1.26: The hidden burden of hemodialysis- personal and economic impacts
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 patients in 2011. 6 The financial burden of care for these individuals is high, accounting for approximately 7% of the Medicare spending ($46.6 billion in 2017) despite only composing approximately 1% of the Medicare population. 6 Out-of-pocket costs for ESRD patients was estimated at $3.5 billion in 2017, demonstrating the significant burden on patients even with a government funded program. 6
Once a decision has been made concomitantly by the clinician and patient to start dialysis, a multidisciplinary team of physicians, nurses, dieticians, pharmacists, and other allied health professionals often become involved in the patient’s care. 1 Pharmacists, in both inpatient and outpatient settings, are involved in activities related to dialysis, medication dosing and medication reconciliation. A systematic review of the literature found that most available evidence of the clinical activities of pharmacists in CKD is descriptive in nature with all studies reporting some positive impact resulting from clinical pharmacist involvement. 1
Case
You are a pharmacist working on an inpatient internal medicine service on a Saturday. Your team is currently consulting nephrology to discuss NK’s case after he has been admitted with bacteremia.
CC: “I have gotten very weak over the last few days. I missed dialysis yesterday [Friday] and was not able to stay the full time Wednesday.”
Patient: NK is a 62-year-old male (71 in, 84 kg) who presented to the emergency department (ED) due to persistent lethargy and weakness. He is frequently seen in the ED due to missed dialysis sessions. During his current hospital admission, he is found to have MRSA bacteremia.
HPI: NK has been a HD patient for seven years now. NK initially started on PD but had multiple episodes of peritonitis, infection, and catheter malfunction that led to a discussion with his nephrologist to consider transitioning to hemodialysis.
PMH: ESRD secondary to diabetic nephropathy; T2DM; neuropathy; chronic lower back pain; major depressive disorder; atrial fibrillation; anemia; mineral bone disease
FH:
- Mother: deceased (breast cancer); HTN
- Father: deceased; T2DM, HTN, and CKD
- Sister: T2DM, HTN, hypothyroidism
SH:
- Drinks alcoholic beverages rarely
- Does not use nicotine, illicit substances, or non-prescribed medications
Medications:
-
Oral therapies
- Fosinopril 20 mg daily
- Amlodipine 10 mg daily
- Bisoprolol 5 mg daily with supper
- Warfarin 1 mg as directed (INR target 2-3)
- Calcitriol 0.25 mcg three times weekly at dialysis
- Sevelamer carbonate 1600 mg three times daily with meals
- Glyburide 2.5 mg daily with breakfast
- Gabapentin 200 mg nightly and before start of each hemodialysis session
- Amitriptyline 25 mg at bedtime
- Fluoxetine 10 mg once daily
- Replavite multivitamin daily in morning
- Acetaminophen 1 g three times a day with meals
-
Parenteral therapies
-
Vancomycin IV per hemodialysis/bacteremia protocol
- For treatment of MRSA bacteremia
- Etelcalcetide 5mg IV three times weekly at dialysis
-
Insulin glargine 10 units SQ nightly
- Morning blood glucose range 84-113 mg/dL
- Iron sucrose 100 mg IV at dialysis
-
Epoetin-alpha 6,000 units IV three times weekly at dialysis
- When Hgb <10 g/dL
-
Vancomycin IV per hemodialysis/bacteremia protocol
Allergies:
-
Morphine intolerance
- Itching within hours of administration on two different occurrences
- No other drug allergies
- No known food allergies
- Allergic to cat dander
Vitals:
-
Dialysis clinic vitals from last Wednesday
- Before dialysis: BP (seated) 160/65 mmHg and HR 72 bpm
- One hour into dialysis: BP 105/60 mmHg and HR 65 bpm
Labs:
| Parameter | Value | Parameter | Value |
|---|---|---|---|
| Na | 139 mEq/L | PTH | 724 pg/mL |
| K | 5.7 mEq/ | RBC | 3.3 x 10 6 cells/mm 3 |
| Cl | 101 mEq/L | Platelets | 160 x 10 6 cells/mm 3 |
| CO 2 | 17 mEq/L | Hgb | 9.3 g/dL |
| BUN | 53 mg/dL | Hct | 34.7% |
| SCr | 9.2 mg/dL | HgbA1c | 6.9% |
| Glu | 103 mg/dL | Ferritin | 234 microg/L |
| Ca | 9.3 mg/dL | TSAT | 27% |
| Phos | 5.3 mg/dL |
Surgical history: Above the knee amputation of right leg (three years prior) secondary to osteomyelitis
SDH: Over the last three years, NK has confided in the nephrology team’s social worker that his situation has become more difficult since a right leg amputation due to a bone infection and long-standing T2DM. He is frustrated because his dialysis sessions are scheduled very early in the morning when there are no busses running from his place to the dialysis center or if the bus is running, he cannot get to the stop fast enough and misses it entirely then still has to pay for a cab.
He was previously employed as a truck driver but was unable to continue work after his amputation and was laid off. He is scared because money is tight, and he has even had to start taking his medications differently to make sure they last before he can afford to get them filled again, especially when he needs to meet his deductible or is in his Medicare coverage gap “donut hole”. NK has been trying to make ends meet and pay for all the “stuff” that goes with dialysis, but he feels alone and frustrated.
NK is divorced with two adult children (ages 27 and 31). He doesn’t want to lean on his daughters too much because they are stressed with work and already make sure he has a place to live, with food and company. This week has been more difficult because NK has been trying to interview for different jobs between dialysis sessions so has been missing a lot of time in the clinic. NK thought it was the stress that made him feel weaker over the last few days but this morning when his one of his daughters came to help him get upstairs for breakfast, he almost passed out when he got up. He was shivering and could barely sit. His daughter called 911 and he was brought by ambulance to the ED.
Case Questions
- What are the most common criteria considered for dialysis in ESRD?
- List the most common burdens associated with dialysis and describe how these burdens can be taken into consideration for NK’s case.
- Describe the role of the pharmacist as part of the clinical team in helping patients with management of ESRD.
- Provide an approach to help NK manage cost of medications due to recent financial burdens. Which medications could be discontinued or changed?
- Describe the funding of dialysis programs within the United States.
- Discuss dialysis associated burdens from a patient perspective on a global scale. How are these burdens similar and different from the United States?
- List factors that increase the economic burden of dialysis outside of those covered by Medicare.
Author Commentary
Patients on dialysis face a myriad of health care challenges including transportation to and from dialysis sessions, 7 including rigid time requirements by transportation companies, co-morbidities that can impair self-transportation, renovascular and dialysis complications that can impair driving abilities, and lack of social support. The ability for a patient to get to dialysis is critical due to the documented increase in morbidity and mortality associated with dialysis non-compliance. 8 Medicare specifically accounts for the funding of those on renal replacement therapy and this small patient population accounts for a substantial portion of the overall Medicare spending given the relatively small patient pool. 6 However, realizing the myriad expenses for patients, both direct (e.g., out-of-pocket medical payments, transportation costs, the price of healthy foods) and indirect (e.g., the economic losses through decreased work opportunities) is key to understanding the total financial burden of ESRD.
Pharmacists play a significant role in the care of dialysis patients. In the community setting, they are one of the most accessible providers and can answer medication related questions, which is especially important given that many dialysis patients face polypharmacy challenges. In the ambulatory and institutional setting, pharmacists collaborate with providers to optimize medication and non-medication treatments. In these roles, pharmacists may be the first to assess the patient’s social determinants of health and address those barriers to optimize patient care. Pharmacists are encouraged to engage with the interdisciplinary team (e.g., nephrologist, dietician, social work, nurses, and other professions) to resolve these challenges and decrease the burden placed on the patient.
Patient Approaches and Opportunities
It is important to identify social determinants of health that may adversely impact patients who have ESRD. Patients should have a clear understanding of dietary needs, access to reliable transportation, and the ability to access health care resources. Pharmacists can play a significant role in assessing and addressing gaps in health literacy within this patient population as it pertains to medications.
In reviewing medications for patients on dialysis, it is important to discuss the patient’s ability to afford those medications and to manage their medication regimen. Patients should be counseled on the timing of medications with regard to their dialysis sessions. As non-nephrology providers may not have as much experience with drug dosing for patients with ESRD, it is important that all medications be evaluated for efficacy and safety. Potential adverse effects and drug interactions should be communicated with patients’ nephrologists and other prescribing providers to limit adverse events and improve patient outcomes.
Related chapters of interest:
- Interprofessional collaboration: transforming public health through team work
- Deprescribing in palliative care: applying knowledge translation strategies
- Digging deeper: improving health communication with patients
External resources:
- Kidney 360. Global Dialysis Perspective series. https://kidney360.asnjournals.org/cc/globdial
References
- Stemer G, Lemmens-Gruber R. Clinical pharmacy activities in chronic kidney disease and end-stage renal disease patients: a systematic literature review. BMC Nephrol 2011;12:35.
- Centers for Disease Control and Prevention. Chronic kidney disease in the United States, 2019. https://www.cdc.gov/kidneydisease/pdf/2019_National-Chronic-Kidney-Disease-Fact-Sheet.pdf . Accessed December 29, 2020.
- Liu KD, Chertow GM. Chapter 306: Dialysis in the treatment of renal failure. In: Jameson JL, Fauci AS, Kasper DL, Hauser SL, Longo DL, Loscalzo J, eds. Harrison’s Principles of Internal Medicine . 20th ed. McGraw-Hill Education. 2018: 2121-2126.
- Wang V, Vilme H, Maciejewski ML, Boulware LE. The economic burden of chronic kidney disease and end-stage renal disease. Semin Nephrol 2016;36(4):319-330.
- Cohen LM, Germain MJ. Caregiver burden and hemodialysis. Clin J Am Soc Nephrol 2014;9(5):840-2.
- Han Y, Saran R. Global dialysis perspective: United States. Kidney360 . 2020;1(10): 1137-42.
- Chenitz KB, Fernando M, Shea JA. In-center hemodialysis attendance: patient perceptions of risks, barriers, and recommendations. Hemodial Int 2014;18(2):364-73.
- Leggat JE Jr, Orzol SM, Hulbert-Shearon TE, Golper TA, Jones CA, Held PJ, Port FK. Noncompliance in hemodialysis: predictors and survival analysis. Am J Kidney Dis 1998;32(1):139-45