1. Mason, Diana J. PhD, RN, FAAN, AJN Editor-in-Chief

Article Content

Two years ago, while attending the retirement party of Delores Gumbs, past president of the Caribbean Nurses Organization, in St. Croix, U.S. Virgin Islands, I sat next to Senator Douglas Canton, chairman of that country's Committee on Health, Hospitals, and Human Services. He told me that the island's tourism, and thus its economy, had not yet recovered from the September 11, 2001, terrorist attacks. He talked of redressing the problem by opening renal dialysis units and advertising St. Croix as a vacation spot for people with end-stage renal disease. I thought this was a brilliant idea, considering the fact that there are about 4,000 dialysis centers in the United States, according to a U.S. Government Accountability Office (GAO) estimate, and that number is expected to grow.


More than 400,000 Americans have end-stage renal disease, and 300,000 undergo dialysis at the expense of Medicare. In a 2001 article in the Journal of the American Society of Nephrology, Xue and colleagues estimated that by 2010 there would be 651,330 people with end-stage renal disease, with 520,240 on dialysis, costing Medicare $28.3 billion (the United States Renal Data System projects that a stunning 2.24 million people may have end-stage renal disease by 2030). In the July 20, 2004, issue of the Annals of Internal Medicine, Hsu and colleagues dubbed end-stage renal disease "a worldwide public health crisis," noting that the rate of new cases is outpacing that of chronic kidney disease.


Sound like an investment opportunity? Perhaps, but nurses should view it as a tragedy, for two reasons.


First, those needing dialysis are not being given adequate care. The GAO reported in 2003 that a substantial number of dialysis facilities, two-thirds of which are operated by four for-profit chains, provided inadequate care for anemia. And while dialysis may lengthen lives, the quality of patients' lives is often compromised significantly as the disease progresses. In its excellent publication Clinical Practice Guidelines for Chronic Kidney Disease: Evaluation, Classification, and Stratification, the National Kidney Foundation reports that functioning and well-being worsen as kidneys decline.


Second, and more important, efforts toward preventing chronic kidney and end-stage renal disease are insufficient. Nephrology nurses know this, but hardly anyone else acknowledges it. I learned about this issue when I met with nurses involved in the National Kidney Foundation's Kidney Disease Outcome Quality Initiative (K/DOQI). They told me that the progression of chronic kidney disease could be slowed if it's diagnosed early, risk factors such as diabetes and hypertension are managed, and cardiovascular and other complications are prevented.

FIGURE. No caption a... - Click to enlarge in new windowFIGURE. No caption available.

The nurses spoke of glomerular filtration rate (GFR), which I learned about in physiology courses, when I believed that it was something only nephrology nurses worried about. But I realize that all nurses must concern themselves with GFR, if they're to identify patients at risk for chronic kidney disease. For example, in the September 23, 2004, issue of the New England Journal of Medicine, Go and colleagues reported that a reduced GFR in people with chronic kidney disease was associated with higher risk of cardiovascular events ("hospitalization for coronary disease, heart failure, stroke, or peripheral arterial disease") and death.


This month, AJN launches a six-part, bimonthly series on chronic kidney disease, supported in part by a grant from the National Kidney Foundation. Sally Burrows-Hudson, the series editor and author of the first article, was one of two nurses on the K/DOQI steering committee that provided oversight for K/DOQI's clinical practice guidelines. Formerly with Amgen, a major funder of the foundation's K/DOQI, Burrows-Hudson writes about her family's experience and provides an overview of the disease. Nurses have long claimed that prevention is elemental to nursing. If you believe that to be true, then the challenge before you is clear: do more than you've ever done before to prevent the development and progression of chronic kidney disease in your patients.