Evaluating the Effectiveness of a Smart Screening and Tiered Management Tool for Diabetic Kidney Disease in Primary Care: A Cluster Randomized Trial (SMART-DKD)

This is a cluster-randomized controlled trial aiming to evaluate the effectiveness of an intelligent standardized screening and risk-stratified management tool for diabetic kidney disease (DKD) among adults with type 2 diabetes in primary care settings.

Background China has a high prevalence of type 2 diabetes, and 30%-40% of diabetic patients develop DKD, the leading cause of end-stage kidney disease. Primary care facilities lack convenient, standardized digital tools to screen, grade and manage DKD systematically, leading to delayed detection and suboptimal kidney protection for diabetic patients. This study develops a localized intelligent DKD management system integrated into primary care electronic medical records (HIS) to solve this gap.

Study Design & Participants

We will recruit 30 primary healthcare institutions (15 urban community health centers, 15 rural township health centers) across Longyou County, with at least 200 registered type 2 diabetes patients at each site. A total of 3,000 eligible adults aged 18-75 years diagnosed with type 2 diabetes will be enrolled, randomly assigned in a 1:1 cluster ratio to two groups:

Intervention group (15 sites, 1,500 patients): Receive the intelligent DKD screening and graded management plug-in embedded in local HIS. The tool automatically calculates estimated glomerular filtration rate (eGFR), generates DKD risk stratification, sends reminders for regular urine albumin creatinine ratio (UACR) testing, and provides individualized treatment, follow-up and referral guidance.

Control group (15 sites, 1,500 patients): Receive routine standard diabetes management following national primary care diabetes guidelines, without access to the intelligent DKD digital support system.

Study Procedures All participants complete a baseline screening visit (V1) to sign informed consent, review medical history, complete physical examinations, and undergo lab tests including UACR, serum creatinine, fasting blood glucose, glycated hemoglobin, lipid profile and urinalysis. Follow-up visits are scheduled at 3 months (V2), 6 months (V3), and 12 months (V4) after baseline, repeating physical checks and core laboratory testing. An optional extended observational follow-up continues until 24 months, with biospecimens collected and shipped to the central research laboratory for unified testing. Participants may withdraw voluntarily at any time without impact on routine clinical care, and unscheduled visits will be arranged if adverse events or abnormal lab results occur.

Key Study Outcomes Primary Outcome: Change in log-transformed urine albumin creatinine ratio (UACR) from baseline to the 12-month follow-up, comparing the two management models.

Secondary Outcomes: 12-month DKD screening rate, DKD diagnosis rate, standardized DKD treatment rate, and change in eGFR over 12 months. The study also assesses the operability of the intelligent management tool and patient treatment adherence in primary care.

Risks & Benefits Potential Risks: Participants will undergo routine fasting blood draws and urine collection at each visit, which may cause minor temporary pain, bruising, or rare vasovagal reactions during venipuncture.

Benefits: All participants receive free regular DKD-related laboratory testing covered by the research team. Intervention group patients receive personalized, automated kidney risk management recommendations to slow DKD progression. Any study-related injury will receive free medical treatment and corresponding compensation from the research project.

Data Protection & Ethics All participant personal information and biological samples are fully anonymized with unique study codes and stored in encrypted databases with restricted access. The study strictly complies with the Declaration of Helsinki, Chinese GCP, and domestic clinical research regulations. All participants provide written informed consent before enrollment, with full rights to withdraw at any stage without penalty. Study results will be published in peer-reviewed journals and presented at academic conferences to improve nationwide primary care DKD prevention and control.

Statistical Analysis All analyses will use intention-to-treat, modified intention-to-treat, per-protocol, and safety analysis datasets. Mixed models for repeated measures, t-tests, rank-sum tests, and Fisher's exact tests will be applied to compare between-group differences, with multiple imputation used to handle missing primary endpoint data. All adverse events will be coded using MedDRA and summarized to evaluate the safety profile of the intervention strategy.

Study Overview

• Status: Not yet recruiting
• Conditions: Type 2 Diabetes Mellitus; Diabetic Kidney Disease
• Intervention / Treatment: Behavioral: Intervention Name Clinical decision support system for diabetic kidney disease (DKD-CDSS); Behavioral: Routine guideline-based diabetes management

Detailed Description

This cluster-randomized controlled trial assesses the effectiveness of an integrated intelligent digital plug-in for standardized screening and stratified clinical management of diabetic kidney disease (DKD) within primary care electronic medical record (HIS) systems, compared against routine guideline-based diabetes care without digital decision support. The study addresses widespread under-screening, inconsistent risk stratification and substandard long-term renal protection for adults living with type 2 diabetes at community and township healthcare facilities across China. Thirty primary care institutions (15 urban community health centers, 15 rural township health centers) will undergo 1:1 cluster randomization to intervention or control arms, with a total target enrollment of 3,000 participants with type 2 diabetes (1,500 per arm). All study procedures comply with the Declaration of Helsinki, Chinese GCP and national regulations for investigator-initiated clinical research.

Eligibility Criteria Institutional Inclusion Criteria Each participating primary care site must register ≥200 managed type 2 diabetes patients under national basic public health services; have internet-connected HIS terminals to operate the digital management tool; complete on-site laboratory capacity to perform UACR, serum creatinine, fasting glucose, HbA1c, lipid panel and urinalysis with validated internal and external quality control; possess standardized biospecimen collection, temporary storage and cold-chain transport protocols to deliver blood and urine samples to the central testing laboratory at the First Affiliated Hospital of Chongqing Medical University; and secure full written commitment from site leaders and clinicians to complete recruitment, intervention and follow-up per protocol. Institutions with a record of premature project withdrawal due to poor investigator compliance within the past two years are excluded.

Participant Inclusion Criteria Age 18 to 75 years inclusive, any gender; Confirmed type 2 diabetes mellitus per the 2024 Chinese Type 2 Diabetes Prevention and Treatment Guidelines; Able to provide written informed consent voluntarily. Participant Exclusion Criteria Active severe systemic illness or acute disease flare at screening; Moderate-to-severe psychiatric disorders including depression, bipolar disorder, schizophrenia, or documented suicidal ideation; Cognitive impairment or language barriers preventing full understanding of study procedures and communication with research staff; Concurrent enrollment in another DKD screening or interventional research trial; Any other condition judged by investigators to preclude safe trial participation.

Participant Early Withdrawal Rules Participants may withdraw consent and exit the trial at any time without penalty to routine medical care. Mandatory withdrawal triggers include participant death, identification of non-diabetic kidney disease during follow-up, persistent severe non-adherence disrupting endpoint assessment, or three consecutive failed follow-up contacts within one month. All withdrawn participants will complete a standardized exit assessment within six weeks of discontinuation (exempt if full lab testing was completed within the prior four weeks), with all withdrawal reasons fully documented in case report forms.

Intervention and Control Definitions The intervention arm deploys a customized DKD screening and graded management plug-in embedded in local HIS. The digital tool auto-calculates eGFR, generates standardized DKD risk stratification, delivers automated UACR screening reminders, and provides individualized guidance on glycemic/blood pressure targets, medication adjustment, follow-up scheduling and specialist referral thresholds. Control sites deliver conventional diabetes management following national primary diabetes guidelines and public health chronic disease protocols, with no access to the intelligent digital module, automated renal function calculations or clinical alert prompts. All participating clinicians receive unified baseline training on general diabetes care; only intervention-site staff receive additional training on the digital tool's functions.

Trial Visit Schedule and Assessments Screening/baseline visit (V1, -2 to 0 weeks) confirms eligibility, collects informed consent, captures demographics, medical/surgical history, chronic medication records, standardized physical measurements, and baseline blood/urine biospecimens for central laboratory testing of UACR, serum creatinine, urinalysis, fasting glucose, HbA1c and lipids. Mandatory follow-up visits occur at 3 months (V2 ±15 days), 6 months (V3 ±15 days) and 12 months (V4 ±15 days), repeating identical physical exams, laboratory testing, adverse event documentation and medication reconciliation. An extended observational phase runs through Month 24 with repeated biomarker and clinical data collection. Unscheduled visits are permitted for participants with abnormal lab values or clinically significant adverse events, with all encounters fully recorded. All baseline, 12-month and 24-month biospecimens are shipped to the central research laboratory for unified testing.

Primary and Secondary Study Endpoints Primary Outcome Between-group difference in natural log-transformed urine albumin-creatinine ratio (UACR) from baseline to the 12-month follow-up timepoint, analyzed via repeated measures mixed-effects models (MMRM) across all longitudinal visits. Missing primary endpoint data will be handled via multiple imputation.

Secondary Outcomes (all assessed at 12 months post-baseline) Institutional DKD screening rate among enrolled type 2 diabetes participants; Confirmed DKD clinical diagnosis rate; Rate of guideline-concordant standardized DKD treatment; Change in estimated glomerular filtration rate (eGFR) from baseline to 12 months; Real-world operability of the intelligent digital tool in primary care and participant long-term follow-up adherence.

Safety Endpoints All adverse events will be coded per MedDRA version 28.0 or newer, including hyperkalemia, acute kidney injury, severe hypoglycemia and other clinically significant laboratory abnormalities. Incidence rates of adverse events are compared between groups using Fisher's exact test to identify safety signals; all serious adverse events undergo detailed causality assessment, narrative documentation and standardized reporting.

Analysis Populations

Four distinct analytical datasets will be generated for outcome evaluation:

Intention-to-Treat (ITT): All cluster-randomized participants, primary population for main efficacy analysis; Modified ITT (mITT): ITT participants who completed baseline assessment and at least one DKD screening visit, used for sensitivity analyses of efficacy endpoints; Per-Protocol (PPS): mITT participants with complete 12-month UACR/eGFR data and no major protocol violations, for robustness testing of primary outcomes; Safety Set (SS): All participants with at least one safety evaluation visit, used for all adverse event analyses.

Continuous secondary endpoints will be analyzed with t-tests or Wilcoxon rank-sum tests based on normality; categorical screening, diagnosis and treatment rates use Fisher's exact test. All statistical testing employs a two-sided alpha of 0.05, with analyses performed using R or SAS software.

Risks, Benefits and Data Confidentiality Minimal procedural risks to participants include transient pain, bruising or rare vasovagal reactions from routine venipuncture and urine collection. All trial-related laboratory testing is provided free of charge by the research team with no participant out-of-pocket costs. Intervention arm participants receive individualized digital renal risk management recommendations to slow DKD progression. Any study-related injury qualifies participants for free clinical treatment and project-funded compensation; no monetary incentives are offered for enrollment or follow-up. All participant identifiers are anonymized via unique study codes, with encrypted electronic databases and locked physical archives limiting data access to designated research and audit staff only. De-identified aggregate study results will be published in peer-reviewed journals and presented at academic conferences without disclosure of individual participant information.

• Study Type: Interventional
• Enrollment (Estimated): 3000
• Phase: Not Applicable

Contacts and Locations

• Study Contact: Name: Zhihong Wang, Doctor of Philosophy; Phone Number: +86 13883021919; Email: towzh713@126.com

Study Locations

• China
  • Chongqing Municipality
    • Chongqing, Chongqing Municipality, China
      • Chongqing
      • Contact: Qing Yan, Bachelor; Phone Number: +86 023-89011876; Email: cyfyykyc@cqmu.edu.cn

Participation Criteria

Eligibility Criteria

• Ages Eligible for Study: Adult; Older Adult
• Accepts Healthy Volunteers: No

Description

Inclusion Criteria:

• Aged 18-75 years old.
• Diagnosed with type 2 diabetes mellitus.
• Able to complete follow-up visits and relevant examinations as required.
• Voluntary participation with signed informed consent.

Exclusion Criteria

• Complicated with severe hepatic, renal, cardiac or malignant tumor diseases.
• With acute complications of diabetes or severe infectious diseases within 3 months.
• Pregnant or lactating women.
• Participating in other similar clinical intervention studies.
• Unable to cooperate with study management due to cognitive or mental disorders.

Study Plan

How is the study designed?

Design Details

• Primary Purpose: Health Services Research
• Allocation: Randomized
• Interventional Model: Parallel Assignment
• Masking: Single

Number of Arms

2

Arms and Interventions

Participant Group / Arm	Intervention / Treatment
Experimental: DKD Clinical Decision Support System Intervention Group; The participating primary medical institutions in this group adopt the DKD standardized screening and intelligent graded management software embedded as a plug-in into the HIS system. The digital tool can automatically calculate eGFR, complete DKD risk stratification, send intelligent reminders for UACR screening, and provide individualized treatment targets, follow-up plans and referral prompts in line with relevant guidelines. All enrolled subjects receive unified physical examinations and laboratory tests at each scheduled visit according to the research protocol.	Behavioral: Intervention Name Clinical decision support system for diabetic kidney disease (DKD-CDSS); This study's intervention is a hospital information system-embedded diabetic kidney disease clinical decision support system (DKD-CDSS). It automatically computes eGFR, completes DKD risk stratification, triggers UACR screening reminders, and outputs individualized guideline-aligned glycemic, blood pressure, lipid control targets, medication adjustment suggestions, follow-up schedules and specialist referral advice for type 2 diabetes patients. Unlike general diabetes management software, this CDSS focuses specifically on early renal injury screening and hierarchical standardized treatment of DKD, and is tailored for primary care community and township medical institutions. The control arm only adopts traditional manual routine diabetes management without this dedicated DKD auxiliary decision-making module.
Active Comparator: Routine Conventional Diabetes Management Group; The participating primary medical institutions in this group carry out routine diabetes management in accordance with the National Primary Diabetes Prevention and Control Guidelines and national basic public health service requirements, without using the DKD intelligent screening and graded management tool developed in this study. There are no digital auxiliary functions such as automatic eGFR calculation, risk grading, intelligent follow-up and referral reminders during the whole management process. All enrolled subjects receive the same physical examination items and laboratory testing frequency as the intervention group.	Behavioral: Routine guideline-based diabetes management; Participants in this arm receive routine diabetes management in accordance with national primary diabetes prevention and control guidelines without access to the dedicated DKD clinical decision support system. Clinicians rely on their own clinical experience to judge DKD risk, arrange UACR screening, adjust hypoglycemic and hypotensive drugs, and formulate follow-up plans, without automatic system reminders or standardized hierarchical treatment recommendations targeting diabetic kidney disease. The inspection schedule and physical examination items are completely consistent with the intervention group, while all medical decision-making links do not get auxiliary prompts from the DKD-specific CDSS.

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Change in urinary albumin-to-creatinine ratio (UACR) from baseline to 1 year after intervention	Compare the difference in the change of UACR levels between the DKD-CDSS intervention group and routine management group at 1 year of intervention. Spot urine specimens are tested by unified laboratory standards to quantify urinary albumin and creatinine, which reflects the degree of early renal damage in patients with type 2 diabetes mellitus.	1 year after intervention initiation

Secondary Outcome Measures

Outcome Measure	Measure Description	Time Frame
DKD screening rate at 1 year after intervention	Proportion of enrolled type 2 diabetes patients completing standardized DKD-related screening examinations within 1 year of intervention, compared between two groups.	1 year after intervention initiation
DKD diagnosis rate at 1 year after intervention	Proportion of subjects newly diagnosed with diabetic kidney disease after standardized assessment within 1 year of intervention, with inter-group comparison.	1 year after intervention initiation
Standardized treatment rate of DKD at 1 year after intervention	Proportion of patients with confirmed DKD receiving guideline-concordant standardized hypoglycemic, antihypertensive and renal protective treatment after 1-year intervention, compared across arms.	1 year after intervention initiation
Change in estimated glomerular filtration rate (eGFR) from baseline to 1 year after intervention	Compare the variation of eGFR values from baseline to the 1-year follow-up between the two groups, to evaluate the alteration of renal filtration function in type 2 diabetes patients.	1 year after intervention initiation

Collaborators and Investigators

• Sponsor: First Affiliated Hospital of Chongqing Medical University

Study record dates

Study Major Dates

• Study Start (Estimated): July 30, 2026
• Primary Completion (Estimated): September 30, 2028
• Study Completion (Estimated): September 30, 2028

Study Registration Dates

• First Submitted: July 13, 2026
• First Submitted That Met QC Criteria: July 13, 2026
• First Posted (Actual): July 16, 2026

Study Record Updates

• Last Update Posted (Actual): July 16, 2026
• Last Update Submitted That Met QC Criteria: July 13, 2026
• Last Verified: July 1, 2026

More Information

Terms related to this study

• Keywords: Cluster randomized trial; Primary care; Type 2 diabetes; Diabetic kidney disease; CDSS
• Additional Relevant MeSH Terms: Urogenital Diseases; Endocrine System Diseases; Male Urogenital Diseases; Kidney Diseases; Urologic Diseases; Female Urogenital Diseases; Female Urogenital Diseases and Pregnancy Complications; Metabolic Diseases; Glucose Metabolism Disorders; Diabetes Mellitus; Diabetes Complications; Nutritional and Metabolic Diseases; Diabetes Mellitus, Type 2; Diabetic Nephropathies
• Other Study ID Numbers: 2024ZD0523305; ZZ2024-567-02 (Other Identifier: The Medical Research Ethics Review Committee of the First Affiliated Hospital of Chongqing Medical University)

Plan for Individual participant data (IPD)

• Plan to Share Individual Participant Data (IPD)?: NO

Drug and device information, study documents

• Studies a U.S. FDA-regulated drug product: No
• Studies a U.S. FDA-regulated device product: No