Running head CHRONIC KIDNEY DISEASE 1 .docx

Running head: CHRONIC KIDNEY DISEASE
1
Chronic Kidney Disease: Problems, Perceptions, and Strategies
for Intervention
David Brown
Walden University
HLTH 4900, Section 2, Capstone
November 16, 2013
Instructor: Dr. Jody Early
CHRONIC KIDNEY DISEASE: PROBLEMS, PERCEPTIONS,

AND STRATEGIES FOR INTERVENTION 2
Abstract
Chronic kidney disease is considered one of the most significant
health issues affecting
morbidity and mortality and contributes heavily to the state of
global health. Chronic kidney
disease (CKD) and end-stage renal disease (ESRD) are chronic
illnesses that have a dramatic
impact on the cost of health care delivery in the United States.
Early detection and intervention
are critical to the long-term prognosis of this patient
population; however, a health disparity
exists because not everyone who is at risk for CKD has access
to resources for screening and
treatment. One of the goals of community-level and national
programs is to create parity of care
by focusing attention on marginalized communities that are at a
statistically higher risk for CKD.
The global impact of CKD and ESRD is significant because
long-term survival depends on
expensive technology and many regions of the world lack the
resources needed to treat this
disease. Health behavior and culture are known contributors to
the long-term survivability of the

disease. Since early detection is the key, creating screening
programs that target populations at
greatest risk will have the highest impact, and be the most cost-
effective solution to combating
this chronic illness.
Chronic Kidney Disease: Problems, Perceptions, and Strategies
for Intervention
Chronic kidney disease (CKD) is considered one of the primary
global health issues and
contributes significantly to the social burden of care. CKD,
along with cardiovascular disease,
diabetes, chronic respiratory disease, and cancer, is a chronic
illness that is classified as a non-
communicable disease (Healthy People 2020, 2013). Non-
communicable diseases have a
significant societal impact to domestic growth, productivity,
and health care costs and are the
most common cause of morbidity and premature death in the
United States (Couser, Remuzzi,
Mendis, & Tonelli, 2011). Chronic illnesses are also

characterized by physical and emotional
stressors that can become overwhelming when simultaneously
coping with multiple
comorbidities (Moulton, 2008). Although the World Health
Assembly has determined that non-
communicable diseases contribute heavily to the state of global
health, they concede that public
health policy can dramatically affect patient morbidity and
mortality (Couser et al., 2011). CKD
is a public health threat that is on the rise and will likely not
slow without deliberate intervention.
This literature review will describe the impact that chronic
kidney disease and end-stage renal
disease have on the global burden of care, as well as detail the
issues that contribute to health
care disparities affecting this patient population. Factors that
affect morbidity and mortality will
also be discussed and a solution will be presented that has the
potential to reduce the health
system burden and improve the prognosis of many who suffer
from this chronic disease.
Chronic Kidney Disease Statistics and Epidemiological Data
The impact of chronic kidney disease and end-stage renal
disease (ESRD) on the federal

Medicare budget is staggering. In 2008, CKD cost $60 billion
and ESRD totaled $39.5 billion,
which was 27% of the annual Medicare budget (Rettig, 2011).
Recently, studies have reported
that approximately 26 million Americans have some degree of
CKD (Navaneethan, Aloudat, &
Singh, 2008). Only 5% of the people in the most treatable early
stages of CKD are aware they
have the disease, and almost 50% of those in stage 4 remain
unaware unless diagnosed with a
comorbid condition such as hypertension or diabetes (Couser et
al., 2011). As with many
illnesses, prevention and wellness programs that offer CKD
screening can improve long-term
outcomes.
Prevention and Wellness Strategies for At-Risk Populations
Prevention and wellness strategies do much for mitigating the
physiologic damage from
CKD, and can extend the productivity and mortality within this
patient population. The greatest

benefits are realized when detection and intervention occur
early in the disease cycle; however,
limiting factors such as genetic, environmental, and social
barriers interfere with efforts to
deploy prevention and wellness strategies that can also screen
for health issues (Pearson, 2008).
Although CKD is an illness that affects all cultural,
geopolitical, and socioeconomic classes, not
all groups have the same clinical outcomes. Native Americans,
Asian and Pacific Islanders, and
Hispanics have a greater likelihood of progressing to ESRD, and
African Americans are four
times more likely than Caucasians to suffer renal failure
requiring a kidney transplant (National
Medical Association, n.d.). The data indicates that a significant
disparity exists between
Caucasians and other ethnic groups in the diagnosis and
treatment of CKD. Evaluative and
preventative strategies are a part of high quality health care
delivery, and involve interventions
that incorporate a diet plan, exercise routine, and medication
protocol. Intervention strategies
should be tailored to the particular community since each of the
disparate groups has ethnic and

cultural differences that must be factored to ensure
interventional plan compliance.
The Impact of Quality Health Care Delivery on CKD
High quality health care delivery can have a dramatic impact
on the morbidity and
mortality of people suffering from CKD. A study conducted by
the National Kidney Foundation-
Kidney Disease Outcomes Quality Initiatives has proven that
hospitalizations are reduced, and
mortality is improved if patients are referred to a nephrologist
within one month of new onset
CKD (Navaneethan et al., 2008). This study also discovered that
individuals were more likely to
be delayed in getting a referral if they were part of a minority,
uninsured, less educated, or
elderly. Access to service, proper screening, and appropriate
follow-through are challenges that
must be addressed if this disparity is to be eliminated.
Evaluation and comprehensive counseling
on social and environmental factors that negatively impact

health are important acute
interventions, and long-term health benefits are seen when early
referral to a nephrologist and
access to follow-up care are provided (Collins, Gilbertson,
Snyder, Chen, & Foley, 2010).
Currently, numerous programs exist that focus on high-risk
populations and are designed to
provide access to screening and follow-up care. The National
Kidney Foundation (2013)
sponsors KEEP Healthy, which is an extension of their Kidney
Early Evaluation Program
(KEEP) and brings a nationally sponsored, community-based
initiative designed to screen and
educate in regions that have statistically higher CKD
populations. The Kidney Care Prevention
Program (KCPP) is a regional community-based program in
North Carolina that staff trained
kidney care coordinators and educators who can intervene early
in the disease process, and can
offer support through early-stage CKD intervention and
management (Harward & Falk, 2008).
These are only two examples of community-based programs
designed to provide individuals
with the best chance at early detection and intervention. Many

such programs exist, and more are
being offered as federal funding becomes available.
The Global Impact of CKD
Although the impact of CKD on the United States and most
developed countries is
significant, it is much worse in less developed countries.
Screening programs are essential for
early detection, but many areas of the world lack the
infrastructure to be able to offer these
services. Limited access to care and technology, poor living
conditions and diet, and an
inadequate supply of pharmaceuticals results in rapid
conversion from CKD to ESRD, which is
quickly followed by death (Couser et al., 2011). When CKD
progresses to ESRD, the only cure
is a kidney transplant. Renal replacement therapy, which is also
known as hemodialysis, can be
used as a bridge to transplant. There are 2 million people
currently on hemodialysis worldwide,
which constitutes only 12% of the global CKD population, and

nearly all of them are treated in
just five countries, including the United States, Japan,
Germany, Brazil, and Italy (Couser et al.,
2011). This means that 88% of the world population does not
have a bridge to transplant, nor do
they have access to renal transplantation surgery. When viewed
from this perspective, it becomes
clear just how devastating a diagnosis of CKD can be to most of
the world’s population.
Health Behavior and CKD
Health behavior plays a significant role in an individual’s
ability to cope with and
manage chronic illness. Health behavior is so important in
disease management that many health
behavior models have been created in an effort to understand
the link. One of the oldest health
behavior theories is the Health Belief Model (HBM). The HBM
asserts that people have an
inherent readiness to act, which is built from life experiences,
self efficacy, the perception of
vulnerability to a given health problem, the severity of the
issue, and the barriers and benefits to
taking positive action (Williams, Manias, Liew, Gock, &
Gorelik, 2012). Life experiences fall in

the category of mediating factors, which also includes
demographics, level of education,
structural, and social variables. It is theorized that mediating
factors that greatly impact CKD are
primary causes of the current health disparity (Williams et al.,
2012). Recognizing these
variables and creating practices that mitigate them are the keys
to creating health parity across
the different CKD population groups. Culture can also affect
health behavior and should be
considered when creating screening and intervention programs.
Culture and CKD
An individual’s culture influences their perspectives on health
and wellness, which can
subsequently affect how well they manage their disease. One of
the challenges with managing
patient populations that have a high incidence of undiagnosed
and undertreated CKD is that they
tend to be culturally and linguistically diverse (CALD) groups
(Williams et al., 2012). Chronic

disorders such as CKD, diabetes, and cardiovascular disease
require a strict adherence to lifestyle
modification instructions and medication protocols. Limited
health literacy, poor cognition, or a
language barrier inhibits effective communication and has been
shown to result in poor health
outcomes (Norris & Nissenson, 2008). These communities are
also at risk because they cannot
afford health care, have decreased access the health system, and
have little or no access to
screening and testing facilities (Rettig, Norris, & Nissenson,
2008). These communities often
shun modern health services because historically conditioned
biases have created in an inability
to trust or feel safe in contemporary health care delivery centers
(Rettig et al., 2008).
Establishing community-based health clinics that are staffed and
managed by lay health advisors,
especially in regions that have heavy racial and ethnic
populations, will not only create
community buy-in, but also create agents of change. Lay health
advisors are community
members who have a natural tendency to help, and are provided
training and support so they can

assist and advise others in their community on various health
issues (Pullen-Smith & Plescia,
2008). Overcoming health care disparities will require lay
health advisors to be recruited from
within the affected patient population. Recruiting members from
within the community has
resulted in improved attitudes as community members gain
control over their own health issues.
The Role of Technology in Treating CKD
Patients with CKD and ESRD rely heavily on technology to
manage their disease
process. Point-of-care testing that can measure creatinine,
glucose, albumin, and other critical
blood values allows clinics to mobilize and bring much needed
health care into the community
instead of waiting for members of at-risk groups to be proactive
and seek screening centers
(Harward & Falk, 2008). The mobile centers have been
instrumental in finding individuals who
are in the early stages of CKD and respond best to early

intervention.
When CKD progresses to ESRD, the person must learn to
embrace the technology that
will sustain his or her life until renal transplantation can be
offered. Being tethered to a dialysis
machine several days a week for six hours at a time, constant
testing, and living with a dialysis
catheter or fistula create a technological burden that can be
overwhelming. Embracing
technology is not easy for patients to do because machine
dependency runs contrary to the
freedom and autonomy that the individual previously enjoyed.
Acculturation occurs when the
patient conforms to behavior patterns and routines that are
needed in order to exist indefinitely
on machine dependency (Harward & Falk, 2008). At the point of
acculturation, the patient fully
embraces the new technology and accepts it as an integral part
of life.
Legal and Ethical Issues Impacting CKD
Besides technology concerns, there are many legal and ethical
issues surrounding the
condition of CKD that can impact an individual’s ability to
obtain the necessary treatment. In

October 1972, the federal government passed the Social
Security Amendments, which extended
Medicare coverage to the disabled, and officially recognized
ESRD as a disability (Vassalotti,
Gracz-Weinstein, Gannon, & Brown, 2006). In 2009, the
American Recovery and Reinvestment
Act (ARRA) shifted the focus from reactive and therapeutic
intervention, to a proactive and
preventative model (Menzin et al., 2011). Currently, instead of
waiting and treating the terminal
disease of ESRD, which is ineffective, inefficient, and costly,
clinicians are screening for CKD
in at-risk populations so that appropriate intervention can occur
at a stage where the disease
process can be halted or even reversed.
There are other federal programs that help those suffering from
CKD. A second example
of a public policy that focuses on active intervention is the
Medicare Improvements for Patients
and Providers Act of 2008 (MIPPA), which provides funding to

education programs for
individuals with stage 4 CKD (Menzin et al., 2011). The MIPPA
has proven successful at
providing funding that creates highly effective targeted
education.
The Interdisciplinary Team’s Approach to Treating CKD
The process of screening, treatment, and education need the
involvement from many
disciplines within health care. An interdisciplinary team
approach can be the best way to manage
complex illnesses such as CKD. Working within culturally and
linguistically diverse
communities require teams that can provide a range of health
care needs, facilitate
communication, and serve as patient advocates and
representatives. Interdisciplinary teams
typically include physicians, technicians, linguists, social
workers and case managers, and
community advocates, among others (Sinasac, 2012). These
teams must also collaborate with
community agencies, which can enhance the effectiveness of
health promotion efforts (Sinasac,
2012). Public health strategies can also include non-traditional
groups such as community

service organizations, American Indian tribes, boys and girls
clubs, and faith-based
organizations, which can penetrate deeper into the communities
and reach individuals where they
live, work, play, eat, and pray (Pullen-Smith & Plescia, 2008).
Interdisciplinary teams allow for
the breadth of services needed to make a significant impact on
CKD screening and intervention.
The Scholar-Practitioner’s Role in Treating CKD
My role as a scholar-practitioner is to be aware of social
disparities and endeavor to
correct observed societal imbalances. CKD is considered one of
the most significant health care
disparities that exist in America today. As a scholar-
practitioner, I must be a leader and advocate
for positive social change within my community. Becoming
involved with organizations such as
the National Kidney Foundation’s KEEP Healthy program, the
Minority Intervention and Kidney
Education (MIKE) program, or local organizations like the

Kidney Care Prevention Program
(KCPP) are ways that I can influence social change as it relates
to CKD and ESRD.
Opportunities exist for me to become a trained kidney care
coordinator/educator and lead efforts
to promote health and wellness activities (Harward & Falk,
2008). Being a scholar-practitioner, I
can be involved with identifying a need and targeting the
appropriate patient populations by
researching health status statistics and epidemiology studies,
developing focus groups, assessing
social marketing strategies, and analyzing current evidence-
based practices to be used in creating
new public health policies (Sinasac, 2012). As a scholar-
practitioner, a worthy goal would be to
spearhead the formation of a new organization that brings health
care services to minority
communities, socioeconomically depressed people, and the
uninsured and underinsured. Another
way I can have an impact in my community and make a positive
social change is to involve
myself with an existing organization whose goal is to eliminate
racial and ethnic health
disparities for chronic illnesses such as CKD. Through these

types of actions, I can fully embrace
the role of scholar-practitioner and become an agent of positive
social change.
References
Collins, A. J., Gilbertson, D. T., Snyder, J. J., Chen, S. C., &
Foley, R. N. (2010). Chronic
kidney disease awareness, screening and prevention: Rationale
for the design of a public
education program. Nephrology (Carlton), 15 Suppl 2, 37–42.
doi:10.1111/j.1440-
1797.2010.01312.x
Couser, W. G., Remuzzi, G., Mendis, S., & Tonelli, M. (2011).
The contribution of chronic
kidney disease to the global burden of major noncommunicable
diseases. Kidney
International, 80(12), 1258–1270. doi:10.1038/ki.2011.368
Harward, D. H., & Falk, R. J. (2008). The Kidney Care
Prevention Program: An innovative
approach to chronic kidney disease prevention. North Carolina
Medical Journal, 69(3),

233–236.
Healthy People 2020. (2013, April 10). Chronic kidney disease.
HealthyPeople.gov. Retrieved
November 8, 2013, from
http://www.healthypeople.gov/2020/topicsobjectives2020/overvi
ew.aspx?topicid=6
Menzin, J., Lines, L. M., Weiner, D. E., Neumann, P. J.,
Nichols, C., Rodriguez, L., … Mayne,
T. (2011). A review of the costs and cost effectiveness of
interventions in chronic kidney
disease: Implications for policy. Pharmacoeconomics, 29(10),
839–861.
doi:10.2165/11588390-000000000-00000
Moulton, A. (2008). Chronic kidney disease: The diagnosis of a
“unique” chronic disease.
CANNT Journal, 18(1), 34–38.
National Kidney Foundation. (2013). Kidney early evaluation
program publications. Retrieved
November 8, 2013, from
http://www.kidney.org/news/keep/index.cfm

National Medical Association. (n.d.). Chronic kidney disease in
the African American
community. Consensus Report of the NMA.
Navaneethan, S. D., Aloudat, S., & Singh, S. (2008). A
systematic review of patient and health
system characteristics associated with late referral in chronic
kidney disease. BMC
Nephrology, 9(1), 3. doi:10.1186/1471-2369-9-3
Norris, K., & Nissenson, A. R. (2008). Race, gender, and
socioeconomic disparities in CKD in
the United States. Journal of the American Society of
Nephrology : JASN, 19, 1261–70.
doi:10.1681/ASN.2008030276
Pearson, M. (2008). Racial disparities in chronic kidney
disease: Current data and nursing roles.
Nephrology Nursing Journal, 35(5), 485–489.
Pullen-Smith, B., & Plescia, M. (2008). Public health initiatives
to prevent and detect chronic
kidney disease in North Carolina. North Carolina Medical
Journal, 69(3), 224–226.
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ESRD entitlement. The New

England Journal of Medicine, 364, 596–8.
doi:10.1056/NEJMp1014193
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kidney disease in the United
States: a public policy imperative. Clinical journal of the
American Society of
Nephrology, 3, 1902–10. doi:10.2215/CJN.02330508
Sinasac, L. (2012). The community health promotion plan: A
CKD prevention and management
strategy. CANNT Journal, 22(3), 25–28.
Vassalotti, J., Gracz-Weinstein, L., Gannon, M., & Brown, W.
(2006). Targeted screening and
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Kidney Early Evaluation
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(2012). Working with CALD
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management in people with kidney disease, diabetes, and
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