26 The hidden burden of hemodialysis: personal and economic impacts
26 The hidden burden of hemodialysis: personal and economic impacts
Kelsey Hennig, PharmD, BCPS
Branden D. Nemecek, PharmD, BCPS
Mira Maximos, PharmD, MSc, ACPR, BScPhm, BHSc
Topic Area
Renal disease
Learning Objectives
At the end of this case, students will be able to:
- Describe the epidemiology of chronic kidney disease and end stage renal disease in the United States
- Evaluate personal and economic burdens that may be relevant for patients with end stage renal disease
- Identify the role and most common responsibilities of the pharmacist in the care of patients with end stage renal disease
Introduction
Chronic kidney disease (CKD) affects a growing number of individuals worldwide, with a prevalence of between 5 to 15% in US adults.1,2 The highest incidence of CKD is in those 65 years of age or older, with diabetes mellitus and hypertension being primary causes in adults.2 CKD and end stage renal or kidney disease (ESRD/ESKD) are often associated with increased rates of mortality and morbidity, with progression of CKD to ESRD associated with frequent complications, such as electrolyte abnormalities, anemia of chronic disease, secondary hyperparathyroidism, hypertension, metabolic disorders, and pruritus.1 In ESRD, the two main dialysis modalities are hemodialysis (HD) and peritoneal dialysis (PD); there is also the option for renal transplantation.3 Patient factors, local practice-patterns, and clinician-patient discussion are needed to decide on the best possible patient centered modality of treatment for ESRD; with hemodialysis being the most common therapeutic modality in the United States.3
The personal and economic impacts of ESRD and dialysis are significant. A large proportion of the impact is due to incurred healthcare costs for managing clinical complexity, comorbidities, loss of productivity as well as associated premature mortality.4 From a societal perspective, ESRD affects the patient, caregiver, employer, and healthcare system as a whole in the United States.4 Patients with ESRD must manage direct costs of medical procedures, diagnostics, laboratory tests, medications, vaccinations, healthcare provider visits, hospitalizations, dialysis, transportation to and from appointments as well as absenteeism from work due to these factors.4 With varying modalities for dialysis, including the option for more frequent home-based dialysis, the complexity of patient and caregiver burdens are high, especially as in varying instances those caregivers may be unpaid family compared to paid caregivers in other instances.5
The macro-level economic impacts of ESRD in the United States are also widespread. The Medicare program is the predominant payer for those patients receiving dialysis, with the remainder of care funded by Medicaid or other payers.6 While the government is the primary funding source, most dialysis services are provided through private, for-profit, facilities with two private companies caring for an estimated 63% of dialysis patie