asymptomatic kidney damage and potentially ending in near total kidney failure—ESRD—which requires renal replacement therapy for ongoing survival. According to the Centers for Disease Control and Prevention (CDC), 37 million adults in the US have CKD and most of them are unaware of their condition. The clinical stages of CKD are defined by declining glomerular filtration rates (GFR) and albuminuria categories indicating increasing damage to kidney function. Equations for estimating GFR include adjustments for race, because non-Hispanic blacks have higher GFR than non-Hispanic whites at the same level of serum creatinine. Similarly, males have higher GFR than females and younger people have higher GFR than older people at the same levels of creatinine. Introduction Page 6 of 19 April 2021 While CKD is typically progressive, it does not affect all patients at the same rate. Racial minorities have a greater risk of progressing from CKD to ESRD and progress more rapidly than their non-Hispanic white counterparts. Progression of CKD Normal GFR Increased CKD Risk Kidney Damage Decreasing GFR Kidney Failure Complications (e.g., anemia, hypertension, hypoglycemia, cardiovascular disease, mineral and bone disturbances, malnutrition, depression) Death CKD Stage Treatment Strategies Screen for CKD Risk Factors CKD Risk Reduction; SCreening Diagnosis & Treatment; Slow Progression Treat Complications, Estimate CKD Progression Replacement by Dialysis or Transplant Source: Adapted from Eckardt, K.U., Coresh, J., Devuyst, O., Johnson, R.J., Kottgen, A., Levey, A.S. (2013). Evolving Importance of Kidney Disease: From Subspecialty to Global Health Burden. Global Kidney Disease. 382; 9887: 158-169. Available at https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(13)60439-0/fulltext It is also true that the vast majority of patients with CKD do not ever progress to kidney failure. CKD is considered a disease multiplier because it often occurs with other conditions such as diabetes, hypertension or heart disease. Notably, CKD patients have a heightened risk of cardiovascular disease and death at every stage of CKD. The two conditions are linked: CKD and heart disease share risk factors such as diabetes and hypertension, and each condition can lead to or worsen the other. CKD is diagnosed through a blood test measuring serum creatinine and a urine test to assess albumin. CKD is staged using both results over a 3-month time period. In the early stages of CKD (Stages 1–3), the focus of care is on slowing or preventing progression and treating complications; in the later stages (Stages 4–5), the focus of care shifts to planning for kidney failure. The KDIGO Heat Map displays the risk of progression for each GFR category. Progression of CKD is related to control of comorbidities, (diabetes, hypertension, cardiovascular disease), prevention of additional damage (acute kidney injury, nephrotoxic agents), optimizing health consequences (anemia, proteinuria), and recognition of population-based risk (race/ethnicity, age, family history). Early diagnosis and appropriate treatment can prevent or delay progression to later-stage CKD, resulting in decreased morbidity, mortality and costs. Introduction Page 7 of 19 April 2021 KDIGO Heat Map (KDIGO, 2017) Source: Kidney Disease Improving Global Outcomes (KDIGO). (2017). KDIGO 2017 Clinical Practice Guideline Update for the Diagnosis, Evaluation, Prevention, and Treatment of Chronic Kidney Disease – Mineral and Bone Disorder (CKD-MBD). Available at https://kdigo.org/wp-content/uploads/2017/02/2017-KDIGO-CKD-MBD-GL-Update.pdf Primary Care Is Key to Reducing Disparities in Chronic Kidney Disease Interventions that can slow progression of CKD include early identification, controlling blood pressure, controlling blood glucose, reducing albuminuria, eating a healthy diet and maintaining a healthy lifestyle. Primary care practice teams have an opportunity to apply population health strategies that may improve identification of individuals with CKD, improve care for patients with CKD and slow progression of the disease. As the front line of health care, primary care is especially important for conditions such as CKD, which may not cause symptoms until the late stages of disease. By increasing awareness of known racial, ethnic and economic disparities in care for CKD, this guide encourages primary care professionals to adopt strategies that can improve health care and health for vulnerable populations. Introduction Page 8 of 19 April 2021 Example: Indian Health Service Improvements in Care for Chronic Kidney Disease The Indian Health Service (IHS) cut the rate of kidney failure in half for Native Americans with diabetes by applying population health approaches to patients with noted socioeconomic disparities. In 1996, American Indians and Alaska Natives had the highest rates of diabetesrelated ESRD incidence, compared with other racial and ethnic groups in the US. By 2013, the incidence of diabetes-related ESRD had decreased from 57.3 percent in 1996 to 26.5 percent in 2013 (Bullock et al., 2017). The decrease coincided with incorporating the assessment and treatment of CKD into IHS standards for managing diabetes. While the IHS had previously adopted systematic approaches to controlling diabetes, including multidisciplinary team-