The prevalence, incidence, and medical expenses of end-stage renal disease (ESRD) is extremely high in Taiwan, China; so decreasing the incidence of ESRD is a major work for kidney disease prevention in Taiwan, China. Current chronic kidney disease (CKD) guideline suggests multidisciplinary team (MDT) care for CKD patient with estimated glomerular filtration rate (eGFR) less than 30 mL/(min·1.73 m2). MDT includes not only nephrologist but also nursing specialty, dietitian, social worker, psychologist, and other professional personnel. The aim of the MDT care is to preserve renal function, decrease complications, provide nutrient support and nephrotoxic drug consultation, establish the concept of renal replacement therapy and preparation for dialysis access, provide the renal transplantation information, and give the psychosocial support. These cares should provide to CKD patients one year before starting renal replacement therapy. The MDT care for CKD could delay the progression from CKD to ESRD, lower the mortality and hospitalization of CKD, slow the renal function decline, provide better medical care and quality of life for patients, and decrease the medical expenditures. Besides, advanced CKD patients receiving MDT care have higher arteriovenous access preparation rate that prevent the additional intervention and hospitalization while starting dialysis. MDT care also decreases the hospitalization costs and medical expenditures, and decrease 3-year mortality rate after dialysis initiation. The further developing MDT care includes: (1) providing personalized renal care and treatment model, and intergraded care by cardiology-nephrology-diabetes-neurology model; (2) new iCKD care with health management platform and care mode combined with communication technology; (3) shared decision making for choice of renal replacement therapy; (4) advance care planning clinic for palliative treatment of ESRD. All MDT care hopes to establish a person-oriented care policy, provides a better quality care model, not only for the patient’s personalized medical care, but also hopes to improve the overall kidney disease care and prevention work. In addition, we can extend the CKD prevention and treatment experience to other countries worldwide.