AMCP Nexus Abstracts Present Findings on Clinical, Financial Burdens Associated With CKD

Conference abstracts explored the relationship between serum phosphate levels on mortality in patients with chronic kidney disease (CKD) and cost burdens for employers as patients transition to end-stage renal disease.

Abstracts presented at the Academy of Managed Care Pharmacy’s 2021 Nexus meeting detailed the impact of serum phosphate levels on mortality in patients with chronic kidney disease (CKD) as well as the cost burdens associated with patients transitioning from type 2 diabetes to end-stage renal disease (ESRD).

One abstract sought to review evidence published on serum phosphate level and mortality in patients with CKD who are dialysis-dependent to understand whether current data suggests that there is a link between slightly elevated ranges of elevated phosphate and mortality1. The investigators searched 2 databases for articles published between January 1, 2000 and February 3, 2021, finding 1295 citations, of which 33 reported on mortality risk estimates.

In total, 27 out of the 33 studies found that higher phosphate was independently, statistically significantly associated with increased mortality risks. Additionally, 23 studies evaluated phosphate level categorically, finding that a 1-unit increase in phosphate was associated with a 1.04 to 1.41 increased mortality risk.

The investigators said that their summary of published data supports the frequently-cited associated between high phosphate levels and mortality in patients receiving dialysis and that although many studies compared mortality risk between guideline-recommended range and higher than recommended range, few studies examined whether a risk associated with being in the higher end of or slightly about the recommended range also exists.

Another abstract explored the rate of new onset ESRD among a commercially insured population with type 2 diabetes and CKD and calculated the total medical costs during the employer primary coverage period2.

Employer-sponsored group health plans are the primary payer for insured members who develop ESTD for a 30-month coordination period or until the patient turns 65 years old. The coordination period kicks in after a patient has been on dialysis for 3 months, which is when the member qualifies for Medicare as a secondary payer until it becomes primary as the coordination period ends. This puts employers at risk of covered all medical costs for up to 33 months that are associated with employees or dependents develop ESRD.

The investigators collected proprietary commercial claims data from 2 databases from 2015 to 2019, identifying a population of patients between the ages of 18 and 64 years with continuous eligibility in all of 2015 and at least 1 month of 2016. Identification of newly onset ESRD required 3 consecutive months of outpatient dialysis or a kidney transplant in 2016 as well as no ESRD claims in 12 moths prior to the first ESRD claim in 2016.

Among the 18,492,858 members that met the eligibility criteria in 2016, 2059 were identified to have newly onset ESRD and 1074 (52.2%) met the criteria for type 2 diabetes and CKD in the baseline period. Those 1074 patients represented an annual ESRD transition rate of 1.3% among the 79,940 members with type 2 diabetes and CKD.

Of the 1074 members transitioning to ESRD in 2016, 81.3% did not turn 65 during the 33-month post-index date. The patients who did turn 65 during the post-index period had 16 months of exposure on average.

The annualized amount paid by employers per patient for the post-index period was estimated to be $256,000, which included $47,000 for inpatient claims, $172,000 for outpatient claims, $24,000 for professional claims, and $13,000 for pharmacy claims. The outpatient claims amount also encompassed the $130,000 spent for dialysis, which accounted for 51% of the total annualized paid amount.

The investigators said that members who develop ESRD contribute a significant burden to employer health care costs and that treatments that could delay the progression of CKD to ESRD could help reduce ESRD-related costs to employers.


  1. Kistler K, Fusco N, Stephenson B, Fogli J. Serum phosphate level and mortality in patients with dialysis-dependent chronic kidney disease: an up-to-date comprehensive, systematic literature review. Presented at: AMCP Nexus 2021; October 18, 2021-October 21, 2021. Abstract E15.
  2. Kong S, Bazell C, Learly S, et al. The cost burden to employers of type 2 diabetes members transitioning to end-stage renal disease. Presented at: AMCP Nexus 2021; October 18, 2021-October 21, 2021. Abstract E6.