Under-detected and Underdiagnosed: Optimizing Kidney Care

Chronic kidney disease (CKD) is an often-underdiagnosed condition that occurs when the kidneys have been damaged and therefore have reduced function for at least 3 months.

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Chronic kidney disease (CKD) is an often-underdiagnosed condition that occurs when the kidneys have been damaged and therefore have reduced function for at least 3 months.1 CKD affects approximately 37 million people in the United States (with as many as 90% unaware that they have the disease) and is a common comorbidity for those with diabetes and/or high blood pressure, two patient populations for which many employers have deployed targeted solutions.

CKD is associated with high health care costs, premature death, high risk for cardiovascular events and high risk for hospitalizations even before patients progress to end-stage renal disease (ESRD).2 ESRD refers to the point when a person needs dialysis or a transplant to survive. While Medicare becomes the primary payer for dialysis in ESRD patients after 33 months, there are opportunities to positively impact care for these patients earlier in their treatment journey. Kidney transplants are the ideal ESRD treatment because they have a higher likelihood of long-term quality of life improvement for recipients.3 However, due to organ shortages, many remain on dialysis for years as they strive to manage their condition.

In addition to the high health care costs, patients with late-stage CKD (stages 4 or later; see below for more information) also face significant challenges maintaining workplace productivity and overall quality of life. The productivity of employees with family members suffering from late-stage CKD can also be impacted as they serve as caregivers for their loved ones. In-center dialysis tends to be time-consuming, while home peritoneal dialysis requires the placement of an abdominal catheter by the patient, which some may not be able to complete themselves.

Many patients start dialysis before ever seeing a nephrologist, indicating a lack of systematic CKD management throughout the U.S. health care ecosystem. There has also been an increased focus on improving kidney care at the federal level. Multiple opportunities exist for employers to better cater to their employees living with this disease while also having a positive impact on their health care spend.

What Is Chronic Kidney Disease?

The term “chronic kidney disease” refers to lasting damage to the kidneys that tends to worsen over time. The five stages of kidney disease are based on the estimated glomerular filtration rate (eGFR), a quantitative measure of how well the kidneys are filtering waste from the blood.4 While early-stage kidney disease is usually asymptomatic, as the disease progresses to end stage, symptoms can include fatigue; swollen ankles, feet or hands; shortness of breath; as well as blood in the urine.5 Kidney damage can cause waste to build up in the body as well as other health problems such as heart disease and strokes. Major risk factors for kidney disease include diabetes, high blood pressure and family history of kidney failure.4 Kidney function can be assessed using either blood tests that can be ordered by primary care providers (PCPs) or urinalysis, used to look for proteins and to further risk stratify.1

Kidney failure, or ESRD, refers to CKD stage 5 and is the point at which the kidneys may stop functioning altogether.6 Currently, the kidney care ecosystem is focused on treating ESRD patients “crashing” into the hospital in acute renal failure, when the kidneys stop working suddenly and patients experience abdominal pain, back pain, fever, rash and vomiting, among other symptoms.  To facilitate timely diagnosis, basic kidney function levels should be routinely checked at PCP visits, especially for high-risk populations. Routine CKD screening can be considered part of the ongoing care and disease management for those with diabetes or high blood pressure.1

Coverage and Reimbursement Landscape

In July 2019, the Administration released an Executive Order mandating innovation in kidney care, with a specific focus on addressing awareness, prevention and treatment of the disease.  Emerging payment models outlined in this Executive Order will apply to Medicare beneficiaries with late-stage CKD and ESRD, as well as those who receive kidney transplants.

Below are the Executive Order’s key goals and objectives:

  • Increasing access to available organs for kidney transplants;
  • Expanding reimbursement for living donors;
  • Emphasizing better coordination of care for beneficiaries;
  • Prolonging the amount of time before a patient’s kidneys fail; and
  • Achieving prepared starts on dialysis when necessary.

Depression remission is also a key priority given the higher risk inherent in this population. These models will also feature payment adjustments to incentivize nephrologists and dialysis centers to better cater to patient preference for site of care (at-home dialysis versus in-center).  Employers can adopt the above-mentioned aspects of kidney care with their partners in primary care.

ESRD is unique in that Medicare becomes the primary payer for ESRD patients 33 months after a patient’s diagnosis. Therefore, ensuring a smooth transition of care for employees from commercial plans to Medicare is important to promoting positive health outcomes long term. This can be achieved through case management as well as the deployment of wellness and navigation platforms to effectively communicate the transition of benefits and implications for the employee and their family. Medicare coverage for ESRD patients will end if they no longer need dialysis and/or the patient has a successful kidney transplant (defined as patients going 36 months after surgery without organ rejection), further demonstrating the importance of efficient coordination between care teams in the event that an employee reenters commercial coverage.7

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CKD/ESRD Treatment and Therapies

Depending on the underlying cause, some types of kidney disease can be treated. Often, though, CKD has no cure. Treatment usually consists of measures to help control signs and symptoms, reduce complications and slow progression of the disease.8Sustained high blood pressure as well as diabetes are known to damage the kidneys, making it critical to slow the progression of these chronic conditions.9 Other kidney disease complications can include heightened cholesterol levels, anemia, weak bones and swelling of the limbs. As part of a comprehensive treatment protocol, patients may also be placed on a lower protein diet to minimize waste products in the blood.

Once a patient reaches the point at which their kidneys can no longer keep up with waste and fluid clearance on their own, they are considered to have ESRD. Kidney transplants or dialysis are the only available treatments for this patient population.

1 | Kidney Transplants: While kidney transplants are not a cure for kidney disease, transplanted kidneys are more effective at filtering wastes and keeping patients healthy compared to dialysis.3 Kidney transplants are unique as the organ can come from a living donor: in fact, people who receive a kidney from a living donor usually have fewer complications than do those who receive a kidney from a deceased donor.10 Patients also must be deemed suitable candidates for transplant surgery; while each transplant center sets its own guidelines, common factors affecting candidacy include active infections, smoking/substance abuse, having serious heart disease and/or obesity.11


2 | Dialysis: Dialysis artificially removes waste products and excess fluid from the blood when the kidneys stop working properly. Hemodialysis involves a machine that filters waste and excess fluid from the blood and can take place either at home or at dialysis centers and/or other health care facilities. Peritoneal dialysis features a catheter being inserted into the abdomen with a dialysis solution that absorbs waste and excess fluid. After a period of time, this solution drains from the body, taking the waste products with it.8 Like hemodialysis, peritoneal dialysis can take place at home or in centers and/or other health care facilities.

Although home dialysis is not suitable for every case, it can be more convenient and easier on patients’ bodies. Home dialysis is also less expensive overall; once patients are properly trained, it does not require nursing assistance.12 However, only 10% of total dialysis patients in the U.S. use at-home treatments, although evidence shows doing so tends to yield a much better patient experience for the following reasons:

  • Timing: in-center dialysis typically takes 3-4 hours, not including travel. Home dialysis, whether hemodialysis or peritoneal dialysis, happens at home and is a less time-consuming process, enabling patients to be more mobile.
  • Frequency: Trials have shown that more frequent dialysis is more effective than in-center dialysis three times a week. With home dialysis, patients can conduct the procedure more often and around their schedule, leading to better outcomes.

Nationwide shortages of dialysis fluids and other supplies are possible as an unforeseen consequence of the global pandemic caused by the novel coronavirus: approximately 3% to 9% of patients with confirmed COVID-19 develop an acute kidney injury (AKI), with many requiring dialysis treatments.13 Regardless of age, people with AKI are at increased risk of developing serious complications from COVID-19.

3 | Conservative/Palliative Care: For those who choose not to undergo dialysis or a kidney transplant, conservative measures can be used to manage their condition. However, life expectancy typically drops to months at best once the kidneys have failed completely.

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Opportunities for Employers

Consider including kidney transplants in Center of Excellence (COE) arrangements: Although there is a significant shortage of available kidneys for transplant in the U.S., with kidney transplant wait times of 3-5 years depending on geographic location, employers can ensure their employees go to the highest quality providers by implementing COEs. In addition to providing access to high-volume, experienced nephrologists and surgeons, kidney transplant COEs use cutting edge technologies to cater to a wider array of candidates who might otherwise be rejected as organ recipients. These centers also often have donor identification programs such as paired and altruistic donations to provide more ways for people to receive living donor kidneys.10

Bolster decision support programs: Risk stratification is key to implementing a systematic early detection program, where all patients receive the right care at the right time in their disease course and high-risk patients receive care as soon as possible. This is achieved by targeting patients with both diagnosed and misdiagnosed/undiagnosed kidney disease and then using lab results to enroll those at high risk in further education programs. For those already experiencing decreased kidney function, it is best to explore transplant as early as possible in their disease course and before they need to start dialysis.

Implement early detection programs to promote CKD prevention: The vast majority of people living with CKD in the United States do so unknowingly. Solutions focused on early detection have entered the market and can assist in flagging these individuals for targeted education and prevention initiatives.

Incorporate CKD screening into existing diabetes/blood pressure management programs: Routine CKD screening can be considered ongoing care and disease management for those with diabetes or high blood pressure, since uncontrolled high blood sugar can cause damage to the kidneys, and hypertension can either lead to kidney damage or even be caused by it. Ensure that chronic disease management programs include kidney function screenings and CKD education materials to improve the chances of early detection.

Provide caregiver supports for employees with family members managing CKD/ESRD: Hemodialysis routinely requires 3- to 5-hour sessions in a dialysis facility several times a week as a treatment for late- stage CKD. Decisions on whether to pursue finding a living donor among family members and friends can be difficult to manage as well. Whether a spouse, parent or other family member opts for dialysis, transplant or is focused on other complications related to their kidney disease, companies can assist their employees in managing their daily tasks through comprehensive leave and telework programs as well as other supports.

Conclusion

CKD patient populations often intersects those with diabetes and high blood pressure, a significant swath of many employers’ covered lives. As with other chronic conditions, early interventions and lifestyle changes are key to delaying disease progression. Ensuring that employees have the information and tools necessary to manage their disease can result in reduced downstream costs for the employer  and a higher quality of life for employees and their families.

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