Thirty-seven million Americans, or one in every seven people, have chronic kidney disease (CKD). Surprisingly, however, 90% of these people are not aware they have this disease.
What is CKD?
According to the National Institutes for Health (NIH), “Chronic kidney disease (CKD) means your kidneys are damaged and can’t filter blood the way they should. The disease is called “chronic” because the damage to your kidneys happens slowly over a long period of time.”[1]
A consortium of government agencies, universities, and other national organizations, collectively called the CKD Surveillance System, provides a large volume of data that can help clinicians and others understand the impact CKD has on the healthcare system. For example, more than 360 each day either start dialysis or undergo kidney transplant. For the Medicare population alone, the resulting cost totals more than $87 Billion for patients with the diagnosis of CKD, and more than $37 Billion for patients with end stage kidney disease.[2]
Risk factors for CKD include diabetes, high blood pressure, heart disease, obesity, family history of CKD, and older age.
Of these, the primary contributors are diabetes (1 in 3 patients with CKD) and hypertension (1 in 5 patients with CKD).[3] The accompanying graphs illustrate the prevalence of these two diseases in the US.[4]
Indicators of CKD
Signs and symptoms of chronic kidney disease develop over time if kidney damage progresses slowly. Loss of kidney function can cause a buildup of fluid or body waste or electrolyte problems. Depending on how severe it is, this can also cause a host of other symptoms, including:
Nausea
Vomiting
Loss of appetite
Fatigue and weakness
Sleep problems
Urinating more or less
Decreased mental sharpness
Muscle cramps
Swelling of feet and ankles
Dry, itchy skin
High blood pressure (hypertension) that's difficult to control
Shortness of breath, if fluid builds up in the lungs
Chest pain, if fluid builds up around the lining of the heart
Stages of Kidney Failure
Glomerular filtration rate (GFR) is a calculation that determines how well the blood is filtered by the kidneys. It estimates how much blood passes through filters called glomeruli each minute. According to the National Kidney Foundation, although it can vary according to age, sex, and body size, a normal GFR is generally measured as ≥ 90 ml/min/1.73 m2.[5]
CKD is indicated when GFR measures less than 60 mL/min/1.73 m2 for 3 or more months, irrespective of the cause. (Note that decreased kidney function for less than 3 months may be considered acute kidney injury.) When GFR falls <30 mL/min/1.73m2, referral to a nephrologist is recommended. Whenever possible, early referral is preferred.
The stages of CKD are defined as follows. (Note: these do not apply to children less than 2 years of age due to calculation anomalies with body surface area.)
Stage 1 – Normal GFR (≥ 90 mL/min); with some kidney damage. Diagnosis and treatment of underlying disorders, comorbid conditions. Goal is to slow of the progression of disease and complications.
Stage 2 – Mild decrease in GFR (to 60-89 mL/min). Treatment continues of underlying disorders to slow disease progression.
Stage 3 – Moderate decrease in GFR (to 30-59 mL/min); evaluation and treatment of complications. Patients may present with edema (swelling hands/feet), changes in urinary output, elevated blood pressure, bone disease, anemia. Consult with a nephrologist is usually recommended. May be subdivided into stage 3A (GFR 45-59 mL/min) and 3B (GFR 30-44 mL/min)
Stage 4 – Severe decrease in GFR (to 15-29 mL/min); preparation for dialysis/transplant. Patients likely present with edema (swelling hands/feet), changes in urinary output, elevated blood pressure, bone disease, anemia. Patients likely have metabolic abnormalities. Active discussion regarding treatment options (RRT or transplant) should initiate. Placement of an AV fistula may be considered as GFR decreases.
Stage 5 – This stage is characterized by kidney failure or End Stage Renal Disease (ESRD). GFR <15 mL/min. The patient is nearing or already requiring dialysis/transplant. Patients can be listed for transplant when GFR falls below 20 mL/min
Patients in Stages 1 and 2 are usually asymptomatic. The rate of progression is based on the underlying disease, comorbidities, treatment, and other individual factors. [6]
Treatment
When a patient reaches the end stages of CKD, the primary treatment available involves transplantation or dialysis.
Live and deceased donor transplantation: Milliman estimated that average 2020 billed costs for kidney transplant are $443k. Approximately 90,000 patients are waitlisted for kidney transplant. Median wait time is 3-5 years dependent on health, compatibility, and organ availability. In March 2021, United Network for Organ Sharing (UNOS) released a new organ allocation system expanding geographic borders for organ procurement aiming to reduce geographic disparity in distribution. At this time the US is divided into 11 regions. There are over 22,000 kidney transplants and over 900 kidney/pancreas transplants are, performed annually.
Hemodialysis: $486,410-$594,501/year (National Average)
Peritoneal dialysis: $343,969-$382,188/year (National Average)
Continuous Renal Replacement Therapy (CRRT)/Hemofiltration: $116,661-$142,584/CCRT (National Average) for less than 2 weeks (treatment only; does not include ICU or any other charges or treatments associated with hospitalization).
Medical Management is recommended as the primary objective overall with compliance and good medical care for all patients in all stages. For those in early-stage disease, disease progression can significantly be slowed by good practices.
Article by Bobbi Worth, RN, BSN, PHN, CCM, Managed Care Specialist. For more information about how this may affect your plan, please contact your Summit ReSources care specialist. The following sources were used as reference material for this article:
https://www.cdc.gov/kidneydisease/prevention-risk/CKD-common-serious-costly.html
https://www.mayoclinic.org/diseases-conditions/chronic-kidney-disease/symptoms-causes/syc-20354521
Centers for Disease Control and Prevention. Chronic Kidney Disease Surveillance System—United States. website. http://www.cdc.gov/ckd
AMS PredictDx: Chronic Kidney Disease/Chronic Renal Failure/End-Stage Renal Disease (ESRD) (mdstrat.com)