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To create a world without kidney diseases, the ASN Alliance for Kidney Health elevates care by educating and informing, driving breakthroughs and innovation, and advocating for policies that create transformative changes in kidney medicine throughout the world.

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Kidney Week

Abstract: TH-PO938

Use of Population Management Tools to Identify Patients at High-Risk of ESRD Progression

Session Information

Category: CKD (Non-Dialysis)

  • 1903 CKD (Non-Dialysis): Mechanisms


  • Zheng, Sijie, The Permanente Medical Group, Oakland, California, United States
  • Al-Moomen, Rushdy M., The Permanente Medical Group, Oakland, California, United States
  • Chen, Yiann E., Kaiser Permanente Medical Center, Richmond, California, United States
  • Mroz, Joanna, The Permanente Medical Group, Oakland, California, United States
  • Pravoverov, Leonid, Kaiser Permanente, Oakland, California, United States

Group or Team Name

  • The Permanente Medical Group

The current health care system focuses on treatment rather than prevention of illness. There is inadequate support for patients who are unable to adhere to complex medical therapies. Transition from CKD to ESRD is a perfect example: many patients are not engaged in renal care due to psycho-social issues such as denial, lack of understanding of disease, or lack of financial resources for travel and/or medications. Kaiser Permanente Northern California (KPNC) is an integrated health care system providing care for 4.3 million members. In 2016, KPNC East Bay Nephrology department started a pilot to identify patients with moderate to advanced CKD who had not received Nephrology care.


We used our Electronic Medical Record (EMR) system to identify late stage CKD patients (eGFR less than 30 ml/min) who have not been seen by a Nephrologist. The patient list was monitored daily by a nurse and reviewed weekly with a Nephrologist. Nephrologists screened patients to determine if they were appropriate for referral to nephrology specialty care. Primary care providers were contacted with recommendation to review chart and determine if those patients may benefit from referral to nephrology care.


After the implementation of the pilot, many patients who would likely have been “lost to follow up” were captured by this program. The Nephrology team educated patients about the presence of advanced CKD and developed a comprehensive plan of care (Figure).


Establishing a “safety net” by developing an automated process of identifying patients with elevated risk characteristics and enrolling them in a structured CKD care program can potentially lead to a smoother transition to ESRD in our integrated health care system. In addition, this program supports the development of individualized care pathways depending on patient-identified goals of care.

Population Management of CKD Patients by Building a Safety Net to Identify High Risk Patients


  • Private Foundation Support