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                  Kidney Disease: The Basics

                  Kidney Patients and Coronavirus

                  People with kidney disease, transplant recipients, and people with other severe chronic medical conditions are at higher risk for developing serious complications from COVID-19, also known as coronavirus.

                  People on dialysis can have weaker immune systems, making it harder to fight infections. However, it is important to know that kidney patients need to continue with their regularly scheduled dialysis treatments, whether they take place in a dialysis center or at home, and to take necessary precautions as recommended by their healthcare team.

                  People with a kidney transplant need to take anti-rejection medicines (also known as immunosuppressive medicines). These medicines work by keeping the immune system less active, which can make it harder to fight infections. It is important to keep taking these medicines. It is also important to wash hands, maintain good hygiene and follow the recommendations from their healthcare team.

                  Research on COVID-19 and kidney disease indicates the following:

                  • Early data from Wuhan and New York City show that an estimated 14–30% of COVID-19 patients lose kidney function, with many ICU patients requiring dialysis.
                  • In hot spots within the United States such as New York City, early estimates indicate that 20-40% of COVID-19 ICU patients develop kidney failure and need emergency dialysis.
                  • New data from New York City show that the mortality rate for kidney transplant patients from COVID-19 is as high as a staggering 30%.

                  Health Disparities, CKD, and the COVID-19 Crisis
                  Disparities in overall health, healthcare, and healthcare outcomes for racial and ethnic minorities have long been an issue in the U.S.vi The landmark 1985 landmark HHS Heckler Report documented higher mortality rates for minorities. Despite some progress, in 2017, life expectancy for white females was 81.0 years compared to 78.1 years for black females and 76.1 to 71.5 years for males, respectively.

                  In addition to health disparities, some racial and ethnic minority groups are also at increased risk for both kidney disease and COVID-19 and are, therefore, especially vulnerable.

                  Kidney health disparities

                  These disparities are related to systemic, clinical, social, patient, and clinician factors. Overall, minority groups are at increased risk of progressing from developing CKD and experiencing more rapid progression of CKD to end-stage kidney disease (ESKD). Non-Hispanic African-American and Hispanic people experience more rapid decline of kidney function than non-Hispanic Whites. Lastly, African Americans and Hispanics are also less likely to be treated with kidney transplant than Whites. (See section below: “Populations: Who is at Risk for CKD?”)

                  COVID-19 disparities
                  Racial and ethnic minority groups have been hit disproportionately hard by the COVID-19 pandemic. For instance, higher COVID-19 mortality in African-American populations has been reported in New Orleans, Chicago, Milwaukee, and Detroit. 70% of the people who have died from coronavirus in Louisiana are African-American, who make up 32% of the population. African Americans are 14% of the population in Michigan, but represent 40% of COVID-19 deaths. And according to data released by the New York City Department of Health on May 6, 2020, African Americans and Hispanics represent two-thirds of COVID-19 hospitalizations and deaths in the city, while comprising just over half of the city’s population.

                  The reasons for these disparities include: lack of healthcare access; high percentages of minorities working in “essential” and low-wage jobs with high public exposure; population density in low-income areas making social distancing difficult; high percentages of comorbid conditions in minority populations; lack of health insurance; among other factors. Unemployment, food insecurity, and unstable or substandard housing conditions have also been implicated as contributing factors.

                  What can be done

                  *Extra public health precautions like social distancing and mask wearing, priority virus testing, food safety, patient engagement in care, etc.

                  *Targeted, culturally appropriate education on social distancing, masks, and hand washing

                  *Mandated personal protection for essential service workers, e.g., custodial and clerical staff, mass

                  transit operators, sanitation workers, food service workers; as well as testing for themselves and their families.

                  *Financial and insurance protection for uninsured workers

                  *Targeted testing in dense housing and other environments

                  *Testing at walk-in facilities for people who don’t have cars

                  *Support of local and state task forces to correct racial/ethnic COVID-19 disparities. Louisiana and Michigan recently formed tasks force to tackle racial COVID-19 disparities. Other states and regions could as well.

                  *Structuring targeted vaccination programs for when a COVID vaccine is developed

                  *Gathering more robust clinical data on COVID and these disparities

                  For complete, up-to-the minute information on kidney disease and COVID-19, go to:

                  http://www.forgedfromreverie.com/coronavirus/kidney-disease-covid-19

                  Chronic kidney disease, or CKD, causes more deaths than breast cancer or prostate cancer. It is the under-recognized public health crisis. It affects an estimated 37 million people in the U.S. (15% of the adult population; more than 1 in 7 adults) and approximately 90% of those with CKD don’t even know they have it. 1 in 3 American adults (approximately 80 million people) is at risk for CKD. CKD is more common in women (15%) than men (12%). CKD is the 9th leading cause of death in the U.S.1 In 2017, over 500,000 patients received dialysis treatment, and over 200,000 lived with a kidney transplant. The National Kidney Foundation (NKF) has led the way in rallying action on this problem.

                  What is Chronic Kidney Disease?

                  Chronic kidney disease (CKD) means your kidneys are damaged and losing their ability to keep you healthy. In the early stages of the disease, most people do not have symptoms. But as CKD gets worse, wastes can build up in your blood and make you feel sick. You may develop other problems like high blood pressure, anemia, weak bones, poor nutritional health, and nerve damage. Because kidneys are vital to so many of the body’s functions, CKD also increases your risk of having heart and blood vessel disease. While these problems may happen slowly and without symptoms, they can lead to kidney failure, which can appear without warning. Once kidneys fail, dialysis or a kidney transplant is needed to stay alive.

                  What Causes CKD?

                  The two main causes of CKD are diabetes and high blood pressure. These two conditions were the primary diagnosis in 75% of kidney failure cases between 2015-2017: 47% of new ESKD patients had a primary diagnosis of diabetes, the leading cause of ESKD, while 29% of new ESKD patients had a primary diagnosis of hypertension, the second leading cause of ESKD. Other conditions that can lead to ESKD are: glomerulonephritis (diseases that damage the kidney's filtering units), which are the third most common type of CKD; inherited diseases, such as polycystic kidney disease; malformations at birth that occur as a fetus develops; lupus and other immune diseases; obstructions such as kidney stones or an enlarged prostate; and repeated urinary tract infections.

                  People with CKD are at greater risk for cardiovascular disease and death at all stages of CKD. CKD and heart disease are linked and have common risk factors, such as diabetes and hypertension. Each condition can lead to or worsen the other.

                  How Big is This Problem? How Many Lives Are Affected?

                  An estimated 37 million American adults (1 in 7 adults; 15% of adults) are estimated to have CKD, but most don’t know they have it. In fact, about 1 in 2 people with very low kidney function (not on dialysis) don’t know they have CKD. Approximately 1 in 3 adults with diabetes and 1 in 5 adults with high blood pressure may have CKD. In 2017, 746,557 Americans had kidney failure, and needed dialysis or a kidney transplant to survive. Nearly 500,000 of these patients received dialysis at least 3 times per week to replace kidney function. Nearly 125,000 people started ESKD treatment in 2017, of which 120,834 started dialysis, and 20,945 received a kidney transplant. At the end of 2017, more than 222,848 Americans were living with a kidney transplant.

                  Only 23,400 Americans received a kidney transplant in 2019, while about 100,000 Americans are waiting for one. Less than one-third of these transplants came from living donors. Living and deceased kidney donors are crucial: 12 people die every day while waiting for a kidney transplant. Over 3,500 kidneys from deceased donors are surgically discarded each year; NKF is making efforts to utilize more of these kidneys for transplantation. People with CKD are five to ten times more likely to die prematurely than they are to progress to ESKD. Over 100,000 people with ESKD died in 2017.

                  Populations:

                  Who is at Risk for CKD?

                  1 in 3 American adults is at risk for CKD. Some demographic groups are at higher risk. Risk factors for CKD include: diabetes; high blood pressure; family history of kidney failure; age 60 or older; obesity; heart disease; past damage to kidneys; and being in minority populations that have rates of diabetes or high blood pressure, such as African Americans, Hispanics, Asians, Pacific Islanders, and Native Americans.

                  The risk of developing ESKD among African Americans is roughly 3 times higher than Whites. Compared to non-Hispanics, Hispanics are almost 1.3 times more likely to receive a diagnosis of kidney failure. Asians and Native Americans also have a higher prevalence of CKD than Whites. Minority groups are at increased risk of progressing from CKD to ESRD and of progressing more rapidly. Non-Hispanic African-American and Hispanic people experience more rapid decline of kidney function than non-Hispanic Whites. There are disparities in the quality of primary care for patients of different racial, ethnic, and socioeconomic groups who have CKD and CKD risk factors. These disparities are related to patient, clinician, clinical, and systemic factors.

                  Patients receiving dialysis in areas with populations that are largely African American, low-income, or of lower educational attainment, are less likely to have received pre-dialysis care from a nephrologist. One study found that 52% of Hispanic patients on hemodialysis and not received pre-dialysis care from a nephrologist, compared to 44% of non-Hispanic patients. However, healthcare professionals are becoming increasingly aware of the importance of nonmedical factors on health, such as where and how a person lives. Primary care teams can help reduce these disparities through concerted action.

                  Many children and adolescents have conditions that, if left untreated, dramatically increase their risk for CKD and ESKD: about 4% of youths (12–19 yrs) in the U.S. have hypertension, while about 10% have elevated blood pressure. In children aged 2-19 years, the prevalence of obesity is 18.5% (about 13 million), and 193,000 people younger than 20 years are living with diagnosed diabetes. The growing prevalence of these conditions in children means that the incidence and prevalence of CKD will likely increase further in the coming years.

                  Children and Adolescents with CKD
                  5,814 children (<18 yrs old) in the U.S. lived with ESKD in 2017. They are 30 times more likely to die prematurely than healthy children. For instance, in one study, adolescents (<18 yrs old) with ESKD since childhood had a life expectancy of 38 years if they were treated with dialysis during childhood, and 63 years if they received a kidney transplant during childhood.

                  The primary causes of pediatric ESKDin the U.S. between 2012-2016 were: primary glomerular disease (22.3%), CAKUT (congenital anomalies of the kidney and urinary tract; 21.9%), cystic/hereditary/congenital disorders (11.7%), and secondary glomerular disease/vasculitis (10.1 %). Urinary tract infections can also lead to kidney infections, which can cause long-term damage to the kidneys.

                  In 2019, 760 children (<18 yrs old) received a kidney transplant and more than 1,000 children (<18 yrs old) are waiting for a donated kidney.

                  How is CKD Treated?

                  The best treatment of CKD is facilitated by early detection, when the disease can be slowed or stopped. Early treatment includes diet, exercise, medications, lifestyle changes, and treating risk factors like diabetes and hypertension. However, once kidneys fail, treatment with dialysis or a kidney transplant is needed.

                  Dialysis comes in two forms: hemodialysis or peritoneal dialysis. Both forms remove wastes and extra fluid from your blood. Patients receive hemodialysis usually 3–4 times a week, either at home or at a dialysis center. During hemodialysis, your blood is pumped through a dialysis machine, where it is cleaned and returned to your body. With peritoneal dialysis, your blood is cleaned inside your body every day through the lining of your abdomen using a special fluid that is periodically changed. Peritoneal dialysis can be done at home, at work, at school, or even during travel. Home dialysis is an increasingly popular mode of treatment, and is associated with better outcomes.

                  A kidney transplant places a healthy kidney into your body from a deceased donor or from a living donor, such as a close relative, spouse, friend, or generous stranger. A kidney transplant, however, is a treatment, not a cure. Antirejection and other medications are needed to maintain the transplant. Per the United States Renal Data System, about 21,000 kidney transplants were performed in the United States in 2017. The active waiting list remains substantially larger than the supply of donor kidneys, which presents a continuing challenge.

                  Although it is very important for patients who are nearing the need for dialysis or kidney transplantation to be cared for by a nephrologist, in 2017, 33.4% of incident ESRD patients had received little or no pre-ESRD nephrology care.

                  What are the Costs?

                  In 2017, Medicare costs for all people with all stages of CKD were $120 billion. In 2017 Medicare spent $84 billion for people with CKDand an additional $36 billion for people with ESKD. For 2017, the per person per year (PPY) spending on all ESRD patients was $79,931.

                  In 2016, Medicare spent an estimated $23,558 per-person to care for someone with non-ESKD CKD, nearly double the spending on the average Medicare beneficiary.

                  In 2017, Medicare spent $91,795 per hemodialysis patientand $35,817 per transplant patient. Early detection of CKD could save a substantial percentage of these costs.

                  Almost 75%of new ESKD patients (2009–2011) applied for Medicare. In 2017 669,620 of Medicare beneficiaries had kidney failure (ESKD), accounting for 7.2% of the overall claims paid by Medicare.

                  For kidney transplant recipients, Medicare Part B spent $2,232 on immunosuppressive drugs, PPPY (2017). And for ESKD patients, Medicare Part D prescription spending (2016) was 4.1 times greater than non-ESKD patients.

                  Prevention

                  Early detection is the most effective way to combat CKD. There are two simple, quick, and inexpensive tests for CKD: A urine test albumin-creatinine ratio (ACR), measures the amount of protein (albumin) in your urine.

                  Damaged kidneys leak protein into your urine when it should be in your bloodstream. A blood test, creatinine, is used to measure your glomerular filtration rate (GFR), which tells how well your kidneys are working to remove wastes from your blood. It is the best way to check kidney function.

                  And preventative medicine pays off: A recent report from the Centers for Disease Control and Prevention (CDC) states that between 1996 and 2013, there was a 54% decrease in the incidence of diabetes-related ESKD in Native American and Alaska Natives since the Special Diabetes Program for Indians (SDPI) began in 1997. The CDC estimates that the decrease in ESKD related to diabetes resulted in 2,200 to 2,600 fewer cases of diabetes-related ESKD, and estimates $436 to $520 million in savings to Medicare over ten years.

                  But there is still a lot work to be done— because kidney disease has many social as well as medical aspects. A recent report issue by the CDC stated that one in four adults with advanced chronic kidney disease is food insecure.

                  What Does It Feel Like to Have Chronic Kidney Disease? Ask People Who Know.

                  "I was diagnosed with CKD in 2000. I had extreme fatigue; my world kept shrinking around me. I remember waking up in the morning, feeling like I hadn’t slept at all.…I had high blood pressure and migraine headaches. Working closely with my doctor, I've been able to put my CKD into remission. As a chef, I enjoy food, so developing recipes that are good for people with kidney disease … has become my passion."
                  — Duane, Spokane, WA

                  “Dialysis was, and still is, the most painful thing, physically and emotionally, I've had to endure. You are hooked to a machine that feels like a vacuum, occasionally pulling on your insides, pulling you apart. Once hooked up, you cannot move or go anywhere beyond the tubing. I wouldn't wish it upon anyone to experience dialysis….”
                  — Hannah, Henrico, VA

                  “Since my kidney transplant, I feel like me again. I’m back to working and back to being a full-time student in the nursing program. I feel so much freedom and gratitude. Life is simply incredible. I’ve even done a bit of traveling—it’s all such a blessing!”
                  — Cindy, Queens, NYC

                  The National Kidney Foundation (NKF) is the largest, most comprehensive, and longstanding patient-centric organization dedicated to the awareness, prevention, and treatment of kidney disease in the U.S. For more information about NKF, visit www.forgedfromreverie.com

                  You can view a fully annotated fact sheet here.

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