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Articles of Interest

Decrease the Increase

By Glen H. Stanbaugh, Jr., MD, FACP

Several years ago a collection of concerned Texans who had dissimilar avocations but shared a similar goal, met in Austin,  hoping to find a way to help save the Texas Kidney Health Care (KHC) program from imminent legislative extinction.

Dr. Martin White, Rita Littlefield, Dr. Karon Simpson, myself and many others gathered to rescue a most needed Texas program – Texas Kidney Health Care.

I suggested a name for our endeavor, the Texas Renal Coalition (TRC). For the most of the next two decades, the coalition advocated in Austin for legislative support for low income end stage renal disease (ESRD) patients covered by KHC.  Our efforts eventually helped to maintain funding for KHC and their financially “challenged” ESRD patients/clients.  (Forty percent of total Texas ESRD patients receive KHC benefits).

The coalition eventually coalesced into a Texas-wide 501(c) (3) not-for profit. Its mission included education, advocacy, and prevention.

Three years ago the coalition, along with many ESRD experts and organizations, including the National Kidney Foundation, the American Society of Nephrology, the Centers for Disease Control and Prevention (CDC), and others realized that continued expansion of the ESRD population was outgrowing state and federal resources available to treat ESRD patients.

Transplant lists were getting longer as well as the “wait time” for a kidney transplant lengthening. In addition, ESRD patients receiving life-saving treatment with maintenance dialysis also were living longer, adding to the dialysis patient population. Dialysis centers were continuing to expand as the numbers of new ESRD patients grew.

Dr. Anton C. Schoolwerth (Senior CDC Chronic Renal Disease Consultant and Dartmouth professor of medicine) authored a review article in a CDC journal about this problem. This article documented the growing ESRD population, and methods and treatments presently available, which can ameliorate or even halt chronic kidney disease (CKD) progression to ESRD.

The TRC, supported by grants from the C.H. Foundation in Lubbock, developed and then began in January 2007 an ESRD Prevention, Multimedia, Educational Pilot focused on high-risk patients, their families, their primary care physicians, the general population, and patients with hypertension and diabetes.

This TRC initiative started in late 2006 with lectures/talks I made to medical students, residents, and Texas Medical Association members. This was followed by 30-second TV public service announcements in the “pilot” area (two or three times a day from January 2007 to present).

Recently, this TRC initiative has been strengthened and continued by the Texas Department of State Health Services (DSHS) financed by legislative appropriation of $500,000/year (times two years), thanks to the Texas Legislature and especially Sen. Robert Duncan and his staff. The goal remains prevention of ESRD. The Lubbock pilot referred to as “Decrease the Increase” of new cases of ESRD and the identical DSHS program is called “Love Your Kidneys”.

Our goal is to lower the increase of new ESRD cases by 10 percent or more each year, thus preventing or slowing the progression of ESRD by education. Due to the usual slow progression of many types of CKD, positive results may take two to three years to be obvious.

However, TRC and the DSHS Chronic Kidney Disease program will require further significant future funding to make our ESRD prevention program available Texas-wide. This year DSHS/TRC has funds to take “Love Your Kidneys” to Lubbock, the Rio Grande, and Harlingen.) TV, radio, and print media are expensive in Texas’ larger markets; however, they are accessible if further funding is available.

Assuming this initiative produces a “Decrease in the Increase,” it likely will stand alone as a government program that will save lives, while saving money!

Additionally, yet quite important – extra benefits occur making the target audience more aware of the importance of strict  blood pressure and diabetes control, and thereby  reducing potentially fatal co-morbidities and conditions affecting countless millions afflicted with hypertension and diabetes mellitus.

The Public Health Response

By Anton C Schoolwerth, MD, MSHA. Dartmouth. Hitchcock Medical Center, Lebanon, NH


Studies have shown that late detection and treatment of CKD contributes to high morbidity and mortality rates with associated high costs. CKD has been identified as a significant public health problem, with substantial economic impact, but no national public health program, combining the resources of the federal and state governments, currently exists. On the national level, the Centers for Disease Control and Prevention (CDC) are only now beginning to organize a public health kidney program. No state has mounted an organized program on CKD. Such a program could assist in identifying members of high risk populations, develop culturally appropriate community-based approaches for improving CKD prevention and control, and increase the number of persons with CKD who are detected in a timely fashion.  Such a program would also educate health professionals and people with kidney disease about CKD and thus reduce variation in practice among health care providers who care for patients with CKD.

The Texas Renal Coalition (TRC) supports the urgent development and has implemented an educational multi-media campaign to increase awareness, early diagnosis and treatment of CKD in order to decrease the rate of progression of the disease and the number of patients reaching ESRD, to decrease complication rates, especially of cardiovascular disease, and to reduce mortality. The multi-media campaign will target individuals at high risk for CKD, their family members, primary care physicians and the general public. This prevention initiative developed by TRC is called “Decrease the Increase” of new cases of ESRD. A pilot project is presently underway in Lubbock, Texas and surrounding communities. This TRC campaign initiative has the following goals: 1) Gradually attain a 50% decrease in new cases of ESRD/year; 2) Preserve or improve kidney function in patients who have CKD; 3) Maintain quality of life; 4) Preserve health care resources and tax dollars; and 5) Save lives.

Recommendation:  Provide $4 million to fund the Texas-wide “Decrease the Increase” Campaign. This campaign will entail a multi-media approach designed to increase awareness, early diagnosis and treatment of chronic kidney disease and its consequences.  Specifically, the campaign will emphasize the following: 1) Individuals with diabetes mellitus, hypertension and a family history of kidney disease, diabetes or hypertension are at increased risk for CKD, especially if they are members of minorities or are elderly; 2) Strict control of high blood pressure and tight blood sugar control can reduce the rate of disease progression; 3) Treatment of obesity and hyperlipidemia (elevated cholesterol) may reduce disease progression and its consequences; 4) The use of angiotensin converting enzyme inhibitors (ACEIs) and angiotensin receptor blockers (ARBs) play an important  role in stabilizing kidney function; 5) Appropriate referral to a kidney doctor is important. 6) Avoidance of drugs that are toxic to the kidneys is critical.

This campaign along with the National Kidney Foundation’s “Kidney Early Evaluation Program (KEEP)” should lead to enhanced identification of patients with CKD and the initiation of early, effective therapy. In so doing, this campaign is expected to be cost neutral, in that the funds invested early will be realized in a reduction of individuals reaching ESRD. A conservative estimate is that after the first year a 10% decrease and by the fifth year a 50% decrease in new cases of ESRD will be achieved. The TRC believes strongly that an educated patient and an informed physician and staff employing these methods are the best hopes at present for limiting the “increase” of new cases of ESRD.


*KHC only partially covers some ESRD-related medications, transportation to and from dialysis and transplant centers (13 cents/mile and 4 drugs/month).