The cost of treating kidney failure in the United States through dialysis and transplant increased from $16.74 billion in 1998 to $42.5 billion in 2009. For those same years Medicare paid $12.04 billion and $29.03 billion of the total.
Source: National Institutes of Health
For this story, Springfield News-Sun Staff Writer Tom Stafford interviewed local kidney failure and kidney transplant patients and nephrologists; reveiwed transplant and treatment statistics from the Centers for Disease Control and the National Kidney Foundation; dug into Medicare statistics, and interviewed one of the nation’s foremost experts on kidney disease at the National Institutes of Health.
Heather Dwyer rented a table at a festival in Urbana this summer and printed 500 fliers and 1,000 business cards to advertise that she’s a person with Type B blood looking on her own for a kidney donor to match.
If she gets a transplanted kidney, the woman whose heart stopped three times last year in the operating room won’t be the only one to benefit.
So will the public health insurance program Medicare, which spent $29 billion in 2009 on kidney care.
Danielle Estep, a spokeswoman for the National Kidney Foundation Serving Ohio and Kentucky, said that, on average, it costs $71,000 a year to treat a dialysis patient and $17,000 for a transplant recipient.
Even taking into account the cost of the transplant operation, Medicare estimates the financial break-even point at three years, shorter than most energy saving light bulbs.
And because the kidney is more efficient in filtering blood and performing other functions than a machine, patient outcomes are much better, too.
After Dwyer’s heart stopped the third time and she emerged from a coma, doctors gave up on trying to prepare her for hemodialysis, the traditional treatment in which blood purified by an artificial filter outside the body.
The 39-year-old divorced mother of two now undergoes nightly peritoneal dialysis in her Springfield home, a process that draws toxins from the blood through the small capillaries of the membrane lining the abdominal cavity.
The filtering is done with by a machine Medicare provides, part of the substantial sum it pays out to keep people with kidney failure alive.
Of the $42.5 billion spent nationwide in 2009 to support 400,000 dialysis patients and 172,000 transplant recipients, Medicare paid 68 percent of that bill.
As large as it seems, that number represented good news to those who follow the trends.
Leading up to the year 2000, kidney failure “grew faster than people had thought possible,” said Paul Eggers, director of the Kidney and Urological Branch of the National Institute of Diabetes and Digestive and Kidney Disease, one of the National Institutes of Health.
From 1980-2009, rates of kidney failure, also called End Stage Renal Disease or ESRD, increased 600 percent, from 290 cases per million to 1,738 cases per million. The overall cost of dialysis and transplants nearly doubled from 1998 ($16.74 billion) to 2005 ($31.99 billion).
Getting in line
Dwyer tried to find a rare Type B donor on her own.
The flier she produced explained Dwyer’s ESRD is from polycystic kidney disease, a genetic condition that’s the fourth leading cause of kidney failure. Still trying to find a kidney donor match on her own, Dwyer also is preparing to get on the kidney transplant waiting lists at the University of Cincinnati and the Wexner Medical Center at Ohio State University.
Her step-father is considering donating a kidney on her behalf, something that would qualify Dwyer for so-called paired donation. People who have friends and relatives willing to donate a kidney but are not good matches can contact others in the same situation.
Willing donors and paired patients begin to line up, allowing transplants to proceed. Last year, the Wexner Medical Center at Ohio State University helped to manage a six-donor exchange. These so-called chains are also augmented by a Never Ending Altruistic Donor network of those willing to donate a kidney to any recipient who is a match.
The National Kidney and Urologic Diseases Information Clearinghouse has a statistical description of how much better patients fare with transplants than dialysis: “At 85.5 percent, the five-year survival rate for transplant patients is more than twice the 35.8 percent survival rate for dialysis patients.”
Springfielder Laura Hildebrand, who donated a kidney to her husband, describes the difference a transplant makes more plainly.
When Jim Hildebrand, 53, was on dialysis after the chemotherapy that cured his stomach cancer ruined his kidneys, “he looked like death warmed over,” his wife said.
Since his March 20 transplant, he looks fully alive.
Mrs. Hildebrand, 54, had to have weight loss surgery before she could qualify to donate her kidney, but said she “never had any doubt” that hers would be a match for her husband.
The Centers for Disease Control report that brothers and sisters provide the most matches from living donors at 28.2 percent. Next come children at 16.4 percent. But spouses come in at 10.26 percent. Non-relatives make up 22.26 percent or more than 1 in 5 donors.
(Most people can function well with a single kidney, and the screening process helps to assure only those with healthy kidney function surrender a kidney.)
A transplant from a living donor now makes up about 30 percent of transplants annually. The remaining 70 percent are from deceased donors. Although the survival rates of people with transplants from living donors is higher (97 percent vs. 93 percent at one year and 83 percent vs. 75 percent at five years), all transplant recipients fare better than those on dialysis.
On the other hand, kidney specialists say dialysis offers to kidney patients what people with end stage heart disease, liver disease and other organ diseases don’t have: a way to stay alive.
The local picture
Ohio averages about 1,000 kidney transplants a year, 25 percent from living donors.
In Springfield and Clark County, “We average about 20 transplants a year” said Dr. George Varghese, a nephrologist. One of the longest living recipients is a woman who received a kidney from a deceased donor 30 years ago.
Varghese came to Springfield in the early 1980s and established a practice that has grown to four doctors. Now, he said, he and his partners “would rather work with internists or family doctors” to lessen the chance that those with kidney disease ever need a specialist’s help.
How successfully Varghese and others are will have implications for the future those with kidney disease and the financial health of Medicare and private insurance programs that help pay for kidney care.
The good news of the past 10 years in ESRD treatment has been that the expected wave of increase of patients with kidney failure has not come. Varghese said there has been a “big initiative” to control patients’ blood sugar and blood pressure levels, the latter through the use of drugs called ACE Inhibitors.
One demographic factor expected to challenge that success is the nation’s aging population. According to the National Kidney Foundation, one-fifth of ESRD patients are 75 and older, more than a third are 65 and older and 86 percent are 45 and older.
Eggers said those connected with kidney disease are watching two other demographic factors. The first is the increase the portion of the U.S. population of groups that suffer higher rates of kidney disease.
While 277 whites per million have kidney failure, the rate is 976 per million for African Americans, who as a result while making up 13.1 percent of the population make up 31 percent or nearly one third of dialysis patients. The growing Hispanic population also suffers ESRD one and a half time the rate of non-Hispanic whites.
The second factor is the increased incidence of diabetes overall.
Forty four percent of those afflicted with kidney failure suffer from diabetes, and incidence of kidney trouble “is on the order of 10 times what it is if you don’t have diabetes,” said Eggers.
A 2010 study by the Centers for Disease Control and Prevention said “the prevalence of total diabetes (diagnosed and undiagnosed) in the United States will increase from its current level of about 1 in 10 adults to between 1 in 5 and 1 in 3 adults.”
Ironically, that expected increase is in part due to the successful management of diabetes: As the disease is better managed, more live with it longer, increasing the proportion of people with diabetes.
But doctors are worried that these two causes of kidney failure may skitter out of control as rates of obesity rise and, with them, the incidence of both diabetes and high blood pressure.
The damage high blood pressure does before detection is one reason the National Kidney Foundation has established its Kidney Early Evaluation Program or KEEP.
Startlingly, 40 percent of people who go on dialysis don’t know they have a kidney problem until the week before dialysis begins.
Varghese said many people who have high blood pressure are unaware of it until damage has been done as well. Complicating matters, some don’t feel any symptoms until after they begin drug therapy, which can make it difficult for doctors to keep patients on their medications.
Dr. Yamini Teegala, assistant medical director at Springfield’s Rocking Horse Center, said that diabetes presents similar challenges.
Although she said has patients in their 70s and 80s who “are doing excellent” by watching their blood sugar levels, “we (also) have patients that lose both their limbs” because of the damage done to their blood vessels from high blood sugar and “still don’t understand.”
She describes the the potential consequences of rising obesity as being “beyond comprehension.”
Dr. Alok Agrawal, a Wilmington nephrologist who serves on the board of directors of the National Kidney Foundation Serving Ohio and Kentucky, says that 80 percent of Type II diabetes is attributable to obesity and 70 percent of hypertension. And that’s not all.
“The same thing is causing heart disease, strokes. It is causing cancers. Five of the cancers are clearly known to be from obesity,” which he said in all is tied to “about 25 conditions.”
To that end, he helped to create a health education initiative called STOP and CHECK: Stop The Obesity Pandemic and Counter High blood pressure, Elevated blood sugar, Cardiovascular and Kidney disease.
“If we control obesity, we will prevent hypertension and diabetes or be in better control,” he said. “The kidney disease will decrease, the amount of money spent will decrease, the adverse effects of medications decrease, and the cost goes down.”
Giving the billions of dollars riding on the proposition, those ifs are big enough to boost the blood pressures of those worrying over the problem.
About the Author