Case Scenario

An 82-year-old man presents to his family physician to discuss his kidney function test results. He has well-controlled hyperlipidemia and hypertension treated with 40 mg of atorvastatin and 20 mg of lisinopril daily. His body mass index is normal. He exercises three or four times per week for 30 minutes on a stationary bike and follows a Mediterranean diet. Recent laboratory testing found a blood urea nitrogen level of 29 mg per dL (10.35 mmol per L), serum creatinine level of 1.43 mg per dL (126.41 μmol per L), and an estimated glomerular filtration rate (eGFR) of 49 mL per minute per 1.73 m² that was similar three months ago and not associated with albuminuria, classifying him with stage 3a chronic kidney disease (CKD). Before the visit, the patient shared the results with his brother-in-law, a retired cardiologist, who told him to request an urgent nephrology referral because the patient was in danger of progressing to kidney failure and eventually needing dialysis. The patient is concerned by this news and has many questions.

Clinical Commentary

CKD is abnormal kidney structure or function lasting more than three months.¹ The condition affects more than 47 million people in the United States and is most often associated with long-standing hypertension and diabetes mellitus.² CKD is associated with significant morbidity, mortality, and increased health care costs, particularly in patients requiring dialysis. It is an independent risk factor for cardiovascular disease and all-cause mortality.1 A 2016 report showed that Medicare spending for patients with CKD was more than $52 billion, representing 20% of all Medicare spending.² It is unclear how much of that spending is related to the treatment of end-stage kidney disease compared with milder forms of CKD that may not progress to dialysis.