A synthesis of Kidney Disease

Introduction to Kidney Disease

Kidney Disease refers to kidney damage or a decreased level of kidney function. There are levels of severity in kidney disease, starting from mild to severe cases, and can eventually lead to kidney failure/end-stage renal disease if not treated appropriately. There are also cases of acute kidney injury where kidney function unexpectedly and rapidly declines due to other diseases and infections (Kidney Foundation, 2022). In all cases, the basic principle is that any level of kidney disease will affect the filtering units of the kidney and the ability to remove waste, toxins, and excess fluids from the body. For the more severe cases of kidney disease such as Chronic Kidney Disease (CKD) and End-Stage Renal Disease (ESRD), life-sustaining treatments such as dialysis and kidney transplant are required. The below figure explains the process of kidney disease starting at mild severity which requires nephrology follow-ups and moves to the more severe cases which require dialysis.

(Vélez‑Bermúdez et al., 2022)

It is important to spread awareness of kidney disease because of its prevalence in the community. 1 in 10 Canadians have kidney disease, which is equivalent to roughly 4 million people nationwide. The number of Canadians living with ESRD has increased by 35% since 2009 (Kidney Foundation, 2020). As I was trying to understand why there is a lack of awareness for kidney disease, I reflected on the first weeks of MHST 601 as we navigated the idea of “health” and what it entails. According to the World Health Organization (WHO), “Health is a state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity” (World Health Organization, 2022). Although this is correct, many researchers, philosophers, and health Subject Matter Experts (SMEs) believe that this definition of health is outdated. I am also inclined to believe that the definition of “health” should expand further than WHOs interpretation and include awareness and education for the general population. Through my e-portfolio and past blogs, I have endeavored to build health by spreading awareness of kidney disease.

Applying the Social-ecological Model to Determinants of Kidney Disease

Creating awareness of kidney disease requires us to understand the determinants of health. Determinants of health are a broad range of personal, social, economic, and environmental factors that determine individual and community health (Government of Canada, 2022, para. 2). Health Canada lists a broad range of health determinants such as income, social status, employment, education, physical environments, social supports, access to health services, race, etc. These determinants have a strong association with kidney disease. Factors such as household income, health insurance, educational attainment, geographical residence, substance abuse, culture, diet, obesity, and stress influence kidney disease (Nzerue et al., 2002). These determinants differ in the level of influence for each person. The social-ecological model (SEM) implements four levels of factors and considers the complex interplay between individual, relationship, community, and societal factors. In the case of kidney disease, factors such as diet, stress, substance abuse, and educational attainment are individual influences for CKD. These interventional approaches can be implemented for a person at risk of or with CKD.

The migration of the population to inner city areas with higher poverty levels and substance abuse can lead to health consequences when interacting with such physical and economic deterioration. Geographical placement is a community factor in the SEM in which the environment can influence the risk and management of CKD. Some populations have cultural expectations, which play a role in influencing the risk and management of CKD. Because of these cultural expectations, those populations may refuse medical interventions. Cultural norms are recognized as a societal level factor and require education and promotion of kidney disease interventions. Although the SEM has different categories, it is important to illustrate the complex interplay between the different levels. For example, an at-risk patient with a low socioeconomic status (individual factor) has to live in a high-poverty area where unhealthy dietary options and substance abuse are prevalent (community factor). High-poverty areas are densely populated and lack the availability of healthcare services (Williamson et al., 2006). The high demand for medical services in these areas is unmet because of the burdens and stress placed on the local health units. The constant strain on the health network results in at-risk populations not receiving proactive education and screening for chronic diseases such as CKD (societal factor).

(Centers for Disease Control and Prevention, 2019b)

As mentioned earlier, there are levels to kidney disease severity, and most Canadians with kidney disease have mild to moderate severity cases, which can be managed through diet, healthy lifestyle, and medication. There are more than 50,000 Canadians who have severe cases of kidney disease, such as CKD or ESRD and require renal replacement treatment (Kidney Foundation, 2020). Approximately 58% of Canadians with severe kidney disease receive dialysis (Kidney Foundation, 2020). Different dialysis modalities, such as hemodialysis, peritoneal dialysis, and home dialysis, have different eligibility criteria. Ideally, the decision to undergo dialysis modality should depend on patients’ preferences and occur within a shared decision-making context with a nephrology provider. Nephrology providers should then inform and advise patients on their treatment options to facilitate a collaborative approach with patients to reach a final dialysis decision that aligns with patient needs and preferences. However, of the patients receiving dialysis, modality rates are heavily skewed, with more than 75% receiving hemodialysis. Influences such as medical eligibility, nephrology team support, geographical location, and pre-dialysis healthcare access skew the decision of dialysis modality (Vélez‑Bermúdez et al., 2022). We can apply the social-ecological model to explain the disparities that affect the dialysis modality decision as seen in the picture below.

(Vélez‑Bermúdez et al., 2022)

Transplantation is another treatment for patients with severe cases of kidney disease and, in almost all circumstances, occurs after a patient has been placed on dialysis treatment. Kidney transplant is the most desired and cost-effective modality of renal replacement therapy for patients with ESRD (Abecassis et al., 2008). With this in mind, it is important to note that in 2020, only 11% of Canadians receiving dialysis were placed on a transplant waiting list (Kidney Foundation Canada, 2020). The University of Toledo College of Medicine wrote an article explaining that factors unrelated to medical eligibility influence a patient’s decision to elect a kidney transplant (Lombardi et al., 2021). Education, health care and access, economic stability, neighborhood and built environment, and social and community context were the social determinants of health in CKD/ESRD and the kidney transplant process (Lombardi et al., 2021).

(Lombardi et al., 2021)

Kidney Disease Patients as Vulnerable Populations

The Covid-19 pandemic drastically changed how medical services are delivered. Throughout the pandemic, the messaging was consistent, and the priority was to protect vulnerable populations from the transmission of infectious diseases. According to the American Journal of Managed Care (AJMC), vulnerable populations are defined as those at greater risk for poor health status and healthcare access, experience significant disparities in life expectancy, access to and use of healthcare services, morbidity, and mortality (American Journal of Managed Care, 2006). The CKD and ESRD group is a vulnerable population, and a study conducted in the United Kingdom suggested that CKD is a key risk factor for Covid-19 mortality (Gansevoort et al., 2020). According to the CDC, patients undergoing dialysis treatment have an increased risk of infections and have weakened immune systems, which require frequent hospitalizations and surgeries (Centers for Disease Control and Prevention, 2019a). Hospitalization is a high-risk setting for acquiring infections (Centers for Disease Control and Prevention, 2019a). When looking within the dialysis population, there are further points of vulnerability for access to renal replacement treatment in populations of low socio-economic status, such as ethnic minorities and Indigenous communities (Erdmann et al., 2020).

Future Direction of Kidney Disease Health

The first ever treatment for kidney failure was invented and carried out by Willem Kolff and Belding Scribner in 1943 (Himmelfarb et al., 2020). Kolff and Scribner pioneered the artificial kidney to provide patients with acute kidney injury an opportunity to live longer by undergoing the process of dialysis today. There have been many achievements in creating more effective kidney disease interventions since 1943. However, the future direction of healthcare concerning kidney disease is challenging. In Canada alone, the number of patients receiving dialysis has nearly doubled in the past 20 years (Canadian Institution for Health Information, 2020). Furthermore, the demand for kidney disease treatment is constantly growing, and the rate for renal replacement therapy grows by 1.1% per year (Canadian Institution for Health Information, 2020). To compound these challenges, growth in the general population in cities has led to hemodialysis capacity problems in major urban centers such as Toronto, Vancouver, Montreal, and Winnipeg. This is exacerbated by healthcare budget constraints and the high cost of real estate in these cities. It has led to a greater emphasis on home dialysis, transplantation, and conservative care and more discussion about ESKD prevention (Blake, 2020).

Additionally, some future directions for kidney disease have ongoing challenges and disparities in the present context. For example, we looked at how dialysis patients have been skewed towards hemodialysis due to individual, relationship, community, and societal determinants; However, these factors need to be improved in order to shift the paradigm toward home dialysis. In the same respect, the determinants of kidney transplants must also be improved for the CKD population in order to provide them with more favorable opportunities to receive transplants instead of permanent maintenance dialysis. Despite the challenges, exciting and innovative research is being done to provide CKD and ESRD patients with treatment other than dialysis and transplantation. Future treatments may include artificial kidneys, which are both implantable and wearable, as well as the regeneration of kidney nephrons to improve kidney function (Nagasubramanian, 2021).

(Nagasubramanian, 2021)

Ending Remarks

As a final note, kidney disease will remain a chronic disease, and the general public and the kidney disease population must be aware of determinants, trajectories, inequalities, ongoing challenges, and future directions. As I began the process of blogging, I wanted to focus my content on a health topic that is relevant to both myself and the current Canadian health context. Working in nephrology, I see the challenges and barriers to accessing kidney disease resources while this chronic disease becomes more prevalent in the general public. In addition, using the concepts I have learned in MHST 601 has allowed me to share this information in a more systematic approach that goes into greater detail about kidney disease. I have enjoyed creating this content, and I hope you have enjoyed reading and sharing it with others.

References

Abecassis, M., Bartlett, S. T., Collins, A. J., Davis, C. L., Delmonico, F. L., Friedewald, J. J., ... & Gaston, R. S. (2008). Kidney transplantation as primary therapy for end-stage renal disease: a National Kidney Foundation/Kidney Disease Outcomes Quality Initiative (NKF/KDOQI™) conference. Clinical Journal of the American Society of Nephrology, 3(2), 471-480.

American Journal of Managed Care. (2006). Vulnerable Populations: Who Are They? https://www.ajmc.com/view/nov06-2390ps348-s352

Blake, P. G. (2020). Global dialysis perspective: Canada. Kidney360, 1(2), 115.

Canadian Institution for Health Information. (2020). Trends in end-stage kidney disease in Canada, 2020 — Infographic. https://www.cihi.ca/en/trends-in-end-stage-kidney-disease-in-canada-2020-infographic

Centers for Disease Control and Prevention. (2019a). Dialysis Safety. https://www.cdc.gov/dialysis/index.html

Centers for Disease Control and Prevention. (2019b). The social-ecological model: A framework for prevention. https://www.cdc.gov/violenceprevention/about/social-ecologicalmodel.html

Chan, C. T., Collins, K., Ditschman, E. P., Koester-Wiedemann, L., Saffer, T. L., Wallace, E., & Rocco, M. V. (2020). Overcoming barriers for uptake and continued use of home dialysis: an NKF-KDOQI conference report. American Journal of Kidney Diseases, 75(6), 926-934.

Erdmann, R., Morrin, L., Harvey, R., Joya, L., Clifford, A., & Soroka, S. (2020). Canadian Senior Renal Leaders Community of Practice: Vulnerable Populations With Chronic Kidney Disease—Evidence to Inform Policy. Canadian Journal of Kidney Health and Disease, 7, 2054358120930977.

Gansevoort, R. T., & Hilbrands, L. B. (2020). CKD is a key risk factor for COVID-19 mortality. Nature Reviews Nephrology, 16(12), 705-706.

Government of Canada. (2022). Social determinants of health and health inequities. https://www.canada.ca/en/public-health/services/health-promotion/population-health/what-determines-health.html

Himmelfarb, J., Vanholder, R., Mehrotra, R., & Tonelli, M. (2020). The current and future landscape of dialysis. Nature Reviews Nephrology, 16(10), 573-585.

Kidney Foundation. (2020). Facing the facts [PDF]. https://kidney.ca/KFOC/media/images/PDFs/Facing-the-Facts-2020.pdf

Lombardi, C., Glosser, L., Knauss, H., Norwood, T., Berry, J., & Ekwenna, O. (2021). Impact of Social Determinants of Health on Chronic Kidney Disease: A Review of Disparities in Renal Transplantation: Socioeconomic Impact on Kidney Transplant. Translation: The University of Toledo Journal of Medical Sciences, 9(1).

Nagasubramanian, S. (2021). The future of the artificial kidney. Indian Journal of Urology: IJU: Journal of the Urological Society of India, 37(4), 310.

Nzerue, C. M., Demissochew, H., & Tucker, J. K. (2002). Race and kidney disease: role of social and environmental factors. Journal of the National Medical Association, 94(8 Suppl), 28S.

Vélez-Bermúdez, M., Adamowicz, J. L., Askelson, N. M., Lutgendorf, S. K., Fraer, M., & Christensen, A. J. (2022). Disparities in dialysis modality decision-making using a social-ecological lens: a qualitative approach. BMC nephrology, 23(1), 1-13.

Williamson, D. L., Stewart, M. J., Hayward, K., Letourneau, N., Makwarimba, E., Masuda, J., ... & Wilson, D. (2006). Low-income Canadians’ experiences with health-related services: implications for health care reform. Health Policy, 76(1), 106-121.

World Health Organization. (2022). WHO remains firmly committed to the principles set out in the preamble to the Constitution. https://www.who.int/about/governance/constitution