The Public Health Implications of Chronic Kidney Disease in San Diego

Abstract

Background: Chronic Kidney Disease (CKD) is a condition in which an individual’s kidney slowly stops functioning and they become dependent on dialysis¹. CKD affects about 1 in 7 US adults. Although this condition is well-managed within hospitals and dialysis clinics, it is not thoroughly discussed outside of the clinic. This lack of public emphasis on CKD causes an overall lack of awareness of its existence, and the disease often goes undetected within people who are in its earlier stages. Objective: To research and investigate the core factors that influence the health of individuals with CKD and design an evidence-based intervention to benefit adults age 40 and older in San Diego, California. Methodology: To complete this report we consulted 55 articles from Pubmed, the Centers for Disease Control (CDC), the National Kidney Foundation, and other sources that involve CKD on the national level and/or in San Diego. Additionally, a district health-pathway coordinator and a S-ICU nurse from San Diego were interviewed to gain further insight into the determinants of CKD and potential public health solutions. The findings from the literature review and stakeholder interviews were all synthesized in a plan of action. Results: The populations with the highest rate of CKD in San Diego are people aged 40 and above, who have a family history of kidney disease, or have pre-existing conditions such as hypertension or diabetes². Conclusion: CKD is a prevalent issue within the San Diego community. This report puts forward a sustainable plan of action to benefit individuals 40 and above at risk of the disease. Considering its commonality, there should be an expanded focus on CKD education.

Keywords: Public Health Intervention, Chronic Kidney Disease, CKD, Kidney Disease, Dietary Restrictions, CKD education

Introduction

Chronic Kidney Disease (CKD) is a condition that affects ~850 million people yearly worldwide³. Each year, Medicare spending totals $130 million (more than 24% of total spending) for patients with CKD, but the disease is far less prevalent in public conversation than diseases like cancer or heart disease. CKD is known as a “silent killer” because it progresses fast without showing symptoms. Thus, ongoing research to uncover the risk factors and early symptoms of the disease are important for improving patient outcomes. It is also essential to better communicate the findings of these studies so that patients and their providers can act on them.

The dietary restrictions placed on people affected by CKD can be quite complex to maintain. Some common restrictions include limited phosphorus intake, electrolyte monitoring and low liquid intake. It can be quite difficult to keep up with the demands of these restrictions, and therefore can cause people to stop effectively managing their CKD. Without this management, the person has an increased chance of landing themselves back in the hospital or shortening their lifespan.

The outcome of CKD can be improved with lifestyle changes such as exercise, reduced stress, increased check-ups, and adhering to the aforementioned dietary restrictions. People from lower-income backgrounds may not have as many resources such as healthy food options (e.g., people living in food deserts), and open spaces to exercise in. There are significant disparities among different groups which need to be addressed.

This report aims to investigate CKD on a national and a local level, identify the risk factors influencing the disease, and design an evidence-based intervention to improve awareness across San Diego, CA. In this report, we will first demonstrate the public health importance of CKD. Next, we will summarize our literature review and justify the target population for our evidence-based plan of action. We will also discuss the perspectives of our stakeholders, who are knowledgeable in CKD. Then, using the Quintuple Aim, a framework that aims to improve healthcare by focusing on five interrelated goals (population health, the patient experience, the healthcare provider experience, medical costs, and health equity), we will propose a one-year plan of action in San Diego to encourage education and  improve the well-being of individuals with CKD. Finally, we will reflect on the strengths and limitations of the plan.

Although management of CKD is robust within the clinical setting (hospitals and dialysis clinics), general lack of education regarding CKD makes this care difficult to maintain in nonclinical settings such as homes, causing decreased quality of life, social isolation, and premature death. Therefore, utilizing a public health approach to increase awareness of CKD is necessary to boost preventative efforts. Additionally, CKD disproportionately affects poor and marginalized populations, and is associated with high healthcare costs⁴. People living in underserved communities have less access to resources such as reliable public transportation  and access to appropriate medical care to put these preventative and recovery-related actions into place⁵. These disparities must be addressed through a public health perspective to improve equitable health outcomes for everyone affected by CKD.

Methods

First, we conducted a literature review to deepen our understanding of CKD on the national and local levels. Pubmed, Google Scholar, the Centers for Disease Control and Prevention (CDC), the National Kidney Foundation (NKF), and other sources were consulted for the literature review. Overall, we utilized a total of 55 articles.

Furthermore, stakeholder interviews were conducted to deepen our insight concerning CKD through alternative perspectives. A total of fifteen stakeholders were found, with two expressing interest in being interviewed. The stakeholder interviews were conducted by the two research investigators who are from San Diego, who are also authors of this paper. Key questions asked during the stakeholder interviews included how CKD patients were cared for in a hospital setting, and the importance of education and spreading awareness of the disease. A transcript was written up for both interviews, and was later summarized in a coherent document.

To develop the Plan of Action, results from the literature review, such as the effects of a general lack of education regarding CKD-friendly foods, were taken into account.  The Plan of Action is focused on educating individuals who have CKD, or are over the age of 40 via in-person events. We felt that these measures would be well suited to the target population, as some part of the population might not be as comfortable with digital technology and virtual events as younger generations. The in-person events would involve a guest speaker, such as a nephrologist, who could come in and speak about CKD, its symptoms, and effective ways to prevent it. The flyers would include statistics of people who are at risk of CKD, locations of dialysis clinics, and places to screen for CKD.

Our research team consists of students from San Diego, Irvine, and Springboro, as well as a student mentor from Irvine who provided guidance throughout the writing process. Potential stakeholders were found by authors Elizabeth Duhig and Mursal Obaid through connections with a local hospital and their school district.

Literature Review: Justification for Target Population

CKD is a progressive disease that affects up to 800 million individuals worldwide⁶. It is most prevalent in people older than 40, who make up 67.8% of total cases⁷. San Diego has a higher rate of CKD than most other cities in California, with about 20.68% of people over the age of 65 having CKD as of 2019⁸. Within San Diego County, the City of Imperial Beach has the highest mortality rates¹³.

Over time the body weakens and organs, particularly the kidneys, begin to become less efficient. Comorbidities such as hypertension, diabetes or cardiovascular disease, which also become more prevalent with age, can significantly increase the risk of CKD⁹. An outsized proportion of those effected are African American, American Indian or Hispanic¹². These groups are at high risk in part due to the higher rates of diabetes and high blood pressure in these populations¹⁰.  Nationwide, African-Americans are 3.4x more likely to develop CKD than white Americans, and Hispanic Americans are 1.5x more likely to develop CKD¹¹.

Financial factors – such as reduced income, a relative lack of education, and financial stress –  can also affect CKD risk. Although 92.1% of people in the United States are medically insured as of 2022¹⁴, undergoing dialysis multiple times a week and having other treatments related to CKD can nonetheless cause financial strain and increased out-of-pocket costs for CKD patients and their loved ones. Additionally, a lack of education on CKD can limit individuals’ ability to monitor electrolytes and adhere to dietary restrictions such as minimum phosphorus intake and reduced liquid intake of any kind¹⁵. In San Diego, the UC San Diego Health Kidney Disease and Hypertension Center offers dietary education and counseling, including nutrition plans and educational resources tailored to the needs of CKD patients.

On an interpersonal level, strong connections between patients and their caregivers and families are essential to promoting better health outcomes. Some patients with CKD may not wish to be a social burden on others¹⁶, and thus isolate themselves, leading to worse health outcomes. San Diego has communities with support networks such as Dialysis Patient Citizens (DPC), which advocates for dialysis patients and offers additional resources such as support group networks and educational materials. Patients can connect through online forums and local chapter events.

Although 37 million Americans have CKD ¹⁷, 90% of them aren’t aware that they have CKD until late stages of the disease when their situation becomes dire¹⁸ due to low CKD screening in hospitals. As a result,  many individuals are diagnosed with CKD during its later stages, when it is too late to intervene. Multiple organizations in San Diego are focusing on helping individuals screen for and manage their CKD and related comorbidities. The University of California, San Diego alone has a number of programs, including the Kidney Transplant Program andChronic Kidney Disease Program. These programs ensure that patients get top-class resources to help them identify, cope with and manage the disease.

On a community level, there are initiatives to encourage awareness on CKD. San Diego has a variety of community health centers such as San Diego Family Health Centers, La Maestra Community Health Centers, and Vista Community Clinic that support CKD patients with healthcare services and help with managing CKD and other chronic diseases.

On a policy level, there have been many steps taken to support CKD patients. For example, the federal government’s Advancing American Kidney Health (AAKH) Initiative supports CKD patients through initiatives to reduce the incidence of kidney failure, enhance patient choice through affordable treatments, and increase access to kidney transplantation¹⁹ . In San Diego, and nationwide, the Centers for Medicare and Medicaid Services (CMS) provide guidance and resources for kidney care. Patients and providers in San Diego can receive support provided by government policies such as the AAKH Initiative through many different local programs and services.