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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: FR-PO255

Improving Patient and System Outcomes Through Integrated Care for CKD

Session Information

Category: CKD (Non-Dialysis)

  • 1902 CKD (Non-Dialysis): Clinical, Outcomes, and Trials


  • Beaulieu, Monica C., St. Paul's Hospital and University of British Columbia, Vancouver, British Columbia, Canada
  • Canney, Mark, University of British Columbia, North Vancouver, British Columbia, Canada
  • Induruwage, Dilshani, BC Provincial Renal Agency , Vancouver, British Columbia, Canada
  • Levin, Adeera, St. Paul's Hospital and University of British Columbia, Vancouver, British Columbia, Canada

Group or Team Name

  • BC Kidney Care Committee

In British Columbia Canada, patients with Chronic Kidney Disease not on dialysis (CKD-ND) are cared for by interprofessional kidney care clinics (KCC’s) using an integrated chronic disease model of care within a system which includes decision support and clinical pathways, a single information system, feedback and audit systems, process and outcomes measures, provincial education of health care providers, policy makers, and patients, and dedicated patient focused funding. The BC-KCC’s are integrated into a larger province wide renal network, with accountability for patient and system outcomes.


We describe the impact of a series of initiatives in KCC’s to standardize education and support decision making and access for home- based therapies (HBT), conservative care (CC) and pre-emptive transplantation (Tx) over time. Initiatives were introduced sequentially, using change management and adult education principles, with materials developed by a diverse group of health care professionals and supported administratively with provincial dissemination.


In March 2018, the cohort has 10,979 pts; mean age 71, median GFR 33 ml/min/1.73m2 at registration; 54% are male, 50% DM and 43% have CVD. 1285 new pts and 1017 pts exited KCC. Table 1 describes the 6 monthly prevalence of key outcomes over time. Documented treatment decisions for those with GFR <20 have increased slightly, as has formal symptom assessments, and numbers of pts choosing and starting on HBT and following conservative care pathways.


An integrated approach based on fundamentals of chronic care models has led to improved patient outcomes systemwide in BC.