The care pathway for patients with chronic kidney disease: The essential coordination between community health care professionals and care facilities

Abstract

Chronic kidney disease (CKD) is a major public health issue, affecting around 10% of the world’s population. Its silent progression and its numerous etiologies (most commonly diabetes and vascular nephropathies) complicate early detection and management. Many patients reach kidney failure without prior nephrological care. Coordination between outpatient care (GPs, pharmacists, nurses) and specialist facilities is therefore essential to improve screening, delay the progression to dialysis, and improve patients’ quality of life. The CKD package, introduced in 2019, provides financial support to health care facilities with the aim of facilitating a multidisciplinary approach before end-stage renal diseases. It promotes a patient-centered approach, including nephrologists, nurses, dieticians, psychologists, etc. Community health care professionals play a crucial role in identifying and referring patients to specialists. Coordination with nephrologists means faster diagnosis and better support. Advanced practice nurses and nurse coordinators play a structuring role in personalized monitoring. Digital tools, remote monitoring, and artificial intelligence offer new ways for optimizing patient care. Finally, the general public’s persistent lack of knowledge about CKD calls for enhanced information campaigns. The aim of all these initiatives is to build a more fluid, anticipated, and personalized care pathway, centered on the patient’s quality of life.