Implementation pRogram to Improve Screening and Management for CKD in Diabetes (IRIS-CKD) (Program 2)

Inclusion Criteria:

• (CKD Management)

• Adults with type 2 diabetes (T2D)

• Receiving primary care within the healthcare system, visit within 24 months (any PCP provider, including APP)

• Evidence of CKD based on laboratory testing within the past 2 years (must beconfirmed during screening if not checked within 3 months of enrollment):

• UACR >300 mg/g or

• eGFR <45 ml/min/1.73 m2 or

• UACR ≥30 mg/g with eGFR <60 ml/min/1.73 m2

• Receiving <100% GDMT at baseline. For patients with UACR <30 mg/g, GDMTincludes sodium-glucose cotransporter-2 inhibitors (SGLT2i) therapy. For allother eligible patients, GDMT includes ACEi/ARB, SGLT2i, and Finerenone, unlesscontraindications for any of these therapies exist (e.g., hyperkalemia,diabetic ketoacidosis, etc.).

Exclusion Criteria:

• (CKD Management)

• Type 1 diabetes

• Most recent eGFR <20 ml/min/1.73 m2

• Prior kidney transplant

• Autosomal dominant polycystic kidney disease (ADPKD)

• Active pregnancy or plans for conception within 1 year