March 13th 2008 heralds the third annual World Kidney Day – an event that will be celebrated in more than 60 countries. We take this opportunity to recount how this concept has gained worldwide traction and momentum and to reflect on the challenges faced by its creators and supporters.
There have probably been many individuals who conceived of marking one calendar day in which to call attention to the seriousness of kidney disease globally; many may even have shared their thoughts with others. But there is one individual who not only conceived the idea but was persistent in persuading many in leadership positions to bring this notion – a World Kidney Day – to fruition. This individual is also the founder of the International Federation of Kidney Foundations (IFKF): Joel Kopple. He first conceived the idea of World Kidney Day in 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 with simple and cheap tests yet national detection programs are rare; and that while it can be treated with existing, effective therapies, few people with CKD receive appropriate health care.
In September 2003 Kopple wrote to Warwick Prime, then President of the IFKF, and proposed an annual World Kidney Day. In order to make it truly an international collaborative effort, representatives of IFKF and the International Society of Nephrology (ISN) met in November 2003, and at that meeting, Kopple presented a précis entitled, "Proposal for the Establishment of a World Kidney Day." A World Kidney Day ISN-IFKF liaison committee was established, with the initial members being Bill Couser, John Dirks, Joel Kopple, Warwick Prime, and Jan Weening. In 2004, both the IFKF Executive Committee and the ISN Council endorsed the World Kidney Day program, and ISN agreed in 2005 to commit sufficient resource to enable a first World Kidney Day to go ahead on 7th March 2006. An editorial about WKD was published that month in 8 scientific journals. Despite being planned with only short notice and few resources, kidney organizations in 45 countries enthusiastically embraced the first World Kidney Day and organized health screening events, road shows, walkathons, public lectures and press conferences. It was clear that World Kidney Day was responding to an urgent need and 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 and agreed on a formal organizational structure for World Kidney Day. A memorandum of understanding between IFKF and ISN for the planning and implementation of an annual World Kidney Day was signed in June 2006 by the two presidents, Bill Couser (ISN) and Sudhir Shah (IFKF). The document stated that, “Based on a proposal and invitation by IFKF, IFKF and ISN jointly agree to declare an annual World Kidney Day to increase awareness, detection, prevention, and treatment of kidney and related diseases.” The “World Kidney Day” name and logo were trademarked and are now jointly owned by IFKF and ISN.
A WKD steering committee was established with eight members; four members nominated by each organization, as well as a scientific advisory committee. ISN agreed to provide the initial funding necessary for the central operational management of a World Kidney Day project team.
The continued leadership of the ISN/IFKF Steering Committee in 2007 helped secure funding from global sponsors; create a World Kidney Day logo, slogan, website and “brand”; widely disseminate designs for posters, banners, t-shirts and other promotional materials which could be adapted for local use; gain the moral support of celebrities ranging from Tom Hanks to Jacques Rogge; and enlist the participation of 66 countries.
The remarkable initiative and ingenuity of kidney organizations on March 8th 2007 can be viewed on www.worldkidneyday.org" The WKD website will feature planned activities for March 13th 2008, which promises to be an even greater event, with continued emphasis on the message that “kidney disease is common, harmful and treatable”.
Public Awareness
World Kidney Day offers a crucial, visible opportunity to inform and educate health policy makers, those at highest risk of CKD, but also the general public. One of our greatest challenges is general ignorance about the kidneys. Surveys made before the advent of WKD have shown that less than 5% of the general population knows where the kidneys are located and what they do. Therefore, the WKD 2008 international campaign theme – “Amazing Kidneys!” – stresses the positive message that kidneys are truly “amazing”. A focus for the general public is on simple facts about what kidneys do for us on a daily basis – for example, “Every day our kidneys filter and clean 200 liters of blood”. “Amazing kidney stories” can also be used – stories about kidney patients, kidney organ donors, and health professionals who are “exceptional” in some way. World Kidney Day offers an increasingly visible opportunity to tailor public awareness messages to the media for wide impact.
The Importance of CKD
While each country and region may adopt different priorities for World Kidney Day from year to year – choosing, for example, to promote living donor kidney transplantation or to push for improvements in dialysis facilities – in many countries 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 raise awareness 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 world which shape and reform health policy. It is an opportunity to launch high-profile, new initiatives that will impact on CKD and to seek the endorsement of agencies who can help to ensure such initiatives become embedded into routine healthcare.
Since the term CKD came into usage and its staging was defined (1), there has been a flurry of investigative activities and publications on its importance (2-6). Recently published studies have confirmed that CKD is a common disorder globally, 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 by volunteer organizations alone.
Two simple and cheap tests are available to detect CKD: urine for protein and blood for serum creatinine, and hence estimated GFR. Despite this, the task of developing widespread detection and management programs for CKD that produce improved outcomes at a reasonable cost is formidable. It is unlikely that even developed countries have adequate financial and human resources for wholepopulation screening programs for CKD, and in any case there is so far no evidence that these are cost-effective.
Based on current information, we recommend that all countries have targeted screening programs. Steps to establishing an effective program include:
In the UK, for example, there has been encouraging progress over the last few years towards the establishment of such a program. The reporting of eGFR is now mandated in all UK clinical laboratories, and guidelines for the detection and management of CKD have been widely accepted (12). This progress has been made more straightforward by a government-directed and funded healthcare system, which allows several aspects of the program to be linked to reimbursement for family physicians, who are already obliged to maintain computerized listings of all those with diabetes, hypertension and coronary heart disease. There will be much greater challenges in countries where health care is provided by multiple independent agencies or in the developing world where resources available for health care are much less.
In advocating for these programs which are now proving successful and cost-effective, we favor small but sure-footed steps (5, 10); we must be careful that screening tests identify patients with true disease, for whom intervention will make a critical difference by delaying or avoiding ESRD, or by modifying risk factors for cardiovascular disease which is so closely linked with CKD. This may be particularly true in the elderly – who are those with the highest prevalence of CKD, and in whom preventive therapy is less likely to improve survival or quality of life (5).
In parallel, we must press for research programs to address the many unanswered questions about CKD, not least to understand better the factors which predict the minority of those with stage 3 CKD who progress to ESRD, and to test the efficacy of our new healthcare strategies for CKD.
The momentum of World Kidney Day is assured and we anticipate many more than the 60 countries will be reporting to us their initiatives and successes on March 13th 2008. The WKD Steering Committee and Project Team will continue to provide a toolkit of resources for each WKD including messages, logos, posters, and designs for other materials. The power of WKD is generated by local action, led by those who understand the specific kidney health issues in their countries and who use this day to showcase successful initiatives already taken, and launch positive changes in healthcare systems and practices. For meaningful progress to be made, activities related to kidney disease are needed throughout the year. Our vision is that WKD serves as an annual energizing and unifying event through which health care providers, the general public, and the government bodies which make health care policy all unite to improve early detection programs and optimize medical care for those millions worldwide who can benefit from an improved awareness of CKD as a global health issue.
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