[Congressional Record Volume 141, Number 36 (Monday, February 27, 1995)]
[Extensions of Remarks]
[Pages E441-E442]
From the Congressional Record Online through the Government Publishing Office [www.gpo.gov]


          PREVENTION OF PROGRESSION TO END-STAGE RENAL DISEASE

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                        HON. FORTNEY PETE STARK

                             of california

                    in the house of representatives

                        Monday, February 27, 1995
  Mr. STARK. Mr. Speaker, I would like to address this issue of kidney 
disease and its progression to end-stage renal disease [ESRD]. The 
Social Security Act section 1881 has established the ESRD Program as 
part of Medicare in order to provide treatment for patients with renal 
failure. Currently there are about 200,000 beneficiaries of the ESRD 
Program. The average ESRD patient is now costing the health care 
system--primarily Medicare--an estimated $51,000 per year, or $4,250 
per month. The number of patients entering the ESRD Program is 
increasing, and these patients are sicker than in the past. Obviously, 
delaying the onset of kidney failure could greatly improve a patient's 
quality of life and 
[[Page E442]] simultaneously save Medicare substantial amounts of 
money.
  An ESRD patient can choose either transplantation or dialysis. 
Without these measures, kidney failure is lethal. Dialysis, a 
mechanical cleansing of the blood, is disruptive to an individual's 
lifestyle and negatively impacts on one's quality of life. The work 
force is diminished daily as patients learn that they must begin 
dialysis treatment. In fact a recent study found that only 11 percent 
of the interviewed patients were employed. If we focused our energies 
on delaying the day which a patient must accept the burden of dialysis, 
we could realize a cost savings and improve the patient's quality of 
life.
  As a result of the evidence before us, I am today introducing 
legislation to require the Medicare agency to conduct a 3-year 
demonstration program to quantify the cost and benefits associated with 
identifying patients who are approaching renal failure, providing a 
range of services to them, and thus effectively delaying the onset of 
complete renal failure. The demonstration will attempt to determine 
whether the savings from a prevention program, including improvement in 
quality of life measurements and job retention, exceed the cost of the 
preventive services themselves.
  The prevention of progression to renal failure should be the primary 
focus when constructing treatment goals for patients with renal 
disease. While all the preventive measures that will consistently 
produce an increase in survival are as yet undetermined, there is a 
wealth of evidence that many patients can be effectively managed so as 
to delay the day that dialysis is needed to survive. I feel that the 
medical community knows enough about such preventive strategies and the 
patient populations that would most benefit from them to explore the 
idea of extending the Medicare ESRD benefit package to these patients 
prior to dialysis.
  A recent NIH consensus panel concluded that because comorbid factors 
affecting the outcome of renal disease are present prior to the onset 
of renal failure, patients should referred to a renal team for 
evaluation before dialysis begins. This team should consist of a 
physician, nurse, social worker, dietitian, and mental health 
professional and focus on the reduction in mortality and morbidity of 
the patient. There should be an interest in controlling hypertension 
and diabetes, reducing cardiovascular risk factors, correcting 
metabolic, endocrinologic, and hematologic abnormalities, treating 
underlying illnesses, evaluating and modifying psychological and social 
stressors, and setting nutritional parameters.
  More specific guidelines for the prevention of progression to renal 
failure that can be undertaken encompass the following: First, 
encouraging smoking cessation, reducing obesity, increasing aerobic 
exercise, reducing the intake of fat and cholesterol, correcting 
anemia, monitoring calcium and phosphorous; second, implementing the 
most recent American Diabetic Association guidelines for strict 
management of diabetes; third, reducing exposure to environmental 
toxins including analgesic abuse, lead poisoning, and other 
nephrotoxins; fourth, managing hypertension through prescription of 
angiotensin converting enzyme inhibitors and calcium channel blockers 
preferentially; fifth, regulating diet to maintain normal acid-base 
balance and intravascular fluid volume; and sixth, evaluating and 
correcting malnutrition.
  Diabetes is the No. 1 cause of renal failure in the United States. 
Approximately 25-35 percent of new ESRD patients have diabetes as the 
underlying etiology. Greater than 65 percent of all ESRD is due to 
diabetes and hypertension combined. The intensive management of both 
hypertension and diabetes has the benefit of reducing the time to the 
onset of dialysis. Although the progression to ESRD is rare in people 
with hypertension, there is the paradox of its continuing increase 
despite improvements in blood pressure control in the general 
population and reduction in mortality from other complications 
associated with hypertension. Cardiovascular mortality accounts for 
approximately 50 percent of deaths in patients receiving dialysis, 
highlighting the need for control of risk factors such as hypertension, 
smoking, anemia, obesity, and lipid abnormalities.
  Furthermore, the racial differences manifested in the increased risk 
of hypertension-related ESRD for blacks, and the excess risk of ESRD 
for low income, poorly educated blacks and whites must stimulate new 
evaluation of these problems. The correlation between lower 
socioeconomic status and ESRD has been examined, with several inter-
related factors possibly playing a role, including: lack of appropriate 
access to health care, lack of a primary care physician, lack of 
insurance, and non-compliance with a treatment regimen. Further 
examination of the relationship between hypertension, renal disease, 
and the interrelated factors must be undertaken in order to develop and 
implement viable treatment regimens that will have lasting effects.
  The patients in the ESRD Program have not only suffered through the 
tremendous burden of kidney failure, but their quality of life is 
further worsened by factors that can be corrected. The medical 
community needs to identify patients with renal disease prior to the 
onset of renal failure in order to reduce the burden of dialysis, 
thereby allowing these patients to remain viable members of the work 
force. The benefits of weight loss, regulation of fat intake, and 
reduction of stress have all become commonplace in the layperson's 
repertoire of medical knowledge. Strict control of diabetes, 
hypertension, diet, and psychological stressors can also have a real 
benefit for patients with kidney disease in reducing the onset of renal 
failure, subsequently improving the quality of life, and ultimately 
retrieving some patients from the brink of dialysis.


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