March 13, 2008, heralds the third annual World Kidney Day – an event that willbe celebrated in more than 60 countries. We take this opportunity to recount howthis concept has gained worldwide traction and momentum and to reflect on thechallenges faced by its creators and supporters.
The Beginnings of World Kidney Day
There have probably been many individuals who conceived of marking one calendarday in which to call attention to the seriousness of kidney disease globally;many may even have shared their thoughts with others. But there is oneindividual who not only conceived the idea but was persistent in persuading manyin leadership positions to bring this notion – a World Kidney Day – to fruition.
This individual is also the founder of the International Federation of KidneyFoundations (IFKF): Joel Kopple. He first conceived the idea of World Kidney Dayin the spring of 2003, recognizing that CKD is a global, public health threat,but is typically low on government health agendas; that it can be detected withsimple and cheap tests yet national detection programs are rare; and that whileit can be treated with existing, effective therapies, few people with CKDreceive appropriate health care.
In September 2003 Kopple wrote to Warwick Prime, then President of the IFKF, andproposed an annual World Kidney Day. In order to make it truly an internationalcollaborative effort, representatives of IFKF and the International Society ofNephrology (ISN) met in November 2003, and at that meeting, Kopple presented aprécis entitled, "Proposal for the Establishment of a World Kidney Day."
A World Kidney Day ISN-IFKF liaison committee was established, with the initialmembers being Bill Couser, John Dirks, Joel Kopple, Warwick Prime, and JanWeening. In 2004, both the IFKF Executive Committee and the ISN Council endorsedthe World Kidney Day program, and ISN agreed in 2005 to commit sufficientresource to enable a first World Kidney Day to go ahead on 7th March 2006. Aneditorial about WKD was published that month in 8 scientific journals.
Despitebeing planned with only short notice and few resources, kidney organizations in45 countries enthusiastically embraced the first World Kidney Day and organizedhealth screening events, road shows, walkathons, public lectures and pressconferences. It was clear that World Kidney Day was responding to an urgent needand tapping the tremendous energy and motivation of kidney health professionals,patients and their friends and relatives across the globe.
That success was recognized by those from ISN and IFKF who met in April 2006 andagreed on a formal organizational structure for World Kidney Day. A memorandumof understanding between IFKF and ISN for the planning and implementation of anannual World Kidney Day was signed in June 2006 by the two presidents, BillCouser (ISN) and Sudhir Shah (IFKF). The document stated that, "Based on aproposal and invitation by IFKF, IFKF and ISN jointly agree to declare an annualWorld Kidney Day to increase awareness, detection, prevention, and treatment ofkidney and related diseases." The "World Kidney Day" name and logo weretrademarked and are now jointly owned by IFKF and ISN.
A WKD steering committee was established with eight members; four membersnominated by each organization, as well as a scientific advisory committee. ISNagreed to provide the initial funding necessary for the central operationalmanagement of a World Kidney Day project team.
The continued leadership of the ISN/IFKF Steering Committee in 2007 helpedsecure funding from global sponsors; create a World Kidney Day logo, slogan,website and "brand"; widely disseminate designs for posters, banners, t-shirtsand other promotional materials which could be adapted for local use; gain themoral support of celebrities ranging from Tom Hanks to Jacques Rogge; and enlistthe participation of 66 countries.
The remarkable initiative and ingenuity of kidney organizations on March 8th2007 can be viewed on www.worldkidneyday.org. The WKD website will feature plannedactivities for March 13th 2008, which promises to be an even greater event, withcontinued emphasis on the message that "kidney disease is common, harmful andtreatable".
The Main Challenges and Aims of World Kidney Day
World Kidney Day offers a crucial, visible opportunity to inform and educatehealth policy makers, those at highest risk of CKD, but also the general public.One of our greatest challenges is general ignorance about the kidneys. Surveysmade before the advent of WKD have shown that less than 5% of the generalpopulation knows where the kidneys are located and what they do.
Therefore, theWKD 2008 international campaign theme – "Amazing Kidneys!" – stresses thepositive message that kidneys are truly "amazing". A focus for the generalpublic is on simple facts about what kidneys do for us on a daily basis – forexample, "Every day our kidneys filter and clean 200 liters of blood". "Amazingkidney stories" can also be used – stories about kidney patients, kidney organdonors, and health professionals who are "exceptional" in some way. World KidneyDay offers an increasingly visible opportunity to tailor public awarenessmessages to the media for wide impact.
The Importance of CKD
While each country and region may adopt different priorities for World KidneyDay from year to year – choosing, for example, to promote living donor kidneytransplantation or to push for improvements in dialysis facilities – in manycountries it is the detection and management of chronic kidney disease (CKD)which will be the dominant kidney health issue. On WKD we must aim to raiseawareness about the heavy burden of CKD on human lives and health care budgets,and put CKD on the agenda of governments and other institutions around the worldwhich shape and reform health policy. It is an opportunity to launchhigh-profile, new initiatives that will impact on CKD and to seek theendorsement of agencies who can help to ensure such initiatives become embeddedinto routine healthcare.
Since the term CKD came into usage and its staging was defined (1), there hasbeen a flurry of investigative activities and publications on its importance(2-6). Recently published studies have confirmed that CKD is a common disorderglobally, with as many as 90% of those who have CKD remaining unidentified (7,8). The fact that CKD is a major public health issue is now beyond dispute (9),and it is obvious that an issue of this magnitude cannot be addressed byvolunteer organizations alone.
Two simple and cheap tests are available to detect CKD: urine for protein andblood for serum creatinine, and hence estimated GFR. Despite this, the task ofdeveloping widespread detection and management programs for CKD that produceimproved outcomes at a reasonable cost is formidable. It is unlikely that evendeveloped countries have adequate financial and human resources forwholepopulation screening programs for CKD, and in any case there is so far noevidence that these are costeffective.
CKD Detection Programs
Based on current information, we recommend that all countries have targetedscreening programs. Steps to establishing an effective program include:
- Reporting of estimated GFR by all laboratories measuring serum creatinine
- Measurement of eGFR and proteinuria in those at the highest risk of CKD, including all those with diabetes, hypertension, coronary heart disease and cerebrovascular disease who constitute the majority of patients with CKD and with end stage renal disease (ESRD)
- Regular measurement of blood pressure, eGFR and proteinuria in those identified with CKD
- Establishing targets for blood pressure control in those with CKD, and appropriate use of drugs blocking the renin-angiotensin system
- Agreeing on guidelines for identifying the minority of people with CKD who benefit from the specialist advice of a nephrologist as well as the routine care of a family physician
In the UK, for example, there has been encouraging progress over the last fewyears towards the establishment of such a program. The reporting of eGFR is nowmandated in all UK clinical laboratories, and guidelines for the detection andmanagement of CKD have been widely accepted (12). This progress has been mademore straightforward by a government-directed and funded healthcare system,which allows several aspects of the program to be linked to reimbursement forfamily physicians, who are already obliged to maintain computerized listings ofall those with diabetes, hypertension and coronary heart disease. There will bemuch greater challenges in countries where health care is provided by multipleindependent agencies or in the developing world where resources available forhealth care are much less.
In advocating for these programs which are now proving successful andcost-effective, we favor small but sure-footed steps (5, 10); we must be carefulthat screening tests identify patients with true disease, for whom interventionwill make a critical difference by delaying or avoiding ESRD, or by modifyingrisk factors for cardiovascular disease which is so closely linked with CKD.This may be particularly true in the elderly – who are those with the highestprevalence of CKD, and in whom preventive therapy is less likely to improvesurvival or quality of life (5).
In parallel, we must press for research programs to address the many unansweredquestions about CKD, not least to understand better the factors which predictthe minority of those with stage 3 CKD who progress to ESRD, and to test theefficacy of our new healthcare strategies for CKD.
World Kidney Day is Here to Stay
The momentum of World Kidney Day is assured and we anticipate many more than the60 countries will be reporting to us their initiatives and successes on March13th 2008. The WKD Steering Committee and Project Team will continue to providea toolkit of resources for each WKD including messages, logos, posters, anddesigns for other materials. The power of WKD is generated by local action, ledby those who understand the specific kidney health issues in their countries andwho use this day to showcase successful initiatives already taken, and launchpositive changes in healthcare systems and practices.
For meaningful progress tobe made, activities related to kidney disease are needed throughout the year.Our vision is that WKD serves as an annual energizing and unifying event throughwhich health care providers, the general public, and the government bodies whichmake health care policy all unite to improve early detection programs andoptimize medical care for those millions worldwide who can benefit from animproved awareness of CKD as a global health issue.
- NKF: K/DOQI clinical practice guidelines for chronic kidney disease: evaluation, classification, and stratification. Part IV: definition and classification of stages of chronic kidney disease. Am J Kid Dis 39:S46-S75, 2002
- Archibald G, Bartlett W, Brown A, et al.: UK Consensus Conference on Early Chronic Kidney Disease – 6 and 7 February 2007. Nephrol Dial Transplant 22:2455-2457, 2007
- Vassalotti JA, Lesley AS, Levey AS: Testing for chronic kidney disease: A position statement from the National Kidney Foundation. Am J Kid Dis 50:169-180, 2007
- Levey AS, Atkins R, Coresh J, et al.: Chronic kidney disease as a global public health problem: Approaches and inititatives – a position statement from Kidney Disease Improving Global Outcomes. Kidney Int 72:247-259, 2007
- Couser WG: CKD – The Promise and the Perils J Am Soc Nephrol in press, 2007
- Himmelfarb J: Chronic kidney disease and the public health. JAMA 297:2630-2633, 2007
- Stevens PE, O'Donoghue DJ, S. dL, et al.: Chronic kidney disease management in the United Kingdom: NEOERICA project results. Kidney Int 72:92-99, 2007
- Coresh J, Byrd-Holt D, Astor BC, et al.: Chronic kidney disease awareness, prevalence, and trends among U.S. adults, 1999 to 2000. J Am Soc Nephrol 16:180-188, 2005
- 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 (serial online) 3:2, 2006
- Kiberd B: The chronic kidney disease epidemic: Stepping back and looking forward. J Am Soc Nephrol 17:2967-2973, 2006
- Kallen AJ, Patel PR: In search of a rational approach to chronic kidney disease detection and management [commentary]. Kidney Int 72:3-5, 2007
- Joint Specialty Committee on Renal Medicine of the Royal College of Physicians and Renal Association, and the Royal College of General Practitioners. Chronic kidney disease in adults: UK guidelines for identification, management and referral. London: Royal College of Physicians 2006. http://www.renal.org/CKDguide
World Kidney Day 2007 Scientific Advisory Board
Vittorio E. Andreucci, Italy
Rashad S. Barsoum, Egypt
Allan J. Collins, USA
David C.H. Harris, Australia
Bernardo Rodriguez Iturbe, Venezuela
Paul E. De Jong, The Netherlands
Robert W. Schrier, USA
Philip Kam Tao Li, China