American Journal of Kidney Diseases
Volume 53, Issue 3 , Pages 522-535, March 2009

Comprehensive Public Health Strategies for Preventing the Development, Progression, and Complications of CKD: Report of an Expert Panel Convened by the Centers for Disease Control and Prevention

  • Andrew S. Levey, MD

      Affiliations

    • Division of Nephrology, Tufts Medical Center, Boston, MA
    • Corresponding Author InformationAddress correspondence to Andrew S. Levey, MD, Division of Nephrology, Tufts Medical Center, 800 Washington St, Box 391, Boston, MA 02111
    • ,
  • Anton C. Schoolwerth, MD, MSHA

      Affiliations

    • Dartmouth-Hitchcock Medical Center, Hanover, NH
    • ,
  • Nilka Ríos Burrows, MPH, MT

      Affiliations

    • Division of Diabetes Translation, Centers for Disease Control and Prevention
    • Centers for Disease Control and Prevention
    • ,
  • Desmond E. Williams, MD, PhD

      Affiliations

    • Centers for Disease Control and Prevention
    • ,
  • Karma Rabon Stith, PhD, CHES

      Affiliations

    • Danya Int, Inc
    • ,
  • William McClellan, MD, MPH

      Affiliations

    • Rollins School of Public Health, Emory University, Atlanta, GA

Received 8 September 2008; accepted 24 November 2008.

Article Outline

Chronic kidney disease (CKD) is a public health threat in the United States, with increasing prevalence, high costs, and poor outcomes. More widespread effort at the prevention, early detection, evaluation, and management of CKD and antecedent conditions could prevent complications of decreased kidney function, slow the progression of kidney disease to kidney failure, and reduce cardiovascular disease risk. In 2006, the Centers for Disease Control and Prevention (CDC) launched an initiative on CKD. As part of this initiative, the CDC convened an expert panel to outline recommendations for a comprehensive public health strategy to prevent the development, progression, and complications of CKD in the United States. The panel adapted strategies for primary, secondary, and tertiary prevention for chronic diseases to the conceptual model for the development, progression, and complications of CKD; reviewed epidemiological data from US federal agencies; and discussed ways of integrating public health efforts from various agencies and organizations. The panel recommended a 10-point plan to the CDC to improve surveillance, screening, education, and awareness directed at 3 target populations: people with CKD or at increased risk of developing CKD; providers, hospitals, and clinical laboratories; and the general public. Cooperation among federal, state, and local governmental and private organizations will be necessary to carry out these recommendations.

Index Words: Chronic kidney disease, prevention, public health

 

Chronic kidney disease (CKD) is a growing public health threat in the United States, with an increasing prevalence of kidney failure and earlier stages of CKD, high costs, and poor outcomes.1, 2, 3, 4 CKD is one of a number of chronic diseases affecting primarily the elderly and leading to substantially increased risk of cardiovascular disease (CVD), with a disproportionate burden in racial and ethnic minorities. As with hypertension, diabetes, and hypercholesterolemia, CKD is silent in its early stages, but can be detected from simple clinical and laboratory measurements. Treatment now is available to prevent complications of decreased kidney function, slow the progression of kidney disease, and reduce CVD risk.2 CKD testing can detect earlier stages of CKD, and the same methods used in clinical practice can be used to screen populations at increased risk.5 Public health interventions are available to improve the treatment and prevent the development of hypertension and diabetes, the 2 most common causes of CKD in adults.6, 7 Thus, the tools to reduce the burden of CKD are already available, but a comprehensive public health approach has not yet been developed.

Physician organizations in the United States have recognized the need to improve care for patients with kidney failure and earlier stages of CKD.8, 9 In 2006, the Centers for Disease Control and Prevention (CDC), as requested by Congress, launched an initiative on CKD.10 As part of this initiative, the CDC convened an expert panel meeting to outline recommendations for comprehensive public health strategies to prevent the development, progression, and complications of CKD in the United States. This report summarizes the findings of the panel from its meeting in March 2007 and its recommendations to the CDC.

Back to Article Outline

The Public Health Threat From CKD 

The incidence, prevalence, mortality, and cost for patients with kidney failure treated by dialysis and transplantation, the end stage of CKD, have increased steadily during the past 2 decades and are projected to continue to increase through 2020 (Table 1).11 The recent stabilization of incidence rates of treated kidney failure is encouraging, but appears to reflect a mixture of several trends.12 First, the increase in age and comorbidity of patients initiating dialysis therapy during the past decade suggests that part of the prior increase in incidence may have been caused by increases in treatment, in addition to increases in kidney failure. Possibly, the stabilization of incidence rates in some groups reflects stabilization in treatment. Second, the decrease in incidence rate in some groups, such as in young white people with diabetes mellitus, strongly suggests delay in kidney failure because of improvements in the treatment of patients with earlier stages of disease in this high-risk group. The continuing increase in incidence rate in the elderly and racial and ethnic minorities may represent important disparities in health care. Incidence rates for African Americans and Native Americans are nearly 3 and 2 times greater than for whites, respectively. Incidence rates for people older than 65 years are nearly 3 times greater than for younger people (Fig 1).2, 11

Table 1. Kidney Failure in the United States
  • View full-size image.
  • Figure 1. 

    Trends in treated kidney failure by race and age. Incidence counts and rates for kidney failure treated by dialysis and transplantation (A) by race, adjusted for age and sex, and (B) by age, adjusted for race and sex. Reproduced with permission from the 2007 Annual Data Report of the US Renal Data System.11

There is more than a 50-fold greater prevalence of patients with earlier stages of CKD, defined as albuminuria or decreased estimated glomerular filtration rate (GFR), compared with patients with treated kidney failure.13 Approximately 13% of the noninstitutionalized US adult population is now estimated to have CKD (26 million individuals), an increase from 10% almost 10 years earlier.13, 14 The increase is greatest in the elderly and appears to be caused in part by an increasing prevalence of diabetes and hypertension.

Altogether, these findings have dramatic potential consequences for the burden of CKD. First, the age-related decrease in GFR, long considered a “normal” part of aging, is associated with complications, increased risk of adverse outcomes, and high costs. Second, the aging of the population portends continuing increases in the number of cases of CKD, even if the incidence rate remains stable. Third, the increasing prevalence of obesity may lead to an earlier age of onset of hypertension and diabetes that could lead to an increasing incidence rate of kidney failure and CVD. Fourth, mounting costs for dialysis and transplantation are occurring at the same time that costs for other chronic diseases are increasing. The care of patients with chronic diseases consumes a large fraction of health care resources.15 The epidemic of obesity is expected to magnify these costs.

These findings are not unique to the United States. Throughout the world, chronic noncommunicable diseases are increasingly recognized as a public health threat.16 Prevalence estimates for treated kidney failure vary widely, in part because of limited availability of dialysis and transplantation. In Japan, Taiwan, and Thailand, where dialysis and transplantation are paid for by the government, the prevalence of treated kidney failure is as high as in the United States.17 The prevalence of earlier stages of kidney disease in developed countries within Europe, Asia, and Australia also appears similar to that observed in the United States.18, 19, 20 Accurate data for developing countries are not available. Developing countries are now experiencing the burden of noncommunicable chronic diseases, although communicable chronic diseases are not yet under control. For all countries, prevention, early detection, and intervention would be more cost-effective than treatment for kidney failure.

Back to Article Outline

The Panel and its Review 

The panel co-chairs were selected by the CDC, and other members were invited because of their knowledge of epidemiology, clinical practice guidelines, and current initiatives on screening and surveillance for CKD in the United States. The panel adapted preventive strategies for chronic diseases to the conceptual model for the development, progression, and complications of CKD; reviewed epidemiological data from US federal agencies; and discussed ways of integrating public health efforts for the prevention, detection, evaluation, and management of CKD. The recommendations were developed during the panel's 2-day meeting in March 2007, in which representatives from federal agencies and US voluntary health organizations were invited to participate. The agenda and a roster of participants are available at the CDC website.21 The report was prepared by the authors, with review and approval by all members of the expert panel and by the CDC. Figure 2 shows a conceptual model for CKD and its relationship to the classification of preventive strategies.2, 3, 4, 22, 23 Table 2 links these preventive strategies with clinical and epidemiological features of CKD and US clinical practice guidelines.2, 6, 7, 11, 14, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35, 36, 37, 38, 39, 40, 41, 42, 43, 44, 45, 46 Guidelines were searched through MEDLINE under “guidelines prevention treatment (chronic kidney disease)” and through the National Guideline Clearinghouse under “chronic kidney disease.” Table 3 lists existing programs for public health efforts for CKD.11, 13, 14, 25, 47, 48, 49, 50, 51, 52, 53, 54, 55, 56, 57, 58, 59, 60, 61, 62, 63, 64, 65, 66, 67, 68

  • View full-size image.
  • Figure 2. 

    Conceptual model of the public health approach for chronic kidney disease (CKD). Green circles, stages of CKD; blue circles, potential antecedents or consequences of CKD; thick arrows between circles, risk factors associated with the initiation and progression of disease that can be affected or detected by interventions; purple circles, outcomes of CKD. “Complications” refers to all complications of CKD and its treatment, including complications of decreased glomerular filtration rate (hypertension, anemia, malnutrition, and bone and mineral disease) and cardiovascular disease. Preventive strategies are shown below the target populations and risk factors to which they apply. Primary, secondary, and tertiary prevention refer to CKD. Modified and reprinted with permission.2

Table 2. Description, Prevalence Estimates, Public Health Strategies, and Clinical Guidelines for CKD and Antecedent Conditions
Preventive Strategies†CKD Stage or Antecedent ConditionsDescriptionGFR (mL/min/1.73 m2)Prevalence⁎ N [1,000s] (%)Related Terms and ICD-9 CodesPublic Health Strategies and Clinical Guidelines
Primary preventionAntecedentconditionsAt increased riskNA CKD risk factorsGlycemic and blood pressure control6, 7; ACE inhibitor/ARB use24; CKD awareness and education2, 25, 26, 27, especially in patients at increased risk
Age ≥ 60 y50,600(23.2)
Hypertension65,000(32.3)
Diabetes20,600(9.6)
CVD71,300(34.2)
Family history of CKDNational data not available

Secondary preventionCKDstage1Kidney damage with normal or ↑ GFR≥903,600(1.78)Albuminuria, proteinuria, hematuria; 585.1CKD education and testing for patients at increased risk24, 25, 28; glycemic and blood pressure control6, 7, 30; ACE inhibitor/ARB use6, 7, 26, 27, 29; other treatments to slow CKD progression2; counseling on nutrition30; evaluation and control of dyslipidemia31 and other CVD risk factors2; treatment of hepatitis C32; follow recommended clinical guidelines2
CKDstage2Kidney damage with mild ↓ GFR60-896,500(3.24)Albuminuria, proteinuria, hematuria; 585.2
CKDstage3Moderate ↓ GFR30-5915,500(7.69)Chronic renal insufficiency, early renal insufficiency; 585.3Follow recommended clinical guidelines above; evaluation and control of anemia33 and bone metabolism34; care of transplant recipients35; ESRD treatment choices36 and vascular access37
CKDstage4Severe ↓ GFR15-29700(0.35)Chronic renal insufficiency, late renal insufficiency, pre-ESRD; 585.4

Tertiary preventionCKDstage5Kidney failure<15 (or dialysis)400(0.20)Renal failure, uremia, ESRD; 585.5, 585.6 (if ESRD), V codes for dialysis or transplantationDialysis adequacy38, 39; vascular access37; anemia33; CVD40; nutrition30; bone metabolism34; evaluation for transplantation41; and initiation and withdrawal from dialysis42; follow recommended clinical guidelines2

Note: Conversion factor: GFR in mL/min/1.73 m2 to mL/s/1.73 m2, ×0.01667.

Abbreviations: ACE, angiotensin-converting enzyme; ARB, angiotensin receptor blocker; CKD, chronic kidney disease; CVD, cardiovascular disease; ESRD, end-stage renal disease; GFR, glomerular filtration rate; ICD-9, International Classification of Diseases, Ninth Revision; NA, not applicable; NHANES, National Health and Nutrition Examination Survey.

⁎Prevalence estimates for antecedent conditions based on data in people 20 years or older.43, 44, 45 Prevalence for CKD stages 1 to 4 is projected from the NHANES (1999-2004) for the population of 200 million adults aged 20 years or older in 2000.14 Prevalence for CKD stage 5 is based on 300,000 patients treated by dialysis in 2001 to 200211 and an assumed additional 100,000 not treated by dialysis.46

†Primary prevention is directed at people at increased risk of CKD; secondary prevention, at patients with CKD stages 1 to 4, divided into 2 groups based on CKD stages 1 to 2 (kidney damage) and stages 3 to 4 (decreased GFR); and tertiary prevention, at patients with kidney failure, including those treated by dialysis and transplantation.

Table 3. Existing Programs for Surveillance, Screening, and Education and Awareness for CKD in the United States

Abbreviations: CDC, Centers for Disease Control and Prevention; CKD, chronic kidney disease; CMS, Centers for Medicaid & Medicare Services; ESRD, end-stage renal disease; KEEP, Kidney Early Evaluation Program; NCHS, National Center for Health Statistics; NHANES, National Health and Nutrition Examination Survey; NIDDK, National Institute of Diabetes and Digestive and Kidney Diseases; NKDEP, National Kidney Disease Education Program; NKF, National Kidney Foundation; QIO, Quality Improvement Organizations; USRDS, US Renal Data System.

Back to Article Outline

Conceptual Framework and Testing for CKD 

Figure 2 shows the chronic disease model for CKD, emphasizing stages of CKD and antecedents, outcomes, and risk factors for the development, progression, and complications of CKD.2, 3, 4, 22, 23 CKD is defined as either kidney damage or GFR less than 60 mL/min/1.73 m2 for 3 months or longer, regardless of the cause of kidney disease.2, 3, 4 The most common markers of kidney damage include abnormalities in urine, such as albuminuria (usually ascertained as a spot urine albumin-creatinine ratio > 30 mg/g), abnormalities in kidney imaging results, or a history of kidney transplantation. GFR usually is estimated from an equation using serum creatinine level, age, sex, and race.5, 68, 69 Stages of CKD are defined by level of GFR.

CKD is a heterogeneous condition, varying according to the cause and type (pathology) of kidney disease, severity, rate of progression, and comorbid conditions. Typically, CKD evolves over a long time, during which the disease can be detected by means of laboratory tests before the onset of symptomatic kidney failure. In the majority of patients, CKD can be detected by using 2 simple tests: a urine test for albumin and a blood test for serum creatinine to estimate GFR.5 Because of the lesser accuracy of estimating equations at higher levels of GFR, GFR estimates greater than 60 mL/min/1.73 m2 are not reported as a numeric value by clinical laboratories, and it may be difficult to interpret GFR estimates just less than 60 mL/min/1.73 m2 in some people.70 In this range, interpretation of GFR estimates depends on results of tests for markers of kidney damage and the clinical context. Restricting routine testing to patients at increased risk of CKD reduces false-positive results and enables more efficient use of resources.

Back to Article Outline

Continuum of Disease Prevention 

Strategies for disease prevention may be divided into primary, secondary, and tertiary according to the presence or absence of disease and its severity. The panel applied these strategies to CKD. Table 2 links these preventive strategies with additional clinical description of stages of CKD and antecedent conditions, recent prevalence estimates, and US clinical practice guidelines.2, 6, 7, 11, 14, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35, 36, 37, 38, 39, 40, 41, 42, 43, 44, 45, 46

Primary Prevention 

Primary prevention includes preventing the development of risk factors for CKD, such as hypertension and diabetes, and preventing the development of CKD in populations at increased risk. Recent trials have shown that lifestyle modification can reduce the incidence of diabetes in high-risk individuals,7 and reductions in dietary salt intake can decrease blood pressure and reduce the incidence of hypertension.6 Several studies have shown the potential to prevent or delay the development of albuminuria in patients with diabetes by using strict glucose control or an angiotensin-converting enzyme inhibitor.24, 71, 72, 73 Primary prevention strategies have not yet been proved for CKD caused by hypertension or other causes of CKD.

Secondary Prevention 

Secondary prevention includes slowing the progression and treating complications in patients with kidney damage (stages 1 to 2) and decreased GFR (stages 3 to 4).2 In patients with stages 1 to 2, in which GFR is normal or only mildly impaired, interventions include evaluation, treatment of the underlying cause of kidney disease, and general measures to slow kidney disease progression and reduce CVD risk. In patients with stages 3 to 5, in which GFR is moderately to severely impaired, additional interventions are necessary for complications of decreased GFR, such as hypertension, anemia, malnutrition, and bone and mineral disorders. The knowledge and practice of the detection, treatment, and control of CKD and associated risk factors for progression in US populations is substantially less than optimal.47, 74, 75, 76, 77 The key to effective secondary prevention is the early identification and treatment of CKD in those at increased risk. The panel considered 3 main risk groups: patients with hypertension or diabetes, patients with CVD, and people with a family history of CKD.

Hypertension and Diabetes 

Clinical trials have shown the efficacy of therapies to slow the progression of CKD caused by hypertension and diabetes.6, 7, 26, 27, 29 The benefits of treating patients with early kidney disease may include CVD risk reduction.78, 79 There are no data from large clinical trials to assess the efficacy of screening; however, cost-effectiveness analyses suggest benefit for patients with diabetes80, 81, 82 or patients with hypertension aged 60 years or older.83

Cardiovascular Disease 

Recent data show CVD as a risk factor for loss of kidney function and development of CKD.84, 85 Guidelines now recommend testing for CKD in patients with CVD risk factors or clinical CVD.28 The rationale for screening patients with CVD and CVD risk factors is that the prevalence of CKD is greater in these groups. Moreover, in the “CKD subgroup,” CVD risk factor levels are greater and more difficult to control, outcomes are worse, costs are higher, and strategies for CVD risk reduction and treatment differ in patients with compared with those without CKD.86, 87 Some have referred to CKD as a “multiplier” for CVD risk.88, 89 As with all CVD risk factors, the increase in absolute risk is greater in people with other risk factors. Many clinical trials of patients with CVD risk reduction or treatment excluded patients with later stages of CKD90; however, analyses of trials that included patients with earlier stages of CKD generally showed that the beneficial effect of treatment in the CKD subgroup is as large as or larger than in the group without CKD.91, 92, 93

Family History 

There is substantial evidence that members of families with an index member with kidney failure are at increased risk of kidney failure.94 Individuals who report a family member with kidney failure have an increased prevalence of hypertension, diabetes, and earlier stages of CKD.95 A recent population-based study of older US adults found a high prevalence of family history of kidney failure and that these individuals were more likely to be African American and women, have a history of diabetes, and be overweight or obese.96

Tertiary Prevention 

Tertiary prevention includes improving care for patients with kidney failure. Clinical practice guidelines have been developed for many aspects of care,30, 33, 36, 37, 38, 39, 41 and recent data show an association between achievement of clinical performance measures based on these guidelines and improved survival.97

Back to Article Outline

Existing Programs 

Table 3 lists existing programs for surveillance, screening, and enhancing education and awareness.11, 13, 14, 25, 47, 48, 49, 50, 51, 52, 53, 54, 55, 56, 57, 58, 59, 60, 61, 62, 63, 64, 65, 66, 67, 68

Surveillance 

Surveillance refers to an activity to provide key information about CKD, such as time, location, magnitude, and severity, to guide implementation of medical and public health measures to control the progression of CKD and its complications. Federally funded population-based registries and surveys that can be used for surveillance for various stages of CKD include the US Renal Data System (USRDS),11, 48 National Health and Nutrition Examination Survey (NHANES),13, 14, 50, 51 Centers for Medicare & Medicaid Services (CMS) End-Stage Renal Disease (ESRD) Network System,52, 53, 54, 55, 56, 57, 58 and Quality Improvement Organizations (QIOs; Table 3).64

Screening 

Screening is an activity whereby persons in a defined population who are not aware of CKD are tested to detect the disease and subsequently treated to reduce the risk of progression of CKD and its complications. There is no current federal program for CKD screening. The National Kidney Foundation (NKF) Kidney Early Evaluation Program (KEEP) is an example of an ongoing screening program targeting populations at increased risk.65

Enhancing Education and Awareness 

These programs are essential to educate providers, patients and their families, and the public about CKD and its consequences. The National Kidney Disease Education Program (NKDEP) was established in 2000 with the goal of decreasing the burden of CKD in the United States.66

Back to Article Outline

Recommendations 

The existing programs described provide a rich epidemiological database to indicate the populations at increased risk of the development, progression, and complications of CKD. Table 4 lists the panel's recommendations to the CDC to improve translation of prevention into practice. Recommendations are grouped according to the target population. For each recommendation, a specific action is proposed, with examples of existing programs and systems within organizations with responsibility for public health activities regarding CKD or other related chronic diseases. Integration of activities of multiple organizations will be necessary to carry out these recommendations.

Table 4. Recommendations of the Expert Panel to the CDC

Abbreviations: BRFSS, Behavioral Risk Factor Surveillance System; CDC, Centers for Disease Control and Prevention; CHERISH, CKD Health Evaluation and Risk Information Sharing; CKD, chronic kidney disease; CME, continuing medical education; CMS, Centers for Medicare & Medicaid Services; DQIP, Diabetes Quality Improvement Project; eGFR, estimated glomerular filtration rate; HEDIS, Healthcare Effectiveness Data and Information Set; KDOQI, Kidney Disease Outcomes Quality Initiative; KEEP, Kidney Early Evaluation Program; MMWR, Morbidity and Mortality Weekly Report; NCQA, National Committee for Quality Assurance; NHANES, National Health and Nutrition Examination Survey; NIH, National Institutes of Health; NKDEP, National Kidney Disease Education Program; NKF, National Kidney Foundation; PCP, primary care provider; QIO, Quality Improvement Organizations; RPA, Renal Physicians Association; USRDS, US Renal Data System.

People With CKD or at Increased Risk of Developing CKD 

Recommendations 1 to 7 can be carried out by governmental agencies and nongovernmental organizations with a public health mission. Improving the detection of CKD in populations at increased risk (recommendation 5) is paramount. Table 5 provides more detail about recommended CKD testing for populations at increased risk.2, 6, 26, 27, 28, 29 Additional research about prediction of risk and strategies to improve outcomes is a key part of these recommendations.

Table 5. Current Recommendations for Screening for CKD

Note: Conversion factors for units: urine ACR in mg/g to mg/mmol, ×0.113; GFR in mL/min/1.73 m2 to mL/s/1.73 m2, ×0.01667.

Abbreviations: ACR, albumin-creatinine ratio; ADA, American Diabetes Association; AHA, American Heart Association; CAD, coronary artery disease; CHF, congestive heart failure; CKD, chronic kidney disease; CVD, cardiovascular disease; eGFR, estimated glomerular filtration rate; JNC7, Joint National Commission for Prevention, Detection, Evaluation and Treatment of High Blood Pressure, 7th Report; MI, myocardial infarction; NKF, National Kidney Foundation; PVD, peripheral vascular disease.

Providers, Hospitals, and Clinical Laboratories 

Recommendations 8 and 9 are to strengthen provider education and improve laboratory procedures for CKD reporting. These measures will be necessary to improve the detection, evaluation, and management of CKD.

General Public 

Recommendation 10 is to increase public awareness of CKD. Improved health-related decision making will be essential for primary, secondary, and tertiary prevention.

These recommendations are applicable to patients with a number of chronic diseases, not just CKD. This is consistent with the recognition of CKD as a key component of a cluster of chronic diseases, including hypertension, diabetes, and CVD, affecting primarily the elderly and leading to substantially increased risk of mortality, morbidity, and cost. CKD commonly coexists with these other conditions; thus, it will be most efficient for a public health strategy for CKD to emphasize opportunities for CKD detection in coordination with existing public health strategies for these other diseases.

Back to Article Outline

Current Status and Activities 

Current CDC Projects 

The CDC is developing capacity and infrastructure for a public health approach to CKD in collaboration with partners from other government agencies, universities, and national organizations. The CDC CKD initiative includes projects in the areas of kidney disease surveillance and epidemiology, screening, health outcomes research, and health economics.10, 98 These efforts should result in improved assessment of the burden of CKD in the United States, a screening program for CKD in states, documentation of direct and indirect costs of CKD, and development of a model that will not only help predict the development, progression, and complications of CKD, but also test the effectiveness of various public health interventions. The CDC has also developed a kidney disease interest group with other divisions and centers at the CDC and participates with other federal agencies, including the National Institutes of Health (National Institute of Diabetes and Digestive and Kidney Diseases [NIDDK] and NKDEP), CMS, and US Department of Veterans Affairs. The CDC kidney interest group and partners from states, universities, and other organizations published kidney-related reports in CDC's weekly journal to highlight National Kidney Month and World Kidney Day.99

Global Initiatives 

There is growing international interest in developing public health policies for CKD. World Kidney Day, an initiative of the International Federation of Kidney Foundations and the International Society of Nephrology, has been observed annually since March 2006 and seeks to send a message to the public, government health officials, health professionals, patients, and families that “CKD is common, harmful, and treatable.”86, 87 KDIGO (Kidney Diseases: Improving Global Outcomes) is an independent nonprofit foundation governed by an international board to promote the coordination, collaboration, and integration of initiatives to develop and implement clinical practice guidelines.4 A KDIGO position paper issued in 2006 noted that few countries have policies for CKD and most are unaware of the high prevalence of CKD, its contribution to other diseases, or its economic burden.100 KDIGO recommends that all governments adopt a public health policy for CKD, which should include support for screening and surveillance and public education programs.

The plan outlined for the United States may also be relevant to other developed countries with well-established infrastructure for public health. Developing countries face substantial obstacles to the initiation of public health programs for patients with all chronic diseases. CKD should be considered when implementing programs for other chronic diseases.

Back to Article Outline

Summary 

At the request of the CDC, the expert panel reviewed the current state, evidence, and issues related to CKD and recommended a comprehensive public health strategy to prevent the development, progression, and complications of CKD in the United States. The strategy focuses on primary, secondary, and tertiary prevention initiatives; targets people with CKD and at increased risk of developing CKD, providers, and the general public; and encourages integration of activities of multiple organizations with responsibility for public health activities for patients with chronic diseases. This strategy can be translated locally and globally to improve outcomes for CKD.

Back to Article Outline

Acknowledgements 

The CDC Expert Panel was co-chaired by Drs Levey and McClellan. In addition to the authors, the members of the CDC Expert Panel were Allan J. Collins, MD (Director, USRDS Coordinating Center, Minneapolis, MN); Josef Coresh, MD, PhD, MPH (Johns Hopkins Medical Institutions, Baltimore, MD); Thomas H. Hostetter, MD (Department of Medicine, Albert Einstein College of Medicine, New York, NY); T.G. Patel, MD (Renal Diseases, Diabetes, and Oncology, Veterans Administration, Washington, DC); Neil R. Powe, MD, MPH, MBA (Welch Center for Prevention, Epidemiology and Clinical Research, Johns Hopkins School of Medicine and Johns Hopkins School of Public Health, Baltimore, MD); Michael Rocco, MD, MSCE (Section on Nephrology, Wake Forest University School of Medicine, Wake Forest, NC); and Mark Rutkowski, MD (Internal Medicine and Nephrology, Southern California Permanente Medical Group, Baldwin Park, CA).

The CDC Expert Panel acknowledges the assistance of Regina Jordan, MPH, from the CDC; Kelly Munly, MS, Mayra Bennett, BA, Michelle Bonds, BA, Henry Wong, PhD, and Namratha Swamy, PhD, from Danya Int Inc; and Robert Bruce, BA, and Maia Leppo, BA, from Tufts Medical Center.

The findings and conclusions in this report are those of the authors and do not necessarily represent the position of the CDC.

Support: None.

Financial Disclosure: Dr Schoolwerth serves on an advisory board for Ortho Biotech Inc, from which he has also received honoraria, and owns stock in Merck & Co Inc and Pfizer Inc.

Back to Article Outline

References 

  1. Schoolwerth AC, Engelgau MM, Hostetter TH, et al. Chronic kidney disease: A public health problem that needs a public health action plan. Prev Chronic Dis. 2006;[serial online], Apr http://www.cdc.gov/pcd/issues/2006/apr/05_0105.htmAccessed December 21, 2008
  2. National Kidney Foundation. K/DOQI Clinical Practice Guidelines for Chronic Kidney Disease: Evaluation, classification, and stratification. Am J Kidney Dis. 2002;39(suppl 1):S1–S266
  3. Levey AS, Coresh J, Balk E, et al. National Kidney Foundation practice guidelines for chronic kidney disease: Evaluation, classification, and stratification. Ann Intern Med. 2003;139:137–147
  4. Levey AS, Eckardt KU, Tsukamoto Y, et al. Definition and classification of chronic kidney disease: A position statement from Kidney Disease: Improving Global Outcomes (KDIGO). Kidney Int. 2005;67:2089–2100
  5. Vassalotti JA, Stevens LA, Levey AS. Testing for chronic kidney disease: A position statement from the National Kidney Foundation. Am J Kidney Dis. 2007;50:169–180
  6. Chobanian AV, Bakris GL, Black HR, et al. The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure: The JNC 7 Report. JAMA. 2003;289:2560–2572
  7. American Diabetes Association. Standards of medical care in diabetes—2006. Diabetes Care. 2006;29(suppl 1):S1–S71
  8. Parker TF, Blantz R, Hostetter T, et al. The chronic kidney disease initiative. J Am Soc Nephrol. 2004;15:708–716
  9. Hull AR, Parker TF. Proceedings from the Morbidity, Mortality and Prescription of Dialysis Symposium, Dallas, TX, September 15-17, 1989. Am J Kidney Dis. 1990;15:375–383
  10. Centers for Disease Control and Prevention. Chronic kidney disease initiative. http://www.cdc.gov/diabetes/projects/kidney.htmAccessed November 11, 2008
  11. US Renal Data System. USRDS 2007 Annual Data Report. Bethesda, MD: The National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases; 2007;
  12. Burrows NR, Wang J, Geiss LS, Venkat Narayan KM, Engelgau MM. Incidence of end-stage renal disease among persons with diabetes—United States 1990-2002. MMWR Morbid Mortal Wkly Rep. 2005;54:1097–1100
  13. Coresh J, Selvin E, Stevens LA, et al. Prevalence of chronic kidney disease in the United States. JAMA. 2007;298:2038–2047
  14. Coresh J, Astor B, Greene T, Eknoyan G, Levey A. Prevalence of chronic kidney disease and decreased kidney function in the adult US population: Third National Health and Nutrition Examination Survey. Am J Kidney Dis. 2003;41:1–12
  15. US Renal Data System. USRDS 2005 Annual Data Report. Bethesda, MD: The National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases; 2005;
  16. Yach D, Hawkes C, Gould CL, Hofman KJ. The global burden of chronic diseases: Overcoming impediments to prevention and control. JAMA. 2004;291:2616–2622
  17. Lysaght MJ. Maintenance dialysis population dynamics: Current trends and long-term implications. J Am Soc Nephrol. 2002;13(suppl 1):S37–S40
  18. Chen J, Wildman RP, Gu D, et al. Prevalence of decreased kidney function in Chinese adults aged 35 to 74 years. Kidney Int. 2005;68:2837–2845
  19. Hallan SI, Coresh J, Astor BC, et al. International comparison of the relationship of chronic kidney disease prevalence and ESRD risk. J Am Soc Nephrol. 2006;17:2275–2284
  20. Chadban SJ, Briganti EM, Kerr PG, et al. Prevalence of kidney damage in Australian adults: The AusDiab Kidney Study. J Am Soc Nephrol. 2003;14(suppl 2):S131–S138
  21. Centers for Disease Control and Prevention. Disease Public Health Resource (Diabetes Project: Kidney Disease Initiative). http://www.cdc.gov/diabetes/projects/kidney.htm[updated January 11, 2008]. Accessed December 29, 2008
  22. Gordon RS. An operational classification of disease prevention. Public Health Rep. 1983;98:107–109
  23. Froom P, Benbassat J. Inconsistencies in the classification of preventive interventions. Prev Med. 2000;31:153–158
  24. Ruggenenti P, Fassi A, Ilieva AP, et al. Preventing microalbuminuria in type 2 diabetes. N Engl J Med. 2004;351:1941–1951
  25. National Kidney Foundation. Kidney Early Evaluation Program (KEEP) annual data report 2006. Am J Kidney Dis. 2007;49(suppl 3):S1–S130
  26. National Kidney Foundation. KDOQI Clinical Practice Guidelines and Clinical Practice Recommendations for Diabetes and Chronic Kidney Disease. Am J Kidney Dis. 2007;49(suppl 2):S1–S180
  27. National Kidney Foundation. K/DOQI Clinical Practice Guidelines for Hypertension and Antihypertensive Agents in Chronic Kidney Disease. Am J Kidney Dis. 2004;43(suppl 1):S1–S290
  28. Brosius FC, Hostetter TH, Kelepouris E, et al. Detection of chronic kidney disease in patients with or at increased risk of cardiovascular disease: A science advisory from the American Heart Association Kidney and Cardiovascular Disease Council; the Councils on High Blood Pressure Research, Cardiovascular Disease in the Young, and Epidemiology and Prevention; and the Quality of Care and Outcomes Research Interdisciplinary Working Group: Developed in collaboration with the National Kidney Foundation. Circulation. 2006;114:1083–1087
  29. Molitch ME, DeFronzo RA, Franz MJ, et al. Nephropathy in diabetes. Diabetes Care. 2004;27(suppl 1):S79–S83
  30. National Kidney Foundation. K/DOQI Clinical Practice Guidelines for Nutrition in Chronic Renal Failure. Am J Kidney Dis. 2000;35(suppl 2):S1–S140
  31. National Kidney Foundation. K/DOQI Clinical Practice Guidelines for Management of Dyslipidemias in Chronic Kidney Disease. Am J Kidney Dis. 2003;41(suppl 3):S1–S92
  32. Kidney Disease: Improving Global Outcomes (KDIGO clinical practice guidelines for the prevention, diagnosis, evaluation and treatment of hepatitis C in chronic kidney disease). Kidney Int Suppl. 2008;109:S1–S99
  33. National Kidney Foundation. KDOQI Clinical Practice Guidelines and Clinical Practice Recommendations for Anemia in Chronic Kidney Disease. Am J Kidney Dis. 2006;47(suppl 3):S1–S146
  34. National Kidney Foundation. K/DOQI Clinical Practice Guidelines for Bone Metabolism and Disease in Chronic Kidney Disease. Am J Kidney Dis. 2003;42(suppl 3):S1–S202
  35. Kasiske BL, Vazquez MA, Harmon WE, et al. Recommendations for the outpatient surveillance of renal transplant recipients (American Society of Transplantation). J Am Soc Nephrol. 2000;11(suppl 15):S1–S86
  36. Renal Physicians Association. Clinical Practice Guidelines on Shared Decision-Making in the Appropriate Initiation of and Withdrawal From Dialysis. Washington DC: Renal Physicians Association; 1997;
  37. National Kidney Foundation. KDOQI Clinical Practice Guidelines for Vascular Access. Am J Kidney Dis. 2006;48(suppl 1):S176–S247
  38. National Kidney Foundation. KDOQI Clinical Practice Guidelines for Hemodialysis Adequacy, Update 2006. Am J Kidney Dis. 2006;48(suppl 1):S2–S90
  39. National Kidney Foundation. KDOQI Clinical Practice Guidelines for Peritoneal Adequacy, Update 2006. Am J Kidney Dis. 2006;48(suppl 1):S91–S97
  40. National Kidney Foundation. K/DOQI Clinical Practice Guidelines for Cardiovascular Disease in Dialysis Patients. Am J Kidney Dis. 2005;45(suppl 3):S1–S153
  41. Kasiske BL, Cangro CB, Hariharan S, et al. The evaluation of renal transplantation candidates: Clinical practice guidelines. Am J Transplant. 2001;1(suppl 2):S3–S95
  42. Bolton WK. Renal Physicians Association clinical practice guideline: Appropriate patient preparation for renal replacement therapy: Guideline number 3. J Am Soc Nephrol. 2003;14:1406–1410
  43. US Census Bureau. Annual estimates of the population by five-year age groups and for sex for the United States: April 1, 2000 to July 1, 2006. http://www.census.gov/popest/national/asrh/NC-EST2006/NC-EST2006=01.xlsAccessed December 3, 2008
  44. Thom T, Haase N, Rosamond W, et al. Heart disease and stroke statistics—2006 Update: A report from the American Heart Association Statistics Committee and Stroke Statistics Subcommittee. Circulation. 2006;113:e85–e151
  45. Centers for Disease Control and Prevention. National Diabetes Fact Sheet: General Information and National Estimates on Diabetes in the United States, 2005. Atlanta, GA: US Department of Health and Human Services, Centers for Disease Control and Prevention; 2005;
  46. O'Hare AM, Bertenthal D, Covinsky KE, et al. Mortality risk stratification in chronic kidney disease: One size for all ages?. J Am Soc Nephrol. 2006;17:846–853
  47. Kausz AT, Guo H, Pereira BJ, Collins AJ, Gilbertson DT. General medical care among patients with chronic kidney disease: Opportunities for improving outcomes. J Am Soc Nephrol. 2005;16:3092–3101
  48. Gilbertson DT, Liu J, Xue JL, et al. Projecting the number of patients with end-stage renal disease in the United States to the year 2015. J Am Soc Nephrol. 2005;16:3736–3741
  49. Li S, Foley RN, Collins AJ. Anemia and cardiovascular disease, hospitalization, end stage renal disease, and death in older patients with chronic kidney disease. Int Urol Nephrol. 2005;37:395–402
  50. Coresh J, Byrd-Holt D, Astor B, et al. Chronic kidney disease awareness, prevalence, and trends among U.S. adults, 1999 to 2000. J Am Soc Nephrol. 2005;16:180–188
  51. Centers for Disease Control and Prevention. Prevalence of chronic kidney disease and associated risk factors—United States, 1999-2004. MMWR Morbid Mortal Wkly Rep. 2007;56:161–165
  52. Sehgal AR. Impact of quality improvement efforts on race and sex disparities in hemodialysis. JAMA. 2003;289:996–1000
  53. McClellan WM, Hodgin E, Pastan S, McAdams L, Soucie M. A randomized evaluation of two health care quality improvement program (HCQIP) interventions to improve the adequacy of hemodialysis care of ESRD patients: Feedback alone versus intensive intervention. J Am Soc Nephrol. 2004;15:754–760
  54. Wolfe RA, Hulbert-Shearon TE, Ashby VB, Mahadevan S, Port FK. Improvements in dialysis patient mortality are associated with improvements in urea reduction ratio and hematocrit, 1999 to 2002. Am J Kidney Dis. 2005;45:127–135
  55. McClellan WM, Krisher JO. Collecting and using patient and treatment center data to improve care: Adequacy of hemodialysis and end-stage renal disease surveillance. Kidney Int Suppl. 2000;74:S7–S13
  56. McClellan WM, Soucie JM, Krisher J, Caruana R, Haley W, Farmer C. Improving the care of patients treated with hemodialysis: A report from the Health Care Financing Administration's ESRD Core Indicators Project. Am J Kidney Dis. 1998;31:584–592
  57. Matchar DB, Patwardhan MB, Samsa GP, Haley WE. Facilitated process improvement: An approach to the seamless linkage between evidence and practice in CKD. Am J Kidney Dis. 2006;47:528–538
  58. McClellan WM. Improving the quality of care for CKD: Can we do it again?. Am J Kidney Dis. 2006;47:549–552
  59. Cook CB, Penman A, Cobb AB, Miller D, Murphy T, Horn T. Outpatient diabetes management of Medicare beneficiaries in four Mississippi fee-for-service primary care clinics. J Miss State Med Assoc. 1999;40:8–13
  60. Jencks SF, Cuerdon T, Burwen DR, et al. Quality of medical care delivered to Medicare beneficiaries: A profile at state and national levels. JAMA. 2000;284:1670–1676
  61. Wu WY, Chen JJ, Shih A. Effect of quality improvement organization activities on outpatient diabetes care in eastern New York State. Med Care. 2006;44:1142–1147
  62. McBean AM, Jung K, Virnig BA. Improved care and outcomes among elderly Medicare managed care beneficiaries with diabetes. Am J Manag Care. 2005;11:213–222
  63. McClellan WM, Millman L, Presley R, Couzins J, Flanders WD. Improved diabetes care by primary care physicians: Results of a group-randomized evaluation of the Medicare Health Care Quality Improvement Program (HCQIP). J Clin Epidemiol. 2003;56:1210–1217
  64. Institute of Medicine. Medicare's Quality Improvement Organization Program: Maximizing Potential (pathways to quality health care) (ed 1). Washington DC: National Academy; 2006;
  65. Brown WW, Collins A, Chen SC, et al. Identification of persons at high risk for kidney disease via targeted screening: The NKF Kidney Early Evaluation Program. Kidney Int Suppl. 2003;83:S50–S55
  66. Hostetter TH, Lising M. National Kidney Disease Education Program. J Am Soc Nephrol. 2003;14(suppl 2):S114–S116
  67. National Institutes of Health. National Kidney Disease Education Program. http://nkdep.nih.gov/Accessed December 21, 2008
  68. Myers GL, Miller WG, Coresh J, et al. Recommendations for improving serum creatinine measurement: A report from the laboratory working group of the National Kidney Disease Education Program. Clin Chem. 2006;52:5–18
  69. Levey AS, Coresh J, Greene T, et al. Using standardized serum creatinine values in the Modification of Diet in Renal Disease Study equation for estimating glomerular filtration rate. Ann Intern Med. 2006;145:247–254
  70. Stevens LA, Coresh J, Deysher AE, et al. Evaluation of the MDRD Study equation in a large diverse population. J Am Soc Nephrol. 2007;18:2749–2757
  71. Remuzzi G, Macia M, Ruggenenti P. Prevention and treatment of diabetic renal disease in type 2 diabetes: The BENEDICT Study. J Am Soc Nephrol. 2006;17(suppl 2):S90–S97
  72. UK Prospective Diabetes Study (UKPDS) Group. Intensive blood-glucose control with sulphonylureas or insulin compared with conventional treatment and risk of complications in patients with type 2 diabetes (UKPDS 33). Lancet. 1998;352:837–853
  73. The Diabetes Control and Complications Trial Research Group. The effect of intensive treatment of diabetes on the development and progression of long-term complications in insulin-dependent diabetes mellitus. N Engl J Med. 1993;329:977–986
  74. Kazmi W, Kausz A, Khan S, et al. Anemia: An early complication of chronic renal insufficiency. Am J Kidney Dis. 2001;38:803–812
  75. Obrador GT, Ruthazer R, Arora P, Kausz A, Pereira BJG. Prevalence of and factors associated with sub-optimal care prior to initiation of dialysis in the United States. J Am Soc Nephrol. 1999;10:1793–1800
  76. Nissenson A, Collins A, Hurley J, Petersen H, Pereira B, Steinberg E. Opportunities for improving the care of patients with chronic renal insufficiency: Current practice patterns. J Am Soc Nephrol. 2001;12:1713–1720
  77. Kausz AT, Khan SS, Abichandani R, et al. Management of patients with chronic renal insufficiency in the Northeastern United States. J Am Soc Nephrol. 2001;12:1501–1507
  78. Asselbergs FW, Diercks GF, Hillege HL, et al. Effects of fosinopril and pravastatin on cardiovascular events in subjects with microalbuminuria. Circulation. 2004;110:2809–2816
  79. Buse JB, Ginsberg HN, Bakris GL, et al. Primary prevention of cardiovascular diseases in people with diabetes mellitus: A scientific statement from the American Heart Association and the American Diabetes Association. Circulation. 2007;115:114–126
  80. Golan L, Birkmeyer JD, Welch HG. The cost-effectiveness of treating all patients with type 2 diabetes with angiotensin-converting enzyme inhibitors. Ann Intern Med. 1999;131:660–667
  81. Kiberd BA, Jindal KK. Screening to prevent renal failure in insulin dependent diabetic patients: An economic evaluation. BMJ. 1995;311:1595–1599
  82. Palmer AJ, Weiss C, Sendi PP, et al. The cost-effectiveness of different management strategies for type I diabetes: A Swiss perspective. Diabetologia. 2000;43:13–26
  83. Boulware L, Jaar B, Tarver-Carr M, Bruncati F, Powe N. Screening for proteinuria in US adults: A cost-effectiveness analysis. JAMA. 2003;290:3101–3114
  84. McClellan WM, Langston RD, Presley R. Medicare patients with cardiovascular disease have a high prevalence of chronic kidney disease and a high rate of progression to end-stage renal disease. J Am Soc Nephrol. 2004;15:1912–1919
  85. Elsayed EF, Tighiouart H, Griffith J, et al. Cardiovascular disease and subsequent kidney disease. Arch Intern Med. 2007;167:1130–1136
  86. Collins AJ, Couser WG, Dirks JH, et al. World Kidney Day: An idea whose time has come. Am J Kidney Dis. 2006;47:375–377
  87. Levey AS, Andreoli SP, DuBose T, Provenzano R, Collins AJ. Chronic kidney disease: Common, harmful, and treatable—World Kidney Day 2007. Am J Kidney Dis. 2007;49:175–179
  88. McCullough PA, Lepor NE. Piecing together the evidence on anemia: The link between chronic kidney disease and cardiovascular disease. Rev Cardiovasc Med. 2005;6(suppl 3):S4–S12
  89. Sarnak MJ, Levey AS, Schoolwerth AC, et al. Kidney disease as a risk factor for development of cardiovascular disease: A statement from the American Heart Association Councils on Kidney in Cardiovascular Disease, High Blood Pressure Research, Clinical Cardiology, and Epidemiology and Prevention. Circulation. 2003;108:2154–2169
  90. Coca SG, Krumholz HM, Garg AX, Parikh CR. Underrepresentation of renal disease in randomized controlled trials of cardiovascular disease. JAMA. 2006;296:1377–1384
  91. Tonelli M, Moye L, Sacks FM, Kiberd B, Curhan G. Pravastatin for secondary prevention of cardiovascular events in persons with mild chronic renal insufficiency. Ann Intern Med. 2003;138:98–104
  92. Mann JF, Gerstein HC, Pogue J, Bosch J, Yusuf S. Renal insufficiency as a predictor of cardiovascular outcomes and the impact of ramipril: The HOPE randomized trial. Ann Intern Med. 2006;134:629–636
  93. Solomon SD, Rice MM, Jablonski KA, et al. Renal function and effectiveness of angiotensin-converting enzyme inhibitor therapy in patients with chronic stable coronary disease in the Prevention of Events with ACE inhibition (PEACE) trial. Circulation. 2006;114:26–31
  94. Queiroz Madeira EP, da Rosa Santos O, Ferreira Santos SF, Alonso da Silva L, MacIntyre Innocenzi A, Santoro-Lopes G. Familial aggregation of end-stage kidney disease in Brazil. Nephron. 2002;91:666–670
  95. Ramirez SP, McClellan W, Port FK, Hsu SI. Risk factors for proteinuria in a large, multiracial, southeast Asian population. J Am Soc Nephrol. 2002;13:1907–1917
  96. McClellan W, Speckman R, McClure L, et al. Prevalence and characteristics of a family history of end-stage renal disease among adults in the United States population: Reasons for Geographic and Racial Differences in Stroke (REGARDS) renal cohort study. J Am Soc Nephrol. 2007;18:1344–1352
  97. Rocco MV, Frankenfield DL, Hopson SD, McClellan WM. Relationship between clinical performance measures and outcomes among patients receiving long-term hemodialysis. Ann Intern Med. 2006;145:512–519
  98. US National Institutes of Health. National Institute on Aging (Health ABC Description). http://www.nia.nih.gov/ResearchInformation/ScientificResources/HealthABCDescription.htmAccessed February 16, 2008
  99. Notice to Readers: World Kidney Day—March 13, 2008. MMWR Morbid Mortal Wkly Rep. 2008;57:207
  100. Levey AS, Atkins R, Coresh J, et al. Chronic kidney disease as a global public health problem: Approaches and initiatives—A position statement from Kidney Disease: Improving Global Outcomes. Kidney Int. 2007;72:247–259

 Because an author of this manuscript is an editor for AJKD, the peer-review and decision-making processes were handled entirely by an Associate Editor (Michael Shlipak, MD, University of California, San Francisco) who served as Acting Editor-in-Chief. Details of the journal's procedures for potential editor conflicts are given in the Editorial Policies section of the AJKD website.

PII: S0272-6386(08)01730-7

doi:10.1053/j.ajkd.2008.11.019

American Journal of Kidney Diseases
Volume 53, Issue 3 , Pages 522-535, March 2009

Article Tools

* Image Usage & Resolution