Chronic kidney disease has 5 stages defined by the ability filter blood through that organ. Normal kidney function is an estimated glomerular filtration rate (eGFR) of 100 milliliters per minute. Stage 3 CKD is defined by an eGFR of 31 to 60 milliliters per minute on a standard blood test. Stage 4 is 30 to 16 and stage 5 is 15 or less (needs dialysis) In patients with commercial insurance, patients with no CKD cost $7537 dollars per patient per year. Stage 4-5 patients cost $76,969 dollars per patient year. There is a 57% increase in cost with each advancing stage. Most of the costs are related to admissions and readmissions. The rise in cost per patient is exponential with advancing disease and the number of patients with CKD is rapidly increasing. As you can see from the graph above, patients in early CKD cost $20,000 per patient per year and in late stage 3, costs are up to roughly $24,000 per patient. Expenditures really jump in stage 4 to $40,000 per patient per year and the ability to bend the cost curve there is reduced because the key medications for optimal medical therapy (OMT) cannot be used or must be used with great caution. Costs in stage 5 exceed $100,000 per patient per year. The patterns are similar in the Medicare population.
Optimal medical therapy (OMT) should begin at an eGFR of 70 ml/min (approaching stage 3) and it should be continued down to 30 ml/min (stage 4). Beyond that the OMT medicines are more difficult to use and we should start early and work hard to keep kidney function at stage 3 or greater. Once eGFR falls below 30, nephrology referral is the best course of action. The biggest benefit to patients is OMT prior to reaching an eGFR of 30 to slow progression of CKD. Patients with CKD receiving usual care—the care that most of us receive— progress to dialysis six times as often as those receiving OMT. We owe it to our patients to make certain they receive this treatment.
In terms of slowing progression, are there evidence-based interventions beyond blood pressure control and limiting excessive dietary protein?