Dialysis Access, Church CKD Screening Address Kidney Care Inequities

A structured outpatient dialysis pathway for unfunded patients with end-stage kidney disease (ESKD) at a safety-net hospital reduced monthly emergency department (ED) visits by 87% and lowered direct costs by 83%, according to data presented at the American Society of Nephrology (ASN) Kidney Week 2026 in Denver, Colorado.¹ The quality improvement study also found that dialysis adequacy remained high, although several markers of mineral bone disease, anemia, and vascular access did not improve.

The study was presented in an oral abstract session titled “Kidney Health Equity: From Research to Impact” at ASN Kidney Week 2026, with research focused on extending and improving kidney care in underserved populations. A second study from Texas reported 5-year outcomes of church-based chronic kidney disease (CKD) screening in a predominantly African American community, finding that participants who accepted referral to a clinic improved their blood pressure and albuminuria over 12 months.²

The Impact of Emergency-Only Dialysis in Safety-Net Systems

“Safety-net hospitals disproportionately care for unfunded and socially vulnerable patients,” the study authors explained.¹ “In [ESKD], limited access to scheduled outpatient dialysis often forces reliance on emergency-only dialysis, with recurrent ED presentations for life-threatening complications. This fragmented model worsens outcomes, increases costs, and creates significant operational strain on emergency and inpatient service.”

The single-center, pre-post quality improvement study took place at a large, urban, academic-affiliated safety-net hospital. A multidisciplinary, nephrology-led program with population health support created a structured outpatient dialysis pathway for unfunded patients with ESKD.

“Our goal was to replace these fragmented [services] and create a reliable pathway for these patients,” study author Juan Duque, MD, associate professor of clinical medicine in the Katz Family Division of Nephrology and Hypertension at the University of Miami Miller School of Medicine, explained during his presentation at ASN Kidney Week.

Key performance indicators were aligned with CMS dialysis quality metrics and high-reliability organization principles, and monthly quality assessment and performance improvement meetings guided changes to the program. Outcomes included ED use, dialysis quality and adherence, comorbidity management, and health care costs.

ED Visits, Costs Fall for Unfunded Patients With ESKD

The program delivered between 300 and 471 hemodialysis treatments per month (mean [SD], 402 [56]), with a mean (SD) census of 32.8 (3.5) patients. Monthly acute care encounters declined by 88%, from 40.3 to 4.7, and monthly ED visits fell by 87%, from 29.7 to 4.0, which corresponded to an estimated 308 fewer visits per year. The 6-month moving average of direct costs decreased by 83%, acute care costs fell by 75%, and per-member-per-month costs dropped by 49%. During the presentation, Duque said the reductions were evident 6 months after the program began, with direct costs falling from $125,000 to $22,000 per month.

Dialysis adequacy (Kt/V of at least 1.2) was achieved in a mean (SD) of 99.7% (1.0%) of patients, and provider engagement improved significantly (P < .01). Bacteremia remained low, at 1.2% (2.0%). However, the proportion of patients with parathyroid hormone levels above 600 pg/mL rose (29.6% [12.5%]; P = .02), 24.6% (7.1%) had hemoglobin levels below 10 g/dL, and tunneled catheter use remained high (38.0% [7.8%]; P = .04).

“It’s a very complex population, non-compliant, but so far I can tell you that having a structured outpatient pathway can transform the care for these unfunded patients, and we can do a lot for them,” Duque said.

Community-Based CKD Screening in an Under-Resourced Population

In the second study, community health workers screened 800 individuals at church-based health fairs over 5 years using automated blood pressure measurement and urine albumin-to-creatinine ratio (UACR) dipstick testing.²

While presenting the research at ASN Kidney Week, Aisha Montgomery, MD, MPH, of Baylor Scott & White Health in Dallas, Texas, emphasized the importance of screening in under-resourced, minoritized, racial and ethnic minority communities where populations are at a disproportionately higher risk of CKD. Concurrently, historic mistrust of research and health systems in these communities can limit follow-through after positive screening for conditions like high blood pressure or CKD in a setting such as a health fair, Montgomery explained.

In the study, participants with a UACR above 30 mg/g were offered kidney-focused clinical care at no out-of-pocket cost and invited back to the church for follow-up at 12 months, regardless of whether they accepted referral. Montgomery described meeting participants where they were, in a way that built and maintained trust, as the innovation of the program.

“We establish trust with the participants by using the community health workers and by conducting the screenings at churches, so we didn't ask them to come into a clinic or hospital,” Montgomery said. “We met them where they were, where they were coming for their regular religious practices. That reduced barriers for them to get their health care. We also used some trusted messengers: community health workers come from their neighborhoods, and they see them every day. They know them, so they were able to receive the message better from the [community health workers] to engage in actual research.”

Of the 256 participants who screened positive for microalbuminuria by dipstick, 210 were confirmed by laboratory testing and offered clinic referral; 140 accepted and 70 declined. Ninety-five participants who accepted referral (45% of those with confirmed microalbuminuria) stayed in clinic care for at least 12 months and completed the follow-up church evaluation. In this group, mean (SD) systolic blood pressure improved from 148.1 (12.4) to 139.1 (10.3) mm Hg (P < .01), and mean (SD) UACR improved from 111.8 (54.1) to 95.6 (49.0) mg/g (P < .01).

Among the 50 participants who declined referral but returned for follow-up, mean (SD) systolic blood pressure worsened from 147.6 (12.3) to 152.1 (12.7) mm Hg (P < .01), and mean (SD) UACR worsened from 105.7 (51.3) to 114.0 (49.4) mg/g (P < .01). In the presentation, Montgomery noted that 22 individuals in the group who declined referral had improved UACR at follow-up.

“The trust[ed] community messengers and the no-cost care from the nephrologists [helped] to overcome the barriers to care that we typically see, and these findings support the fact that scaling community partner screening to care models in similar under-resourced minority communities could be a good tactic,” Montgomery said.

References

1. Duque J, Hood J, Madigan T; Dialysis and Population Health, Jackson Health System. Improving care for unfunded patients with ESKD through a high-reliability organizational framework in a safety-net health system. Abstract presented at: American Society of Nephrology Kidney Week 2026; October 22-25, 2026; Denver, Colorado. Abstract FR-OR059.

2. Montgomery AH, Simoni J, Aksan N, Kahlon M, Wesson DE. Five-year outcomes of community-based CKD screening and referral in an under-resourced, predominantly African American population. Abstract presented at: American Society of Nephrology Kidney Week 2026; October 22-25, 2026; Denver, Colorado. Abstract FR-OR055.

3. Chronic kidney disease in the United States. CDC. Updated March 31, 2026. Accessed October 23, 2026. https://www.cdc.gov/kidney-disease/php/data-research