Kidney Disease: The Basics

Kidney disease, also known as chronic kidney disease or CKD, causes more deaths than breast cancer or prostate cancer (NVS 2021 report of 2018 data). It is the under-recognized public health crisis.

• Kidney disease affects an estimated 37 million people in the U.S. (15% of the adult population; more than 1 in 7 adults).
• Approximately 90% of those with kidney disease don't know they have it.
• And 2 of 5 adults with severe kidney disease don't know they have it.
• 1 in 3 adults in the U.S. (approximately 80 million) is at risk for kidney disease.
• Kidney disease is more common in women (14%) than men (12%). But for every 2 women who develop end-stage kidney disease (ESKD), 3 men's kidneys fail.
• Kidney disease is a leading cause of death in the U.S.
• About 1 in 2 people with very low kidney function (not on dialysis) don't know they have kidney disease.
• Approximately 1 in 3 adults with diabetes and 1 in 5 adults with high blood pressure may have kidney disease.
• Without increased investment in prevention, the total number of patients with kidney failure will likely exceed 1 million by 2030.
• COVID-19 is targeting people with kidney disease, kidney transplant patients, and those at risk for kidney disease.

Chronic kidney disease (CKD) means your kidneys are damaged and losing their ability to keep you healthy by filtering your blood. In the early stages of the disease, most people do not have symptoms. But as kidney disease gets worse, wastes can build up in your blood and make you feel sick. You may develop other problems, like high blood pressure, anemia, weak bones, poor nutritional health, and nerve damage. Because kidneys are vital to so many of the body's functions, kidney disease also increases your risk of having heart and blood vessel disease. While these problems may happen slowly and without symptoms, they can lead to kidney failure, which can appear without warning. Once kidneys fail, dialysis or a kidney transplant is needed to stay alive. Kidney failure is also called kidney failure with replacement therapy (KFRT).

The two main causes of kidney disease are diabetes and high blood pressure.

• These two conditions were the primary diagnosis in 76% of kidney failure cases between 2015-2017: 47% of new KFRT patients had a primary diagnosis of diabetes, the leading cause of KFRT, while 29% of new KFRT patients had a primary diagnosis of hypertension, the second leading cause of KFRT.
• Other conditions that can lead to KFRT are: glomerulonephritis (diseases that damage the kidney's filtering units), which are the third most common type of kidney disease; inherited diseases, such as polycystic kidney disease; malformations at birth that occur as a fetus develops; lupus and other immune diseases; obstructions such as kidney stones or an enlarged prostate; and repeated urinary tract infections, which can also lead to kidney infections and can cause long-term damage to the kidneys.
• People with kidney disease are at greater risk for cardiovascular disease and death at all stages of kidney disease. Kidney disease and heart disease are linked and have common risk factors, such as diabetes and hypertension. Each condition can lead to or worsen the other.

The best treatment of kidney disease is facilitated by early detection, when the disease can be slowed or stopped. Early treatment includes diet, exercise, medications, lifestyle changes, and treating risk factors like diabetes and hypertension. However, once kidneys fail, treatment with dialysis or a kidney transplant is needed.

• Dialysis comes in two forms: hemodialysis (HD) or peritoneal dialysis (PD). Both forms remove wastes and extra fluid from your blood. Patients receive hemodialysis usually 3–4 times a week, either at home or at a dialysis center. During hemodialysis, your blood is pumped through a dialysis machine, where it is cleaned and returned to your body. With peritoneal dialysis, your blood is cleaned inside your body every day through the lining of your abdomen using a special fluid that is periodically changed. Peritoneal dialysis can be done at home, at work, at school, or even during travel. Home dialysis is an increasingly popular mode of treatment, and is associated with better outcomes.
• A kidney transplant places a healthy kidney into your body from a deceased donor or from a living donor, such as a close relative, spouse, friend, or generous stranger. A kidney transplant, however, is a treatment, not a cure. Antirejection and other medications are needed to maintain the transplant. Per the United States Renal Data System (USRDS), more than 22,000 (22,393) kidney transplants were performed in the United States in 2018. The active waiting list remains substantially larger than the supply of donor kidneys, which presents a continuing challenge.
• Although it is very important for patients who are nearing the need for dialysis or kidney transplantation to be cared for by a nephrologist, in 2018, 38.8% of incident (newly occurring) KFRT patients (18–44 years) had received little or no pre-KFRT nephrology care.

• In 2018, 785,883 Americans had kidney failure, and needed dialysis or a kidney transplant to survive (2 in every 1.000 people). Approximately 500,000 of these patients received dialysis at least 3 times per week to replace kidney function and about 200,000 lived with a kidney transplant.
• About 130,000 people started KFRT treatment in 2018, of which approximately 128,000 started dialysis as the initial mode of therapy.
• In 2018, 22,393 people received a kidney transplant. By the end of 2018, a total of 229,887 Americans were living with a kidney transplant.
• While about 100,000 Americans are waiting for a kidney transplant, only 22,817 Americans received one in 2020. About one-third of these transplants came from living donors.
• Living and deceased kidney donors are crucial: 12 people die every day while waiting for a kidney transplant.
• In 2016, more than 3,600 kidneys from deceased donors were surgically discarded; NKF is making efforts to utilize more of these kidneys for transplantation.
• People with kidney disease are five to ten times more likely to die prematurely than they are to progress to KFRT. More than 100,000 people with KFRT died in 2018.

• 1 in 3 adults in the U.S. is at risk for kidney disease. Some demographic groups are at higher risk. (See "What's Behind Racial Disparities in Kidney Disease?" section.)
• Risk factors for kidney disease include: diabetes; high blood pressure; family history of kidney failure; age 60 or older; obesity; heart disease; past damage to kidneys; and being in minority populations that have high rates of diabetes or high blood pressure, such as Blacks or African Americans, Hispanics or Latinos, Asian Americans or Pacific Islanders, and American Indians or Alaska Natives (Note: current CDC/ NHANES demographic terminology.).

People from some groups are more likely to develop kidney disease than others. Many factors can contribute to these groups being at higher risk, ranging from societal to medical reasons.

• A breakdown of kidney disease rates within demographic categories of the general population of the United States for 2015—2018 (USRDS, Prevalence of CKD in U.S. adults within age, sex, race/ethnicity, & risk factor categories) showed: 16.0% Non-Hispanic Black or African American; 15.7% Non-Hispanic White; 11.9% Hispanic or Latino (2018).
• Among Medicare FFS (fee-for-service) beneficiaries, kidney disease is highest among Blacks or African Americans (33%), followed by American Indians or Alaska Natives (30%), Hispanics or Latinos (28%), and Asian Americans or Pacific Islanders (26%). Whites (23%) beneficiaries had the lowest percentages of kidney disease (2018).
• Non-Hispanic Black or African-American and Hispanic or Latino people experience more rapid decline of kidney function than non-Hispanic Whites. Minority communities in general are at increased risk of progressing from CKD to KFRT and of progressing more rapidly.
• Blacks or African Americans are about 3 times more likely than Whites to develop kidney failure. Blacks or African Americans are 13% of the U.S. population, while representing 35% of those with kidney failure.
• Black or African-American race is also associated with increased risk for acute kidney injury (AKI).
• Blacks or African Americans also suffer higher rates of comorbid conditions, such as diabetes and high blood pressure, resulting in higher rates of fair/poor health (age 18+, 22% Blacks or African Americans vs. 16% Whites).
• Compared to non-Hispanics, Hispanics or Latinos are almost 33% (1.3 times) more likely to receive a diagnosis of kidney failure.
• Native Hawaiians, Pacific Islanders, American Indians and Alaska Natives also have a higher prevalence of kidney disease than Whites.
• There are disparities in the quality of primary care for patients of different racial, ethnic, and socioeconomic groups who have kidney disease and kidney disease risk factors. These disparities are related to patient, clinician, clinical, and systemic factors. Patients receiving dialysis in areas with populations that are largely Black or African American, low-income, or of lower educational attainment, are less likely to have received pre-dialysis care from a nephrologist. One study found that 52% of Hispanic or Latino patients on hemodialysis had not received pre-dialysis care from a nephrologist, compared to 44% of non-Hispanic patients.
• Blacks or African Americans and Hispanics or Latinos are also less likely to be treated with kidney transplantation than Whites.
• On average, Black or African-American transplant candidates wait longer than White transplant candidates for kidney, heart, and lung transplants.
• In 2018, 57% of White patients with KFRT received in-center hemodialysis, versus 72% of Black or African- American patients. This may reflect fewer Black or African-American patients utilizing home dialysis options.

Many children and adolescents have conditions that, if left untreated, dramatically increase their risk for kidney disease and KFRT: about 4% of youths (12–19 yrs) in the U.S. have hypertension, while about 10% have elevated blood pressure. In children aged 2–19 years, the prevalence of obesity is 18.5% (about 13 million), and 210,000 people younger than 20 years are living with diagnosed diabetes. The growing prevalence of these conditions in children means that the incidence and prevalence of kidney disease will likely increase further in the coming years.

• 6,427 children (<18 yrs old) in the U.S. lived with KFRT in 2017.
• According to one study, children with KFRT are 30 times more likely to die prematurely than healthy children. In another study, adolescents (<18 yrs old) with KFRT since childhood had a life expectancy of 38 years if they were treated with dialysis during childhood, and 63 years if they received a kidney transplant during childhood.
• The primary causes of pediatric KFRT in the U.S. between 2015–2018 were: primary glomerular disease, CAKUT (congenital anomalies of the kidney and urinary tract), cystic/hereditary/congenital disorders, and primary/secondary glomerular disease/vasculitis. Urinary tract infections can also lead to kidney infections, which can cause long-term damage to the kidneys.
• In 2020, 710 children (<18 yrs old) received a kidney transplant.
• More than 1,000 children (<18 yrs old) are waiting for a donated kidney.
• Recent USRDS data indicates substantial racial and ethnic disparities in KFRT treatment for children and adolescents
  • White children were twice as likely to receive a kidney transplant as Black or African-American children (20.8% versus 10.0%).
  • More Black or African-American (57.3%) children than White (40.5%) children-initiated hemodialysis (HD).
  • Hispanic or Latino children received a kidney transplant less often than non-Hispanic children (12.0% versus 20.2%) and initiated HD more often and PD less often.
  • The median kidney transplant waitlist time for children, by race: 35.2 months for Black or African-American children; 34.0 months for children of other race groups (not Black, White, or Asian); 23.3 months for White children; and 20.3 months for Asian-American children.

In 2018, Medicare costs for all people with all stages of kidney disease were $130 billion. In 2018 Medicare spent $81 billion for people with kidney disease and an additional $49.2 billion for people with KFRT. For 2018, per person per year (PPPY) spending on KFRT patients was $80,426. Early detection of kidney disease could save a substantial percentage of these costs.

• Per type of KFRT treatment, Medicare spent: $93,191 PPPY for HD, $78,741 for PD, and $37,304 for kidney transplant (2018).
• In 2018, Medicare spent an estimated $24,674 PPPY to care for someone with non-KFRT CKD, more than double the spending on the average Medicare beneficiary ($12,899).
• Almost 64.3% of new KFRT patients applied for Medicare (2018).
• In 2018, there were over 500,000 Medicare beneficiaries on maintenance dialysis (about 1% of Medicare fee-for-service population), accounting for 7.2% of the overall claims paid by Medicare.
• Total Medicare Part D spending (2009–2018) rose by 188% for those with CKD ($4.6 to $13.1 billion) and by 37% for those without CKD ($39.5 to $54.2 billion).
• For kidney transplant recipients, Medicare Part B spent $2,453 on immunosuppressive drugs, PPPY (2018).
• Medicare Part D spending was 1.7 times higher for those with CKD ($5392 PPPY) than for those without CKD ($3118 PPPY) (2018).
• Medicare Part D spending was 2.4 times higher for patients with KFRT ($8,173 PPPY) than those without ($3397 PPPY) (2018).
• There is good news, however, for patients burdened with immunosuppressive drug costs when they are no longer covered by the current 36-month limit. The NKF-supported Comprehensive Immunosuppressive Drug Coverage for Kidney Transplant Patients Act (S. 3353/H.R. 5534) was passed by both the U.S. House of Representatives and U.S. Senate in December 2020. This bill ensures that transplant patients on Medicare will receive lifetime unlimited coverage for immunosuppressive medications. This legislation represents a significant, positive change in the lives of many kidney patients.

However, there is still a lot of work to be done: Minority communities may have less access to healthcare than other Americans. For example, studies found that about one-third of Hispanics or Latinos, 20% Blacks or African Americans, and nearly 1 out of 3 American Indians and Alaska Natives were uninsured.

Early Detection

Early detection is the most effective way to combat kidney disease. There are two simple, quick, and inexpensive tests for kidney disease:

Keep Kidneys Healthy

• A kidney damage urine albumin-creatinine ratio (uACR) test measures the amount of protein called albumin in your urine. Damaged kidneys leak protein into your urine; it should be in your bloodstream.
• A kidney function blood test, creatinine, is used to measure your glomerular filtration rate (GFR), which tells how well your kidneys are working to remove wastes from your blood. It is the best way to check kidney function.
• People with kidney disease should: •Lower high blood pressure; •Manage blood sugar levels; •Reduce salt intake; •Avoid NSAIDs, a type of painkiller; •Moderate protein consumption; •Get an annual flu shot
• Everyone should: •Exercise regularly; •Control weight; •Follow a balanced diet; •Quit smoking; •Drink alcohol only in moderation; •Stay hydrated; •Monitor cholesterol levels; •Get an annual physical; •Know your family medical history

Preventative Medicine Pays Off

• A recent report from the Centers for Disease Control and Prevention (CDC) states that between 1996 and 2013, there was a 54% decrease in the incidence of diabetes-related KFRT in Native American and Alaska Natives since the Special Diabetes Program for Indians (SDPI) began in 1997. The CDC estimates that the decrease in KFRT related to diabetes resulted in 2,200 to 2,600 fewer cases of diabetes-related KFRT, and estimates $436 to $520 million in savings to Medicare over 10 years.

The National Kidney Foundation (NKF) is the largest, most comprehensive, and longstanding patient-centric organization dedicated to the awareness, prevention, and treatment of kidney disease in the U.S.

You can view a fully annotated fact sheet here.