World Kidney Day 2009: Think Globally, Act Locally

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Celebrated every year on the second Thursday of March in more than 100 countries on six continents, this year’s World Kidney Day is March 12. The theme is “Keep the pressure down.” Events and screenings will highlight the importance of high blood pressure as one of the key symptoms and causes of chronic kidney disease.

The ASN partners with the National Kidney Foundation, Dialysis Patient Citizens, and the American Society of Pediatric Nephrology to promote World Kidney Day 2009. The organizations will visit congressional and committee offices March 12 to highlight the significance of kidney disease as a serious public health problem and the need for more kidney research.

The following excerpt is from “World Kidney Day 2009: Problems and Challenges in the Emerging Epidemic of Kidney Disease,” an editorial appearing in the March Journal of the American Society of Nephrology. Also watch for articles on World Kidney Day in the Clinical Journal of the American Society of Nephrology. Bakris et al. write about “The Message for World Kidney Day 2009: Hypertension and Kidney Disease: A Marriage that should be Prevented.” Okusa et al. address “The Nexus of Acute Kidney Injury, Chronic Kidney Disease and World Kidney Day 2009.”

World Kidney Day is an occasion to mark growing concerns over the impact of kidney disease on global public health. Although the distribution of etiologies of kidney disease and access to dialysis and transplantation may vary among regions of the world, arguably, one point is universal. An expanding proportion of people in every nation in the world are affected by chronic kidney disease (CKD). Since the prevalence of CKD rises dramatically with age, and is also associated with obesity and diabetes mellitus, kidney disease will be a public health concern for the foreseeable future. As a global community, we need to ask ourselves if we have the strategy in place to fully address the universal health problems arising from kidney disease, given the biological and cultural heterogeneity of populations, diverse environments, and varying capabilities of health-care delivery systems around the world.

The development of guidelines for care is an essential foundation for attacking any global crisis. While standardization is a critical tool to optimize quality of care, physicians and other health-care workers must relinquish some autonomy to implement practice guidelines (1). Empirical data demonstrate that standardized care guidelines are most effective when the evidence supporting protocols and process by which guidelines are created is transparent, and when there is trust in the organization that creates standards. Other specific barriers vary significantly based on practice setting. Given this, the focus should be local and point at the needs of specific communities, taking advantage of local health-care system resources.

Physicians need to treat individual patients with chronic diseases “within the larger context of family, community and society, as well as to treat the community itself (2).” Key questions for each nephrologist to ask are: “Have we adequately disseminated information on the importance of kidney disease as a public health problem in our local area?” and “Have we educated the colleagues we interact with on a daily basis on the availability of practice guidelines and patient-centered educational materials about kidney disease?”

Access to health care, including overcoming currently existing racial and ethnic disparities, is crucial for progress to be made (3). Efforts to increase screening and early identification of kidney disease require knocking down barriers based on inability to pay or on lack of insurance. Research is needed to facilitate the optimal translation of guideline recommendations into actual health-care improvements in diverse populations.

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A gap in the public’s awareness of the risk of kidney disease has been well documented (4). While not surprisingly those with the most advanced disease are most likely to be aware, still less than half of patients with stage 4 CKD were aware of having reduced kidney function in the National Health and Nutrition Examination Survey. In earlier stages of CKD where interventions arguably might have an even more significant impact, awareness is reported to be as low as 3 percent to 8 percent. Prior campaigns that can be emulated include promoting awareness of cardiovascular risk factors such as “hypertension—the silent killer” and the association between good and bad cholesterol in the development of heart disease. The National Kidney Disease Education Program sponsored by the National Institutes of Health provides templates and educational materials to support this effort.

Nationally, progress toward awareness and improvement in care is on the horizon with the Medicare Improvements for Patients and Providers Act (MIPPA) of 2008. In MIPPA, the Kidney Disease Education and Awareness Provisions authorized CMS, beginning January 2009, to conduct pilot initiatives in three states to promote awareness of chronic kidney disease, focusing on prevention. Additionally, the Agency for Healthcare Research and Quality recently hosted an open meeting to gather information and opinions on existing educational resources and programs on kidney disease. Thus momentum is being established that should lead to tangible progress over time.

There are also many examples of local successes that demonstrate the renal community recognizes the importance of more local tailored efforts and how essential it is to act now. In addition to many successful screening programs such as the Kidney Early Evaluation Program (KEEP; see story, p. 12), a number of states have recently begun grassroots campaigns on public awareness and screening. For example, North Carolina has successfully initiated the Kidney Education Outreach Program (KEOP). The objective of this program is to screen and provide education about chronic kidney disease using a mobile unit equipped with a fully functional exam room, restrooms, and a common area.

In the state of Washington, the non-profit Northwest Kidney Center’s Living Well with CKD™ program is addressing CKD through education, health screening, and collaboration with community organizations and health-care providers, with specific outreach to the African-American community. The CDC is also pilot-testing a new kidney disease screening program in California, Florida, New York, and Minnesota in collaboration with the National Kidney Foundation and the Chronic Diseases Research Group. This effort is targeting those who are above the age of 50 or those who have diabetes or hypertension.

Clearly, efforts to recognize CKD as a public health problem are moving forward. We need to recognize that fundamental aspects of kidney disease will likely translate to unique features of a public education/screening and prevention plan. The often-asymptomatic nature of kidney disease in early stages is a major hurdle to effective disease recognition. We need to learn from what has worked in the past to get patients to doctors, doctors to screen, and insurance to cover. We need to never stop asking “why” when we uncover a barrier to improved care.

References

1. 

Mathews SC, Pronovost PJ: Physician autonomy and informed decision making: finding the balance for patient safety and quality. J Am Med Assoc 2008; 300:2913–2915.

2. 

Shortell SM, Swartzberg J: The physician as public health professional in the 21st century. J Am Med Assoc 2008; 300:2916–2918.

3. 

Norris K, Nissenson AR: Race, gender, and socioeconomic disparities in CKD in the United States: J Am Soc Nephrol 2008; 19:1261–1270.

4. 

Plantinga LC, Boulware LE, Coresh J, Stevens LA, Miller ER III, Saran R, Messer KL, Levey AS, Powe NR: Patient awareness of chronic kidney disease: trends and predictors. Arch Intern Med 2008; 168:2268–2275.