INTRODUCTION:Patients with advanced stages of chronic kidney disease (CKD) and dialysis-dependent kidney failure are at a greater risk of cardiovascular events and mortality than those with early stages of CKD. There are no completed definitive randomized trials on the safety and efficacy of anticoagulant therapy in this patient population. METHODS:Treatment of cardiovascular disease with low-dose Rivaroxaban in Advanced Chronic Kidney disease (TRACK) is a multi-center, randomized, placebo-controlled trial (NCT03969953), designed to enrol 1886 adult participants with CKD stage 4 or 5 (estimated glomerular filtration rate 29 mL/min/1.73 m2) or dialysis-dependent kidney failure and high cardiovascular risk (defined as at least one of the following risk factors; coronary artery disease, non-hemorrhagic non-lacunar stroke, peripheral artery disease [PAD], diabetes mellitus, or age 65 years). Participants are randomized to rivaroxaban 2.5 mg twice daily or matching placebo. The primary efficacy outcome is a composite of cardiovascular death, myocardial infarction, stroke, or PAD event. The primary safety outcome is major bleeding, defined as a composite of fatal bleeding, bleeding leading to hospitalization, or symptomatic bleeding in a critical area or organ. From January 2021 through July 2025, 1458 eligible participants (mean age 63.2 years, 700 [48%] age 65 years, 432 [29.6%] women, 715 [49%] dialysis-dependent kidney failure and 743 [51%] CKD stage 4 or 5, 1125 [77.2%] diabetes mellitus, 674 [46.2%] treated with aspirin at baseline) underwent randomization. CONCLUSION:TRACK will evaluate the effect of low dose rivaroxaban on major adverse cardiovascular events in participants with CKD stages 4 and 5 and dialysis-dependent kidney failure, and elevated cardiovascular risk.

Importance:Approximately 10% to 15% of patients with advanced chronic kidney disease (CKD) experience a fatal or nonfatal cardiovascular event annually. The effects of antithrombotic therapies on cardiovascular events in patients with advanced CKD are unknown. Objective:To determine whether low-dose rivaroxaban reduces rates of adverse cardiovascular events compared with placebo in patients with advanced CKD. Design, Setting, and Participants:Randomized, double-blind, placebo-controlled trial conducted at 90 centers in 12 countries. Eligible participants were adults with CKD stage 4 or 5 and patients with dialysis-dependent kidney failure. Participants had a history of either coronary artery disease; nonhemorrhagic, nonlacunar stroke; peripheral artery disease; diabetes; or were 65 years or older. Enrollment occurred between January 2021 and July 2025. The trial was stopped early on August 7, 2025, for lack of efficacy. Final follow-up occurred on October 30, 2025. Statistical analyses were conducted in February and March 2026. Interventions:Patients were randomized 1:1 to receive rivaroxaban 2.5 mg twice daily or placebo. Main Outcomes and Measures:The primary outcome was a composite of cardiovascular death, nonfatal myocardial infarction, stroke, or a peripheral artery disease event. The primary safety outcome was major bleeding. Results:Of 1458 randomized patients (mean [SD] age, 63.2 [11.6] years, 432 [29.6%] female), 1360 (93.3%) completed follow-up. During a median follow-up of 1.7 years, the primary outcome occurred in 164 patients (22.6%) in the low-dose rivaroxaban group and 151 (20.7%) in the placebo group (13.0 vs 11.8 events per 100 person-years; hazard ratio, 1.09 [95% CI, 0.87-1.36]; P = .46). Major bleeding occurred in 64 patients (8.8%) receiving low-dose rivaroxaban and 44 (6.0%) receiving placebo (5.1 vs 3.4 events per 100 person-years; hazard ratio, 1.51 [95% CI, 1.02-2.22]; P = .04). Conclusions and Relevance:In patients with advanced CKD at high cardiovascular risk, low-dose rivaroxaban did not reduce the risk of a composite cardiovascular outcome. Major bleeding rates were significantly higher in the low-dose rivaroxaban group compared with the placebo group. Trial Registration:ClinicalTrials.gov Identifier: NCT03969953.

KEY POINTS:We assessed the feasibility of randomizing hemodialysis patients to an attempt at creating an arteriovenous fistulas with central venous catheters for vascular access. There was no signal of harm associated with randomization to the catheter strategy, and most outcomes favored the catheter group. Patients had strong preferences regarding choice of vascular access, reinforcing the central importance of shared decision making. BACKGROUND:Fistulas are the preferred form of vascular access and historically have been recommended by guidelines because they were associated with improved clinical outcomes and costs. However, there has never been a randomized comparison of catheters with fistulas, and the evidence on which recommendations were based is observational with potential for bias. METHODS:A pilot randomized controlled trial was conducted in 12 hemodialysis centers in Canada and Australia. Patients aged 55 years and older who started hemodialysis using a tunneled or nontunneled central venous catheter for vascular access were randomized to an attempt at fistula creation or continued use of a tunneled central venous hemodialysis catheter. The primary outcome was feasibility, as measured by the proportion of eligible patients who consented to randomization and the proportion of patients randomized to the fistula group who underwent fistula placement within 90 days. Secondary outcomes included invasive access-related procedures, hospitalizations, access-related infections, tissue plasminogen activator usage, and death. RESULTS:A total of 1287 patients were screened, and 67 patients underwent randomization. A total of 25% of eligible patients agreed to randomization, and 71% randomized to the fistula arm underwent fistula placement within 90 days. The most common reason patients declined to participate in the trial was that they preferred to continue to dialyze with their catheter. Patients randomized to fistulas had nominally more access-related interventions, hospitalizations, and bacteremia (most of which were catheter related) while the catheter group experienced greater reliance on thrombolytic therapy. CONCLUSIONS:Findings from this trial suggest that conducting a definitive randomized trial of fistulas versus catheters is not feasible in the current climate. There was no signal of harm associated with randomization to the catheter strategy, and most outcomes favored the catheter group. Patients exhibited strong preferences regarding choice of vascular access. CLINICAL TRIAL REGISTRY NAME AND REGISTRATION NUMBER:ClinicalTrials.gov, NCT02675569 .

Objective:Sodium-glucose co-transporter-2 (SGLT2) inhibitors offer benefits for patients with chronic kidney disease, heart failure, and type 2 diabetes mellitus (with cardiovascular risk factors or atherosclerotic cardiovascular disease) but concerns exist regarding euglycaemic diabetic ketoacidosis (EDKA) during acute illness and surgery. We evaluated SGLT2 inhibitor use, discontinuation patterns, and blood ketone monitoring in intensive care units (ICUs). Design:Prospective, multicentre, cross-sectional point prevalence study as part of The George Institute for Global Health and Australian and New Zealand Intensive Care Society Clinical Trials Group Point Prevalence Program. Setting:Fifty-two ICUs in Australia and New Zealand. Participants:Critically ill adult patients in ICUs on the study day. Main outcome measures:Number of patients receiving an SGLT2 inhibitor at ICU admission, their management, serum ketone levels, and ketoacidosis monitoring procedures. Results:Among 786 patients, 54 (6.9 %) were prescribed SGLT2 inhibitors prior to hospital admission, mostly for type 2 diabetes mellitus (75.9 %) or heart failure (18.5 %). Of these, 28 (51.9 %) had their SGLT2 inhibitor discontinued, primarily due to EDKA concerns. Only 17 (34.6 %) of the studied ICUs had documented ketone measurement policies, with 1 (1.9 %) including SGLT2 inhibitors as an indication for measurement. Of 114 patients with blood ketone measurements, 38 (33.0 %) had elevated levels, of whom 6 (5.2 %) met ketoacidosis criteria. Conclusions:Practice regarding discontinuation of SGLT2 inhibitors and ketone monitoring varies widely. With SGLT2 inhibitor use projected to increase, better understanding their risk-benefit profile in the ICU setting and more systematic approaches to ketone measurement are needed. Future research addressing these practice variations is essential.

PURPOSE:Acute kidney injury (AKI) affects ∼10-15% of hospital admissions in high-income countries and is associated with morbidity, mortality, and costs. Despite this burden, targeted therapies remain lacking, and randomised controlled trials have been slow to accommodate precision medicine. We evaluated temporal changes in the composition of kidney-related basic science research and the implications for AKI treatment development. MATERIALS AND METHODS:We conducted a mapping review of kidney research publications indexed in EMBASE from 1 January 2013 to 31 December 2024. Publications were classified as basic science and further categorised as AKI-related, mechanistic, or therapeutic. Annual publication counts and proportions were summarised descriptively, and simple regression models were used to assess temporal trends. RESULTS:Total kidney research output increased over time (r = 0.86, r2 = 0.75, β1 = 1439.6, p < 0.001), while the proportion classified as basic science declined (r = -0.85, r2 = 0.72, β1 = -0.21, p < 0.001). In contrast, the share of AKI-focused basic science rose markedly (r = 0.99, r2 = 0.98, β1 = 0.54, p < 0.001), with substantial growth in mechanistic (r = 0.94, r2 = 0.89, β1 = 0.88, p < 0.001) and therapeutic studies (r = 0.96, r2 = 0.93, β1 = 0.96, p < 0.001). CONCLUSIONS:Overall kidney research is expanding, with increasing emphasis on AKI discovery science and a growing mechanistic and therapeutic pipeline. These trends support investment in trial infrastructure-such as adaptive platform trials capable of testing multiple, biomarker-enriched therapies-to accelerate translation into clinical practice.

Importance: Approximately 10% to 15% of patients with advanced chronic kidney disease (CKD) experience a fatal or nonfatal cardiovascular event annually. The effects of antithrombotic therapies on cardiovascular events in patients with advanced CKD are unknown. Objective: To determine whether low-dose rivaroxaban reduces rates of adverse cardiovascular events compared with placebo in patients with advanced CKD. Design, Setting, and Participants: Randomized, double-blind, placebo-controlled trial conducted at 90 centers in 12 countries. Eligible participants were adults with CKD stage 4 or 5 and patients with dialysis-dependent kidney failure. Participants had a history of either coronary artery disease; nonhemorrhagic, nonlacunar stroke; peripheral artery disease; diabetes; or were 65 years or older. Enrollment occurred between January 2021 and July 2025. The trial was stopped early on August 7, 2025, for lack of efficacy. Final follow-up occurred on October 30, 2025. Statistical analyses were conducted in February and March 2026. Interventions: Patients were randomized 1:1 to receive rivaroxaban 2.5 mg twice daily or placebo. Main Outcomes and Measures: The primary outcome was a composite of cardiovascular death, nonfatal myocardial infarction, stroke, or a peripheral artery disease event. The primary safety outcome was major bleeding. Results: Of 1458 randomized patients (mean [SD] age, 63.2 [11.6] years, 432 [29.6%] female), 1360 (93.3%) completed follow-up. During a median follow-up of 1.7 years, the primary outcome occurred in 164 patients (22.6%) in the low-dose rivaroxaban group and 151 (20.7%) in the placebo group (13.0 vs 11.8 events per 100 person-years; hazard ratio, 1.09 [95% CI, 0.87-1.36]; P = .46). Major bleeding occurred in 64 patients (8.8%) receiving low-dose rivaroxaban and 44 (6.0%) receiving placebo (5.1 vs 3.4 events per 100 person-years; hazard ratio, 1.51 [95% CI, 1.02-2.22]; P = .04). Conclusions and Relevance: In patients with advanced CKD at high cardiovascular risk, low-dose rivaroxaban did not reduce the risk of a composite cardiovascular outcome. Major bleeding rates were significantly higher in the low-dose rivaroxaban group compared with the placebo group. Trial Registration: ClinicalTrials.gov Identifier: NCT03969953.

BACKGROUND AND HYPOTHESIS:Glucagon-like peptide-1 receptor agonists (GLP1-RAs) are anti-hyperglycaemic agents, with cardioprotective effects, however their renal protective effects remain unclear. We aimed to assess the effects of GLP1-RAs on renal outcomes in patients with or without diabetes. METHODS:We performed a systematic review and meta-analysis with Medline, EMBASE and the Cochrane Register searched to December 2024. The primary outcome was the composite of kidney failure (defined as estimated glomerular filtration rate <15 mL/min/1.73 m2) or dialysis requirement, worsening of renal function and changes in proteinuria. Subgroup analysis was performed based on diabetic status, a (CKD) and individual GLP1-RA drugs. Relative risks (RR) with 95% confidence intervals (CI) for individual trials were pooled using random effects models. RESULTS:We identified 19 trials including 90 882 patients. Mean age was 60.8 years and mean follow-up was 25.9 months. GLP1-RAs were associated with a 19% reduction in the risk of primary renal outcome (RR 0.81, 95% CI 0.73-0.89), a 12% reduction in renal functional decline (RR 0.88, 95% CI 0.81-0.95) and a 0.45 mL/min/1.73 m2 reduction in yearly loss [16 trials, mean difference (MD) 0.45, 95% CI 0.10-0.81]. GLP1-RAs also reduced microalbuminuria by 24% (RR 0.76, 95% CI 0.71-0.82), HbA1c (units: %) by 0.61 (MD -0.61, 95% CI -0.76 to -0.49) and body weight by 5 kg (MD -5.24, 95% CI -7.46 to -3.02). Although there were no significant differences in progression to kidney failure (RR 0.86, 95% CI 0.71-1.05), GLP1-RAs reduced the incidence of major adverse cardiovascular events by 15% (RR 0.85, 95% CI 0.81-0.90) and all-cause mortality by 14% (RR 0.86, 95% CI 0.82-0.91). No significant differences were seen in severe adverse events (RR 0.96, 95% CI 0.90-1.01). However, there were more gastroenterological side effects. CONCLUSIONS:GLP1-RAs demonstrated cardiovascular and renal benefits. Further high-quality randomized trials assessing their effects in patients without diabetes, with or without proteinuria and/or CKD are needed.

Background:Chronic kidney disease (CKD) monitoring and cardiovascular risk management are essential in reducing disease progression and cardiovascular events. This study aimed to understand CKD monitoring and management practices in Australian primary care. Methods:We conducted a retrospective, population-based cohort study of adults who attended general practices participating in MedicineInsight between 1 January 2011 and 30 June 2020 and met diagnostic criteria for CKD. Care quality was assessed in the 18-months following identification of CKD. Core monitoring was defined as at least one assessment of all the following measurements: blood pressure, estimated glomerular filtration rate (eGFR), urine albumin creatinine ratio (UACR), lipid profile, and HbA1c in patients with diabetes. Cardiovascular risk management comprised medication prescription (ACEi/ARB and statin), blood pressure target achievement and LDL cholesterol <2 mmol/L. Modified Poisson regression models adjusted for socio-demographic and clinical characteristics were used to identify patient factors associated with completion of monitoring and medication prescription. Findings:CKD was identified in 140,780 patients, of which 34.2% received core monitoring within 18 months of CKD identification. Measurement of the individual components of the core monitoring outcome varied: blood pressure (88.7%), eGFR (86.0%), UACR (41.1%), lipids (70.9%) and HbA1c (85.5%). ACEi/ARB were prescribed in 65.2% of the cohort and 54.4% were prescribed a statin. Blood pressure targets of <140/90 mmHg and <130/80 mmHg were achieved in 57.9% and 29.3% of patients, respectively. LDL target of <2 mmol/L was achieved in 38.8% of patients. Older age, comorbid diabetes and hypertension were associated with a greater likelihood of monitoring and medication prescription. Interpretation:In this large, population-based study, we observed substantial variation in CKD risk monitoring and the management of cardiovascular risk in patients with CKD. We identified several priority areas for CKD management in primary care including need for improvement in albuminuria monitoring. Funding:University of New South Wales Scientia Program and Boehringer Ingelheim Eli Lilly Alliance.

BACKGROUND:Patients undergoing maintenance dialysis for kidney failure are at substantial risk of cardiovascular morbidity and mortality. We aimed to establish if spironolactone reduces heart failure and cardiovascular deaths in these patients. METHODS:ACHIEVE was an international, parallel-group, randomised controlled trial done in 143 dialysis programmes in 12 countries. Patients were aged 45 years or older, or aged 18 years or older with a history of diabetes, and were receiving maintenance dialysis for kidney failure for at least 3 months at the time of recruitment. Patients who were able to tolerate and adhere to spironolactone 25 mg daily orally during an open-label run-in were randomly assigned (1:1) to continue spironolactone or matching placebo, using a central computerised block randomisation system (block sizes of 4) stratified by centre. Participants, health-care providers, and those assessing outcomes were masked to group assignment. The primary outcome was a composite of cardiovascular mortality or hospitalisation for heart failure analysed as time-to-event in all randomly assigned participants. The trial was registered at ClinicalTrials.gov, NCT03020303. FINDINGS:After a planned interim analysis of 75% of the expected primary outcome events, the external safety and efficacy monitoring committee recommended the trial be stopped early for futility. From Sept 19, 2017, to Oct 31, 2024, 3689 patients were screened for inclusion, 3565 of whom were enrolled in the open-label run-in phase, and 2538 were randomly assigned to spironolactone (n=1260) or placebo (n=1278). 931 (36·7%) participants were female and 1607 (63·3%) were male. Median follow-up was 1·8 years (IQR 0·85-3·35). The composite primary outcome occurred in 258 participants (10·46 events per 100 patient-years) in the spironolactone group and in 276 participants (11·33 per 100 patient-years) in the placebo group (hazard ratio [HR] 0·92 [95% CI 0·78-1·09]; p=0·35). Death from any cause was similar between groups (HR 0·95 [0·83-1·09]) as was hospitalisation for any cause (HR 0·96 [0·87-1·06]). INTERPRETATION:Among patients receiving maintenance dialysis, spironolactone 25 mg daily orally did not reduce the composite outcome of cardiovascular mortality and hospitalisation due to heart failure compared with placebo. This trial did not identify a benefit of initiating spironolactone in patients receiving maintenance dialysis. Future research should consider alternatives to steroidal mineralocorticoid receptor antagonism to reduce cardiovascular morbidity and mortality in patients receiving maintenance haemodialysis. FUNDING:The Canadian Institutes of Health Research, The Medical Research Future Fund, The Health Research Council, The British Heart Foundation, Population Health Research Institute/Hamilton Health Sciences Research Institute, St Joseph's Healthcare Hamilton Division of Nephrology, Accelerating Clinical Trials Consortium, Can-SOLVE CKD Network, and the Dalhousie Department of Medicine.

The Treatment of cardiovascular disease with low dose Rivaroxaban in Advanced Chronic Kidney Disease (TRACK) trial is a randomised quadruple-blind phase IV clinical trial to determine whether low-dose rivaroxaban (2.5 mg daily) reduces the risk of major adverse cardiovascular events compared to placebo. It aims to recruit approximately 2,000 patients with advanced chronic kidney disease (stages 4, 5 or dialysis-dependent) and an elevated cardiovascular risk. This statistical analysis plan pre-specifies the method of analysis for every outcome and key variable collected in the trial. The primary outcome is the time from randomisation to first occurrence of major cardiovascular event including death from cardiovascular cause, myocardial infarction, stroke or peripheral artery disease event. The primary analysis will consist in a Cox proportional hazard model adjusted for stratification variables. The analysis plan also includes planned sensitivity analyses including covariate adjustments and subgroup analyses. ### Competing Interest Statement The authors have declared no competing interest. ### Clinical Trial NCT03969953 ### Funding Statement The TRACK trial is funded by grants from the National Health and Medical Research Council of Australia (2018/GNT1162375), the French Ministry of Health Programme Hospitalier de Recherche Clinique (Projet PHRC-19-0112) and Deutsche Forschungsgemeinschaft, Germany (Project number 506165771). Rivaroxaban 2.5 mg tablets and placebo tablets were provided by Bayer AG, Germany free of cost through the Investigator Initiated Research Support Scheme. ### Author Declarations I confirm all relevant ethical guidelines have been followed, and any necessary IRB and/or ethics committee approvals have been obtained. Yes The details of the IRB/oversight body that provided approval or exemption for the research described are given below: Full ethic approval as been obtained from the following committees: - Australia: South Eastern Sydney Local Health District HREC - Belgium: Commissie voor Ethiek AZ Sint-Jan Brugge-Oostende AV - Canada: Hamilton Integrated Research Ethics Board & Health Research Ethics Board - Biomedical Panel - France: Comite de Protection des Personnes Ouest VI - Germany: Ethikkommission der Universitat zu Lubeck - India:The George Institute Ethics Review Committee - Malaysia: Central Ethics Medical Research and Ethics Committee & Universiti Kebangsaan Malaysia Research Ethics Committee & Medical Research Ethics Committee, University Malaya Medical Centre - Nepal: Tribhuvan Institute of Medicine Research Committee - Singapore: National Health Group Domain Specific Review Board (NHG DSRB) - Saudia Arabia: KAIMRC Institutional Review Board & King Saud University College of Medicine Institutional Review Board - Taiwan: Institutional Review Board of Fu Jen Catholic University Hospital - Tunisia: Comite de Protection des Personnes du Centre CPP I confirm that all necessary patient/participant consent has been obtained and the appropriate institutional forms have been archived, and that any patient/participant/sample identifiers included were not known to anyone (e.g., hospital staff, patients or participants themselves) outside the research group so cannot be used to identify individuals. Yes I understand that all clinical trials and any other prospective interventional studies must be registered with an ICMJE-approved registry, such as ClinicalTrials.gov. I confirm that any such study reported in the manuscript has been registered and the trial registration ID is provided (note: if posting a prospective study registered retrospectively, please provide a statement in the trial ID field explaining why the study was not registered in advance). Yes I have followed all appropriate research reporting guidelines, such as any relevant EQUATOR Network research reporting checklist(s) and other pertinent material, if applicable. Yes Not relevant.

Background: Model drift is a major challenge for applications of clinical prediction models. We aimed to investigate the effect of two strategies to mitigate model drift based on a previously reported prediction model for acute kidney injury (AKI). Methods: Deidentified electronic medical data of inpatients in Sichuan Provincial People's Hospital from January 1, 2019, to December 31, 2022, were collected. AKI was defined by the KDIGO criteria. The top 50 laboratory variables, alongside with sex, age, and the top 20 prescribed medicines were included as predictive variables. In model optimization, the convolution neural network module was replaced by a self-attention module. Periodical refitting with accumulative data was also conducted before temporally external validations. The performance of the innovated model (ATRN) was compared with the previous model (ATCN) and other four models. Results: A total of 150,373 admissions were identified. The annual incidences of AKI varied between 5.57% and 5.8%. The performance of the models which had used temporal features profoundly declined over time. The ATRN model with module more suitable to capture short-term time dependencies outperformed the other five models both in C-statistics and recall rates perspectives. Periodic refitting the prediction model with accumulative data also helped to effectively mitigate the model drift, especially in models with time series data. Conclusions: Enhancing the model's ability to capture short-term time dependencies in time series data and periodic refitting with accumulative data were both capable of mitigating the model drift. The best improvement of model performance was observed in the combination of these two strategies.

BACKGROUND:Approximately 80% of the incident haemodialysis (HD) population in Aotearoa New Zealand relies on HD catheters for vascular access; however, utilisation patterns and outcomes remain poorly characterised. AIM:We described the incidence and outcomes of HD catheters in Aotearoa New Zealand from the prospective data collected as part of the REDUcing the burden of dialysis Catheter ComplicaTIOns: a National approach (REDUCCTION) trial. METHODS:We prospectively collected patient and catheter characteristics from adults (≥18 years) commencing acute or maintenance HD with an incident catheter between August 2018 and March 2020 across six Aotearoa New Zealand nephrology services. The primary outcome was adjudicated-confirmed HD catheter-related bloodstream infections (CRBSIs). Survival analysis using a Cox proportional hazards regression model was performed to determine independent risk factors for HD CRBSI. RESULTS:Among 894 patients (59 years (IQR 48-68), 58% male, 32% Māori), 1337 HD catheters were inserted corresponding to 157 142 catheter days. The confirmed HD CRBSI rate was 0.42/1000 catheter days (66 events). In the multivariable Cox regression, advancing age (HR 0.87 (95% CI 0.80, 0.95), P = 0.001) and tunnelled catheter use (HR 0.31 (0.13, 0.73), P = 0.007) were independently associated with lower HD CRBSI risk, while catheters inserted in operating theatres (HR 2.72 (1.08, 6.83), P = 0.03) were associated with increased infection risk. Methicillin-sensitive Staphylococcus aureus (39%) was the predominant pathogen in confirmed HD CRBSI events. CONCLUSION:This study represents the first prospective analysis of HD CRBSI rates in Aotearoa New Zealand nephrology services, revealing encouragingly low rates. Tunnelled catheters and advancing age demonstrated an independent protective factor against HD CRBSI, a finding that may be relevant when considering HD access in older patients.

BACKGROUND:Chronic kidney disease (CKD) is a growing public health problem in Ethiopia. However, evidence on the health system and contextual factors influencing CKD care remains limited. This study explored the barriers and facilitators to CKD care from the perspectives of healthcare providers and other stakeholders. METHODS:A descriptive qualitative study was conducted using purposive and maximum variation sampling to recruit healthcare providers (including general practitioners, nephrologists/internists, nurse) and non-communicable disease (NCD) officers and program coordinators. Interviews were audio recorded, transcribed, and thematically analysed, underpinned by the Theoretical Domains Framework version 2. RESULTS:Fifteen participants (six general practitioners, five nephrologists/internists, one nurse, and three NCD program officers and coordinators) were included. About 40% of participants had over six years' experience. Key barriers to CKD care included patient misconceptions, low patient and healthcare provider awareness, shortage of health workforce, knowledge gaps among junior healthcare providers, limited resources, high out-of-pocket costs, absence of registries for CKD, weak referral systems, inconsistent access to medicines and diagnostics, lack of structured training, and conflict-related disruptions. Facilitators included adherence to guidelines by senior staff, inclusion of CKD into national non-communicable disease strategies, and increased use of media for public health education. CONCLUSIONS:Addressing key barriers and enhancing prioritisation of CKD by clinicians and policymakers is critical. Strengthening workforce capacity, awareness, referral systems, and integration into national strategies offers opportunities to improve CKD care.