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Kidney Disease Costs Medicare $41 Billion a Year and Yet Often Goes Undetected
More screening is urged for all Americans age 60 and older - not just those with diabetes and hypertension
By LAURA LANDRO CONNECT
Updated Oct. 28, 2013 11:12 p.m. ET
Kidney disease is fast becoming one of the most dangerous and costly health threats in the U.S., and new guidelines recommend screening for all Americans over 60. Laura Landro and Joslin Diabetes Center Kidney Services Chief Robert Stanton discuss. Photo: Getty Images.
Doctors often don't test for it, and patients may have no symptoms until they are in crisis. Yet kidney disease is fast becoming a dangerous health threat, and one of the most costly, in the U.S.
Kidney disease is a frequent complication of diabetes and hypertension that currently costs Medicare about $41 billion a year in treatment, including dialysis. That figure is giving urgency to a push for widespread routine screening.
Chronic kidney disease, generally defined as decreased kidney function for three months or longer, is present in more than 35% of people with diabetes age 20 or above, and in more than 20% with hypertension. Kidneys perform vital functions such as filtering the blood and stimulating red blood cell production. When they don't function correctly, waste and excess fluid build up, which can be fatal. Chronic kidney disease also can lead to bone disorders, anemia and reduced quality of life.
"There is an explosion of kidney disease, but a lot of doctors are not aware of the strong association with diabetes, cardiovascular disease and hypertension," says Robert Stanton, chief of the kidney and hypertension section at the Joslin Diabetes Center, an affiliate of Harvard Medical School, in Boston. "You can slow it down and maybe stabilize it. But if you wait too long, very little can be done," Dr. Stanton says.
The National Kidney Foundation in August expanded its guidelines to recommend annual kidney-disease screening for all Americans over 60—not just those with diabetes and hypertension. Two simple and inexpensive tests of urine and blood samples, often done at an annual physical exam, are used to detect the disease and identify the stage.
Silent 'Explosion'
Kidney-disease rates are set to rise.
Kidney disease affects 26 million Americans, according to the National Kidney Foundation, and costs Medicare some $41 billion a year.
About 6 in 10 Americans will develop moderate kidney disease in their lifetimes, according to Johns Hopkins University research.
Diabetes and hypertension exacerbate kidney disease. Elevated blood sugar and pressure on blood-vessel walls can damage kidneys.
The National Kidney Foundation recommends screening all Americans over age 60—not just those with diabetes and hypertension—with simple urine and blood tests to detect the disease at annual physical exams.
The foundation updated its guidelines after Johns Hopkins University researchers projected the lifetime risk of moderate kidney disease in the U.S. is about 60%, in a study of whites and blacks, with blacks shouldering a disproportionate amount of the disease and with risk increasing with age. Currently, 26 million Americans have kidney disease, the foundation estimates. That doesn't include the incidence of kidney stones, usually a temporary problem but one that increases the risk of developing chronic kidney disease.
It often progresses slowly, but chronic kidney disease is usually irreversible once in advanced stages. That includes end-stage renal disease or kidney failure, for which dialysis or kidney transplant are the primary treatment options.
Enlarge Image
Toni Linder, right, with her brother, Jeff Linder, left, and nephew Scott Linder. Ms. Linder, who had a 2012 kidney transplant, urges others to get tested for kidney disease. Jeff Robinson
Yet even among people with severe kidney disease, fewer than half realize they have it, according to the kidney foundation. Often, primary care doctors either don't recognize the disease or they don't refer patients to a specialist, Dr. Stanton says. He cites the federally-funded U.S. Renal Data System, whose data indicates that 42% of patients newly diagnosed with end-stage renal disease hadn't seen a kidney specialist, or nephrologist, prior to beginning therapy. It is also important for patients to follow up when they get a referral, he says.
Toni Linder, 60, had diabetes, Crohn's disease and other health issues that led her to stop working a decade ago in a medical claims office in Pittsburgh. During a routine blood test in 2009, her primary care doctor told her she had signs of possible kidney disease and referred her to a nephrologist.
"I had a lot of things going on and I couldn't stand the idea of going to one more doctor so I put it off and put it off," she says.
She finally saw a nephrologist in 2009, but says she was in "denial" about her condition. In November 2011, after her second hospital admission for fluid overload, she was started on dialysis.
On a home program, she had to be hooked up to a machine that did the work of her kidneys for two-and-a-1/2 hours five days a week. Because of the strain that food compounds such as salt, potassium, protein and phosphorous can put on the kidneys, she had to avoid processed meat and cheeses, chocolate, diet soda and certain other foods. "I was completely depressed and thought, 'Oh my God, my life has come to an end,' " Ms. Linder says.
Placed on a waiting list for a transplant, Ms. Linder in June 2012 received a kidney from the young victim of a car accident and now takes multiple medications daily to avoid rejection. She volunteers for the National Kidney Foundation, and speaks to various organizations about the importance of organ donation.
"There are so many people waiting for a kidney, you don't want to be in that line," Ms. Linder says. She advises those at risk to get tested. "Do anything you have to do to control your diabetes, your high blood pressure or anything that might be a factor," she says.
Some medical groups disagree with the National Kidney Foundation on screening. The American Society of Nephrology earlier this month recommended screening for all adults, contradicting a new recommendation from the American College of Physicians against screening for adults without risk factors. The physicians college also said evidence was insufficient to evaluate harms and benefits of tests for adults with risk factors. Molly Cooke, president of the physicians group, says her group's guidelines "leave the decision to the judgment of the physician and the preference of the patient."
The most common test screens urine for an excess amount of a protein called albumin, often the first sign of kidney damage. A measure on two occasions exceeding 30 milligrams per gram is a sign of possible kidney disease.
A second test measures the chemical creatinine, which reflects how efficiently kidneys are working. It is used to estimate a patient's glomerular filtration rate, or GFR, which declines with age. A rate of less than 60 milliliters per minute may indicate kidney disease.
"Even though the disease can progress slowly, if you have impaired renal function that is very important for you and your doctor to know," says Kerry Willis, senior vice president for scientific activities at the National Kidney Foundation.
Women, because they live longer on average, are at higher risk, as is anyone with a family history of kidney disease. Patients of any weight can develop it, but obesity increases the risk. Use of over-the-counter pain killers can harm the kidneys. The body needs at least one working kidney to survive.
Judy Ann Gordon, 57 and a patient of Dr. Stanton's at Joslin, has had diabetes since she childhood and learned more than a decade ago that she had kidney disease. She takes blood pressure medications and restricts her intake of otherwise healthy foods, including bananas and leafy greens, because they contain potassium. "To maintain my quality of life, I am mindful of what I need to do to keep my kidneys healthy," she says.
Write to Laura Landro at laura.landro@wsj.com
Corrections & Amplifications
An earlier version of this article incorrectly said a Johns Hopkins University study found both blacks and whites in the U.S. were disproportionately affected by kidney disease.
http://online.wsj.com/news/articles/SB10001424052702304200804579163642368508808