Strategies for improving long-term survival in patients with ESRD

In 2003, more than 320,000 people in the United States were receiving dialysis for ESRD, with predicted increases to 650,000 by 2010 and 2 million by 2030. Mortality from cardiovascular disease (CVD) in patients with ESRD is 10 to 30 times higher than in the general population. The exact mechanism of accelerated CVD in patients with kidney disease is unknown. Treatment costs for ESRD are in excess of $14 billion annually (6.4% of Medicare budget). Strategies to improve long-term outcomes include aggressive risk factor modification, minimization of dialysis complications, and kidney transplantation. Because abnormalities of mineral metabolism contribute to mortality risk, phosphate binder therapy is fundamental. More expensive non-calcium-containing phosphate binders such as sevelamer have been recommended to reduce cardiovascular calcification. However, the lack of outcome data and the $2 to $3 billion annual cost make it difficult to justify widespread utilization of newer binders as first-line therapy. Conversely, kidney transplantation is known to improve survival in ESRD. Progression of atherosclerosis and CVD in patients with renal failure is largely due to loss of renal function per se, and provision of a functioning kidney through renal transplantation halts the progression of CVD and dramatically reduces mortality. Despite this fact, many patients lose Medicare funding for immunosuppressive therapy 3 yr posttransplantation. To achieve the goal of prevention of cardiovascular mortality in patients with ESRD, it clearly would be more prudent, efficacious, and cost-effective to use Medicare prescription drug dollars to provide full coverage for life-long immunosuppressive drug therapy after renal transplantation.