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Primary Medical Care Integrated with Healthy Eating and Healthy Moving is Essential to Reduce Chronic Kidney Disease Progression

      Abstract

      Increasing adverse outcomes in patients with chronic kidney disease reflect growth of patients with early-stage chronic kidney disease and their increasing per population rates of these outcomes. Progression of chronic kidney disease, more than current level of kidney function, is the primary driver of adverse chronic kidney disease-related outcomes. Racial/ethnic minorities progress faster to end-stage kidney disease with greater risk for adverse outcomes. Diabetes and hypertension cause two-thirds of end-stage kidney disease, for which primary medical care integrated with healthy eating and increased physical activity (healthy moving) slows chronic kidney disease progression. Patients with early-stage chronic kidney disease are appropriately managed by primary care practices but most lack infrastructure to facilitate this integration that reduces adverse chronic kidney disease-related outcomes. Individuals of low socioeconomic status are at greater chronic kidney disease risk, and flexible regulatory options in Medicaid can fund infrastructure to facilitate healthy eating and healthy moving integration with primary medical care. This integration promises to reduce chronic kidney disease-related adverse outcomes, disproportionately in racial/ethnic minorities, and thereby reduce chronic kidney disease-related health disparities.

      Keywords

      Clinical Significance
      • Progression of early-stage chronic kidney disease, managed in primary care, contributes most chronic kidney disease-related adverse outcomes.
      • Racial/ethnic minorities suffer greater risk for chronic kidney disease progression.
      • Healthy eating and increased physical activity (healthy moving) integration with primary medical care to yield primary health care can slow progression of chronic kidney disease.
      • Flexible Medicaid options can fund infrastructure to support this integration that will facilitate this primary health care approach.

      Introduction

      Chronic kidney disease is among the few chronic diseases in the United States with increasing prevalence,
      • Bowe B
      • Xie Y
      • Li T
      • et al.
      Changes in the US burden of chronic kidney disease from 2002 to 2016: an analysis of the global burden of disease study.
      is the ninth leading cause of US mortality,
      • Kochanek KD
      • Murphy SL
      • Xu J
      • Arias E
      Deaths: final data for 2017.
      and is increasing disability-adjusted life years lost.
      • Bowe B
      • Xie Y
      • Li T
      • et al.
      Changes in the US burden of chronic kidney disease from 2002 to 2016: an analysis of the global burden of disease study.
      ,
      • Jager KJ
      • Fraser SDS
      The ascending rank of chronic kidney disease in the global burden of disease study.
      Patients with chronic kidney disease contribute broadly to US mortality because they have increased risks for heart disease,
      United State Renal Data System (USRDS)
      USRDS Annual Data Report: Epidemiology of kidney disease in the United States. National Institutes of Health.
      cancer for those over age 65 years,
      • Navaneethan SD
      • Schold JD
      • Arrigain S
      • Jolly SE
      • Nally Jr, JV
      Cause-specific deaths in non-dialysis-dependent CKD.
      and stroke,
      • Masson P
      • Webster AC
      • Hong M
      • Turner R
      • Lindley RI
      • Craig JC
      Chronic kidney disease and the risk of stroke: a systematic review and meta-analysis.
      which represent, respectively, the first, second, and fifth causes of US mortality.
      • Kochanek KD
      • Murphy SL
      • Xu J
      • Arias E
      Deaths: final data for 2017.
      Because patients with chronic kidney disease more likely die from these diseases prior to progressing to end-stage kidney disease,
      • Keith DS
      • Nichols GA
      • Gullion CM
      • Brown JB
      • Smith DH
      Longitudinal follow-up and outcomes among a population with chronic kidney disease in a large managed care organization.
      their deaths from these non-chronic kidney diseases but with underlying chronic kidney disease are not counted as chronic kidney disease-related mortality, making it an under-appreciated cause of US mortality.

      Chronic Kidney Disease Stage and Outcomes

      Increasing chronic kidney disease stage reflects decreasing estimated glomerular filtration rate,
      United State Renal Data System (USRDS)
      USRDS Annual Data Report: Epidemiology of kidney disease in the United States. National Institutes of Health.
      and each subsequent stage is associated with increased mortality.
      • van der Velde M
      • Matsushita K
      • Coresh J
      • et al.
      Lower estimated glomerular filtration rate and higher albuminuria are associated with all-cause and cardiovascular mortality. A collaborative meta-analysis of high-risk population cohorts.
      ,
      • McCullough KP
      • Morgenstern H
      • Saran R
      • Herman WH
      • Robinson BM
      Projecting ESRD Incidence and Prevalence in the United States through 2030.
      Even patients with the comparatively preserved estimated glomerular filtration rate of stage 2 (60-89 mL/min/1.73 m2) suffer increased all-cause and cardiovascular disease mortality than those with normal estimated glomerular filtration rate.
      • van der Velde M
      • Matsushita K
      • Coresh J
      • et al.
      Lower estimated glomerular filtration rate and higher albuminuria are associated with all-cause and cardiovascular mortality. A collaborative meta-analysis of high-risk population cohorts.
      ,
      • Kovesdy CP
      • Coresh J
      • Ballew SH
      • et al.
      Past decline versus current eGFR and subsequent ESRD risk.
      Chronic kidney disease prevalence is increasing among Medicare patients aged 65 years and over, particularly those with stage 3 (estimated glomerular filtration rate 30-59 mL/min/1.73 m2),
      United State Renal Data System (USRDS)
      USRDS Annual Data Report: Epidemiology of kidney disease in the United States. National Institutes of Health.
      the latter being the largest fraction of US patients with chronic kidney disease.
      United State Renal Data System (USRDS)
      USRDS Annual Data Report: Epidemiology of kidney disease in the United States. National Institutes of Health.
      Also, chronic kidney disease-related mortality is increasing,
      United State Renal Data System (USRDS)
      USRDS Annual Data Report: Epidemiology of kidney disease in the United States. National Institutes of Health.
      as is its progression to end-stage kidney disease,
      • McCullough KP
      • Morgenstern H
      • Saran R
      • Herman WH
      • Robinson BM
      Projecting ESRD Incidence and Prevalence in the United States through 2030.
      making chronic kidney disease a major health burden.

      Chronic Kidney Disease Progression and Outcomes

      Although current estimated glomerular filtration rate is an important determinant of adverse outcomes,
      • van der Velde M
      • Matsushita K
      • Coresh J
      • et al.
      Lower estimated glomerular filtration rate and higher albuminuria are associated with all-cause and cardiovascular mortality. A collaborative meta-analysis of high-risk population cohorts.
      its more rapid progression is associated with greater end-stage kidney disease risk
      • Kovesdy CP
      • Coresh J
      • Ballew SH
      • et al.
      Past decline versus current eGFR and subsequent ESRD risk.
      and mortality
      • Naimark DM
      • Grams ME
      • Matsushita K
      • et al.
      Past decline versus current eGFR and subsequent mortality risk.
      independent of current estimated glomerular filtration rate. Because progression from stage 3 to stage 4 (estimated glomerular filtration rate 15-29 mL/min/1.73 m2) yields the greatest proportional increase in mortality
      • Go AS
      • Chertow GM
      • Fan D
      • McCulloch CE
      • Hsu CY
      Chronic kidney disease and the risks of death, cardiovascular events, and hospitalization.
      and care costs
      • Golestaneh L
      • Alvarez PJ
      • Reaven NL
      • et al.
      All-cause costs increase exponentially with increased chronic kidney disease stage.
      than other stage progressions, preventing stage 3 to 4 progression yields the greatest return with respect to minimizing mortality and management costs. Primary care guidelines
      • Qaseem A
      • Hopkins Jr, RH
      • Sweet DE
      • Starkey M
      • Shekelle P
      Clinical Guidelines Committee of the American College of Physicians
      Screening, monitoring, and treatment of stage 1 to 3 chronic kidney disease: a clinical practice guideline from the American College of Physicians.
      recommend nephrology referral only when estimated glomerular filtration rate is <30 mL/min/1.73 m2 (stages 4 and 5) or when urine albumin-to-creatinine ratio exceeds 300 mg/g creatinine
      • Gaitonde DY
      • Cook DL
      • Rivera IM
      Chronic kidney disease: detection and evaluation.
      such that primary care practices manage patients with chronic kidney disease up to and including stage 3. Primary care practices are therefore key to preventing the most critical chronic kidney disease stage progression with its adverse human, medical, and economic outcomes.
      The 2 strongest independent predictors of chronic kidney disease progression for patients in a large health system were proteinuria and elevated systolic blood pressure,
      • Go AS
      • Yang J
      • Tan TC
      • et al.
      Contemporary rates and predictors of fast progression of chronic kidney disease in adults with and without diabetes mellitus.
      both of which are easily identified and managed in primary care settings. Furthermore, patients with diabetes and stage 3 chronic kidney disease compared with earlier stages were more likely to have rapid estimated glomerular filtration rate decline, and the risk was greater for those with more proteinuria.
      • Go AS
      • Yang J
      • Tan TC
      • et al.
      Contemporary rates and predictors of fast progression of chronic kidney disease in adults with and without diabetes mellitus.
      Unfortunately, most patients with diabetes or hypertension followed in primary care settings are unaware of their chronic kidney disease risk
      • Szczech LA
      • Stewart RC
      • Su HL
      • et al.
      Primary care detection of chronic kidney disease in adults with type-2 diabetes: the ADD-CKD Study (awareness, detection and drug therapy in type 2 diabetes and chronic kidney disease).
      and are not routinely assessed for estimated glomerular filtration rate or albuminuria, particularly those insured by Medicaid or Medicare.
      • Alfego D
      • Ennis J
      • Gillespie B
      • et al.
      Chronic kidney disease testing among at-risk adults in the U.S. remains low: real-world evidence from a national laboratory database.
      These data show the tremendous opportunity to improve identification of patients with diabetes or hypertension in primary care settings for interventions that will reduce their risk for these adverse outcomes.

      Socioeconomic/Racial/Ethnic Associations with Chronic Kidney Disease Prevalence and Outcomes

      Individuals of low socioeconomic status are at increased chronic kidney disease risk
      United State Renal Data System (USRDS)
      USRDS Annual Data Report: Epidemiology of kidney disease in the United States. National Institutes of Health.
      ,
      • Vart P
      • Gansevoort RT
      • Coresh J
      • Reijneveld SA
      • Baltmann U
      Socioeconomic measures and CKD in the United States and The Netherlands.
      and are at increased risk for its 2 major causes, diabetes
      • Jaffiol C
      • Thomas F
      • Bean K
      • Jego B
      • Danchin N
      Impact of socioeconomic status on diabetes and cardiovascular risk factors: results of a large French survey.
      and hypertension.
      • Shahu A
      • Herrin J
      • Dhruva SS
      • et al.
      Disparities in socioeconomic context and association with blood pressure control and cardiovascular outcomes in ALLHAT.
      Comparing black and white individuals of the same socioeconomic status, higher diabetes prevalence in black individuals was mediated by differences in established socioeconomic status-related risk factors for diabetes such as obesity and lack of physical activity.
      • Signorello LB
      • Schlundt DG
      • Cohen SS
      • et al.
      Comparing diabetes prevalence between African Americans and Whites of similar socioeconomic status.
      More consistent implementation of lifestyle modifications, including healthy eating and healthy moving, can improve outcomes in patients with diabetes-related chronic kidney disease.
      • Navaneethan SD
      • Zoungas S
      • Caramori ML
      • et al.
      Diabetes management in chronic kidney disease: synopsis of the 2020 KDIGO clinical practice guideline.
      The data highlight opportunities for Medicaid, the government health insurer for individuals with low incomes, to fund interventions shown to reduce the risk for chronic kidney disease and its progression in this population at higher risk for both.
      US racial and ethnic minorities, compared with non-minorities, are more likely to be of low socioeconomic status, more likely to suffer untoward health effects associated with low socioeconomic status,
      • Williams DR
      • Priest N
      • Anderson NB
      Understanding associations among race, socioeconomic status, and health: patterns and prospects.
      and suffer the impact of chronic kidney disease disproportionately.
      United State Renal Data System (USRDS)
      USRDS Annual Data Report: Epidemiology of kidney disease in the United States. National Institutes of Health.
      ,
      • Hsu CY
      • Lin F
      • Vittinghoff E
      • Shlipak MG
      Racial differences in the progression from chronic renal insufficiency to end-stage renal disease in the United States.
      For example, black compared with white individuals have higher chronic kidney disease risk,
      United State Renal Data System (USRDS)
      USRDS Annual Data Report: Epidemiology of kidney disease in the United States. National Institutes of Health.
      and once it is present, black individuals progress faster to end-stage kidney disease.
      • Hsu CY
      • Lin F
      • Vittinghoff E
      • Shlipak MG
      Racial differences in the progression from chronic renal insufficiency to end-stage renal disease in the United States.
      Black individuals also have higher risk for the 2 major causes of chronic kidney disease, diabetes
      • Zelnick LR
      • Weiss NS
      • Kestenbaum BR
      • et al.
      Diabetes and CKD in the United States Population, 2009-2014.
      and hypertension.
      • Musemwa N
      • Gadegbeku CA
      Hypertension in African Americans.
      Following onset of diabetes, a black individual is more likely to develop diabetes-related chronic kidney disease
      • Zelnick LR
      • Weiss NS
      • Kestenbaum BR
      • et al.
      Diabetes and CKD in the United States Population, 2009-2014.
      and more likely than a white individual to die when each has the same estimated glomerular filtration rate.
      • Choi AI
      • Rodriguez RA
      • Bacchetti P
      • Bertenthal D
      • Hernandez GT
      • O'Hare AM
      White/Black racial differences in risk of end-stage renal disease and death.
      Likewise, black individuals with hypertension develop early-stage chronic kidney disease at similar rates to other US population groups with hypertension, but progress faster to end-stage kidney disease,
      United States Renal Data System (USRDS)
      2010 USRDS Annual Data Report: Atlas of Chronic Kidney Disease and End-Stage Renal Disease in the United States. National Institutes of Health.
      with higher mortality.
      • Carnethon MR
      • Pu J
      • Howard G
      • et al.
      Cardiovascular health in African Americans: a scientific statement from the American Heart Association.
      Although black individuals have less medical care access than white individuals,
      • Williams DR
      • Priest N
      • Anderson NB
      Understanding associations among race, socioeconomic status, and health: patterns and prospects.
      health care providers achieve higher performance on chronic kidney disease process measures among black than white individuals.
      • Chu CD
      • Powe NR
      • McCulloch CE
      • et al.
      Trends in chronic kidney disease care in the US by race and ethnicity, 2012-2019.
      This suggests that successful implementation of process measures of medical care such as medication prescription and diagnostic testing are unlikely to fully explain racial/ethnic disparities in adverse chronic kidney disease outcomes. As described for diabetes,
      • Navaneethan SD
      • Zoungas S
      • Caramori ML
      • et al.
      Diabetes management in chronic kidney disease: synopsis of the 2020 KDIGO clinical practice guideline.
      more routine integration of healthy eating and healthy moving with process-driven medical care might reduce these adverse outcomes. Because black, compared with white, individuals are more likely to be of low socioeconomic status,

      Noël RA. U.S. Bureau of Labor Statistics, Spotlight on Statistics: race, economics, and social status. May 2018. Available at:https://www.bls.gov/spotlight/2018/race-economics-and-social-status/home.htm. Accessed May 19, 2022.

      black individuals are more likely to have Medicaid support their health needs. Thus, Medicaid can finance innovative interventions like infrastructure to support integration of healthy eating and healthy moving within primary medical care to help reduce adverse chronic kidney disease-related outcomes.

      Greater Contributions of Early-Stage Chronic Kidney Disease to Adverse Chronic Kidney Disease Outcomes

      Increases in chronic kidney disease-related mortality and of disability-adjusted lives lost
      • Bowe B
      • Xie Y
      • Li T
      • et al.
      Changes in the US burden of chronic kidney disease from 2002 to 2016: an analysis of the global burden of disease study.
      ,
      • Jager KJ
      • Fraser SDS
      The ascending rank of chronic kidney disease in the global burden of disease study.
      are mediated in part by little progress in reducing these outcomes in patients with earlier-stage chronic kidney disease (stages 1-3, estimated glomerular filtration rate ≥30 mL/min/1.73 m2), who are increasing in incidence and in their per-population rate of adverse outcomes.
      • Jager KJ
      • Fraser SDS
      The ascending rank of chronic kidney disease in the global burden of disease study.
      These suboptimal outcomes in patients with early-stage chronic kidney disease might be mediated in part by less-than-optimal implementation of lifestyle recommendations for treatment of diabetes and hypertension. Healthy eating, including high dietary proportions of fruits and vegetables, is recommended first-line diabetes treatment but is less than optimally implemented in most with diabetes.
      American Diabetes Association
      4. Lifestyle management.
      Increased physical activity is also recommended first-line diabetes treatment, but it too is less-than-optimally implemented,
      • Colberg SR
      • Sigal RJ
      • Yardley JE
      • et al.
      Physical activity/exercise and diabetes: a position statement of the American Diabetes Association.
      including in those with diabetes-related chronic kidney disease.
      • Navaneethan SD
      • Zoungas S
      • Caramori ML
      • et al.
      Diabetes management in chronic kidney disease: synopsis of the 2020 KDIGO clinical practice guideline.
      Similarly, healthy eating, including the Dietary Approaches to Stop Hypertension diet, high in fruits and vegetables, is recommended first-line treatment for hypertension but is under-used in these patients.
      • Whelton PK
      • Carey RM
      • Aronow WS
      • et al.
      2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines.
      Increased physical activity is recommended first-line treatment for hypertension but is under-used as well.
      • Barone Gibbs B
      • Hivert MF
      • Jerome GJ
      • et al.
      Physical activity as a critical component of first-line treatment for elevated blood pressure or cholesterol: who, what, and how?: a scientific statement from the American Heart Association.

      Healthy Eating and Healthy Moving Integrated with Medical Care Might Reduce Chronic Kidney Disease Progression

      Prevention of further kidney function decline best begins with management of early-stage chronic kidney disease, which is likely to be recognized first by primary care physicians (Figure 1). Glycemic control in patients with diabetes
      • Jung HH
      Evaluation of serum glucose and kidney disease progression among patients with diabetes.
      and blood pressure control in those with hypertension without diabetes but with proteinuria
      • Ku E
      • Sarnak MJ
      • Toto R
      • et al.
      Effect of blood pressure control on long-term risk of end-stage renal disease and death among subgroups of patients with chronic kidney disease.
      is associated with slower chronic kidney disease progression in its early stages, and such care is typically provided in primary care. Nevertheless, patients with modest estimated glomerular filtration rate reductions below normal (<90 mL/min/1.73 m2) can have persistent progression toward end-stage kidney disease despite recommended kidney-protective interventions including blood pressure control, with regimens including anti-angiotensin II therapy in patients with chronic kidney disease due to diabetes
      • Lewis EJ
      • Hunsicker LG
      • Clarke WR
      • et al.
      Renoprotective effect of the angiotensin-receptor antagonist irbesartan in patients with nephropathy due to type 2 diabetes.
      or to non-diabetic causes.
      • Cheung AK
      • Rahman M
      • Reboussin DM
      • et al.
      Effects of intensive BP control in CKD.
      Persistent progression despite blood pressure control with anti-angiotensin II therapy is particularly prevalent in populations at increased end-stage kidney disease risk, including black individuals
      • Appel LJ
      • Wright Jr, JT
      • Greene T
      • et al.
      Long-term effects of renin-angiotensin system-blocking therapy and a low blood pressure goal on progression of hypertensive chronic kidney disease in African Americans.
      in whom greater progression risk begins at early chronic kidney disease stages, including stages 1 and 2.
      • Peralta CA
      • Katz R
      • DeBoer I
      • et al.
      Racial and ethnic differences in kidney function decline among persons without chronic kidney disease.
      Also, diabetes-related chronic kidney disease progression continues in patients despite sodium-glucose cotransporter-2 inhibitors
      • Navaneethan SD
      • Zoungas S
      • Caramori ML
      • et al.
      Diabetes management in chronic kidney disease: synopsis of the 2020 KDIGO clinical practice guideline.
      and mineralocorticoid receptor antagonists.
      • Bakris GL
      • Agarwal R
      • Anker SD
      • et al.
      Effect of finerenone on chronic kidney disease outcomes in type 2 diabetes.
      Figure 1
      Figure 1Reframed paradigm for CKD management. The bulk of patients with CKD are in its early stages and are managed in primary care where the opportunity to prevent its progression to more advanced stages with its associated adverse outcomes is greatest. This care is best done by comprehensive management of the two major CKD causes, diabetes and hypertension, which includes integration of healthy eating and healthy moving with primary medical care. CKD = chronic kidney disease; CV = cardiovascular; eGFR = estimated glomerular filtration rate.
      Effective lifestyle interventions integrated with pharmacologic therapy available to primary care might further reduce progression risk in early-stage chronic kidney disease (Figure 2). Epidemiologic studies support lower chronic kidney disease incidence
      • Jhee JH
      • Kee YK
      • Park JT
      • et al.
      A diet rich in vegetables and fruit and incident CKD: a community-based prospective cohort study.
      and its slower progression in patients eating “healthy” diets (including high amounts of fruits and vegetables).
      • Liu Y
      • Kuczmarski MF
      • Miller 3rd, ER
      • et al.
      Dietary habits and risk of kidney function decline in an urban population.
      Metabolic acidosis associated with enhanced chronic kidney disease progression
      • Goraya N
      • Simoni J
      • Jo CH
      • Wesson DE
      Treatment of metabolic acidosis in patients with stage 3 chronic kidney disease with fruits and vegetables or oral bicarbonate reduces urine angiotensinogen and preserves glomerular filtration rate.
      can be improved by dietary addition of fruits and vegetables,
      • Goraya N
      • Simoni J
      • Jo CH
      • Wesson DE
      A comparison of treating metabolic acidosis in CKD stage 4 hypertensive kidney disease with fruits and vegetables or sodium bicarbonate.
      and this adjunctive treatment in patients with chronic kidney disease on guideline-recommended pharmacologic kidney protection slowed estimated glomerular filtration rate decline.
      • Goraya N
      • Simoni J
      • Jo CH
      • Wesson DE
      Treatment of metabolic acidosis in patients with stage 3 chronic kidney disease with fruits and vegetables or oral bicarbonate reduces urine angiotensinogen and preserves glomerular filtration rate.
      Epidemiologic studies support lower chronic kidney disease incidence in general populations eating low sodium diets,
      • Sugiura T
      • Takase H
      • Ohte N
      • Dohi Y
      Dietary salt intake is a significant determinant of impaired kidney function in the general population.
      and in patients with chronic kidney disease, this intervention reduced blood pressure
      • Saran R
      • Padilla RL
      • Gillespie BW
      • et al.
      A randomized crossover trial of dietary sodium restriction in stage 3-4 CKD.
      and slowed progression.
      • Smyth A
      • O'Donnell MJ
      • Yusuf S
      • et al.
      Sodium intake and renal outcomes: a systematic review.
      Because increased dietary sodium attenuated the kidney-protective effects of angiotensin-converting enzyme inhibitors
      • Vegter S
      • Perna A
      • Postma MJ
      • Navis G
      • Remuzzi G
      • Ruggenenti P
      Sodium intake, ACE inhibition, and progression to ESRD.
      and angiotensin receptor blockers,
      • Lambers Heerspink HJ
      • Holtkamp FA
      • Parving HH
      • et al.
      Moderation of dietary sodium potentiates the renal and cardiovascular protective effects of angiotensin receptor blockers.
      dietary sodium restriction might also enhance kidney protective effects of angiotensin-converting enzyme inhibitors and angiotensin receptor blockers, both mainstream therapy for chronic kidney disease.
      Chapter 3: Management of progression and complications of CKD.
      Increased physical activity is also associated with reduced chronic kidney disease incidence,
      • Parvathaneni K
      • Surapaneni A
      • Ballew SH
      • et al.
      Association between midlife physical activity and incident kidney disease: the Atherosclerosis Risk in Communities (ARIC) study.
      and interventional studies will determine if this intervention that improves glycemic
      American Diabetes Association
      4. Lifestyle management.
      and blood pressure
      • Barone Gibbs B
      • Hivert MF
      • Jerome GJ
      • et al.
      Physical activity as a critical component of first-line treatment for elevated blood pressure or cholesterol: who, what, and how?: a scientific statement from the American Heart Association.
      control also reduces chronic kidney disease risk or its progression in patients with its 2 major causes, diabetes and hypertension.
      United State Renal Data System (USRDS)
      USRDS Annual Data Report: Epidemiology of kidney disease in the United States. National Institutes of Health.
      Figure 2
      Figure 2Interventions to slow or prevent CKD progression. ACE = angiotensin-converting enzyme; ARBs = angiotensin II receptor blockers; CKD = chronic kidney disease; SGLT-2 = sodium-glucose cotransporter-2.

      A Reframed Paradigm for Early-Stage Chronic Kidney Disease Care

      Outcomes for patients with earlier-stage chronic kidney disease might improve with a reframed care paradigm that integrates healthy eating and healthy moving with standard primary medical care, as recommended for diabetes
      American Diabetes Association
      4. Lifestyle management.
      and hypertension.
      • Whelton PK
      • Carey RM
      • Aronow WS
      • et al.
      2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines.
      This paradigm recognizes that nearly all components of chronic kidney disease guideline care for patients with early-stage chronic kidney disease
      Chapter 3: Management of progression and complications of CKD.
      constitute elements of care that are already commonly addressed in primary care settings,
      • Qaseem A
      • Hopkins Jr, RH
      • Sweet DE
      • Starkey M
      • Shekelle P
      Clinical Guidelines Committee of the American College of Physicians
      Screening, monitoring, and treatment of stage 1 to 3 chronic kidney disease: a clinical practice guideline from the American College of Physicians.
      ,
      • Gaitonde DY
      • Cook DL
      • Rivera IM
      Chronic kidney disease: detection and evaluation.
      and is illustrated in Figure 1. This approach aligns with a new vision of “high quality primary care” that emphasizes integration of resources like healthy eating with medical care and recognizes the critical role of communities in provision of primary care.
      National Academies of Sciences, Engineering, and Medicine
      Implementing High-Quality Primary Care: Rebuilding the Foundation of Health Care.
      Executing this paradigm in communities of low socioeconomic status, appropriate foci for strategies to reduce chronic kidney disease incidence,
      • Vart P
      • Gansevoort RT
      • Coresh J
      • Reijneveld SA
      • Baltmann U
      Socioeconomic measures and CKD in the United States and The Netherlands.
      requires investment in infrastructure to integrate healthy eating
      • Vilar-Compte M
      • Burrola-Mendez S
      • Lozano-Marrufo A
      • et al.
      Urban poverty and nutrition challenges associated with accessibility to a healthy diet: a global systematic literature review.
      and healthy moving
      • Rawal LB
      • Smith BJ
      • Quach H
      • Renzaho AMN
      Physical activity among adults with low socioeconomic status living in industrialized countries: a meta-ethnographic approach to understanding socioecological complexities.
      with primary medical care. This integration will help generate a shift from delivery of primary medical care toward a model facilitating primary health care and prevention with the goal of reducing or preventing adverse chronic kidney disease-related outcomes.
      This shift to primary health care for chronic kidney disease requires new infrastructure to facilitate healthy eating and healthy moving programs, and would add resources to existing primary care delivery systems that currently largely support office-based medical care. New programs would go beyond typical office-based attempts to help patients achieve important health behavior changes, which often involve provider recommendations that patients seek options for healthy eating and healthy moving through programs that are often unconnected to their ongoing medical care. A more ideal scenario would provide infrastructure for healthy eating and healthy moving that is functionally connected with the medical infrastructure to provide the 3 components of primary health care (medical care + healthy eating + healthy moving) as a single enterprise. In low-income, largely racial/ethnic minority communities, this approach led to decentralized community-based platforms for healthy eating and healthy moving, including institutions of faith and community centers, each with low barriers to access. Healthy eating and healthy moving infrastructure consisted of “Farm Stands” at local community centers and churches along with structured physical activity programs at many of these locations. These platforms for healthy eating and healthy moving function collaboratively with centralized clinics that provide the medical component of primary health care, and community health workers help maintain functional connections among these infrastructure components.
      • Wesson D
      • Kitzman H
      • Halloran KH
      • Tecson K
      Innovative population health model associated with reduced emergency department use and inpatient hospitalizations.
      Infrastructure supporting healthy eating and healthy moving in communities of low socioeconomic status should be in these communities to lower barriers to access, given the challenges faced by residents of such communities to access health system services.
      • Wesson DE
      • Lucey CR
      • Cooper LA
      Building trust in health systems to eliminate health disparities.
      Optimizing usage of such resources in these communities with justifiable mistrust of health systems due to historical mistreatment requires affirmation by “trusted agent” community entities like faith-based institutions or local community centers.
      • Wesson DE
      • Lucey CR
      • Cooper LA
      Building trust in health systems to eliminate health disparities.
      ,

      Centers for Disease Control and Prevention. Diabetes Self-Management Education and Support (DSMES) Toolkit. Return on investment. March 12, 2018. Available at: https://www.cdc.gov/diabetes/dsmes-toolkit/business-case/roi.html. Accessed May 19, 2022.

      Many “trusted agent” community-based organizations provide social and support services, including chronic disease self-management programs, nutrition counseling, and physical activity programs.
      • Wesson DE
      • Kitzman-Ulrich H
      How academic health systems can achieve population health in vulnerable populations through value-based care: the critical importance of establishing trusted agency.

      Recent Policies Support Integration of Healthy Eating and Healthy Moving into Primary Care for Chronic Kidney Disease

      The Kidney Care Choices Model being assessed by the Center for Medicare and Medicaid Innovation (CMMI) focuses on chronic kidney disease stages 4 and 5, including those with end-stage kidney disease, and so is directed at nephrologists, not primary care providers. While important, these models do not allow for a more holistic approach to chronic kidney disease progression through primary care management of patients with earlier-stage disease in whom protective strategies can most impactfully reduce adverse outcomes. Accordingly, it seems prudent for CMMI to consider primary care practitioners in future incentives for forthcoming iterations of payment modeling to reduce chronic kidney disease-related adverse outcomes.
      Given the disproportionately elevated risk for chronic kidney disease in low socioeconomic status communities and that Medicaid is the government insurer for individuals with low-incomes, Medicaid is an attractive program through which to support community-based, kidney-protective strategies inclusive of healthy eating and healthy moving integrated with primary medical care to achieve this new standard of primary health care. Medicaid programs are increasingly exercising regulatory options to address health needs that go beyond provision of traditional medical care through non-medical drivers of health care, including healthy eating and healthy moving.

      Healthify. Leveraging Medicaid section 1115 waivers to address social determinants of health. Available at:https://get.healthify.us/leveraging-medicaid-section-1115-waivers-for-sdoh?referral_source=blog&campaign_source=wp-medicaid-waivers. Accessed March 16, 2021.

      This approach is particularly relevant, recognizing that medical care accounts for only about 10%-20% of modifiable contributors to healthy population outcomes.
      • Hood CM
      • Gennuso KP
      • Swain GR
      • Catlin BB
      County health rankings: relationships between determinant factors and health outcomes.
      While Medicaid traditionally does not cover non-medical service expenditures, many state programs are addressing these needs through managed care contracts and other authorities made available to them,

      Crook HL, Zheng J, Bleser WK, Whitaker RG, Masand J, Saunders RS. How are payment reforms addressing social determinants of health? Policy implications and next steps. Milbank Memorial Fund and Duke-Margolis Center for Health Policy. February 4, 2021. Available at:https://www.milbank.org/publications/how-are-payment-reforms-addressing-social-determinants-of-health-policy-implications-and-next-steps/. Accessed May 19, 2022.

      including use of alternative payment models.

      Frieden J, Washington ed. MEDPAGE Today. Medicaid will be a bigger target of alternative payment models, CMS official says. October 13, 2021. Available at: https://www.medpagetoday.com/meetingcoverage/phc/95029. Accessed May 19, 2022.

      The Accountable Health Communities Model launched in 21 states by CMMI in 2017 examines Medicare and Medicaid beneficiaries to determine if identifying and addressing their health-related social needs, including through community navigation services, and connecting them with community-based resources, will improve health outcomes, reduce utilization of health care resources, and reduce health care costs.

      RTI International. Accountable Health Communities (AHC) Model Evaluation. First Evaluation Report. December 2020. Research Triangle Park, NC: RTI International. Available at: https://innovation.cms.gov/data-and-reports/2020/ahc-first-eval-rpt. Accessed May 19, 2022.

      The model funds multiple entities in the health care “value chain,” such as community service providers (including providers of healthy food), clinical delivery sites, and “bridge” organizations, including nonprofits that provide functional connections among contributing entities. This analysis identified food insecurity as the most reported health-related social need.

      RTI International. Accountable Health Communities (AHC) Model Evaluation. First Evaluation Report. December 2020. Research Triangle Park, NC: RTI International. Available at: https://innovation.cms.gov/data-and-reports/2020/ahc-first-eval-rpt. Accessed May 19, 2022.

      Home delivery of medically tailored meals to nutritionally vulnerable individuals reduced hospitalizations and lowered medical spending,
      • Berkowitz SA
      • Terranova J
      • Hill C
      • et al.
      Meal delivery programs reduce the use of costly health care in dually eligible Medicare and Medicaid beneficiaries.
      and modeling shows that increased healthier food consumption can lead to cost-effective health improvements.
      • Berkowitz SA
      • Terranova J
      • Hill C
      • et al.
      Meal delivery programs reduce the use of costly health care in dually eligible Medicare and Medicaid beneficiaries.
      In response, some states are using flexibility within Medicaid,

      Healthify. Leveraging Medicaid section 1115 waivers to address social determinants of health. Available at:https://get.healthify.us/leveraging-medicaid-section-1115-waivers-for-sdoh?referral_source=blog&campaign_source=wp-medicaid-waivers. Accessed March 16, 2021.

      including managed care contracts and other available authorities

      Crook HL, Zheng J, Bleser WK, Whitaker RG, Masand J, Saunders RS. How are payment reforms addressing social determinants of health? Policy implications and next steps. Milbank Memorial Fund and Duke-Margolis Center for Health Policy. February 4, 2021. Available at:https://www.milbank.org/publications/how-are-payment-reforms-addressing-social-determinants-of-health-policy-implications-and-next-steps/. Accessed May 19, 2022.

      to pay for home-delivered meals.
      • Berkowitz SA
      • Terranova J
      • Hill C
      • et al.
      Meal delivery programs reduce the use of costly health care in dually eligible Medicare and Medicaid beneficiaries.
      ,
      • Lee Y
      • Mozaffarian D
      • Sy S
      • et al.
      Cost-effectiveness of financial incentives for improving diet and health through Medicare and Medicaid: a microsimulation study.
      Leveraging support from Medicare and Medicaid, North Carolina built a statewide infrastructure, including incentives to address nonmedical drivers of health including nutrition, showing allowable Medicaid options that states can use to provide adjunctive services that support health like healthy eating.
      • Wortman Z
      • Tilson EC
      • Cohen MK
      Buying health for North Carolinians: addressing nonmedical drivers of health at scale.
      These experiences reinforce the increasing recognition of the importance of healthy eating as a critical component of health care.
      • Downer S
      • Berkowitz SA
      • Harlan TS
      • Olstad DL
      • Mozaffarian D
      Food is medicine: actions to integrate food and nutrition into healthcare.
      Medicaid has also provided grants to support incentives for participants to join programs for structured physical activity,

      Van Vleet A, Rudowitz R. An overview of Medicaid incentives for the prevention of chronic diseases (MIPCD) grants. The Kaiser Commission on Medicaid and the Uninsured. Issue Brief. September 2014. Available at:https://www.kff.org/medicaid/issue-brief/an-overview-of-medicaid-incentives-for-the-prevention-of-chronic-diseases-mipcd-grants/. Accessed May 19, 2022.

      recognizing its benefits to reduce adverse outcomes in chronic disease, including in chronic kidney disease.
      • Castaneda C
      • Gordon PL
      • Uhlin KL
      • et al.
      Resistance training to counteract the catabolism of a low-protein diet in patients with chronic renal insufficiency. A randomized, controlled trial.
      Recognizing the value of community-based platforms that provide resources for evidenced-based lifestyle modifications like healthy eating, health systems have worked with community-based institutions that provide services such as nutrition and have shown that such collaborations can reduce health care costs and generate a return on investment.
      • Wesson DE
      • Kitzman-Ulrich H
      How academic health systems can achieve population health in vulnerable populations through value-based care: the critical importance of establishing trusted agency.
      Accordingly, during fiscal year 2021, 27 state Medicaid directors required their Managed Care Organizations to partner with community-based organizations or social-service providers to integrate their services with traditional medical care.

      Kaiser Family Foundation. States reporting social determinant of health related policies required in Medicaid managed care contracts. Available at:https://www.kff.org/other/state-indicator/states-reporting-social-determinant-of-health-related-policies-required-in-medicaid-managed-care-contracts/?currentTimeframe=0&sortModel=%7B%22colId%22:%22Location%22,%22sort%22:%22asc%22%7D. Accessed September 30, 2021.

      These examples show Medicaid's embrace of community-based platforms for delivery of non-medical care resources that, when integrated with medical care, provides this expanded vision of health care. Many health system/community entity collaborations include engaging cultural, faith-based, and community-based organizations.

      Centers for Medicare & Medicaid Services (CMS). Building strong community partnerships to address social needs. April 2021. Available at:https://innovation.cms.gov/media/document/ahcm-casestudy-healthnet. Accessed January 7, 2022.

      Analysis in the Accountable Health Communities Model revealed that establishing trust was key for beneficiaries to accept the necessary navigation for accessing health-promoting resources.

      RTI International. Accountable Health Communities (AHC) Model Evaluation. First Evaluation Report. December 2020. Research Triangle Park, NC: RTI International. Available at: https://innovation.cms.gov/data-and-reports/2020/ahc-first-eval-rpt. Accessed May 19, 2022.

      Engaging with community-based organizations allows health systems to leverage the trust that these organizations have already established with communities, facilitating beneficial health outcomes.
      • Wesson DE
      • Lucey CR
      • Cooper LA
      Building trust in health systems to eliminate health disparities.
      ,

      Centers for Disease Control and Prevention. Diabetes Self-Management Education and Support (DSMES) Toolkit. Return on investment. March 12, 2018. Available at: https://www.cdc.gov/diabetes/dsmes-toolkit/business-case/roi.html. Accessed May 19, 2022.

      These health system/community collaborations indicate the importance of the community context in delivering care, particularly in low socioeconomic status communities.
      • Etz RS
      • Zyzanski SJ
      • Gonzalez MM
      • Reves SR
      • O'Neal JP
      • Stange KC
      A new comprehensive measure of high-value aspects of primary care.
      Health system practices engaged in community collaborations are best able to achieve goals of the Patient Centered Medical Home through optimal use of lay staff who enable practices to achieve these goals, in part by helping free up providers to focus on tasks only they can perform.
      • Wagner EH
      • Flinter M
      • Hsu C
      • et al.
      Effective team-based primary care: observations from innovative practices.
      This supports the benefits of health systems collaborating with community-based organizations to aid the transition from simply providing medical care to delivering health care.
      • Wesson DE
      • Lucey CR
      • Cooper LA
      Building trust in health systems to eliminate health disparities.

      Conclusions

      Patients with early-stage chronic kidney disease incur most of the adverse outcomes from this chronic disease, and its progression contributes importantly to these outcomes. Comprehensive management of its 2 major causes—diabetes and hypertension—including integration of healthy eating and healthy moving with primary medical care to yield primary health care, promises to reduce these adverse outcomes and to do so disproportionately in racial/ethnic minorities, thereby reducing chronic kidney disease-related health disparities. Recent policy initiatives will help this strategy by incentivizing identification of early-stage chronic kidney disease and incentivizing infrastructure support for healthy eating and healthy moving, especially in low-income communities at high risk for chronic kidney disease.

      Acknowledgments

      The authors acknowledge the guidance and contributions of Dr. Dawn Parsell and Dr. Jun Shao (both employees of Tricida, Inc.) in the development of this manuscript. The authors would like to thank Dr. Jun Shao for the design of the Figures and editorial support.

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