Cleaveland: Milestones in chronic renal disease

Cleaveland: Milestones in chronic renal disease

January 29th, 2009 in Health

By Dr. Clif Cleaveland

Though remarkable advances have occurred in managing chronic kidney disease during my professional lifetime, much remains to be done, as this timeline will show.

1964: During my medical internship at Vanderbilt Hospital in Nashville, we can offer little to patients with end-stage kidney failure. I recall with sadness an elderly couple who faced the sale of their farm to pay for treatment for the husband whose kidneys no longer functioned because of long-standing high blood pressure.

1965: President Johnson signs Medicare into law in July. People 65 and older can seek benefits for treatment of chronic kidney disease.

1965: The Nashville Veterans Administration Hospital acquires three dialysis (artificial kidney) machines and offers outpatient treatment for veterans suffering kidney failure. Families of such patients flock to Nashville, including a family of four who moved into the upstairs of our duplex. We witness a remarkable resurgence of the father's health as he undergoes thrice-weekly dialysis. Because of limited facilities and time slots, the hospital establishes a committee to select, in essence, who will live.

1969: Our youngest son develops a form of kidney failure. Devoted care of pediatricians at Fort Knox, Nashville and Chattanooga guide his complete recovery, employing new medical strategies.

1973: Medicare extends benefits to adults of any age who require dialysis for chronic kidney failure. This becomes the first disease-specific Medicare benefit. That same year, Dr. Jackson Yium moves to Chattanooga, becoming the area's first nephrologist (medical kidney specialist). He establishes an inpatient, dialysis unit at Erlanger hospital and promotes a rapid expansion of services in our community. A prefabricated structure is erected at the hospital's loading dock to provide outpatient dialysis services for patients who previously had to travel to Nashville by bus three times weekly for treatment.

(Currently, multiple outpatient, dialysis clinics and a dozen nehprologists serve more than 600 patients in the greater Chattanooga area. Dialysis centers open in Cleveland and Athens. A small number of patients choose home dialysis with equipment purchased by Medicare or elect a method of nighttime dialysis that can be personally performed.)

1989: Kidney transplants become available with the arrival in Chattanooga of Dr. Daniel Fisher. Thus, our city can offer a full range of services for patients with severe, chronic kidney failure. Patients with kidney transplants enjoy a substantially longer life than patients maintained on long-term dialysis. In subsequent years, medications and techniques to manage the care of patients with transplants steadily improve.

2005: The most recent clinical data portray an increasing incidence of chronic kidney disease, from 10 percent in 1994 to 13 percent of U.S. adults in 2004. In 2005 almost half a million Americans are under treatment for severe disease, including more than 100 thousand who begin treatment that year. In the same year, 85 thousand deaths result from chronic kidney failure.

Diabetes and high blood pressure cause the majority of cases of chronic kidney failure. Blacks remain twice as likely as whites and Hispanics to develop kidney failure. Our country continues to have the highest incidence of end-stage kidney disease in the world.

While more than 17 thousand patients receive kidney transplants, 75,000 remain on waiting lists. Patients on chronic dialysis number more than 340,000. The cost of dialysis remains stable at about $50,000 per patient per year. Cost for a year's anti-rejection medication for transplanted patients averages $25,000 per patient per year.

Against this sobering backdrop, kidney centers emphasize earlier diagnosis of chronic renal impairment. The goal is to offer earlier intervention with medication to slow a relentless progression to complete organ failure. Current estimates place the total number of adults over age 20 with mild to severe chronic kidney disease at 15 million.

The rising numbers of people suffering from chronic kidney impairment parallels our nation's steadily worsening epidemic of adult-onset diabetes and high blood pressure. The incidence of these two conditions is, in turn, linked to our epidemic of obesity.

We must commit to a continuing, vigorous national campaign to address this forerunner of chronic renal disease and so much else that robs people, young and old, of their health.

Contact Clif Cleaveland at