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.

• 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 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.

General Screening
From the perspective of infectious disease and their consequences, evaluation should include eliciting a history of antibiotic allergies, valvular repairs or replacements, a dental assessment, a preoperative urine culture, and a chest radiograph to exclude active pneumonic processes and identify evidence of prior granulomatous or infectious disorders. A purified protein derivative (tuberculin) skin test with appropriate controls should be applied; however, suboptimal reactivity of skin testing in renal failure patients may lead to false-negative results. Isoniazid (INH) prophylaxis may be indicated with an abnormal chest x-ray result representing old tuberculosis despite a negative skin test. Precise recommendations for dosage an duration of therapy should adhere to the Centers for Disease Control guidelines on INH prophylaxis. Additional preoperative assessment should include a history of sexually transmitted diseases such as syphilis, HSV infection, viral hepatitis, and HIV infection.

Immunizations
Pretransplant candidates lacking standard pediatric or adult immunizations, splenectomized patients, and renal failure patients may benefit from pretransplant vaccinations with influenza, pneumococcal, and hepatitis B, diphtheria-pertussis-tetanus, inactivated polio, and measles-mumps-rubella (MMR) vaccines. Suboptimal efficacy of vaccinations in patients with renal failure must be recognized due to the effects of uremia on the immune system, however. Live vaccines should be avoided in immunocompromised patients (e.g., a renal transplant candidate with an underlying condition requiring immunosuppresive medications) and in patients who have undergone solid organ transplantation. Of particular pretransplant concern are pediatric renal failure patients with incomplete primary immunizations of live viral vaccines such as MMR. The general recommendation of avoiding live, attenuated viral vaccines in allograft recipients precludes the completion of the immunization series, thereby exposing the child to the risk of measles. Consequently, pretransplant immunization offers the opportunity to prevent the post-transplantation risks of live, attenuated viral vaccines. In this respect, measles, MMR and varicella vaccines should, ideally, be administered several months before transplantation. Pretransplant vaccination with a live, attenuated CMV vaccine has been reported to result in a reduction in the severity of CMV disease and improved graft survival in seronegative recipients of a CMV-positive allograft, the group considered to be at highest risk for CMV disease. Administration of this vaccine, however, has not been implemented.

Prior to the advent of human recombinant erythropoietin, anemia in these dialysis patients was treated with androgenic steroid hormones and, if necessary, transfusions of red blood cells.

Both of these treatments had important drawbacks. Androgen (male) steroids were administered by weekly injection into the muscle. Their mode of action was to stimulate cells in the bone marrow to produce more red blood cells. Unfortunately, androgens had limited effectiveness and, as a side effect, promoted the development of masculine sexual characteristics such as facial and body hair and even deepening of the voice. Blood transfusions are a more effective way of treating anemia. Their usefulness is limited by the danger of transmitting certain viral diseases, such as hepatitis. Furthermore, blood transfusions contain a large amount of iron. Some of the iron is deposited in the liver and other organs. After many units have been given, the iron may potentially cause disease of these organs.

Benefits of Treatment with Recombinant Human Erythropoietin
The most important benefit of treatment with recombinant human erythropoietin is an increase in the number of red cells in the blood. Once the number of red blood cells available to carry oxygen to all parts of the body increases, you may not require transfusions, unless you have sudden or substantial bleeding, such as from an ulcer of the stomach or intestine.

Dialysis patients with anemia who have received EPO also commonly experience improved quality of life and sense of well-being. After treatment with EPO, many patients notice an improvement in their ability to work, and their sexual performance, appetite, ability to exercise, social activity, sleep, ahir texture and skin color.

Questions in the values history ask about your living environment; your family and friends; your religious background and beliefs; your attitudes toward life in general and toward independence and control, health, doctors, illness, death and dying, and finances. They ask whether you have wishes regarding specific medical procedures, such as dialysis, artificial ventilation, artificial nutrition and hydration and organ donation, and regarding a funeral, eulogy, and obituary. The questions also ask if you have any written documents, particularly advance directives.

Can I be required to have an advance directive?
According to the Patient Self-Determination Act, a federal law, you cannot be required to have an advance directive. This law specifically prohibits health care facilities or providers from conditioning admission or provision of insurance or services upon whether or not you have executed an advance directive.

Why do so few people elect to have advance directives?
Many individuals do not know what an advance directive is, or if they know, do not realize it would be appropriate for them to have. Many others do not have an advance directive because the subject raises unpleasant or frightening issues.

Why should a dialysis patient have an advance directive?
For the same reasons that everyone should have one-and for additional reasons. Dialysis is very effective in prolonging lives of those who would otherwise die of kidney failure. Fortunately, the quality of health and life for the great majority of people on dialysis acceptable and for many substantially better than that. Most people are able to work and can do most of the activities that they wish to do, but as many as 10% of chronic dialysis patients discontinue dialysis because the burdens of illness and treatment outweigh the benefits of continuing to live. Perhaps half of those who discontinue dialysis are no longer able to make decisions for themselves and the time dialysis is discontinued because of inter-current illness with altered consciousness or because of dementia.

By having an advance directive, they are assured of having their own preferences for health care respected, including the continuation of dialysis or of other life-sustaining treatment if that is their preference (or discontinuation, if that is their preference). Furthermore, it is a great relief to family members and to physicians to know a patient’s preferences and to feel secure that they are doing what this person would have wanted them to do.

According to Clinical Renal Toxicology…

“Chemicals can affect the renal function or structures through a direct toxic action or through various systemic effects, such as intravascular hemolysis, rhabdomyolysis, or cardiac failure.”

Such chemicals include:

• Lead
• Cadmium
• Mercury
• Silica

Certain occupations are far more at risk than others. For instance, individuals that work in brazing or nickel-cadium battery manufacturing are exposed to high levels of Cadium. However, someone working in scrap metal recycling in Los Angeles would also likely be exposed to Cadium in the process of recovering the metal, but not as much as the person working in the manufacturing of nickel-cadium batteries.

Lead is another one you really want to watch out for. Occupations most notorious for causing lead exposure are lead battery manufacturing, soldering, smelting, radio repair, glass & ceramic manufacturing, and also paint stripping (in the case of lead-based paints).

If you are concerned about the health risks associated with your current occupation, especially pertaining to renal health, consult your employer. He or she should have additional details.

Also, check out this in-depth look at occupational renal diseases.

You can choose to learn to make their own hemodialysis treatments at home. When you are the only patient, it may become more frequent dialysis treatments or lasting almost replaced the normal work performed by healthy kidneys. Daytime hemodialysis at home (DHHD for short in English) is performed 5-7 days a week for 2 to 3 hours per session and you organize the schedule. If your health insurance plan would pay more than three treatments, you could be brief treatments during the morning or afternoon. Nocturnal home hemodialysis (NHHD by its acronym in English) is done in 3-6 nights a week while you sleep. Whether you choose the DHHD or NHHD, this will allow food and a normal fluid intake, with fewer blood pressure medications and other health problems. Most programs ask patients to do home hemodialysis have a skilled attendant during treatments. Learning to be hemodialysis is like learning to drive a car: it takes a few weeks and, initially, is alarming but then becomes a routine. The dialysis center provides the equipment and training, and assistance by phone 24 hours if you have any questions or problems. New machines for home dialysis are smaller and easier to use than the equipment used in schools.

You have options of dialysis centers and many cities have more than one site to choose from. You can visit a center to see if there are treatments you want or the time it needs. Some centers allow the use of laptops or cell phones or receive visits, others not. Medicare has a list of all centers in the United States on its Web site at www.medicare.gov / dialysis (in English), which shows the quality ratings of each school. Your health plan may have a list of sites where you can go. If you choose a treatment option in a school, it must be near your home to reduce your travel time. If the treatment is done at home, once you are trained, you should only go to the center once a month. So, the center can be as far as you want to travel once a month.

Possible Complications of Dialysis
Vascular access problems are the most common reason for hospitalization among people receiving hemodialysis. Some common problems include infection, blockage by clotting and poor circulation. These problems may prevent their treatments to succeed. You might have to undergo repeated surgeries to achieve a properly functioning access.

Other problems may be caused by rapid changes in water and chemical balance of your body during treatment. Muscle cramps and hypotension (a sudden drop in blood pressure) are two common side effects. Hypotension can make you feel weak, dizzy or sick to your stomach.

Probably need a few months to adjust to hemodialysis. Side effects can often be dealt with swiftly and easily, so you should inform your doctor and dialysis staff suffered any side effects. You can avoid many side effects if you follow a proper diet, limiting fluid intake and taking medications as directed.