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The Use of Risk Prediction to Identify Patients at Risk for Chronic Kidney Disease: Patient and Provider Interventions for Patients at High Risk for Chronic Kidney Disease

The Use of Risk Prediction to Identify Patients at Risk for Chronic Kidney Disease (Short Name: RISK [Risk InterventionS for Chronic Kidney Disease])

Who can join

Ages 18 to 80 · All sexes · Healthy volunteers welcome

Inclusion Criteria:

* At high risk for CKD as determined by CKD model developed in Phase 1
* Age 18-80 as of date of data pull
* At least 12 months of health plan coverage
* Speaks English or Spanish
* We will include both paneled and unpaneled patients

Exclusion criteria:

* On the research exclusion list between 1/1/2013 and date of the data pull
* On hospice, or have conditions that indicate end of life (metastatic cancer, on dialysis, etc.)
* Non-English / non-Spanish speaking (those who are excluded from the intervention arm solely due to language barriers will be reported to the IRB at continuing review).
* Pregnant patients.
* Patients who have a completed both the eGFR and uACR within the 12 months prior to the date of cohort identification.

About the study

This prospective, cluster-randomized trial is structured as a pragmatic study, embedding the outreach intervention within routine clinical workflows. The intervention reflects real-world provider-patient communication methods. The primary research aim is to evaluate, under typical practice conditions, whether structured notification strategies improve follow-up screening.

We will evaluate whether targeted provider and patient-directed communication increases completion of CKD disease lab testing (eGFR and uACR) among individuals identified as being at risk for having CKD based on the model developed in in Phase 1. We will identify up to 1,000 patients with high risk of having CKD. All patients' primary care providers (PCPs) will receive a message notifying them of patients' elevated risk status and the recommendation for CKD testing per standard practice. Additionally, we will randomly allocate providers whose patients will receive letters ( \~n=500 patients) and providers whose patients will receive a phone call ( \~n=250 patients).

What is being tested

• Letter Intervention (other)
• Letter + Phone Call Intervention: (other)
• Augmented usual care (other)

Sponsor: Kaiser Permanente · Participants: 1,500 · Started: Aug 20, 2026

Contact the study team

• Amanda F Pretrik, PhD · Phone: 503-335-2400

Official record on ClinicalTrials.gov — NCT07857200

Locations in the U.S.

Conditions

• Chronic Kidney Disease

From ClinicalTrials.gov, data retrieved Oct 6, 2026. Each study sets its own eligibility; the study team decides who can join.