Shift Toward Upstream Care

Chronic kidney disease (CKD) affects an estimated 35 million people in the United States, yet it remains persistently underdiagnosed, underrecognized, and often addressed late in its course.

Despite a wave of therapeutic innovation over the past decade, including SGLT2 inhibitors, non-steroidal mineralocorticoid receptor antagonists, and GLP-1 receptor agonists, most patients continue to enter care at stage 3b or later, when significant and often irreversible kidney damage has already occurred. Against this backdrop, a recent multidisciplinary virtual forum from HCPLive, led by Muthiah Vaduganathan, MD, MPH, codirector of the Center for Cardiometabolic Implementation Science at Brigham and Women’s Hospital, convened nephrologists from academic and private practice settings across the country to examine a central question: how do we move CKD detection and management upstream?

The discussion centered on operationalizing early identification of CKD using routine biomarkers such as estimated glomerular filtration rate (eGFR) and urine albumin-to-creatinine ratio (UACR), and on improving risk stratification before patients ever see a nephrologist. Participants highlighted national data showing persistent gaps in CKD awareness, particularly among younger individuals, women, and racial and ethnic minority populations.

Even among patients with documented CKD in the medical record, awareness remains low. Compounding the problem is a limited nephrology workforce, making universal early referral neither feasible nor necessary.

Instead, the conversation emphasized redefining early CKD as a cardiovascular risk condition and embedding screening within broader cardio-kidney-metabolic care. With cardiovascular disease remaining the leading cause of death in CKD, panelists argued that early kidney abnormalities, especially albuminuria, should be framed not simply as markers of future dialysis risk, but as powerful indicators of systemic vascular injury.

In an era of disease-modifying therapies capable of slowing progression and reducing cardiovascular events, the forum explored how clinicians, health systems, and payers might rethink detection strategies, referral pathways, and multidisciplinary collaboration.

Throughout the discussion, participants repeatedly returned to the reality that most referrals still occur when eGFR falls < 45 mL/min/1.73 m², while earlier-stage patients, particularly those with preserved eGFR but significant albuminuria, are often missed. UACR testing remains underutilized outside of diabetes care, and confusion persists among primary care clinicians regarding the interpretation of albuminuria versus total proteinuria.

Several panelists described educational initiatives aimed at improving primary care understanding, including reframing albuminuria as the “troponin of the kidney,” yet acknowledged that education alone may not be sufficient. Workforce shortages, time constraints in 20-minute visits, EHR fatigue, and limited health literacy all create structural barriers to earlier detection and intervention.

Ultimately, the forum highlighted a need for system-level change. Potential solutions discussed included risk-based referral models rather than rigid eGFR thresholds, automated EHR or AI-driven lab triggers, payer-aligned quality metrics tied to UACR screening, and community-based outreach in high-risk populations.

The broader shift toward a cardio-kidney-metabolic framework was seen as an opportunity to align specialties around shared therapies and shared risk reduction goals. However, panelists were candid: without stronger incentives, clearer risk stratification tools, and expanded workforce capacity, the promise of early CKD “remission” through modern therapies may remain unrealized.

References

1. US Centers for Disease Control and Prevention. Chronic Kidney Disease in the United States, 2023. May 15, 2024. Accessed February 11, 2026.