We can improve kidney failure treatment even before genetically altered pig kidneys become widely available
April 2, 2024
Kidney failure is miserable for patients. Dialysis helps get toxins out of the body, but generally requires a half day at a dialysis center three days a week, making it hard to keep a job or travel. Kidney transplants are highly effective, but only 27,332 kidney transplants were performed in the US in 2023, and there are 93,000 on the kidney transplant waiting list. The average person waits 3-5 years for a kidney transplant, by which time some are no longer healthy enough to benefit. Discriminatory metrics historically put Black people lower on the dialysis waiting list, although most providers have stopped using algorithms that require more kidney damage before Black people get on the kidney transplant waiting list.
News this week that surgeons implanted a genetically altered pig kidney in a patient in Boston could change the treatment of kidney failure forever, as this could mean always having an adequate supply of replacement kidneys. It will take years before this technology is available to most patients whose kidneys have failed. In the meantime, there are many ways to improve treatment for those whose kidneys have started to fail.
Diabetes is the most common cause of kidney failure; better control of diabetes can slow progression of kidney failure. The GLP-1 drugs (the same drugs now used to treat obesity) are especially effective at decreasing kidney failure progression in diabetics. Those with early kidney failure can improve their outcomes through low protein diets and better blood pressure control. Those who will eventually need dialysis should also actively prepare for this, including getting a “shunt” placed in their forearm to deliver blood to the dialysis machine. Far too many patients have to be hospitalized for their first dialysis because their providers did not recommend this advance preparation. This type of “crash” dialysis requires placing central lines in the neck or chest and has a higher rate of infection and complication than planned dialysis through forearm shunts placed in advance.
Many patients could benefit from home dialysis or peritoneal dialysis (using a tube in the abdomen), but these are rarely used in the United States where most care is delivered in dialysis centers, which yield higher profits for the dialysis providers. In some geographies, dialysis is delivered out of plan at very high unit prices. The United States has the worst age-adjusted mortality from dialysis in developed countries, despite having the highest cost.
Members of employer plans are generally eligible to move to Medicare 33 months after they start dialysis.
Implications for employers:
Query medical carriers about their medical management approach to those with worsening kidney function.
Be sure that carriers transfer members to Medicare when they are eligible.
Ask carriers for their efforts to promote home dialysis and peritoneal dialysis, and for their efforts to get members on kidney transplant lists early.
Ask carriers to report on their care coordination efforts to identify patients with Stage 3-4 chronic kidney disease, to ensure that these individuals optimize their care and are put on a transplant list as soon as feasible.
Ask carriers to report on their efforts to be sure that there are not disparities in placement on kidney transplant waiting lists.
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llustration by Dall-E
Tomorrow: Impact of capping out-of-pocket cost of respiratory inhalers