Screening for Prevention

How will the program assist an individual if he or she is diagnosed with CKD?
We’re going to have a follow-up letter and a follow-up phone call to the individual who was screened. This is all part of the informed consent process. If they identify a physician, he or she will get a letter that provides the screening results. The participants will get information by mail and phone about their probable CKD based on one screening at the first event. We will have a phone call with the participant to encourage them to engage the healthcare system to see their physician. We’re going to try to foster ACE inhibitor angiotensin receptor blocker use in participants with CKD. We are going to try to foster risk factor control: blood pressure management, diabetes management.

What does having the Centers for Disease Control and Prevention as a partner bring to the screening program?
We want to commend the CDC for taking this project on. This is within the Division of Diabetes and Translation, so it includes a kidney disease interest group at the CDC. The CDC is one of the most respected health organizations in the world, so having them involved in funding and a cooperative agreement with the NKF and CDRG is fantastic in terms of bringing attention to the public health problem that CKD poses. The CDC also has multiple facets to address CKD. There’s the Division of Diabetes and Translation that’s involved with the screening program and the kidney disease interest group. There’s also a national center for health statistics that does the NHANES program and also modifies the ICD codes that comes from the World Health Organization for U.S. use. There’s a center for infectious diseases in terms of vaccinations. There’s a national office of public health in genomics—family history is important in CKD and ESRD. There are other initiatives within this program that include a surveillance program. They’re trying to develop an analogous program to the USRDS for CKD. They’re doing a cost analysis with Research Triangle Institute. CDC is addressing the cost burden of CKD in terms of hospitalization, total healthcare costs, quality-of-life years lost, the benefit of cost interventions. CDC also convened an expert panel in March 2007, and that’s actually going to be a full journal issue of the American Journal of Kidney Diseases sometime in late 2008. Each speaker is going to have at least one manuscript in that journal. Having the CDC involved lends us credibility in the public health arena.

I’ve seen patients present very late with CKD, finding out the week or day they start dialysis that they have ESRD, the missed opportunities there, the poor outcomes. We have to be honest; early diagnosis, we think, could improve outcomes. We don’t have the data for that yet, and that’s what’s exciting about this. Also, early diagnosis certainly gives patients more time to have interventions. The patient who is better educated, it makes sense, will probably do better than the patient who finds out the day before they have a catheter inserted into their right internal jugular vein to start dialysis treatments.

CKD is way beyond nephrologists. What I mean, is there’s only about 5,000 or 6,000 nephrologists in the United States. There’s only enough to probably treat most people with stage 4 and 5 CKD. There are probably not enough nephrologists to see everyone, even once a year, with stage 3 CKD in the U.S. We really need to take this to the primary care physicians and the public health arena because there are just not enough nephrologists to do this. What this really gets down to is better management of diabetes, hypertension and cardiovascular disease.

How did the NKF choose the location for the pilot program?
There are five things that we looked at. One is the demographics. We wanted to ensure a diverse study population that reflects the ethnic and racial distribution of the U.S., particularly for chronic kidney disease. We looked at the metropolitan statistical areas in terms of the Medicare 5 percent data for the prevalence of CKD. We wanted to distribute sites throughout the U.S., so we wanted to include the coasts and the Midwest. We considered convenience, and we considered the work experience of the local NKF organization, as well.