Improving chronic kidney disease detection and treatment in the United States: the chronic kidney disease cascade of care (C3) study protocol

BMC Nephrol. 2022 Oct 12;23(1):331. doi: 10.1186/s12882-022-02943-z.


Background: There are major gaps in the implementation of guideline-concordant care for persons with chronic kidney disease (CKD). The CKD Cascade of Care (C3) initiative seeks to improve CKD care by improving detection and treatment of CKD in primary care.

Methods: C3 is a multi-modal initiative deployed in three major academic medical centers within the Department of Veterans Affairs (VA) Health Care System: San Francisco VA, San Diego VA, and Houston VA. The main objective of the first phase of C3 described in this protocol is to establish the infrastructure for universal CKD detection among primary care patients at high-risk for CKD with a triple-marker screen comprising cystatin C, creatinine, and albuminuria. Across the three sites, a comprehensive educational intervention and the integration of primary care-based clinical champions will be employed with the goal of improving CKD detection and treatment. The San Francisco VA will also implement a practice-facilitation intervention leveraging telehealth and health informatics tools and capabilities for enhanced CKD detection. Parallel formative evaluation across the three sites will assess the feasibility and acceptability of integrating cystatin C as part of routine CKD detection in primary care practice. The effectiveness of the interventions will be assessed using a pre-post observational design for change in the proportion of patients tested annually for CKD. Secondary outcomes will assess change in the initiation of cardio-kidney protective therapies and in nephrology referrals of high-risk patients.

Discussion: The first phase of C3 is a multi-facility multi-modal initiative that aims to improve CKD care by implementing a triple-marker screen for enhanced CKD detection in primary care.

Keywords: Cardiovascular diseases; Disease management; Implementation science; Kidney diseases.

Publication types

  • Research Support, N.I.H., Extramural
  • Research Support, Non-U.S. Gov't
  • Research Support, U.S. Gov't, Non-P.H.S.

MeSH terms

  • Creatinine
  • Cystatin C*
  • Humans
  • Primary Health Care / methods
  • Renal Insufficiency, Chronic* / diagnosis
  • Renal Insufficiency, Chronic* / epidemiology
  • Renal Insufficiency, Chronic* / therapy
  • United States / epidemiology
  • United States Department of Veterans Affairs


  • Cystatin C
  • Creatinine