Women in Nephrology Leadership.

Women and men tend to take different paths to leadership, with men being more intentional. When women do undertake leadership activities, they tend to be surprised by how much they enjoy it. Women's leadership styles tend to be more collaborative and inclusive. Women are used to multitasking and tend to persist under difficult circumstances. The nephrology manpower crisis affects both men and women, although some of the drivers are different. There is a persistent and well-known pay disparity between men and women physicians that many have tried to address without consistent success. Strategies also need to be developed to support and encourage both men and women in nephrology.

Prevalence of CKD and comorbid illness in elderly patients in the United States: results from the Kidney Early Evaluation Program (KEEP).

BACKGROUND: Elderly individuals with chronic kidney disease (CKD) have high rates of comorbid conditions, including cardiovascular disease and its risk factors, and CKD-related complications. In individuals aged > or = 65 years, we sought to describe the prevalence of CKD determined from laboratory test results in the Kidney Early Evaluation Program (KEEP; n = 27,017) and National Health and Nutrition Examination Survey (NHANES) 1999-2006 (n = 5,538) and the prevalence of diagnosed CKD determined from billing codes in the Medicare 5% sample (n = 1,236,946). In all 3 data sources, we also explored comorbid conditions and CKD-related complications. METHODS: CKD was identified as decreased estimated glomerular filtration rate (<60 mL/min/1.73 m(2)) or increased albumin-creatinine ratio in KEEP and NHANES; CKD was identified using International Classification of Diseases, Ninth Revision, Clinical Modification codes in Medicare. Investigated comorbid conditions included diabetes, hypertension, high cholesterol level, coronary artery disease, congestive heart failure, cerebrovascular disease, peripheral vascular disease, and cancer, and CKD-related complications included anemia, hypocalcemia, hyperphosphatemia, and hyperparathyroidism. RESULTS: The prevalence of CKD was approximately 44% in both KEEP and NHANES participants, and the prevalence of diagnosed CKD was 7% in Medicare beneficiaries. In all 3 data sets, the prevalence of CKD or diagnosed CKD was higher in participants aged > or = 80 years and those with comorbid conditions. For KEEP and NHANES participants, the prevalence of most comorbid conditions and CKD complications increased with decreasing estimated glomerular filtration rate. For participants with CKD stages 3-5, a total of 29.2% (95% CI, 27.8-30.6) in KEEP and 19.9% (95% CI, 17.0-23.1) in NHANES had anemia, 0.7% (95% CI, 0.4-0.9) and 0.6% (95% CI, 0.3-1.3) had hypocalcemia, 5.4% (95% CI, 4.7-6.1) and 6.4% (95% CI, 5.1-8.0) had hyperphosphatemia, and 52.0% (95% CI, 50.4-53.6) and 30.0% (95% CI, 25.9-34.3) had hyperparathyroidism, respectively. CONCLUSIONS: CKD is common in the elderly population and is associated with high frequencies of concomitant comorbid conditions and biochemical abnormalities. Because CKD is not commonly diagnosed, greater emphasis on physician education may be beneficial.

CKD and cardiovascular disease in screened high-risk volunteer and general populations: the Kidney Early Evaluation Program (KEEP) and National Health and Nutrition Examination Survey (NHANES) 1999-2004.

BACKGROUND: Chronic kidney disease (CKD) is recognized as an independent cardiovascular disease risk state. The relationship between CKD and cardiovascular disease in volunteer and general populations has not been explored. METHODS: The National Kidney Foundation Kidney Early Evaluation Program (KEEP) is a community-based health-screening program to raise kidney disease awareness and detect CKD for early disease intervention in individuals 18 years or older with diabetes, hypertension, or family history of kidney disease, diabetes, or hypertension. KEEP volunteers completed surveys and underwent blood pressure and laboratory testing. Estimated glomerular filtration rate (eGFR) was computed, and urine albumin-creatinine ratio (ACR) was measured. In KEEP, CKD was defined as eGFR less than 60 mL/min/1.73 m(2) or ACR of 30 mg/g or greater. Cardiovascular disease was defined as self-reported myocardial infarction or stroke. Data were compared with National Health and Nutrition Examination Survey (NHANES) 1999-2004 data for prevalence of cardiovascular disease risk factors and cardiovascular outcomes. RESULTS: Of 69,244 KEEP participants, mean age was 53.4 +/- 15.7 years, 68.3% were women, 33.0% were African American, and 27.6% had diabetes. Of 17,061 NHANES participants, mean age was 45.1 +/- 0.27 years, 52% were women, 11.2% were African American, and 6.7% had diabetes. In KEEP, 26.8% had CKD, and in NHANES, 15.3%. ACR was the dominant positive screening test for younger age groups, and eGFR, for older age groups, for both populations. Prevalences of myocardial infarction or stroke were 16.5% in KEEP and 15.1% in NHANES (P < 0.001) and 7.8% in KEEP and 3.7% in NHANES (P < 0.001) for individuals with and without CKD, respectively. In adjusted analysis of both KEEP and NHANES data, CKD was associated with a significantly increased risk of prevalent myocardial infarction or stroke (odds ratio, 1.34; 95% confidence interval, 1.25 to 1.43; odds ratio, 1.37; 95% confidence interval, 1.10 to 1.70, respectively). In KEEP, short-term mortality was greater in individuals with CKD (1.52 versus 0.33 events/1,000 patient-years). CONCLUSIONS: CKD is independently associated with myocardial infarction or stroke in participants in a voluntary screening program and a randomly selected survey population. Heightened concerns regarding risks in volunteers yielded greater cardiovascular disease prevalence in KEEP, which was associated with increased short-term mortality.

The Kidney Early Evaluation Program (KEEP): program design and demographic characteristics of the population.

BACKGROUND: Chronic kidney disease (CKD) recently was identified as a public health problem requiring a public health prevention approach. The National Kidney Foundation Kidney Early Evaluation Program (KEEP), initiated in 2000, meets the definition of a public health program, offering surveillance and early detection of CKD. This report aims to detail demographic characteristics of KEEP participants and compare them with characteristics of participants in the National Health and Nutrition Examination (NHANES) 1999-2004. METHODS: KEEP is a CKD screening program enrolling individuals 18 years and older with a family history of kidney disease or personal or family history of diabetes or hypertension. Simple descriptive statistics were used in the analysis. For comparison, the NHANES sample was restricted to participants with hypertension or diabetes or a family history of hypertension or diabetes. RESULTS: The number of KEEP participants grew exponentially over time. Most participants were aged 46 to 60 years. KEEP enrolled twice as many women as men (68.4% versus 31.5%). Minorities were well represented (33.4% African American, 12.3% Hispanic). Almost 58% of participants had some college or more education, and close to 85.0% had a physician. Compared with NHANES, the KEEP population was older and included a larger proportion of women and African Americans. Self-reported hypertension, self-reported diabetes, obesity, and CKD were higher in KEEP (52.9% versus 38.5%, 26.6% versus 9.9%, 43.6% versus 35.5%, and 22.8% versus 17.6%, respectively). CONCLUSIONS: KEEP has been successful in enrolling individuals at risk of kidney disease, evidenced by the high levels of self-reported hypertension and diabetes.

Factors associated with "do not resuscitate" orders and rates of withdrawal from hemodialysis in the international DOPPS.

BACKGROUND: Worldwide statistics on practice patterns regarding "do not resuscitate" (DNR) orders and patient withdrawal from hemodialysis have not been uniformly collected or analyzed. METHODS: Using data concerning adult hemodialysis patients randomly selected from 308 representative dialysis facilities in France, Germany, Italy, Japan, Spain, the United Kingdom, and the United States participating in the Dialysis Outcomes and Practice Patterns Study, DNR orders were tabulated at study entry from a prevalent cross-section of patients (N = 8615), using multivariate logistic regression to investigate characteristics associated with DNR status, Cox models to identify risk factors for withdrawal from hemodialysis, and scores from the mental component summary (MCS) and physical component summary (PCS) of the SF-36 to assess health-related quality of life. RESULTS: The United States had the highest prevalence of DNR orders (7.5%) and rate of withdrawal from hemodialysis (3.5 per 100 patient-years). Significant and independent associations with higher odds ratio (OR) of DNR were observed for older age (OR 1.16 per 10 years higher, P = 0.03) and nursing home residence (OR 2.34, P = 0.003), and with higher relative risk (RR) of withdrawal from dialysis (RR 2.38, P < 0.001). Patients who withdrew from hemodialysis died within a mean of 7.8 days and a median of 6.0 days. CONCLUSION: The higher prevalence of DNR and rate of withdrawal from hemodialysis in the United States are consistent with its greater legal and cultural emphasis on patient autonomy. By showing characteristics associated with these outcomes, this study contributes to our understanding of why hemodialysis patients request DNR or withdraw from treatment.

Kidney Early Evaluation Program (KEEP). Findings from a community screening program.

PURPOSE: The Kidney Early Evaluation Program (KEEP), which was started in 1997, aims to identify persons at risk for chronic kidney disease (CKD) and encourage at-risk persons to seek evaluation and management from a healthcare provider. METHODS: Community screening was conducted using a standardized questionnaire and test panel that was administered by local affiliates of the National Kidney Foundation (NKF) using volunteer lay and medical personnel. The screening was limited to persons at high risk for CKD, which was defined as those with a personal history of diabetes or hypertension, or a first-order relative with diabetes, hypertension, or kidney disease. The KEEP Data Coordinating Center was established to maintain a de-identified database of demographic information and test results on the screened persons. RESULTS: Data on the first 11,246 participants were analyzed. As expected, the KEEP population was enriched with African Americans and was older than the general population. Diabetes was determined by self-report or abnormal blood glucose levels at screening and was present in 2690 of the persons screened. Chronic kidney disease was identified in 47.4% of this population. CONCLUSIONS: Targeted community screening for kidney disease in a high-risk population can identify a significant number of persons with CKD, enhance awareness of the disease, and may improve health-seeking behavior.

Early detection of kidney disease in community settings: the Kidney Early Evaluation Program (KEEP).

BACKGROUND: Early identification of persons at risk for kidney disease provides an opportunity to prevent or delay its progression and decrease morbidity and mortality. Our hypothesis was that implementation of a targeted screening program in communities with high-risk populations would detect previously unidentified persons with or at high risk for chronic kidney disease (CKD) with a prevalence that exceeds that predicted for CKD in the general population. METHODS: Persons with hypertension or diabetes or a first-order relative with hypertension, diabetes, or kidney disease were screened for kidney disease risk factors. Blood pressure, blood glucose level, serum creatinine level, hemoglobin level, microalbuminuria, hematuria, pyuria, body mass index, and estimated glomerular filtration rate (EGFR) were evaluated. RESULTS: Six thousand seventy-one eligible persons were screened from August 2000 through December 2001: of these persons, 68% were women, 43% were African American, 36% were white, 10% were Hispanic, and 5% were Native American. Most reported high-school education or more (84%) and health insurance coverage (86%). Twenty-seven percent met the screening definitions for diabetes; 64%, for hypertension; 29%, for microalbuminuria; 8%, for anemia; 18%, for hematuria; 13%, for pyuria; 5%, for elevated serum creatinine level; 16%, for reduced EGFR; and 44%, for obesity. Among participants without a reported history of specified conditions, screening identified 82 participants (2%) with diabetes, 1,014 participants (35%) with hypertension, 277 participants (5%) with elevated serum creatinine levels, 839 participants (14%) with reduced EGFRs, and 1,712 participants (29%) with microalbuminuria. Thirty-five percent of participants with a history of diabetes had elevated serum glucose levels at screening (> or =180 mg/dL [10 mmol/L]), and 64% with a history of hypertension did not have blood pressure controlled to less than 140/90 mm Hg. Only 18% of participants with a history of diabetes and 31% with a reduced EGFR had blood pressure controlled to less than 130/80 mm Hg and less than 135/85 mm Hg, respectively. CONCLUSION: Targeted screening is effective in identifying persons with previously unidentified or poorly controlled kidney disease risk factors, as well as persons with a moderately decreased EGFR.