Kidney Early Evaluation Program Research Articles

Kidney Early Evaluation Program: A Community-Based Screening Approach to Address Disparities in Chronic Kidney Disease

The Kidney Early Evaluation Program (KEEP) is a free, community-based, kidney disease screening program designed to detect chronic kidney disease (CKD) early and promote follow-up evaluation with clinicians to ultimately improve outcomes. This program screens individuals with diabetes, hypertension, or those with a first-degree relative with diabetes, hypertension, and/or kidney disease. Data based on 89,552 KEEP participants screened in 49 states from early August 2000 until end of December 2007 disclosed a prevalence of 34% African Americans, 12.4% Hispanics, 5.6% Asian/Pacific Islanders, and 4.5% Native Americans. Compared with the random US population sample in National Health and Nutrition Examination Survey 1999 to 2006 and the US Census Bureau 2000, KEEP represented 3-fold more African Americans and Native Americans and a similar proportion of Hispanics and Asians/Pacific Islanders. Analysis of KEEP data confirm that control of CKD risk factors and awareness of CKD remains low. In conclusion, KEEP is an enriched source of populations at high risk for CKD, and control of the two major CKD risk factors, diabetes and hypertension, remains disappointingly low, especially in high-risk populations, despite disease awareness. A longitudinal component of KEEP will evaluate the impact of the program on health disparities over time and holds promise for improving awareness and possibly future management of CKD risk factors.

Gestational Diabetes Mellitus Alone in the Absence of Subsequent Diabetes Is Associated With Microalbuminuria: Results from the Kidney Early Evaluation Program (KEEP)

Gestational Diabetes Mellitus Alone in the Absence of Subsequent Diabetes Is Associated With Microalbuminuria: Results from the Kidney Early Evaluation Program (KEEP)

Prevalence of CKD and Comorbid Illness in Elderly Patients in the United States: Results From the Kidney Early Evaluation Program (KEEP)

Prevalence of CKD and Comorbid Illness in Elderly Patients in the United States: Results From the Kidney Early Evaluation Program (KEEP)

Dysglycemia Predicts Cardiovascular and Kidney Disease in the Kidney Early Evaluation Program

The cardiometabolic syndrome has been associated with both chronic kidney disease (CKD) and cardiovascular disease (CVD). Using data from the National Kidney Foundation-Kidney Early Evaluation Program, the authors sought to investigate this association in a targeted CKD cohort. A total of 26,992 patients met eligibility criteria including age 18 years and older, diabetes, hypertension, or family history of CKD, diabetes, or hypertension and excluded those taking renal replacement therapy. Individuals were identified by Third Report of the National Cholesterol Education Program Adult Treatment Panel (NCEP-ATP III) criteria (dysglycemia, hypertension, and dyslipidemia) and World Health Organization criteria (obesity and proteinuria). Univariate and multivariate analyses were used to evaluate increasing components of the cardiometabolic syndrome, CKD, and CVD. On multivariate analysis there was a graded relationship between increasing components with an increased prevalence of CKD and CVD. Additionally, there was a graded trend with the stage of dysglycemia (eg, normoglycemia, prediabetes, and overt diabetes) and increasing CKD. However, there was only an increased prevalence of CVD observed in the clinically diabetic group. This trend was also observed with increasing serum glucose levels and an increasing percent of CVD and CKD up to 160 mg/dL. However, prevalent CVD increased at >140 mg/dL and prevalent CKD at >180 mg/dL. Therefore, data support that increasing metabolic components and dysglycemia are strongly associated with an increased prevalence of CKD and CVD.

Obesity is associated with increased parathyroid hormone levels independent of glomerular filtration rate in chronic kidney disease

The objective of the study was to examine the relationship of obesity and parathyroid hormone (PTH) levels among persons with chronic kidney disease (CKD). This was a cross-sectional analysis of 4551 participants in the National Kidney Foundation–Kidney Early Evaluation Program found to have CKD (estimated glomerular filtration rate <60 mL/[min 1.73 m 2]) examining the relationship of body mass index (BMI) and PTH levels. In unadjusted analysis, PTH levels increased with increasing BMI quartiles. After adjustment for age, race, sex, diabetes, calcium, phosphorus, estimated glomerular filtration rate, and presence of microalbuminuria, PTH levels were 7.3% ( P = .008), 11.9% ( P < .0001), and 18.1% ( P < .0001) higher in the second, third, and fourth BMI quartiles, respectively, as compared with the first quartile. In a companion analysis, higher BMI was associated with increased odds of having an elevated PTH measurement (>70 pg/mL). Compared with the first quartile, odds ratios for elevated PTH were 1.26 (95% confidence interval, 1.06-1.50; P = .01), 1.38 (1.15-1.65, P = .0005), and 1.66 (1.37-2.00, P < .0001) for the second, third, and fourth quartiles, respectively. We found no effect modification by race, diabetes, or presence of microalbuminuria. Therefore, in a large community-dwelling population with CKD, the presence of obesity and of increasing BMI is associated with higher PTH levels independent of measured confounders and may be an additional target in the management of secondary hyperparathyroidism in CKD.

The Kidney

Today, it is universally acknowledged that, in hypertension, the kidney is both culprit and victim.1 Kidney malfunction causes hypertension, and hypertension, in turn, aggravates chronic kidney disease (CKD) and accelerates its progression. High blood pressure (frank hypertension and blood pressure values in the high normal range) are clearly correlated to progressive kidney injury, both in experimental2 and in clinical3 observations. All of the current guidelines4,5 recommend lowering of systolic blood pressure to 130 or 125 mm Hg in CKD, and even lower values are recommended if the target level of proteinuria of <1 g per 24 hours has not been achieved.4 There is good evidence of “renoprotection” by lowering blood pressure in patients with renal disease, at least in the presence of proteinuria.3 In CKD patients without proteinuria, eg, autosomal polycystic kidney disease, further renoprotection cannot be achieved by lowering blood pressure below the target blood pressure recommended in patients without CKD6; nevertheless, these patients have a markedly elevated cardiovascular risk, and more stringent lowering of blood pressure is desirable, because, eg, reduction of left ventricular hypertrophy as an index of cardiovascular risk had been documented in such patients.6 The worldwide problem of neglect of hypertension and of insufficient implementation of antihypertensive treatment in CKD patients prompted the International Society of Nephrology and the International Federation of Kidney Foundations to devote this year’s World Kidney Day (http://www.worldkidneyday.org) on March 12th to the issue …

220: The Kidney Early Evaluation Program (KEEP): A Community Based Screening Approach to Address Disparities in CKD

220: The Kidney Early Evaluation Program (KEEP): A Community Based Screening Approach to Address Disparities in CKD

114: Predictors of Self Referred Repeat CKD Screening in the Kidney Early Evaluation Program (KEEP)

114: Predictors of Self Referred Repeat CKD Screening in the Kidney Early Evaluation Program (KEEP)

208: Kidney Early Evaluation Program (KEEP) in Japan

208: Kidney Early Evaluation Program (KEEP) in Japan

226: Diabetes Mellitus and CKD Awareness: The Kidney Early Evaluation Program and National Health and Nutrition Examination Survey

226: Diabetes Mellitus and CKD Awareness: The Kidney Early Evaluation Program and National Health and Nutrition Examination Survey

92: Hypertension in Early-Stage Kidney Disease: An Update From the Kidney Early Evaluation Program

92: Hypertension in Early-Stage Kidney Disease: An Update From the Kidney Early Evaluation Program

Hypertension in Early-Stage Kidney Disease: An Update From the Kidney Early Evaluation Program (KEEP)

Chronic kidney disease (CKD) is a worldwide public health problem. Systolic blood pressure as an associated feature of CKD has not been fully explored in community volunteer and nationally representative samples of the US population. This cross-sectional analysis evaluated hypertension and early-stage CKD in participants in the Kidney Early Evaluation Program (KEEP), a voluntary community-based health screening program administered by the National Kidney Foundation, and the National Health and Nutrition Examination Survey (NHANES) data to assess similarities and differences between these populations. Participants in both databases were 18 years or older. The KEEP database included 88,559 participants and the NHANES included 20,095. Hypertension prevalence was greater in KEEP (69.6%) than NHANES (38.1%; P < 0.001). Compared with NHANES participants, KEEP participants had greater rates of obesity (79.5% versus 51.5%; P < 0.001) and diabetes (28.0% versus 8.9%; P < 0.001). In participants with diabetes, KEEP had slightly greater rates of prevalent hypertension (88.5% versus 85.7%; P = 0.03). In participants with hypertension, CKD stages 3 and 4 were more prevalent in KEEP than NHANES (79.1% versus 69.3%; P < 0.001). Rates of CKD stages 3 and 4 were greater in KEEP than NHANES for the following subgroups: African Americans (72.4% versus 57.4%; P < 0.001), smokers (69.1% versus 55.6%; P = 0.002), and participants with hypercholesterolemia (80.2% versus 71.9%; P < 0.001). In the volunteer KEEP population, rates of hypertension and CKD were greater than in NHANES, most prominently in African Americans and participants with increased cardiovascular risk.

Diabetes Mellitus and CKD Awareness: The Kidney Early Evaluation Program (KEEP) and National Health and Nutrition Examination Survey (NHANES)

Diabetes contributes to increased morbidity and mortality in patients with chronic kidney disease (CKD). We sought to describe CKD awareness and identify factors associated with optimal glycemic control in diabetic and nondiabetic individuals both aware and unaware of CKD. This cross-sectional analysis compared Kidney Early Evaluation Program (KEEP) and National Health and Nutrition and Examination Survey (NHANES) 1999 to 2006 participants with diabetes and CKD. CKD was defined and staged using glomerular filtration rate (estimated by using the 4-variable Modification of Diet in Renal Disease Study equation) and urine albumin-creatinine ratio. NHANES defined diabetes as self-reported diabetes or fasting plasma blood glucose level of 126 mg/dL or greater, and KEEP as self-reported diabetes or diabetic retinopathy, use of diabetes medications, fasting blood glucose level of 126 mg/dL or greater, or nonfasting glucose level of 200 mg/dL or greater. Of 77,077 KEEP participants, 20,200 (26.2%) were identified with CKD and 23,082 (29.9%) were identified with diabetes. Of 9,536 NHANES participants, 1,743 (18.3%) were identified with CKD and 1,127 (11.8%) were identified with diabetes. Of KEEP participants with diabetes and CKD (n = 7,853), 736 (9.4%) were aware of CKD. Trends in lack of CKD awareness were similar for KEEP participants with and without diabetes. Unaware participants with and without diabetes identified with stages 1 and 2 CKD were less likely to reach target glucose levels, defined as fasting glucose level less than 126 mg/dL or nonfasting glucose level less than 140 mg/dL, than those with stages 3 to 5 (odds ratio, 0.69; 95% confidence interval, 0.62 to 0.78; odds ratio, 0.69; 95% confidence interval, 0.58 to 0.81; P < 0.001, respectively). Our data support that KEEP, as a targeted screening program, is a more enriched population with CKD and comorbid diabetes than NHANES. In addition, our findings highlight the relationship between dysglycemia and early stages of unidentified CKD.

Plasma Parathyroid Hormone Level and Prevalent Cardiovascular Disease in CKD Stages 3 and 4: An Analysis From the Kidney Early Evaluation Program (KEEP)

Cardiovascular disease (CVD) is the most common cause of death in patients with chronic kidney disease (CKD). Secondary hyperparathyroidism is common in patients with CKD, and its relationship to CVD is not well defined. This analysis aims to assess whether serum intact parathyroid hormone (PTH) level is an independent risk factor for CVD in patients with CKD stages 3 and 4. In this cross-sectional study, medical history surveys, including CVD events, were collected from 4,472 patients with stages 3 and 4 CKD identified by the National Kidney Foundation Kidney Early Evaluation Program (KEEP), which included blood pressure measurement and laboratory testing. Age, hemoglobin level, estimated glomerular filtration rate, serum phosphorus level, and serum calcium level were evaluated as continuous variables, and plasma PTH levels, by tertile: less than 35, 35 to 70, and greater than 70 pg/mL. Multivariate logistic regression was used to estimate odds ratios (ORs) of CVD predictor variables. Mean age was 68.3 +/- 11.8 years. Of the study population, 68% were women, 69% were white, 6% were current smokers, 45% were obese, 46% had diabetes, and 83% had hypertension. A history of CVD was present for 1,972 (44.1%), and plasma PTH level greater than 70 pg/mL, for 2,239 (50.1%). Multivariate logistic regression showed ORs for CVD events increasing with age (OR, 1.03; P < 0.001), male sex (OR, 1.51; P < 0.001), diabetes (OR, 1.73; P < 0.001), hypertension (OR, 1.43; P < 0.001), and intact PTH level greater than 70 pg/mL (OR, 1.51; P < 0.001; reference, <35 pg/mL). PTH level greater than 70 pg/mL is independently associated with CVD events in patients with CKD stages 3 and 4. No association was observed between serum phosphorus or calcium level and CVD events. These findings provide support for intact PTH testing, along with testing for other indicators of CKD mineral and bone disorders, at earlier CKD stages.

Executive Summary: Kidney Early Evaluation Program (KEEP) 2008 Annual Data Report

Executive Summary: Kidney Early Evaluation Program (KEEP) 2008 Annual Data Report

Screening Populations at Increased Risk of CKD: The Kidney Early Evaluation Program (KEEP) and the Public Health Problem

The epidemiological characteristics of the US end-stage renal disease population growth and increased costs in the late 1980s framed the public health agenda for the development of a community-based chronic kidney disease (CKD) screening program. Development of the National Kidney Foundation Kidney Early Evaluation Program (KEEP) included 2 preliminary screening programs, the Computerized Assessment of Risk and Education and the KEEP pilot, which was organized around the African American Study of Kidney Diseases clinical centers. The current KEEP program, launched in August 2000, targets individuals with diabetes, hypertension, or a family history of diabetes or hypertension or CKD. The screening includes informed consent, health screening questionnaire, diagnostic panel, and physician consultation. Participants are followed up by telephone and mail. Of 100,000 KEEP participants screened, 28.7% have CKD and 6.7% self-reported CKD stages 1 to 5. Conversely, National Health and Nutrition Examination Survey 1999-2002 results show 13.1% CKD prevalence; 2.9% of women and 17.9% of men with an estimated glomerular filtration rate less than 60 mL/min/1.73 m(2) self-report CKD. CKD prevalences in KEEP by stage are 3.1% for stage 1; 4.8%, stage 2; 19.7%, stage 3; and 1.1%, stages 4 and 5, confirming the ability of this targeted screening program to detect CKD early. In addition to identifying individuals at increased risk of kidney disease, KEEP's structured data collection provides an opportunity to advance knowledge about kidney disease and advance the CKD public health agenda.

Status of chronic kidney disease prevention programs: International Federation of Kidney Foundation Members 2005/2007

The International Federation of Kidney Foundations surveyed its members on chronic kidney disease 'prevention' programs in their regions and countries in 2005 and 2007. A profile was developed, representing 28 countries (56% response). Some form of screening activity was reported in 24 of the 28 countries (85.7%). Two countries (7%) had, or anticipated development of, legislated national screening. Programs were conducted by kidney foundations or research groups, and were variously population based, focused on high risk groups or opportunistic. Tests in 63% of responding programs included weight, height, blood pressure, blood glucose, dipstick urinalysis and serum creatinine. Several programs used the USA's Kidney Early Evaluation Program's and International Society of Nephrology's templates. World Kidney Day activities contributed significantly. Stated needs were for more government recognition, firm policies and approaches, and critically, resources. Repeat responders reported progress in 2007, particularly in government interest and education delivery. Despite difficulties, programs are developing in many regions. Most need more resources and some members need substantial and sustained assistance.

Risk Factors for Chronic Kidney Disease among American Indians and Alaska Natives – Findings from the Kidney Early Evaluation Program

Background: American Indians and Alaska Natives (AIAN) have a high incidence of end-stage renal disease. Less is known about chronic kidney disease (CKD) among AIAN and whether risk factors differ for low estimated glomerular filtration rate (eGFR) versus albuminuria with a normal eGFR. Methods: Cross-sectional study examining the associations of age, sex, smoking, obesity, diabetes, hypertension, family history, and geographic region with CKD among a screened population of AIAN participants in the Kidney Early Evaluation Program from 2000 to 2006. CKD was defined by the presence of either a low eGFR, <60 ml/min/1.73 m², or albuminuria, a urine albumin/creatinine ratio ≥30 mg/g. Results: The prevalence of any CKD was 29%, of low eGFR was 17%, and of albuminuria with a normal eGFR was 12%. Older age was the strongest predictor of low eGFR (61+ years OR 8.42, 95% CI 5.92–11.98), followed by hypertension (OR 2.38, 95% CI 1.74–3.26). In contrast, diabetes (OR 2.04, 95% CI 1.57–2.64) and hypertension (OR 2.63, 95% CI 1.93–3.59) were the only predictors of albuminuria among persons with a normal eGFR. Conclusion: The burden of CKD was high among this screened population of AIAN, and different risk factor patterns were associated with low eGFR and albuminuria. Innovative programs and longitudinal research are needed to address CKD among AIAN.

Hypertension Awareness, Treatment, and Control in Chronic Kidney Disease

Background Hypertension prevalence, awareness, treatment, and blood pressure control rates in the population with chronic kidney disease are limited. The objective of this study was to determine the state of blood pressure control in patients with chronic kidney disease. Methods This is a cross-sectional analysis of data of participants with chronic kidney disease from the Kidney Early Evaluation Program. The Kidney Early Evaluation Program is a national-based health screening program for individuals at high risk for kidney disease conducted in 49 states and the District of Columbia. Of 55,220 adults with kidney disease, 10,813 completed information for demographic and medical characteristics used in the analysis. Predictors of blood pressure control were assessed using multiple logistic regression analysis. Results Hypertension prevalence, awareness, and treatment proportions in the screened cohort were high (86.2%, 80.2%, and 70.0%, respectively), but blood pressure control rates were low (13.2%). These proportions increased with advancing stage of kidney disease. Elevated systolic blood pressure accounted for the majority of inadequate control. Male gender (odds ratio [OR] 0.86; 95% confidence interval [CI], 0.75-0.99), non-Hispanic black race (OR 0.76; 95% CI, 0.65-0.89), and body mass index of 30 kg/m 2 or more (OR 0.83; 95% CI, 0.73-0.94) were inversely related with blood pressure control. Those with stage 3 kidney disease were more likely to have blood pressure at goal than those with stage 1 kidney disease (OR 2.08; 95% CI, 1.55-2.80). Conclusion We conclude that despite increased awareness and treatment of hypertension, control rates in these participants are poor. This poor control rate centers around elevated systolic pressure in people who are obese, non-Hispanic black, or male. These data suggest that those who are aware of their kidney disease are more likely to achieve blood pressure control.

41: Applying an Expanded Set of Cognitive Design Principles to Formatting the NKF Kidney Early Evaluation Program Longitudinal Survey (KEEP-LS)

APPLYING AN EXPANDED SET OF COGNITIVE DESIGN PRINCIPLES TO FORMATTING THE NKF KIDNEY EARLY EVALUATION PROGRAM LONGITUDINAL SURVEY (KEEPLS) Jose Luis Calderon, 2 Erik Fleming, Monica Gannon, Shu-Cheng Chen, 4 Joseph A. Vassaloti, 3 Keith C. Norris,. College of Pharmacy, Health Professions Division, Nova Southeastern University, Fort Lauderdale, Florida, Charles R. Drew University of Medicine and Science, Los Angeles, California, National Kidney Foundation, New York, New York, KEEP Data coordinating Center, Minneapolis, Minnesota, David Geffen School of Medicine, University of California, Los Angeles (UCLA) The Kidney Early Evaluation Program (KEEP) is a targeted, community-based screening of populations at greatest risk for chronic kidney disease (CKD), those with high rates of diabetes, hypertension, and a high proportion of racial/ethnic minorities. The KEEP longitudinal study will adopt survey methods similar to those used in KEEP to gather follow-up (F/U) data to measure CKD-related heath status and gauge program effectiveness for repeated KEEP participants with evidence of moderate to severe kidney function deficiency. KEEP has defined objectives to enhance F/U survey response rates and target vulnerable populations who bear the highest CKD risk factor burdens. The KEEP F/U Form was assessed for adherence to six cognitive design principles (simplicity, consistency, organization, natural order, clarity, attractiveness) considered to summate the techniques guiding good survey development, and for the additional cognitive design principles readability and variation of readability across survey items. The form was found to include violations of each cognitive design principle and readability principle, possibly contributing to item nonresponse and low follow-up rates in KEEP. It was revised according to empirically substantiated formatting techniques guided by the principles, and found during qualitative assessment to be more userfriendly, simpler, better organized, more attractive, and easier to read. To ensure ease of use by populations with limited literacy skills, poor health literacy, and limited survey literacy, survey researchers must apply cognitive design principles to survey development to improve participation and response rates.