Chronic kidney disease (CKD) is a common disease that creates a subset of patients with complex, intertwining medical conditions, high morbidity and mortality, high health care expenditures and a low quality of life. Despite our various specialties, we all take care of these patients. CKD presents unique challenges to every clinical scenario.

According to the Centers for Disease Control and Prevention, 15% of adults have CKD. In Arkansas, more than 400,000 people have some degree of kidney failure. On average, CKD patients have more than six symptoms across different organ systems and take more than eight medications.

Low awareness of CKD symptoms, disease course and outcomes cause lower support for these patients. In a large study of CKD patients, stages 3-5, physician documentation was 14.4%. In a survey of high-risk, urban, African American adults, less than 3% named kidney disease as an important health problem, compared with 61% and 55% naming hypertension and diabetes.  Even among patients with stages 4-5 CKD, less than half were aware of
their disease.

Treatment costs for CKD and end-stage renal disease (ESRD) are some of Medicare’s highest costs. Medicare spending for beneficiaries younger than age 65 with CKD exceeded $8 billion in 2014, representing 44% of all health care spending for this age group. Medicare spent $50 billion on CKD patients over age 65; almost 21% of total health care spending for this age cohort.

The most common causes of CKD are diabetes and hypertension. Other risk factors include: African American decent, older age, low birth weight, family history of CKD, smoking, obesity, analgesic medications, exposure to heavy metals, excessive alcohol consumption, acute kidney injury, cardiovascular disease, hyperlipidemia, metabolic syndrome, hepatitis C virus, HIV infection and malignancies.

Staging CKD

CKD is defined by the presence of kidney damage or decreased kidney function for at least three months based on documentation or inference.  Kidney damage is defined by albuminuria >30mg/24 hours, urine sediment abnormalities, electrolyte abnormalities due to tubular disorders, abnormalities shown on renal histology and structural abnormalities shown on imaging. Kidney transplant also qualifies as CKD.

Stage classification is done from estimated glomerular filtration rate (eGFR):

Stage 1: eGFR >90 mL/min/1.73m2 (must meet non-eGFR criterion for CKD)

Stage 2: eGFR 60-89 mL/min/1.73m2 (must meet non-eGFR criterion)

Stage 3: eGFR 30-59 mL/min/1.73m2

Stage 4: eGFR 15-29 mL/min/1.73m2

Stage 5: eGFR <15 mL/min/1.73m2

ESRD or Stage 5D: permanent renal failure requiring chronic dialysis to maintain life

Mortality and morbidity

Mortality rates are higher for Medicare patients with CKD (117.9/1000) than for those without CKD (47.5/1000). Rates of re-hospitalization are higher (22.3%) than for patients without CKD (15.8%). Re-hospitalization rates increase with CKD severity. Coronary artery disease is common in CKD patients. The risk of coronary death or nonfatal MI in adults, with CKD stage 1 to 4 and over the age of 50, is greater than 10% in a 10-year period. The dialysis population has an adjusted one-year survival rate of 76%; dropping to 36% at five years. Patients with stage 4-5 CKD report a poor quality of life; 61% of patients regret their decision to start dialysis.

Controlling CKD
progression

First, identify high-risk patients. Then attempt to reduce the modifiable risk factors such as smoking or obesity, control diabetes and hypertension and use antiproteinuric medications. Nephrology referral is critical. Referring patients to dieticians and CKD education programs also helps slow progression.

If unable to control progression,
patients must understand their remaining options: dialysis, kidney transplant and palliative care.

Dialysis is provided by:

  • In-Center Hemodialysis (IHD), the most common and expensive, involves three- to four-hour treatments, three times weekly. 
  • Home Dialysis (HOD) provides patient autonomy, better clinical outcomes, diet liberalization, ability to continue employment, the convenience of home, patient satisfaction and saves about $19,000 per patient, per year. It most closely mimics the body’s natural renal clearance, with more frequent and longer dialysis.
  • HOD can be administered via peritoneal dialysis (PD), using the peritoneal membrane as a filter; no blood or needles are involved.
  • Home hemodialysis (HHD) usually provides shorter but more frequent dialysis using patient-friendly machines.

Kidney transplantation can be performed with a living or deceased donor. Outside of patients with cirrhosis, most individuals with eGFRs below 20 mL/min/1.73m2 are eligible for transplantation. Most transplants occur after beginning dialysis, but it can occur before the patient needs dialysis. Early referral for transplant evaluation is important.

Palliative care can be discussed when setting treatment goals. For some patients, the burden of chronic disease or frequent hospitalizations prevents an acceptable quality of life. Renal failure compounds this situation and dialysis does not increase quality of life or longevity for some patients.

Improve CKD-patient care:

1. In primary care, recognize high-risk patients, assess GFR using urine dipstick for proteinuria/albuminuria and have the lab calculate eGFR

2. Involve nephrology care as soon as appropriate

3. Optimize care using CKD management guidelines, produced and freely accessible from KDIGO (kdigo.org/guidelines/)

4. Know the options for CKD control and ESRD management s

The authors practice in the Div. of Nephrology, Dept. of Internal Medicine, UAMS.
Complete article originally published Sep. 2018, Journal of the Ark. Medical Society.