Photo by Debra Meeks (From left) Gary A. Puckrein, Ph.D.; Dercell Porter, M.D.; Carolyn Barley Britton, M.D., MS; Sandra L. Gadson, M.D.; Paul W. Crawford, M.D.; and Kamyar Kalantar-Zadeh, M.D., PhD.

African-Americans compose less than 13 percent of the U.S. population but 32 percent of all patients with end-stage renal disease (ESRD), which has led the NMA to begin work on a plan to reduce the impact of ESRD on the African-American population.

The impact of ESRD and how it can be reduced were discussed July 29 during a report by the NMA's End-Stage Renal Disease Disparities Consensus Panel.

"The major point of the report is that the prevalence of end-stage renal disease in the African-American community is extraordinary," said Carolyn Barley Britton, M.D., MS, past president of the NMA and chair of the ESRD program. "Another point of the report is the focus on prevention and what the appropriate treatment should be."

Also of interest, Dr. Britton said, were data presented by Gary A. Puckrein, Ph.D., about the locations of patients who have ESRD.

"You can actually pick out specific zip codes of high disease prevalence. In some cases, you can simply cross the street and change from a high-disease prevalence to a low-disease prevalence population," she said of the findings presented by Dr. Puckrein, president and CEO of the National Minority Quality Forum and a member of the panel.

Two "manageable-risk" diseases, diabetes and hypertension, are closely linked to ESRD, and improved early detection and prevention efforts could reduce their impact on the African-American population, Dr. Britton said. Poverty and lack of insurance coverage, though, are the obstacles in prevention.

"The necessary services are not available or are not available at an adequate level in some communities. Lack of available services is often tied to under-insurance or lack of insurance, both related to poverty and high unemployment rates because so many people obtain insurance through employers," she said, adding that lack of access to medications to control hypertension and diabetes puts patients at risk for ESRD.

Primary care providers must increase their focus on renal function, and patients need to be more aware of their renal function, in addition to cholesterol, glucose and hemoglobin A1c levels, Dr. Britton said.

"We think patients should know their eGFR (estimated glomerular filtration rate), which shows how their kidneys are functioning, so intervention can be planned before a person gets so far along in the curve that they inevitably develop end-stage renal disease," she said. "Aggressive treatment of risk conditions such as diabetes or hypertension is a must.

"The curve needs to be shifted to the left, focusing on early detection and primary prevention, rather than waiting until the kidney is failing and the focus is on dialysis."

Data presented in the report also show that African-Americans are slower than Caucasians to receive kidney transplants as a treatment, and are more likely to develop secondary hyperparathyroidism, a complication of ESRD.

"Hyperparathyroidism requires medication to control, and that medication is expensive," Dr. Britton said. "There is concern that physicians will be less likely to control the hyperparathyroidism and anemia that occurs with end-stage renal disease with appropriate medications if they cannot afford to do so as a result of bundled payments. This must be monitored very carefully to make sure patients are receiving appropriate therapy, and that resources provided to physicians are adequate for medical needs."

The ESRD consensus panel report spotlights the importance of early treatment to control hypertension and diabetes, and the need to understand why ESRD is prevalent in specific hot spots. The next step for the NMA is make sure the general public becomes aware of the data from the report.

"We are considering our ‘next steps,' such as a campaign to inform the public about renal function, similar to that for cholesterol." Dr. Britton said. "We know from other public campaigns that the messaging works and the patient is more informed. We would also like to know more about those 'hot spots' of high-disease prevalence identified by Dr. Puckrein. These might be good areas to target for an intensive public information or a community outreach campaign.

"Another initiative we are considering is to provide toolkits for our doctors about this information to increase their awareness of ESRD prevention, particularly those in primary care and internal medicine who may be taking care of the patient long before end-stage renal failure occurs."

Other panel members were Sandra L. Gadson, M.D., and Kaymar Kelantar-Zadeh, M.D., Ph.D., MPH. Dr. Gadson, a former president of the NMA and a nephrologist in Gary, Ind., presented "Salt Consumption and ESRD in African-Americans." Dr. Kelantar-Zadeh, associate professor of medicine and Pediatrics at the University of California, Los Angeles, presented "Survival Disparities of African-American Dialysis Patients."