THE CASE FOR MORE TESTING OF PERSONS WITHOUT SYMPTOMS OR HISTORY FOR CKD
I read an article yesterday that shocked me. In Renal and Urology News, an article entitled, “Nephrology Society Objects to Call Against Kidney Screening, ” http://www.renalandurologynews.com/nephrology-society-objects-to-call-against-kidney-screening/article/317395/?DCMP=EMC-RENALUROLOGY_ETOC&CPN=&spMailingID=7553773&spUserID=MzE1MTQ0Mzc2NDcS1&spJobID=104488077&spReportId=MTA0NDg4MDc3S0, caught my eye. According to the article, the American College of Physicians, (ACP) had written a paper recommending against screening for Chronic Kidney Disease in adults without symptoms and without a history of renal failure.[i] The American Society of Nephrology (ASN) wasted no time in responding the very next day that this approach was not acceptable.[ii] They called the statement “irresponsible” and confirmed that it “strongly recommends” regular screening for kidney disease, regardless of an individual’s risk factors.[iii]
“ASN and its nearly 15,000 members—all of whom are experts in kidney disease—are disappointed by ACP’s irresponsible recommendation,” asserted ASN executive director Todd Ibrahim in the statement.
Amir Qaseem, MD, PhD, MHA, and coauthors from the ACP’s Clinical Guidelines Committee concluded that the recommendation against CKD screening of asymptomatic adults without CKD risk factors is supported by weak/low-quality evidence. The group’s research had identified no randomized, controlled trials that compared the effect of systematic CKD screening versus no CKD screening on clinical outcomes or that evaluated the harms of such screening.[iv]” (Emphasis added).
The American Society of Nephrology (ASN) recommends that all adults undergo routine screening for chronic kidney disease (CKD), the eight leading cause of death in the United States. This contradicts screening guidelines recently released by the American College of Physicians (ACP).
“If detected early in its progression, kidney disease can be slowed and the transition to dialysis delayed. This evidence-based fact is why regular screening and early intervention by a nephrologist is so important to stemming the epidemic of kidney disease in the United States and why ASN strongly recommends it,” said ASN President Bruce A. Molitoris, MD, FASN.[v] (Emphasis added).
The ASN was quick to point out that because kidney disease is largely asymptomatic in its early stages, one of the main methods to fight the disease and the spread of the disease is early detection and early intervention.[vi] Only early detection/intervention can slow progression of the disease and help patients maintain vital kidney function and quality of life.[vii] Equally objectionable to the ASN was the ACP’s recommendation that there should be no testing of a person taking an ACE inhibitor or an angiotensin II receptor blocker.[viii] Citing high blood pressure and diabetes as the two leading risk factors for the development of CKD, the ASN “emphasizes the importance” of proteinuria testing in adults being treated with antihypertensive medications.[ix]
I was shocked when I read this, so I looked up the genuine article of the ACP’s findings, http://annals.org/article.aspx?articleid=1757302. Sure enough, I found the following findings:
“Recommendation 1: ACP recommends against screening for chronic kidney disease in asymptomatic adults without risk factors for chronic kidney disease. (Grade: weak recommendation, low-quality evidence)
Recommendation 2: ACP recommends against testing for proteinuria in adults with or without diabetes who are currently taking an angiotensin-converting enzyme inhibitor or an angiotensin II–receptor blocker. (Grade: weak recommendation, low-quality evidence).[x]”
What I wanted to discuss with you today is the need for testing and the things that I have been taught about Chronic Kidney Disease (CKD), and the results of undetected kidney disease. According to the National Kidney Foundation, 26 million American adults are estimated to have CKD; many do not know it. Early signs are hard to detect and are easily missed.[xi] 2,492,040 Medicare patients are estimated to have CKD that has not yet become kidney failure.[xii] 594, 374 Americans have irreversible kidney disease or end-stage renal disease (ESRD), therefore require dialysis or a transplant to survive.[xiii]
415,013 of ESRD patients receive dialysis at least 3 times a week, approximately 4 hours a session to replace kidney function.[xiv] 87,460 people with ESRD die every year.[xv] There are 179,631 Americans living with a functioning kidney transplant and in 2012, 16,485 Americans received a kidney transplant.[xvi] According to UNOS, as of the writing of this blog, there are 98,943 Americans on the kidney transplant waiting list.[xvii] 44% of ESRD patients had a primary diagnosis of diabetes, the leading cause of ESRD.[xviii] 24% of ESRD patients had a primary diagnosis of hypertension (high blood pressure), the second leading cause of ESRD.[xix] Nearly 3000 people are added to the kidney waiting list every month; 13 people die each day while waiting for a life-saving transplant; Every 10 minutes someone is added to the transplant list.[xx]
Kidney disease is expensive. 76.3% of new ESRD patients apply for Medicare.[xxi] The annual cost of the Medicare ESRD program is $28.4B.[xxii] The annual Medicare costs to treat people with CKD is $41B or 22.5% of Medicare spending.[xxiii] $124,643 is the average Medicare cost for a kidney transplant in his first year.[xxiv] $86,316 is the average amount spend on a dialysis patient annually.[xxv] After the first year, $24,612 is what Medicare spends on a functioning transplant patient per year, primarily for anti-rejection medication.[xxvi]
Recently in a statement by the NKF to the Senate Committee On Appropriations; Subcommittee On Labor, Health And Human Services, Education, And Related Agencies concerning the Fiscal Year 2014 Appropriations Centers For Disease Control And Prevention Chronic Kidney Disease Program on May 6, 2013, the Foundation said,
“The prevalence of CKD in the United States is higher than a decade earlier. This is partly due to the increasing prevalence of the related diseases of diabetes and hypertension. It is estimated that CKD affects 26 million adult Americans (1) and that the number of individuals in this country with CKD who will have progressed to kidney failure, requiring chronic dialysis treatments or a kidney transplant to survive, will grow to 712,290 by 2015 (2). Kidney disease is the 9th leading cause of death in the U.S. Furthermore, a task force of the American Heart Association noted that decreased kidney function has consistently been found to be an independent risk factor for cardiovascular disease (CVD) outcomes and all-cause mortality and that the increased risk is present with even mild reduction in kidney function. (3) Therefore addressing CKD is a way to achieve one of the priorities in the National Strategy for Quality Improvement in Health Care: Promoting the Most Effective Prevention and Treatment of the Leading Causes of Mortality, Starting with Cardiovascular Disease.
CKD is often asymptomatic, a “silent disease,” especially in the early stages. Therefore, it goes undetected without laboratory testing. In fact, some people remain undiagnosed until they have reached CKD Stage 5 and literally begin dialysis within days. However, early identification and treatment can slow the progression of kidney disease, delay complications, and prevent or delay kidney failure. Accordingly, Healthy People 2020 Objective CKD–2 is to “increase the proportion of persons with chronic kidney disease (CKD) who know they have impaired renal function.” Screening and early detection provides the opportunity for interventions to foster awareness, adherence to medications, risk factor control, and improved outcomes. Additional data collection is required to precisely define the incremental benefits of early detection on kidney failure, cardiovascular events, hospitalization and mortality. Increasing the proportion of persons with CKD who know they are affected requires expanded public and professional education programs and screening initiatives targeted at populations who are at high risk for CKD. As a result of consistent congressional support, the National Center for Chronic Disease Prevention and Health Promotion at CDC has instituted a series of projects that could assist in attaining the Healthy People 2020 objective. However, this forward momentum will be stifled and CDC’s investment in CKD to date jeopardized if line-item funding is not continued.
As noted in CDC’s Preventing Chronic Disease: April 2006, Chronic Kidney Disease meets the criteria to be considered a public health issue: (1) the condition places a large burden on society; (2) the burden is distributed unfairly among the overall population; (3) evidence exists that preventive strategies that target economic, political, and environmental factors could reduce the burden; and (4) evidence shows such preventive strategies are not yet in place. Furthermore, CDC convened an expert panel in March 2007 to outline recommendations for a comprehensive public health strategy to prevent the development, progression, and complications of CKD in the United States.
The CDC Chronic Kidney Disease program has consisted of three projects to promote kidney health by identifying and controlling risk factors, raising awareness, and promoting early diagnosis and improved outcomes and quality of life for those living with CKD. These projects have included the following:
(a) Demonstrating effective approaches for identifying individuals at high risk for chronic kidney disease through state-based screening (CKD Health Evaluation and Risk Information Sharing, or CHERISH).
(b) Conducting an economic analysis by the Research Triangle Institute, under contract with the CDC, on the economic burden of CKD and the cost-effectiveness of CKD interventions.
(c) Establishing a surveillance system for Chronic Kidney Disease. Development of a surveillance system by collecting, integrating, analyzing, and interpreting information on CKD using a systematic, comprehensive, and feasible approach will be instrumental in prevention and health promotion efforts for this chronic disease. The CDC CKD surveillance project has built a basic system from a number of data sources, produced a report and created a website program http://www.cdc.gov/diabetes/projects/kidney/ consisting of information on preventing and controlling risk factors, the importance of early diagnosis, and strategies to improve outcomes. The website, publicly available for clinicians, health professionals, public health policy makers, and patients, also provides links to a number of publications and reports. The next steps include exploring state- based CKD surveillance data ideal for public health interventions through the state department of health…
In summary, undetected Chronic Kidney Disease can lead to costly and debilitating irreversible kidney failure. However, cost-effective interventions are available if patients are identified in the early stages of CKD. With the continued expressed support of Congress, the National Kidney Foundation is confident a feasible detection, surveillance and treatment program can be established to slow, and possibly prevent, the progression of kidney disease. Thank you for your consideration of our testimony.” (Emphasis added).
The NKF has initiated a program they call KEEP.[xxvii] According to the NKF, The Early Evaluation Program (KEEP®), reached over 185,000 individuals at increased risk for developing kidney disease between August 2000 and June 2013.[xxviii] KEEP screenings were offered across the United States to individuals 18 years and older with high blood pressure, diabetes or a family history of kidney failure. KEEP helped to raise awareness about kidney disease among high risk individuals and provide free testing and educational information, so that kidney disease and its complications could be prevented or delayed.[xxix]
KEEP participants received the following services at the screening:
•Blood pressure, height, weight and waist circumference measurements
•Blood and urine tests for signs of diabetes and kidney disease, including
◦Blood glucose check blood sugar
◦Hemoglobin check blood test for anemia
◦Albumin to creatinine ratio (protein in urine)
◦Serum creatinine (measures how well kidneys are filtering blood)
◦Estimated Glomerular Filtration Rate (test for kidney function)
◦Total cholesterol, HDL, LDL and triglycerides
◦Some participants will also had their calcium, phosphorus, PTH and/or Hemoglobin A1c levels checked.[xxx]
After the screening, the National Kidney Foundation:
•Sent participants their results
•Sent results to the participant’s clinician, with their permission
•Referred uninsured participants to a clinician or public health facility, if needed
•Provide additional information, education and support
•Invited participants back to attend a KEEP screening every year.[xxxi]
The professional journals the NKF uses to back up their claims that early testing and detection can slow the progress of kidney disease and prevent people from joining the long line of us that are currently on dialysis and on the waiting list for a kidney are legion.[xxxii] A recent study published in the American Journal of Kidney Diseases found that 59% of Americans will develop kidney disease in their lifetime.[xxxiii] The NKF reacted immediately:
“Nearly six of ten Americans will develop kidney disease in their lifetime, according to a new analysis published in the American Journal of Kidney Disease. In comparison, lifetime risk of diabetes, heart attack and invasive cancer is approximately four in ten.
As a result of this and previous studies, the National Kidney Foundation is calling on healthcare professionals to screen patients in specific high–risk groups for kidney disease – those age 60 or older and those with high blood pressure or diabetes – by adding a simple urine albumin test for kidney damage to annual physical examinations.
“These new data show clearly that Americans are more likely than not to develop kidney disease, which – in its later stages – is physically devastating and financially overwhelming,” said Dr. Beth Piraino, President of the National Kidney Foundation. “Importantly, if caught early, the progression of kidney disease can be slowed with lifestyle changes and medications. This underscores the importance of annual screenings, especially within the at–risk population, to potentially prevent kidney disease and ensure every patient with kidney disease receives optimal care.”
The study, by a team from Johns Hopkins University, combined nationally representative prevalence data on 37,475 individual with kidney disease associated mortality risk data from more than 2 million individuals to create a model detailing lifetime risk. The lifetime risk of moderate kidney disease was 59.1 percent, which translates into 135.8 million people currently alive who will eventually develop moderate kidney disease. For moderate–severe kidney disease, the risk was 33.6 percent, and for severe (stage 4) kidney disease, the lifetime risk was 11.5 percent. Finally, end–stage kidney disease requiring dialysis or kidney transplantation, has a lifetime risk of 3.6 percent which is dramatically higher among African–Americans at 8 percent.
African Americans had a greater risk of developing more advanced disease and developing kidney disease earlier. In contrast, the overall risk was highest in women due to their higher life expectancy and the dramatic rise of kidney disease risk with older age. The authors also noted that kidney disease risk appears to be increasing over the past decades, suggesting their results based on the average risk may be conservative. The rise in obesity and diabetes over the past decades may further increase the lifetime risk of kidney disease.
“With more than half of all Americans at risk, it’s time for all Americans to understand how kidney disease is detected, and for those at elevated risk because of older age, diabetes, hypertension or other risk factors to know whether they have kidney disease or not,” said Dr. Josef Coresh, Professor of Epidemiology, Johns Hopkins Bloomberg School of Public Health, who led the Hopkins team that performed the analysis. “Chronic kidney disease is significantly under–diagnosed, and the consequences of this lack of information can be dire.”
Dr. Morgan Grams, a nephrologist and lead author of the paper pointed out that while severe kidney disease and uncontrolled complications require referral to a nephrologist, the majority of patients with moderately reduced kidney function can be managed well by their regular physician.
Chronic kidney disease is widespread and costly, costing Medicare upwards of $41 billion annually, but awareness and understanding about kidney disease is critically low. An estimated 26 million Americans already have chronic kidney disease, and surprisingly even among those with severe (stage 4) kidney disease fewer than half realize that they have damaged kidneys.
To further assist individuals in understanding their risk of kidney disease, the National Kidney Foundation has developed a simple, interactive online screening test available on its website, kidney.org, and the group encourages those at risk to discuss their results with their health care team to ensure that the proper diagnosis and treatment can be offered.[xxxiv]”
Kidney disease is characterized by a gradual loss of kidney function over time[xxxv]. It increases the risk of complications, including heart disease and premature death[xxxvi]. It is difficult to detect because it mimics other symptoms, including:
•feel more tired and have less energy
•have trouble concentrating
•have a poor appetite
•have trouble sleeping
•have muscle cramping at night
•have swollen feet and ankles
•have puffiness around your eyes, especially in the morning
•have dry, itchy skin
•need to urinate more often, especially at night[xxxvii].
135.8 million Americans have or are expected to have kidney disease in their lifetimes. [xxxviii] Afro-Americans, People over 60, and White Women are particularly at risk.[xxxix] If your family has a history of high blood pressure, a history of kidney failure, if you have diabetes, and/or you are age 60 or above, the NKF is recommending that you have a simple urine and blood albumin test for kidney damage as a part of your annual physical.[xl] Experts now say that 1 in 2 of us could develop chronic kidney disease.[xli] Comparatively, the risk developing diabetes is 1 in 3, heart disease is 1 in 3, and cancer is 1 in 2.[xlii] Tragically, awareness of CKD is unacceptably low. According to the NKF’s experts, only ½ of people with CKD know that they have it.[xliii] Fewer than 50% of the people with severe CKD are aware of it.[xliv]
There is more bad news. The incidence of CKD is on the rise. According to a National Health and Nutrition Examination Survey (NHANES), from 1988-1994 kidney disease rose by 14.5% and from 1999-2004 it rose by 16.85%.[xlv] Most people do not die of kidney failure, but rather there is a high incidence of death resulting from cardiovascular incidents.[xlvi] Another article that I read stated that between 1980 and 2009 the incidence of CKD rose by 600% or from 290 to 1,738 cases per million.[xlvii] According to the American Journal of Kidney Diseases:
“Chronic kidney disease (CKD) is rising in prevalence, increasingly expensive, and associated with a high degree of morbidity and mortality. Reduced estimated glomerular filtration rate (eGFR) is a well-accepted risk factor for all-cause mortality, acute kidney injury, and end-stage renal disease (ESRD), and CKD may carry a coronary heart disease risk similar to that of diabetes. ESRD, the most severe stage of CKD, is associated with a residual life expectancy of less than 5 years. Despite a national education campaign, CKD awareness remains low, and little is known about a given individual’s lifetime risk of CKD.[xlviii]”
Early detection of kidney disease is critical to stopping the progression of the disease.[xlix] If you are diagnosed early enough, you kidney disease can be controlled, slowed or delayed with the help of your doctor.[l]The risks of kidney disease and its complication can be reduced by the simple acts of controlling your blood pressure, maintaining proper weight, quitting smoking, exercising, and avoiding excessive pain medication.[li]
I am living proof of this. Prior to me, I lost a cousin, 2 aunts and an uncle to kidney disease. I lost my Dad to Polycystic Kidney Disease. I was diagnosed a mere 2 months after my Father’s death at the age of 25. At the time it came as a blow to me, but it turned out that early diagnosis was a blessing. I hired a nephrologist, took blood pressure meds, ate a renal diet, and I was tested by my doctor every 6 months. I managed to avoid dialysis for over 30 years and my dialysis now has not been as difficult for me as it could have been because I did what I was told years earlier. As I told you in my last blog, recently my son was tested for PKD. The test came back negative. He’s 26. So I do practice what I’m preaching here. This is why I found the study by the ACP so damaging. I think there is more than ample evidence that early detection and testing is critical to peace of mind, good kidney management, and medically acceptable kidney safety. I encourage all of you to seriously to take the very simple tests to detect kidney failure, because early detection and diagnosis leads to early effective treatment. Avoiding dialysis and waiting on the transplant list should be paramount in your thinking. I am grateful to have those alternatives due to my kidney failure, but the life I had before without kidney failure was a better quality of life. Knowledge is power. Get tested. I remain your advocate!
[i] Yard, Nephrology Society Objects to Call Against Kidney Screening, http://www.renalandurologynews.com/nephrology-society-objects-to-call-against-kidney-screening/article/317395/?DCMP=EMC-RENALUROLOGY_ETOC&CPN=&spMailingID=7553773&spUserID=MzE1MTQ0Mzc2NDcS1&spJobID=104488077&spReportId=MTA0NDg4MDc3S0 (October 23, 2013) (“In a statement issued one day after the new ACP clinical guidelines, published by Annals of Internal Medicine, came out against chronic kidney disease (CKD) screening in asymptomatic adults who do not have risk factors, the ASN confirmed that it “strongly recommends” regular screening for kidney disease, regardless of an individual’s risk factors.”).
[ii] Id. (“The American Society of Nephrology (ASN) is at odds with the new American College of Physicians (ACP) recommendation against screening for chronic kidney disease in asymptomatic adults without risk factors for the condition.
In a statement issued one day after the new ACP clinical guidelines, published by Annals of Internal Medicine, came out against chronic kidney disease (CKD) screening in asymptomatic adults who do not have risk factors, the ASN confirmed that it “strongly recommends” regular screening for kidney disease, regardless of an individual’s risk factors.”).
[v] ASN Emphasizes Need for Early Detection of Kidney Disease, http://www.renalbusiness.com/news/2013/10/asn-emphasizes-need-for-early-detection-of-kidney-disease.aspx (October 23, 2013); ASN disagrees with new guidelines, says adults should be screened for kidney disease, http://www.nephrologynews.com/articles/109817-asn-disagrees-with-new-guidelines-says-adults-should-be-screened-for-kidney-disease (October 23, 2013).
[x] Amir Qaseem, MD, PhD, MHA; Robert H. Hopkins, Jr., MD; Donna E. Sweet, MD; Melissa Starkey, PhD; and Paul Shekelle, MD, PhD, for the Clinical Guidelines Committee of the American College of Physicians, Screening, Monitoring, and Treatment of Stage 1 to 3 Chronic Kidney Disease: A Clinical Practice Guideline From the Clinical Guidelines Committee of the American College of Physicians, http://annals.org/article.aspx?articleid=1757302 (October 22, 2013).
[xi] Flyer distributed to State Advocates by the National Kidney Foundation, www.kidney.org/…/KIDNEY_DISEASE_BY_THE_NUMBERS.pdf (March 2013).
[xx] National Kidney Foundation, Organ Donation and Transplantation Statistics as of June 21, 2013, http://www.kidney.org/news/newsroom/factsheets/Organ-Donation-and-Transplantation-Stats.cfm (2013).
[xxi] Flyer distributed to State Advocates by the National Kidney Foundation, www.kidney.org/…/KIDNEY_DISEASE_BY_THE_NUMBERS.pdf (March 2013).
[xxxii] American Journal of Kidney Disease-KEEP Annual Data Reports, http://www.kidney.org/news/keep/KEEPDataReports.cfm (2013).
[xxxiii] NEW STUDY SHOWS 59 PERCENT OF AMERICANS WILL DEVELOP KIDNEY DISEASE IN THEIR LIFETIME, http://www.kidney.org/news/newsroom/nr/Americans_will_develop_KD_in_their_lifetime.cfm (August 1, 2013); NKF, RPA Urge Screening for those at Risk for Kidney Disease, http://www.renalbusiness.com/news/2013/11/nkf-rpa-urge-screening-for-those-at-risk-for-kidney-disease.aspx (November 4, 2013)(“ “However, screening risk groups is recommended by the NKF and RPA, particularly those with diabetes and/or hypertension. Screening for CKD in these risk groups was shown to be cost effective in a recent analysis,” said Joseph Vassalotti, MD, NKF CFO.
“In addition, NKF and RPA recommend screening for other risk groups to promote early detection and management, including African Americans and at- risk ethnic groups, those age 60 and older and those with family history of kidney failure. CKD detection drives patient awareness and changes management—that is why testing is so important. Control of hypertension can slow progression or loss of kidney function over time, delaying the onset of kidney failure. Management of CKD also includes a patient safety approach to drug prescription practices for certain medications cleared by the kidneys. Avoiding certain medications and judicious use of iodinated contrast media for imaging can prevent acute kidney injury in those at risk with CKD. Lastly, timely nephrology referral and preparation for dialysis and kidney transplantation are dependent on primary care detection,” continued Vassalotti.”); Morales, Understanding The Risks Of Kidney Disease, http://www.pasadenanow.com/main/understanding-the-risks-of-kidney-disease, (Sept 13, 2013)(“ Piraino adds, “if caught early, the progression of kidney disease can be slowed with lifestyle changes and medications. This underscores the importance of annual screenings, especially within the at-risk population, to potentially prevent kidney disease and ensure every patient with kidney disease receives optimal care.”); Infogrpahic, http://www.slideshare.net/KMC127/nkf-infographic-shows-6-in-10-at-ckd-risk (Accessed 2013).
[xxxiv] Id. NKF
, RPA Urge Screening for those at Risk for Kidney Disease
[xxxv] Infogrpahic, http://www.slideshare.net/KMC127/nkf-infographic-shows-6-in-10-at-ckd-risk (Accessed 2013).
[xxxviii] Infogrpahic, http://www.slideshare.net/KMC127/nkf-infographic-shows-6-in-10-at-ckd-risk (Accessed 2013).
[xl] Id. See Also; About Chronic Kidney Disease, http://www.kidney.org/kidneydisease/aboutckd.cfm (Accessed 2013)(“ The two main causes of chronic kidney disease are diabetes and high blood pressure, which are responsible for up to two-thirds of the cases. Diabetes happens when your blood sugar is too high, causing damage to many organs in your body, including the kidneys and heart, as well as blood vessels, nerves and eyes. High blood pressure, or hypertension, occurs when the pressure of your blood against the walls of your blood vessels increases. If uncontrolled, or poorly controlled, high blood pressure can be a leading cause of heart attacks, strokes and chronic kidney disease. Also, chronic kidney disease can cause high blood pressure.
Other conditions that affect the kidneys are:
•Glomerulonephritis, a group of diseases that cause inflammation and damage to the kidney’s filtering units. These disorders are the third most common type of kidney disease.
•Inherited diseases, such as polycystic kidney disease, which causes large cysts to form in the kidneys and damage the surrounding tissue.
•Malformations that occur as a baby develops in its mother’s womb. For example, a narrowing may occur that prevents normal outflow of urine and causes urine to flow back up to the kidney. This causes infections and may damage the kidneys.
•Lupus and other diseases that affect the body’s immune system.
•Obstructions caused by problems like kidney stones, tumors or an enlarged prostate gland in men.
•Repeated urinary infections.”);
Video, What is the Lifetime Risk for Developing Kidney Disease? http://www.youtube.com/watch?v=4ZN8nuKcQpo (Accessed 2013); Video, Experts Discuss New Report on Lifetime Risk for Kidney Disease and NKF’s Screening Recommendations, http://www.youtube.com/watch?v=p6Nq_D4j3JI (Accessed 2013).
[xliv] Infogrpahic, http://www.slideshare.net/KMC127/nkf-infographic-shows-6-in-10-at-ckd-risk (Accessed 2013).
[xlv] http://www.kidney.org/news/keep/pdf/adr2007/02chapter1.pdf (Accessed 2013); American Journal of Kidney Diseases, Vol 51, No 4, Suppl 2 (April), 2008: pp S3-S12; Centers for Disease Control and Prevention of Chronic Kidney Disease and Associated Risk Factors-United States, 1999-2004, MMWR Morbid Mortal Weekly Rep 56: 161-165 (2007).
[xlviii] Grams, Lifetime Incidence of CKD Stages 3-5 in the United States, American Journal of Kidney Diseases
Volume 62, Issue 2 , Pages 245-252, August 2013, http://www.ajkd.org/article/S0272-6386(13)00664-1/fulltext (2013).
[li] Id. Infogrpahic, http://www.slideshare.net/KMC127/nkf-infographic-shows-6-in-10-at-ckd-risk (Accessed 2013).