Kidney Week

Abstract: SA-PO0462

Effect of a Collaborative Management Program on Albuminuria Monitoring and Use of Guideline-Directed Medical Therapy (GDMT) in High-Risk Patients with Diabetes

Session Information

• CKM: Clinical - Screening, Population Management, Care Disparities, and Patient-Centered Outcomes
  October 24, 2026 | Location: Exhibit Hall A, Convention Center
  Abstract Time: 10:00 AM - 12:00 PM

Category: Cardiovascular-Kidney-Metabolic Health

• 602 Cardiovascular-Kidney-Metabolic Health: Clinical

Authors

• Bharati, Bishal, New York City Health and Hospitals Jacobi, New York, New York, United States

Bishal Bharati, MD

• Wagle, Abhishesh, New York City Health and Hospitals Jacobi, New York, New York, United States

Abhishesh Wagle, MD, MBBS

• Bhandari, Sanjeev, New York City Health and Hospitals Jacobi, New York, New York, United States

Sanjeev Bhandari, MD

• Rodriguez, Marcos Alejandro, New York City Health and Hospitals Jacobi, New York, New York, United States

Marcos Alejandro Rodriguez, MD

• Acharya, Anjali, New York City Health and Hospitals Jacobi, New York, New York, United States

Anjali Acharya, MD, MBBS, FASN

• Kwon, Haneul Judy, New York City Health and Hospitals Jacobi, New York, New York, United States

Haneul Judy Kwon, PharmD

• Cartmill, Kimberly, New York City Health and Hospitals Jacobi, New York, New York, United States

Kimberly Cartmill, MD

• Nelson, Ingrid L., New York City Health and Hospitals Jacobi, New York, New York, United States

Ingrid L. Nelson, MD

Background

Diabetic kidney disease (DKD) affects a significant number of patients with type 2 diabetes mellitus (T2DM). Albuminuria testing is critical for risk stratification and GDMT initiation. Despite guidelines for albumin-to-creatinine ratio (UACR) monitoring, albuminuria testing remains suboptimal in primary care settings.

Methods

We conducted a quality improvement initiative in 309 adult patients with T2DM scheduled in Chronic Disease Management (CDM) clinic between 1/1/26 and 3/31/26 in the Bronx. Nephrologists reviewed their charts prior to CDM visit and provided structured recommendations to providers on diagnostic tests [urinalysis (UA), UACR, urine protein-to-creatinine ratio (UPCR), basic metabolic panel (BMP)]; medication management for SGLT2 inhibitors (SGLT2i), ACE inhibitors or angiotensin receptor blockers (ACEi/ARB), GLP-1 receptor agonists (GLP1RA), and non-steroidal mineralocorticoid receptor antagonists (nsMRA); and for Nephrology referral. Completed albuminuria screening was defined as a documented UACR within a year of CDM visit. Implementation was confirmed by chart review.

Results

Out of 309 patients, 38.2% were Black, 49.8% were Hispanic. 31.4% had documented chronic kidney disease (CKD) diagnosis. 222 patients had a UACR documented within a year of their CDM visit while 73 had UACR older than a year, and 14 patients had no UACR data. Post intervention, UACR testing increased by 13% from baseline. CKD was newly identified in 97 patients. Of these, majority had G1 (43.3%) followed by G3 (35.1%) KDIGO CKD stages. Implementation rates for UACR were 51.1%, BMP 55.9%, UA 40.9%, and UPCR 38.7%. Implementation of UACR orders was higher among patients without recent albuminuria screening (57.6%) than those with recent screening (47.6%). GDMT changes were recommended in 93 patients with 16.8% for ACEi/ARB, 13.9% for SGLT2i, 2.6% for GLP1RA, and 1.6% for nsMRA. Implementation of overall GDMT changes was 68.8%. Out of the 23 patients recommended for Nephrology referral, 43.4% had referrals made.

Conclusion

Implementation was suboptimal due to high patient no- show rate. However, this structured collaborative Nephrology-Primary Care model to optimize DKD screening and management shows a positive impact overall. This pilot program is the first step in creating a scalable approach to closing gaps in DKD care.