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Intro to ESRD, Dialysis & Transplantation

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Introduction to ESRD, Dialysis and Transplantation

The incidence of chronic kidney disease (CKD) and the incidence of end stage renal disease (ESRD) is increasing with the aging American population. The National Kidney Foundation estimates that 26 million Americans have some form of kidney disease and over 468,000 Americans are on dialysis. Reports indicate that in America, over $31 billion dollars is spent annually treating renal failure. In 2013 there were approximately 117,000 new cases of renal failure and 89,000 deaths from this diagnosis.  Although maintenance dialysis prevents death from uremia, patient survival remains an important issue. Once renal replacement therapy is initiated, the range of the expected remaining lifespan in the United States Renal Data System (USRDS) report was approximately eight years (varies with race) for dialysis patients 40 to 44 years of age and approximately 4.5 years for those 60 to 64 years of age. These values in older patients are only slightly better than those in patients with lung cancer. In the hemodialysis population, total fee-for-service Medicare expenditures per person per year (PPPY) were $87,945 in 2011. It is also important to underscore that the disease disproportionately affects the nation’s minority and low-income populations: as compared to White Americans, African Americans are 3.5 times more likely to have ESRD, and Native Americans and Hispanic Americans are 1.5 times more likely to have ESRD.

The best solution for a large fraction of the patients with ESRD or those approaching ESRD is renal (kidney) transplantation. A successful transplant requires a suitable donor, major surgery, and a lifetime regimen of immunosuppressant medications to prevent rejection. If successful, renal transplant eliminates the need for dialysis, has the potential to prolong patient’s lives, and is cost effective. However, the availability of organs is the rate limiting step and patients may wait for 6-10 years on the cadaveric organ waiting list until offered a suitable kidney. The number of patients on the waiting list grows almost 8% every year and now exceeds 110,000 patients.

Cost should not be a barrier to kidney transplantation.  In fact, kidney transplantation is almost uniformly less expensive than maintaining a patient on dialysis.  Typical dialysis charges can range between $15,000 – 30,000/month. Taking into consideration the morbidities associated with dialysis and the patient’s underlying condition, billed charges routinely reach $200,000 – 300,000/year. By contrast, estimated charges for a kidney transplant for the entire year of transplant in 2014 are estimated at $334,300. The cost of a kidney transplant is generally “paid back” within 24 months following the transplant. See the table at the end of this review for the breakdown of estimated first-year transplant costs for kidney transplants in 2014.  

Early in the course of ESRD, the costs are borne by the health plan.  While it is true that patients with ESRD are eligible for Medicare, patients are generally not covered by Medicare until 33 months following the diagnosis of ESRD (3 month “eligibility” period followed by a 30 month “coordination” period during which time Medicare is the secondary payor and the health plan remains the primary payor). There are exceptions to this. The rules are quite complicated and you should contact Medicare for clarification of Medicare eligibility and coverage for any given patient.

Because of the excellent outcomes associated with well-matched living related donor kidneys, plus the relatively low cost of the procedure and subsequent follow-up, pre-emptive transplant may be considered in patients with impending ESRD who have suitable living donors.  For most patients, the progress of renal deterioration is linear, regardless of etiology. The need for dialysis and its timing are reasonably predictable.  Given this information, if a suitable donor is available, a preemptive kidney transplant may be considered.  Preemptive transplantation avoids most of the complications of chronic renal failure and preserves the patient in a high-functioning state without the potential long-term disability and additional complications associated with dialysis.  In children, most of the metabolic abnormalities affecting growth and development will be avoided.

Type I diabetics considered for kidney transplant can also be considered for a kidney pancreas transplant, either at the time of the kidney transplant (simultaneous pancreas kidney or SPK) or following the kidney transplant (pancreas after kidney or PAK).