Kidney Disease: Improving Global Outcomes Summit Recommendations on Implementation of Diabetes Management in CKD: From Primary to Data-Driven Collaborative Care

Type 2 diabetes and chronic kidney disease (CKD) are preventable and treatable. Their silent and progressive clinical course calls for structured assessment with timely feedback to patients and care providers for activating decision-making. Apart from CKD, patients with diabetes can have complications affecting multiple organs, notably the cardiovascular system, eyes, and feet. International practice guidelines recommend annual assessment of the eyes, feet, blood, and urine to detect silent complications and measure cardiovascular-kidney-metabolic (CKM) risk factors to ensure early intervention, including treatment to multiple targets and use of organ-protective drugs. In this report, we highlight the barriers and gaps in the implementation of practice guidelines in managing diabetes in CKD with proposed solutions to overcome such barriers. By improving the practice environment and workflow, nurses can be trained to perform protocol-guided evaluation under medical supervision. The systematic data collection enables physicians to make timely decisions, including drug prescriptions and referrals to other specialists to promote collaborative care, whereas nurses can use the personalized data to empower patient self-management and improve health literacy. This ongoing data collection will form a register to align payers, providers, and patients in delivering data-driven and value-based care with the creation of real-world evidence to verify treatment effectiveness and identify care gaps while providing on-the-job training. When accompanied by a biobank, the ongoing collection and analysis of this multidimensional data will refine diagnosis, classification, prognosis, and treatment in pursuit of precision medicine.

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Publication Details

Journal
Kidney International Reports
Published
2025-06-18
DOI
https://doi.org/10.1016/j.ekir.2025.06.010
Citations
1
Primary Topic
Chronic Disease Management Strategies
Type
article
Field-Weighted Citation Impact
1.35
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article

Kidney Disease: Improving Global Outcomes Summit Recommendations on Implementation of Diabetes Management in CKD: From Primary to Data-Driven Collaborative Care

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1 citations
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article

Kidney Disease: Improving Global Outcomes Summit Recommendations on Implementation of Diabetes Management in CKD: From Primary to Data-Driven Collaborative Care

Philip Kam‐Tao Li, Man Wo Tsang, Nikhil Tandon, Kenny Kung, Sophia Zoungas, Sunny H. Wong, Adrian Liew, Andrea O. Y. Luk, Juliana Nga Man Lui, David Vai Kiong Chao, Michael Cheung, Samuel Seidu, Vũ Thị Thanh Huyền, Junne‐Ming Sung, Kit Man Loo, Cheuk‐Chun Szeto, Peter Lin, Martin C. S. Wong, Tanya Green, Maria Leung, Jack Kit‐Chung Ng, Kohjiro Ueki, Lee‐Ling Lim, Victor Hin-Fai Hung, Juliana C.N. Chan, Sydney C.W. Tang, Na Tian, Sing Leung Lui, J.-A. Manski-Nankervis, Kai‐Ming Chow, Kin Lai Chung, Harriet Chung, Maggie Lee, Coral Cyzewski, Fei Chau Pang
article en
1 citations

Abstract

Type 2 diabetes and chronic kidney disease (CKD) are preventable and treatable. Their silent and progressive clinical course calls for structured assessment with timely feedback to patients and care providers for activating decision-making. Apart from CKD, patients with diabetes can have complications affecting multiple organs, notably the cardiovascular system, eyes, and feet. International practice guidelines recommend annual assessment of the eyes, feet, blood, and urine to detect silent complications and measure cardiovascular-kidney-metabolic (CKM) risk factors to ensure early intervention, including treatment to multiple targets and use of organ-protective drugs. In this report, we highlight the barriers and gaps in the implementation of practice guidelines in managing diabetes in CKD with proposed solutions to overcome such barriers. By improving the practice environment and workflow, nurses can be trained to perform protocol-guided evaluation under medical supervision. The systematic data collection enables physicians to make timely decisions, including drug prescriptions and referrals to other specialists to promote collaborative care, whereas nurses can use the personalized data to empower patient self-management and improve health literacy. This ongoing data collection will form a register to align payers, providers, and patients in delivering data-driven and value-based care with the creation of real-world evidence to verify treatment effectiveness and identify care gaps while providing on-the-job training. When accompanied by a biobank, the ongoing collection and analysis of this multidimensional data will refine diagnosis, classification, prognosis, and treatment in pursuit of precision medicine.

Kidney International ReportsVol. 10(8)
Department of Health (CN), The University of Melbourne (AU), Nanyang Technological University (SG), Chinese University of Hong Kong (HK), Hanoi Medical University (VN), Chinese Academy of Medical Sciences & Peking Union Medical College (CN), Peking University (CN), Fudan University (CN), Food and Health Bureau (CN), Tung Wah Hospital (CN), United Christian Hospital (CN), Mount Elizabeth Novena Hospital (SG), University of Malaya (MY), National Center for Global Health and Medicine (JP), Hong Kong Jockey Club (HK), Asia Diabetes Foundation (CN), Prince of Wales Hospital (CN), Ningxia Medical University (CN), Vietnam National Children's Hospital (VN), Canadian Heart Research Centre (CA), National Cheng Kung University Hospital (TW), NIHR Research Delivery Network (GB), Monash University (AU), All India Institute of Medical Sciences (IN), The University of Tokyo (JP), University of Hong Kong (HK)
Openalex Percentile: Top 19%
Chronic Disease Management Strategies
1.35
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