The impending burden of kidney disease

A study published in the March issue of the American Journal of Kidney Diseases projects that the number of new cases of chronic kidney disease (pre-dialysis) will grow significantly through 2030. More than half the U.S. adults aged 30 to 64 years are likely to develop CKD.

Treating kidney disease has become an expensive entitlement for the federal government. While employing various payment strategies over the last four decades to control costs, the number of patients in the ESRD Program has grown significantly. When the Nixon administration signed off on Medicare legislation establishing the program in 1972, it estimated a $35 million annual cost – and most of that would be recoup as people went back into the workforce.

That hasn’t exactly happened, and the cost of the program has mushroomed to around $16 billion a year. There is some justification for that – we suspect lawmakers in 1972 didn’t picture the more complicated patient that gets their kidneys cleansed today: those with diabetes, congestive heart failure, people arriving in the ER needing a temporary catheter and dialysis immediately. Half of the program’s costs are generated on the Part A side: hospitalizations.

Understanding CKD

The National Kidney Foundation, through its Kidney Disease Outcomes Quality Initiative, built the algorithm using a patient’s GFR to define the five stages of kidney disease, with increased progression from 1 to 4 and 5 being kidney failure. But we really don’t dedicate the resources to using it and making it valuable; patients don’t get referred to a nephrologist early enough. It’s like being on a fishing boat out in the ocean trolling for tuna with a spinning rod. The opportunity is there; the tools are not.

It’s coming for many of us

For U.S. adults aged 30 to 49, 50 to 64, and 65 years or older with no CKD at baseline, the study showed that residual lifetime incidences of CKD are 54%, 52%, and 42%, respectively. The prevalence of CKD in adults 30 years or older is projected to increase from 13.2% currently to 14.4% in 2020 and 16.7% in 2030.

The risk for CKD in this younger age group is significant, the authors note. “This compares to lifetime incidences of 12.5% for breast cancer in women, 33% to 38% for diabetes, and 90% for hypertension in middle-aged men and women.”

Among persons with CKD, stage 3a (considered moderate kidney disease) will be the most common stage at all points in time (5.5% today, 5.9% in 2020, and 8.1% in 2030) and account for the largest absolute increase in prevalence between current levels and 2030. Stages 2, 1, and 3b are the next most common. Estimates for stages 4 and 5 show relatively small changes over time. For adults 65 years or older, the prevalence of CKD is projected to decrease from 39.6% currently to 36.4% in 2020 before increasing to 37.8% in 2030. Among persons with CKD over 65 years old, stage 3a will remain the most common stage at all times (19.4% today, 18.1% in 2020, and 20.7% in 2030).

That may offer an opportunity to intercede and slow down the progression of kidney disease. We can do so much better work for patients while their kidneys are still functioning then when they cease to function.

Build the model, they will use it

Many dialysis providers have developed CKD clinics to do exactly that. There is some motivation; many of these patients will eventually need dialysis and providers like to have nephrologists make those referrals. But what about expanding the ESRD Program, the federal entitlement, so that kidney treatment becomes a continuum of care for everyone. Diagnosed with Stage 3 kidney disease at 62 with no insurance? We are going to help you. Because in the long-term, everyone benefits: you the patient, Medicare, and caregivers.

In the AJKD paper’s conclusion, the author suggests the incident and prevalent counts through 2030 can help serve as a wake-up call: we have the opportunity to intercede and deliver care to slow the progression of disease. “…Better forecasts of the future burden of CKD can help planners prepare for future health care needs, raise individuals’ awareness about the importance of keeping kidneys healthy, and stimulate research on interventions to slow the progression of CKD.”

Great ideas. If we want to catch that tuna, let’s start looking for a bigger reel. -by Mark Neumann