Kidney Function

The 1972 kidney disease provisions of Medicare of Public Law 92-603 were effective as of July 1st, 1973. Since that time, amendments have been made to expand the program, including the 1978 provisions of Public Law 95-292, which were effective October 1st, 1978, and the Omnibus Budget Reconciliation Act of 1981. The Omnibus Budget Act of 19990 has expanded Medicare coverage of self-administered EPO for home dialysis patients effective as of 1991, while the Omnibus Reconciliation Act of 1993 extends immunosuppressant coverage from one year to three years.

These Medicare benefits consist of two types of insurance: Part A, or hospital insurance, and Part B, or medical insurance. Almost everyone who is eligible for Medicare is covered by hospital insurance without paying any monthly premium. Hospital insurance covers medically necessary inpatient hospital care and, under certain conditions, medically necessary post-hospital inpatient care in a skilled nursing facility, and home health care provided by a home health agency. The hospital insurance part of Medicare, for example, helps pay for an inpatient stay in an approved surgery. Hospital insurance has an annual deductible, and Medicare payments for services are made directly to the participating facility providing services.

When a person becomes entitled to Medicare hospital insurance because of chronic kidney failure, they are also enrolled for medical insurance or Part B of Medicare. Although they do not have to take this part of Medicare, most of the services and supplies required by chronic kidney failure are covered only by the medical insurance and not by the hospital insurance. The monthly premium for medical insurance protection covers physicians’ services; outpatient hospital services; outpatient maintenance dialysis treatments in an approved dialysis facility; durable medical equipment for use in the home, such as dialysis machine; and almost all items necessary for home dialysis, as well as many other health services and supplies. In addition to monthly premium payments, medical insurance also carries a small annual deductible payment and a 20 percent co-insurance liability.

Note: There is no minimum age required to receive Medicare benefits under the kidney disease provisions, as long as all other eligibility requirements are met.

How to Find Out if You’re Eligible for Medicare Benefits

The law states that you must be a Social Security or Railroad Retirement beneficiary or be “fully or currently” insured in order to be eligible for the kidney disease provisions of Medicare. You are currently insured it you have at least six quarters of coverage during the full 13-quarter period ending with the calendar quarter in which dialysis or a transplant occurs. A patient is fully insured when they have one quarter of coverage under the Social Security program for each year elapsing after 1950 (or after the year the patient attains age 21, if later) to the year in which dialysis or transplant occurs. In no case is more than 40 quarters of coverage required. The spouse or dependent child of an insured individual is also eligible. For more information on eligibility, contact your local Social Security office. A social worker is best suited to assist you in determining whether or not you are eligible for Medicare benefits.

Although we have seen tremendous advancements in the field of kidney research (especially pertaining to kidney failure) in recent years, research is continually progressing in the United States. The primary goals of this ongoing research are to:

• better understand the causes of kidney diseases and kidney failure
• develop new strategies for the treatment and prevention of kidney diseases and kidney failure
• improve dialysis therapies
• increase success rates for kidney transplantation
• find alternative treatment methods for kidney failure

Important Research Accomplishments

As a direct result of intensive research and technological advances, the treatment of kidney failure has changed and expanded. Many advances have made it possible for people with kidney failure to live longer and with fewer complications. Some of these research developments include:

• the use of recombinant erythropoietin to treat the anemia of chronic kidney failure. Erythropoietin has reduced the need for transfusions and has improved the exercise endurance and feeling of well-being of many people who suffer from kidney failure
• a better understanding of the immunology of transplantation that has led to the ongoing development of new medications and tissue typing techniques to prevent the rejection of transplanted kidneys
• the effective use of calitriol, the active form of Vitamin D, for the treatment of a common form of bone disease that occurs with kidney failure
  the identification of another form of bone disease in hemodialysis patients called amyloid bone disease and the development of methods to detect and diminish the accumulation of amyloid in bones and joints
• a major reduction in the occurrence of aluminum bone disease through the use of preventive interventions
  the continued improvement of continuous ambulatory peritoneal dialysis (CAPD) so that the risk of infection has been significantly mitigated

Recent Research Developments

There have been several recent research developments that have led to new ways of preventing kidney failure and treating people with kidney failure.

Recent research has demonstrated that the progression of diabetic kidney disease, a major cause of kidney failure, may be slowed by the use of blood pressure lowering medications called angiotensin-converting enzyme (ACE) inhibitors and by very good control of the blood sugar. In addition, the use of new tests for the early detection of kidney disease in diabetic patients permits earlier intervention with prevenentive measures.

The development of new and more effective antihypertensive medications now offers more treatment options for people with hypertension, which remains a major cause of kidney failure.

The continued development of high-flux dialysis membranes and new biocompatible membranes has improved the efficiency and safety of hemodialysis. The development of new CAPD systems has dramatically reduced the incidence of peritonitis the most common complication of CAPD.

Improvements in the use of immunosuppresive medications in preventing the rejection of transplantations and in tissue-type matching have increased the success rate of kidney transplantation.

Renal cell carcinoma is a malignant tumor of the kidneys resulting from tubular epithelium.

Renal cell carcinoma accounts for about 90% of kidney cancers. It is estimated that in 1989, 23,000 cases were diagnosed, and out of those 23k, 10,000 people died as a result of the disorder. Renal cell carcinoma occurs most frequently in adult men, with the peak occruence in the sixth decade of life. The life expectancy of a patient with metastases at the time of diagnosis is poor; only 5%-20% are alive at the end of the first year. The disorder is usually unilateral, with equal incidence in the right and left kidneys. There is little evidence for specific carcinogens, although tobacco use appears to be associated with development of the tumor.

Pathophysiology

The tumor may appear anywhere in the kidney, and its increasing mass may compress surrounding tissue, causing ischemia, necrosis, and hemorrhage. The tumor may invade the collecting system and branches of the renal vein, even extending in the the inferior vena cava. Although the tumor grows somewhat slowly, metastases can occur at any stage. Primary sites of metastases are the lungs, lymph nodes, liver, and bones. Renal cell carcinoma metastasizes to all visceral organs. Such involvement may be discovered first, an metastases may occur long after the original tumor has been removed.

Treatment

When a patient is diagnosed with renal cell carcinoma, efforts are made to stage the tumor’s development. No radiation or chemotherapy has been found to effect a cure.

A radical extrafascial nephrectomy may be attempted, which is a surgery that involves removing the kidney and tumor, neural and vascular structures at the kidney’s hilum, surrounding perinephric fat, Gerota’s fascia, and the ipsilateral adrenal gland. The prognosis is poor if there is involvement of the renal vein or extension through Gerota’s fascia, extension to the renal lymph nodes or contiguous organs, or distant metastases. The need for nephrectomy depends on the severity of symptoms. Radical nephrectomy is not indicated if there is preoperative evidence of local node involvement or advanced disease. A partial nephrectomy is done if the patient has only one kidney. Staging involves examining local nodes and identifying distant metastases.