Challenges and strategies for managing early-to-moderate chronic kidney disease in primary care: A systematic integrative review in high-income countries

BACKGROUND: Early-to-moderate chronic kidney disease (CKD) is largely managed in primary care, yet reported practices vary across settings. Understanding how CKD is identified and managed in routine practice is essential to inform improvements in care. OBJECTIVE: To synthesise empirical evidence on the management of adults with early-to-moderate CKD in primary care in high-income countries including real-world practices and initiatives to improve CKD management. METHODS: We conducted a systematic integrative review of quantitative, qualitative, and mixed-methods studies published between 2000 and 2022. MEDLINE, Embase, the Cochrane Library, KT+, and PDQ-Evidence databases were searched. Eligible studies reported management practices for early-to-moderate CKD in primary care. Findings were synthesised using a convergent integrated narrative approach. RESULTS: A total of 90 studies were included (46 descriptive, 23 qualitative or mixed-methods studies, and 21 interventional), representing over 33 million patients and 3,180 healthcare professionals. Across studies, substantial variability in screening, monitoring, referral practices, and implementation of management strategies was reported. Low screening rates among at-risk populations, incomplete follow-up after abnormal results, variability in medication use and risk-factor control, and heterogeneous referral practices were common findings. Patients often had limited awareness of CKD, and organisational barriers affected engagement in care. Various initiatives, including interprofessional models, decision-support tools, patient education, and multimodal interventions, showed heterogeneous effects across settings. CONCLUSIONS: Management of early-to-moderate CKD in primary care varies considerably across high-income countries. Reported findings suggest that improving CKD care may require context-adapted strategies combining organisational, clinical, and educational components, particularly those involving multidisciplinary collaboration and decision support.