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Overcoming Barriers to Implementing New Therapies for Diabetic Kidney Disease: Lessons Learned

  • Joshua J. Neumiller
    Correspondence
    Address correspondence to Joshua J. Neumiller, PharmD, Department of Pharmacotherapy, College of Pharmacy and Pharmaceutical Sciences, Washington State University, 412 E. Spokane Falls Blvd, Spokane, WA 99202.
    Affiliations
    Department of Pharmacotherapy, College of Pharmacy and Pharmaceutical Sciences, Washington State University, Spokane, WA
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  • Radica Z. Alicic
    Affiliations
    Providence Medical Research Center, Providence Health and Services, Spokane, WA

    Department of Medicine, University of Washington School of Medicine, University of Washington, Spokane and Seattle, WA
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  • Katherine R. Tuttle
    Affiliations
    Department of Pharmacotherapy, College of Pharmacy and Pharmaceutical Sciences, Washington State University, Spokane, WA

    Department of Medicine, University of Washington School of Medicine, University of Washington, Spokane and Seattle, WA

    Department of Medicine, Nephrology Division, Kidney Research Institute, Institute of Translational Health Sciences, University of Washington, Spokane and Seattle, WA
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      As a result of the growing number of patients with type 2 diabetes mellitus, the prevalence of diabetic kidney disease (DKD) has proven to be one of the fastest growing health care challenges globally. Early detection and initiation of appropriate interventions to slow the progression of DKD are impeded by low awareness of the health consequences of DKD, high complexity of care that includes the need for lifestyle modifications, difficulties with adhering to increasingly complicated medication regimens, and low acceptance and application of guideline-directed management. After 2 decades of status quo in the care of patients with DKD, recently approved glucose-lowering agents are promising to transform care by demonstrating slowed DKD disease progression and improved survival. As has been learned over the last 2 decades, multiple barriers exist to the optimal integration and utilization of new therapies to improve kidney outcomes. The health care community, professional societies, and regulatory agencies must join efforts to develop implementation strategies for increasing DKD awareness, detection, and treatment.

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      References

        • Zimmet P.Z.
        • Magliano D.J.
        • Herman W.H.
        • Shaw J.E.
        Diabetes: a 21st century challenge.
        Lancet Diabetes Endocrinol. 2014; 2: 56-64
        • International Diabetes Federation
        Chapter 3: Global picture.
        in: IDF Diabetes Atlas. 9th Ed. International Diabetes Federation, Brussels, Belgium2019: 32-61
        • de Boer I.H.
        • Rue T.C.
        • Hall Y.N.
        • Heagerty P.J.
        • Weiss N.S.
        • Himmelfarb J.
        Temporal trends in the prevalence of diabetic kidney disease in the United States.
        JAMA. 2011; 305: 2532-2539
        • Saran R.
        • Robinson B.
        • Abbott K.C.
        • et al.
        US Renal Data System 2019 Annual Report: epidemiology of kidney disease in the United States.
        Am J Kidney Dis. 2020; 75 (Svi-Svii)
        • Gregg E.W.
        • Li Y.
        • Wang J.
        • et al.
        Changes in diabetes-related complications in the United States, 1990-2010.
        N Engl J Med. 2014; 370: 1514-1523
        • Lozano R.
        • Naghavi M.
        • Foreman K.
        • et al.
        Global and regional mortality from 235 causes of death for 20 age groups in 1990 and 2010: a systematic analysis for the Global Burden of Disease Study 2010.
        Lancet. 2012; 380: 2095-2128
        • Liyanage T.
        • Ninomiya T.
        • Jha V.
        • et al.
        Worldwide access to treatment for end-stage kidney disease: a systematic review.
        Lancet. 2015; 385: 1975-1982
        • Kidney Disease: Improving Global Outcomes (KDIGO) Diabetes Work Group
        KDIGO 2020 clinical practice guideline for diabetes management in chronic kidney disease.
        Kidney Int. 2020; 98: S1-S115
        • Wyld M.
        • Morton R.L.
        • Hayen A.
        • Howard K.
        • Webster A.C.
        A systematic review and meta-analysis of utility-based quality of life in chronic kidney disease treatments.
        Plos Med. 2012; 9: e1001307
        • Wong G.
        • Howard K.
        • Chapman J.
        • et al.
        How do people with chronic kidney disease value cancer-related quality of life?.
        Nephrology (Carlton). 2012; 17: 32-41
        • Tuttle K.R.
        • Alicic R.Z.
        • Duru O.K.
        • et al.
        Clinical characteristics of and risk factors for chronic kidney disease among adults and children: an analysis of the CURE-CKD Registry.
        JAMA Netw Open. 2019; 2: e1918169
        • Tu K.
        • Bevan L.
        • Hunter K.
        • Rogers J.
        • Young J.
        • Nesrallah G.
        Quality indicators for the detection and management of chronic kidney disease in primary care in Canada derived from a modified Delphi panel approach.
        CMAJ Open. 2017; 5: E74-E81
        • Bello A.K.
        • Ronksley P.E.
        • Tangri N.
        • et al.
        Quality of chronic kidney disease management in Canadian primary care.
        JAMA Netw Open. 2019; 2: e1910704
        • De Cosmo S.
        • Viazzi F.
        • Pacilli A.
        • et al.
        Achievement of therapeutic targets in patients with diabetes and chronic kidney disease: insights from the Associazione Medici Diabetologi Annals initiative.
        Nephrol Dial Transpl. 2015; 30: 1526-1533
        • Stevens P.E.
        • Schernthaner G.
        • Raptis S.
        • Wanner C.
        • Scherhag A.
        • Lameire N.
        Characteristics, cardiovascular comorbidity and medicines management in patients with type 2 diabetes and CKD: results of the IRIDIEM study.
        Kidney Blood Press Res. 2010; 33: 119-128
        • American Diabetes Association
        11. Microvascular complications and foot care: standards of medical care in diabetes – 2021.
        Diabetes Care. 2020; 44: S151-S167
        • Perkovic V.
        • Jardine M.J.
        • Neal B.
        • et al.
        Canagliflozin and renal outcomes in type 2 diabetes and nephropathy.
        N Engl J Med. 2019; 380: 2295-2306
        • Tuttle K.R.
        • Lakshmanan M.C.
        • Rayner B.
        • et al.
        Dulaglutide versus insulin glargine in patients with type 2 diabetes and moderate-to-severe chronic kidney disease (AWARD-7): a multicentre, open-label, randomised trial.
        Lancet Diabetes Endocrinol. 2018; 6: 605-617
      1. Canagliflozin (Invokana®) tablets. Prescribing information. Janssen Pharmaceuticals, Inc., Titusville, NJ2020
        • American Diabetes Association
        9. Pharmacologic approaches to glycemic treatment: Standards of Medical Care in Diabetes – 2020.
        Diabetes Care. 2020; 43: S98-S110
        • Garber A.J.
        • Handelsman Y.
        • Grunberger G.
        • et al.
        Consensus statement by the American Association of Clinical Endocrinologists and American College of Endocrinology on the comprehensive type 2 diabetes management algorithm – 2020 executive summary.
        Endocr Pract. 2020; 26: 107-139
        • Davies M.J.
        • D’Alessio D.A.
        • Fradkin J.
        • et al.
        Management of hyperglycemia in type 2 diabetes, 2018. A consensus report by the American Diabetes Association (ADA) and the European Association for the Study of Diabetes (EASD).
        Diabetes Care. 2018; 41: 2669-2701
        • Buse J.B.
        • Wexler D.J.
        • Tsapas A.
        • et al.
        2019 update to: Management of hyperglycaemia in type 2 diabetes, 2018. A consensus report by the American Diabetes Association (ADA) and the European Association for the Study of Diabetes (EASD).
        Diabetologia. 2020; 63: 221-228
        • Das S.R.
        • Everett B.M.
        • Birtcher K.K.
        • et al.
        2020 expert consensus decision pathway on novel therapies for cardiovascular risk reduction in patients with type 2 diabetes: a report of the American College of Cardiology Solution Set Oversight Committee.
        J Am Coll Cardiol. 2020; 76: 1117-1145
        • Bakris G.L.
        • Agarwal R.
        • Anker S.D.
        • et al.
        Effect of finerenone on chronic kidney disease outcomes in type 2 diabetes.
        N Engl J Med. 2020; 383: 2219-2229
        • Heerspink H.J.L.
        • Parving H.H.
        • Andress D.L.
        • et al.
        Atrasentan and renal events in patients with type 2 diabetes and chronic kidney disease (SONAR): a double-blind, randomised, placebo-controlled trial.
        Lancet. 2019; 393: 1937-1947
        • National Kidney Foundation
        K/DOQI clinical practice guidelines for chronic kidney disease: evaluation, classification, and stratification.
        Am J Kidney Dis. 2002; 39: S1-S266
        • National Kidney Foundation
        KDOQI clinical practice guidelines for diabetes and CKD: 2012 update.
        Am J Kidney Dis. 2012; 60: 850-886
        • Devraj R.
        • Borrego M.E.
        • Vilay A.M.
        • Pailden J.
        • Horowitz B.
        Awareness, self-management behaviors, health literacy and kidney function relationships in specialty practice.
        World J Nephrol. 2018; 7: 41-50
        • Crews D.C.
        • Bello A.K.
        • Saadi G.
        2019 World Kidney Day editorial – burden, access, and disparities in kidney disease.
        J Bras Nefrol. 2019; 41: 1-9
        • Center for Disease Control and Prevention
        Chronic Kidney Disease in the United States, 2019.
        (Available at:)
        • National Kidney Foundation
        Chronic kidney disease change package.
        (Available at:)
        • Purnell T.S.
        • Bae S.
        • Luo X.
        • et al.
        National trends in association of race and ethnicity with predialysis nephrology care in the United States from 2005 to 2015.
        JAMA Netw Open. 2020; 3: e2015003
        • Chu C.D.
        • McCulloch C.E.
        • Banerjee T.
        • et al.
        CKD awareness among US adults by future risk of kidney failure.
        Am J Kidney Dis. 2020; 76: 174-183
        • Plantinga L.C.
        • Boulware L.E.
        • Coresh J.
        • et al.
        Patient awareness of chronic kidney disease: trends and predictors.
        Arch Intern Med. 2008; 168: 2268-2275
        • Tuot D.S.
        • Plantinga L.C.
        • Hsu C.Y.
        • et al.
        Chronic kidney disease awareness among individuals with clinical markers of kidney dysfunction.
        Clin J Am Soc Nephrol. 2011; 6: 1838-1844
        • Shirazian S.
        • Diep R.
        • Jacobson A.M.
        • Grant C.D.
        • Mattana J.
        • Calixte R.
        Awareness of chronic kidney disease and depressive symptoms: National Health and Nutrition Examination Surveys 2005-2010.
        Am J Nephrol. 2016; 44: 1-10
        • Collins A.J.
        • Vassalotti J.A.
        • Wang C.
        • et al.
        Who should be targeted for CKD screening? Impact of diabetes, hypertension, and cardiovascular disease.
        Am J Kidney Dis. 2009; 53: S71-S77
        • Brown W.W.
        • Peters R.M.
        • Ohmit S.E.
        • et al.
        Early detection of kidney disease in community settings: the Kidney Early Evaluation Program (KEEP).
        Am J Kidney Dis. 2003; 42: 22-35
        • Vassalotti J.A.
        • Li S.
        • McCullough P.A.
        • Bakris G.L.
        Kidney Early Evaluation Program: a community-based screening approach to address disparities in chronic kidney disease.
        Semin Nephrol. 2010; 30: 66-73
        • Ene-lordache B.
        • Perico N.
        • Bikbov B.
        • et al.
        Chronic kidney disease and cardiovascular risk in six regions of the world (ISN-KDDC): a cross-sectional study.
        Lancet Glob Health. 2016; 4: e307-e319
        • Tummalapalli S.L.
        • Vittinghoff E.
        • Crews D.C.
        • et al.
        Chronic kidney disease awareness and longitudinal health outcomes: results from the Reasons for Geographic and Racial Differences in Stroke Study.
        Am J Nephrol. 2020; 51: 463-472
        • Waterman A.D.
        • Browne T.
        • Waterman B.M.
        • Gladstone E.H.
        • Hostetter T.
        Attitudes and behaviors of African Americans regarding early detection of kidney disease.
        Am J Kidney Dis. 2008; 51: 554-562
        • Tamura M.K.
        • Anand S.
        • Li S.
        • et al.
        Comparison of CKD awareness in a screening population using the Modification of Diet in Renal Disease (MDRD) Study and CKD Epidemiology Collaboration (CKD-EPI) equations.
        Am J Kidney Dis. 2011; 57: S17-S23
        • Saunders M.R.
        • Snyder A.
        • Chin M.H.
        • Meltzer D.O.
        • Arora V.M.
        • Press V.G.
        Health literacy not associated with chronic kidney disease awareness.
        Health Lit Res Pract. 2017; 1: e117-e127
        • Tuot D.S.
        • Plantinga L.C.
        • Judd S.E.
        • et al.
        Healthy behaviors, risk factor control and awareness of chronic kidney disease.
        Am J Nephrol. 2013; 37: 135-143
        • Whaley-Connell A.
        • Shlipak M.G.
        • Inker L.A.
        • et al.
        Awareness of kidney disease and relationship to end-stage renal disease and mortality.
        Am J Med. 2012; 125: 661-669
        • Schell J.O.
        • Patel U.D.
        • Steinhauser K.E.
        • Ammarell N.
        • Tulsky J.A.
        Discussions of the kidney disease trajectory by elderly patients and nephrologists: a qualitative study.
        Am J Kindey Dis. 2012; 59: 495-503
        • Lopez-Vargas P.A.
        • Tong A.
        • Phoon R.K.S.
        • Chadban S.J.
        • Shen Y.
        • Craig J.C.
        Knowledge deficit of patients with stage 1-4 CKD: a focus group study.
        Nephrology (Carlton). 2014; 19: 234-243
        • Costantini L.
        • Beanlands H.
        • McCay E.
        • Cattran D.
        • Hladunewich M.
        • Francis D.
        The self-management experience of people with mild to moderate chronic kidney disease.
        Nephrol Nurs J. 2008; 35: 147-155
        • Lindqvist R.
        • Carlsson M.
        • Sjödén P.O.
        Perceived consequences of being a renal failure patient.
        Nephrol Nurs J. 2000; 27: 291-297
        • Teasdale E.J.
        • Leydon G.
        • Fraser S.
        • Roderick P.
        • Taal M.W.
        • Tonkin-Crine S.
        Patients’ experiences after CKD diagnosis: a meta-ethnographic study and systematic review.
        Am J Kidney Dis. 2017; 70: 656-665
        • Minutolo R.
        • Gabbai F.B.
        • Chiodini P.
        • et al.
        Sex differences in the progression of CKD among older patients: pooled analysis of 4 cohort studies.
        Am J Kidney Dis. 2020; 75: 30-38
        • Narva A.S.
        • Norton J.M.
        • Boulware L.E.
        Educating patients about CKD: the path to self-management and patient-centered care.
        Clin J Am Soc Nephrol. 2016; 11: 694-703
        • Guessous I.
        • McClellan W.
        • Vupputuri S.
        • Wasse H.
        Low documentation of chronic kidney disease among high-risk patients in a managed care population: a retrospective cohort study.
        BMC Nephrol. 2009; 10: 1-10
        • Ouseph R.
        • Hendricks P.
        • Hollon J.A.
        • Bhimani B.D.
        • Lederer E.D.
        Under-recognition of chronic kidney disease in elderly outpatients.
        Clin Nephrol. 2007; 68: 373-378
        • Boulware L.E.
        • Troll M.U.
        • Jaar B.G.
        • Myers D.I.
        • Powe N.R.
        Identification and referral of patients with progressive CKD: a national study.
        Am J Kidney Dis. 2006; 48: 192-204
        • Lea J.P.
        • McClellan W.M.
        • Melcher C.
        • Gladstone E.
        • Hostetter T.
        CKD risk factors reported by primary care physicians: do guidelines make a difference?.
        Am J Kidney Dis. 2006; 47: 72-77
        • Sperati C.J.
        • Soman S.
        • Agrawal V.
        • et al.
        Primary care physicians’ perceptions of barriers and facilitators to management of chronic kidney disease: a mixed methods study.
        PLoS One. 2019; 14: e0221325
        • Bailie G.R.
        • Eisele G.
        • Liu L.
        • et al.
        Patterns of medication use in the RRI-CKD Study: focus on medications with cardiovascular effects.
        Nephrol Dial Transpl. 2005; 20: 1110-1115
        • Tuttle K.R.
        • Alicic R.Z.
        • Short R.A.
        • et al.
        Medication therapy management after hospitalization in CKD: a randomized clinical trial.
        Clin J Am Soc Nephrol. 2018; 13: 231-241
        • Neumiller J.J.
        • Daratha K.B.
        • Alicic R.Z.
        • et al.
        Medication use, renin-angiotensin system inhibitors, and acute care utilization after hospitalization in patients with chronic kidney disease.
        J Renin Angiotensin Aldosterone Syst. 2020; 21 (1470320320945137)
        • Tuttle K.R.
        • Bakris G.L.
        • Bilous R.W.
        • et al.
        Diabetic kidney disease: a report from an ADA Consensus Conference.
        Diabetes Care. 2014; 37: 2864-2883
        • Nash D.M.
        • Brimble S.
        • Markle-Reid M.
        • et al.
        Quality of care for patients with chronic kidney disease in the primary care setting: a retrospective cohort study from Ontario, Canada.
        Can J Kidney Health Dis. 2017; 4 (2054358117703059)
        • Chen T.K.
        • Knicely D.H.
        • Grams M.E.
        Chronic kidney disease diagnosis and management: a review.
        JAMA. 2019; 322: 1294-1304
        • Plantinga L.
        • Grubbs V.
        • Sarkar U.
        • et al.
        Nonsteroidal anti-inflammatory drug use among persons with chronic kidney disease in the United States.
        Ann Fam Med. 2011; 9: 423-430
        • Blank M.L.
        • Parkin L.
        • Paul C.
        • Herbison P.
        A nationwide nested case-control study indicates an increased risk of acute interstitial nephritis with proton pump inhibitor use.
        Kidney Int. 2014; 86: 837-844
        • Lazarus B.
        • Chen Y.
        • Wilson F.P.
        • et al.
        Proton pump inhibitor use and the risk of chronic kidney disease.
        JAMA Intern Med. 2016; 176: 238-246
        • Xie Y.
        • Bowe B.
        • Li T.
        • Xian H.
        • Balasubramanian S.
        • Al-Aly Z.
        Proton pump inhibitors and risk of incident CKD and progression to ESRD.
        J Am Soc Nephrol. 2016; 27: 3153-3163
        • Forgacs I.
        • Loganayagam A.
        Overprescribing proton pump inhibitors.
        BMJ. 2008; 336: 2-3
        • Neal B.
        • Perkovic V.
        • Mahaffey K.W.
        • et al.
        Canagliflozin and cardiovascular and renal events in type 2 diabetes.
        N Engl J Med. 2017; 377: 644-657
        • Wiviott S.D.
        • Raz I.
        • Bonaca M.P.
        • et al.
        Dapagliflozin and cardiovascular outcomes in type 2 diabetes.
        N Engl J Med. 2019; 380: 347-357
        • Zinman B.
        • Wanner C.
        • Lachin J.M.
        • et al.
        Empagliflozin, cardiovascular outcomes, and mortality in type 2 diabetes.
        N Engl J Med. 2015; 373: 2117-2128
        • Wanner C.
        • Inzucchi S.E.
        • Lachin J.M.
        • et al.
        Empagliflozin and progression of kidney disease in type 2 diabetes.
        N Engl J Med. 2016; 375: 323-334
        • Heerspink H.J.L.
        • Stefánsson B.V.
        • Correa-Rotter R.
        • et al.
        Dapagliflozin in patients with chronic kidney disease.
        N Engl J Med. 2020; 383: 1436-1446
        • U.S. National Library of Medicine
        EMPA-KIDNEY (The study of heart and kidney protection with empagliflozin).
        (Available at:)
        • Marso S.P.
        • Bain S.C.
        • Consoli A.
        • et al.
        Semaglutide and cardiovascular outcomes in patients with type 2 diabetes.
        N Engl J Med. 2016; 375: 1834-1844
        • Gerstein H.C.
        • Colhoun H.M.
        • Dagenais G.R.
        • et al.
        Dulaglutide and cardiovascular outcomes in type 2 diabetes (REWIND): a double-blind, randomised placebo-controlled trial.
        Lancet. 2019; 394: 121-130
        • Marso S.P.
        • Daniels G.H.
        • Brown-Frandsen K.
        • et al.
        Liraglutide and cardiovascular outcomes in type 2 diabetes.
        N Engl J Med. 2016; 375: 311-322
      2. Tuttle KR, Lakshmanan M, Rayner B, Zimmermann AG, Woodward B, Botros FT. Outcomes in type 2 diabetes and moderate-to-severe CKD treated with dulaglutide versus insulin glargine: AWARD-7 [oral presentation]. Poster TH-OR033. Paper presented at: American Society of Nephrology Kidney Week 2018; San Diego, CA.

        • Gerstein H.C.
        • Colhoun H.M.
        • Dagenais G.R.
        • et al.
        Dulaglutide and renal outcomes in type 2 diabetes: an exploratory analysis of the REWIND randomised, placebo-controlled trial.
        Lancet. 2019; 394: 131-138
        • U.S. National Library of Medicine
        A research study to see how semaglutide works compared to placebo in people with type 2 diabetes and chronic kidney disease (FLOW).
        (Available at:)
        • Mottle A.K.
        • Buse J.B.
        • Ismail-Beigi
        • et al.
        Long-term effects of intensive glycemic and blood pressure control and fenofibrate use on kidney outcomes.
        Clin J Am Soc Nephrol. 2018; 13: 1693-1702
        • Jardine M.J.
        • Kasiske B.
        • Adu D.
        • et al.
        Closing the gap between evidence and practice in chronic kidney disease.
        Kidney Int Suppl. 2017; 7: 114-121
        • U.S. Department of Health and Human Services
        HHS launches president Trump’s ‘Advancing American Kidney Health’ initiative.
        (Available at:)
        • Rangaswami J.
        • Tuttle K.
        • Vaduganathan M.
        Cardio-renal-metabolic care models: toward achieving effective interdisciplinary care.
        Circ Cardiovasc Qual Outcomes. 2020; 13: e007264
        • Rangaswami J.
        • Bhalla V.
        • de Boer I.H.
        • et al.
        Cardiorenal protection with the newer antidiabetic agents in patients with diabetes and chronic kidney disease: a scientific statement from the American Heart Association.
        Circulation. 2020; 142: e265-e286
        • Tuttle K.R.
        • Brosius 3rd, F.C.
        • Cavender M.A.
        • et al.
        SGLT2 inhibition for CKD and cardiovascular disease in type 2 diabetes: report of a scientific workshop sponsored by the National Kidney Foundation.
        Diabetes. 2021; 70: dbi200040
        • American Society of Nephrology
        Diabetic kidney disease collaborative.
        (Available at:)
        https://www.asn-online.org/dkd-c/
        Date accessed: November 25, 2020
        • American Diabetes Association
        Standards of medical care in diabetes – 2020 abridged for primary care providers.
        Clin Diabetes. 2020; 38: 10-38
        • American Diabetes Association
        10. Cardiovascular disease and risk management: standards of medical care in diabetes – 2019.
        Diabetes Care. 2019; 42: S103-S123
        • Das S.R.
        • Everett B.M.
        • Birtcher K.K.
        • et al.
        2018 ACC expert consensus decision pathway on novel therapies for cardiovascular risk reduction in patients with type 2 diabetes and atherosclerotic cardiovascular disease: a report of the American College of Cardiology Task Force on Expert Consensus Decision Pathways.
        J Am Coll Cardiol. 2018; 72: 3200-3223
        • American Kidney Fund
        Diabetes education and kidney health: coaching to prevent kidney disease.
        (Available at:)
        • Strand H.
        • Parker D.
        Effects of multidisciplinary models of care for adult pre-dialysis patients with chronic kidney disease: a systematic review.
        Int J Evid-based Healthc. 2012; 10: 53-59
        • Shi Y.
        • Xiong J.
        • Chen Y.
        • et al.
        The effectiveness of multidisciplinary care models for patients with chronic kidney disease: a systematic review and meta-analysis.
        Int Urol Nephrol. 2018; 50: 301-312
        • National Kidney Foundation
        Chronic kidney disease change package: population health strategies for cardiovascular and kidney disease risk reduction.
        (Available at:)