1. A long time dying
The Impact of
Chronic Kidney Disease
infocus
Issue No. 68, December 2015

2. This autumn England hosted the Rugby World Cup, which yet
again was dominated by the Southern hemisphere sides and
notably of course won by the All Blacks in a gripping New
Zealand v. Australia final. Watching from the side-lines was their
formidable former winger Jonah Lomu, who over a decade ago
had a kidney transplant due to chronic renal failure.
Another famous individual who struggled with kidney disease
was the film director Alfred Hitchcock, who died in 1980 of renal
failure, aged 80. If we go back further in history there is yet
another example of a well-known character, albeit a fictional one,
who also appeared to struggle with chronic kidney disease
(alongside rickets) - Tiny Timi
from Charles Dickens’ ‘A
Christmas Carol’!
These three examples seemingly have very little in common, as
they range from a malnourished child, to a former world class
athlete, to a very well-nourished wealthy old man. They are of
course linked by the same illness, chronic kidney disease
(CKD), and each actually represents a major route cause or
trigger of the disease: genetics, obesity, diabetes and
environmental factors.
What is CKD?
Chronic kidney disease describes the presence of long term
Hannover Re UK Life Branch | 2

3. Staging
In 2002 the Kidney Disease Outcomes Quality Initiative (KDOQI),
sponsored by the US National Kidney Foundation, devised a
model defining five stages of CKD. Levels 1-2 are defined by the
presence of markers of renal disease (see Figure 1). This is very
important diagnostically, as up to 50% of renal function can be
lost before creatinine rises out of the normal range and becomes
detectableiv
. In levels 3-5, in addition to the markers of renal
disease, the glomerular filtration rate (GFR) has to be less than 60
ml/min per 1.73m2
for three months (see Table 1).
Glomerular filtration rate (GFR)
In nearly all UK laboratories, GFR is calculated through a serum
creatinine test (eGFRcreatinine), using the Modification of Diet in
Renal Disease (MDRD) calculation, which replaced the older
Albuminuria
Urinary sediment abnormalities (haematuria, red blood or granular cell casts,
renal tubular epithelial cells)
Electrolyte imbalance
Structural damage detected by imaging or histology
Abnormalities caused by tubular disorder
History of renal transplantation
Elevated blood urea
Cockroft-Gault formula. As this calculation tends to be less accurate
for higher stages of CKD, the National Institute for Health and Care
Excellence (NICE) has recommended using the CKD-EPI calculation,
3 | Hannover Re UK Life Branch
Table 1
Figure 1
irreversible, abnormal kidney function or structure. It often
co-exists with other significant co-morbidities such as diabetes
and cardiovascular disease (CVD). It is associated with increased
mortality and ill-health and in a large number of cases, ultimately
leads to end stage renal disease (ESRD)ii
. Patients diagnosed with
CKD in its moderate to severe forms also have a stronger
likelihood of developing acute kidney injury, fall more frequently
and become frailiii.
CKD Stage
1
2
3a
3b
4
5
Description
>90
60 - 89
45 - 59
30 - 44
15 - 29
<15
Normal or increased GFR, with other
evidence of kidney damage
Slight decrease in GFR, with other evidence
of kidney damage
Moderate decrease in GFR, with or without
other evidence of kidney damage
Severe decrease in GFR, with or without
other evidence of kidney damage
Established renal failure
GFR (mI/min/1.73m2)
Markers of Renal Disease

4. Demographics
CKD presents a significant disease burden, with tens of millions
affected across the globe - a burden that keeps increasing. The
World Health Organisation’s Global Burden of Disease index
Hannover Re UK Life Branch | 4
Graph 1: A Comparison of International Prevalence of CKDbut this is still relatively unknown in the UK. However it is
important to note that most UK labs do not report CKD levels1- 2
even though it is estimated that 80-90% of people with CKD
(diagnosed and undiagnosed) fall into these stagesv
. Decreasing
GFR has a strong linear relationship with mortality. Persons with
GFR readings of <60, <45 and <15 ml/min per 1.73m2
respectively have 20%, 60% and 200% higher relative risk of
death, than those with an ‘ideal’ reading of >95 ml/min per
1.73m2vi
.
In the UK, NICE adopted the KDOQI classification in 2004, but in
2008 further split level 3 CKD into sub categories 3a and 3b, and
also introduced the suffix ‘p’ to indicate significant levels of
proteinuria. In 2013 the guidelines further refined proteinuria
risk into three categories based on increasing risk, and defined
by the urinary albumin/creatinine ratio (ACR under 3 mg/mmol or
A1, 3–30 mg/mmol or A2, and over 30 mg/mmol or A3),
recognising that the presence of albuminuria in CKD patients is
an independent marker for increased mortality and progression
to end stage renal disease (ESRD).
shows that in 1990 CKD was ranked as the 27th biggest cause of
death, but rose to 18th place in 2010. This degree of change was
second only to that of HIV and AIDS. The expense of dealing with
this disease is enormous; for one year alone (2009-10) it cost the
UK’s National Health Service £1.45 billion or around 1.3% of all
health spendingvii
, more than breast, lung, colon and skin cancer
combined.
Overall prevalence rates vary, but if CKD is defined as GFR of <60
ml/min per 1.73m2
then rates of 8-10% are common place.
However, when we consider patients with long term unexplained
haematuria or proteinuria (the most common markers), then rates
Source: Jha V, Garcia-Garcia G, 2013 & Orantes, 2014
% Population

5. Causes
The most common causes of CKD are diabetes mellitus,
hypertension (with obesity a factor for both) and ageing (see
Graph 2), as after age 40 GFR reduces by 1 ml/min 1.73m2
per
annum in the general populationviii
. Less frequent causes are
glomerulonephritis, polycystic kidney disease (these develop to
ESRD both rapidly and with greater frequency) or urinary tract
blockages due to chronic infection or kidney stones.
Although ESRD is an obvious risk, most mortality (60%) is
associated with CVD. Indeed those with CKD are two times more
likely to die from CVD than their non-CKD peers and this appears
to be the likely cause of Jonah Lomu's death from a suspected
heart attack. This is unsurprising as 40% have hypertension and
5 | Hannover Re UK Life Branch
30% are diabetic, and smoking prevalence and dyslipidaemia are
also highix
. Increasingly control of blood pressure in the
pre-symptomatic stage is seen as vitally important not just in the
years, but in the decades preceding diagnosis.
In developing countries, environmental factors such as pollution
and pesticides are significant causes. The Central American CKD
epidemic for example is attributed to the working environment of
sugar cane workers. Here a combination of local weather and
extreme workload causes dehydration and heat stress, which in
turn causes the workers to be vulnerable to toxin exposure, in this
case sugar cane ash caused by burning the crop before cuttingx
.
Graph 2: Summary of Expected CKD Stage 3-5
Prevalence In England
are signifigantly higher. An interesting example is El Salvador,
where 20% of the population are affected, and it is estimated that
over 20,000 people have died in the last decade because of the
disease.
Homogenous national level statistics hide population sub-groups
which have increased risks, for example people of south Asian
origin and black people in the UK, Hispanic and Native
Americans in the USA, and Indigenous Australians and Maori in
Australasia.
Source: Aitken, Public Health England

6. The future
One of the by-products of increased longevity is the emergence of
prolonged health issues such as CKD. Consequently in the
developed world, the numbers of those with the disease are
expected to significantly rise in the next few decades; in the UK
for example (see Graph 3) prevalence is set to increase by 50%
from 2.6m in 2011 to 4.2m in 2036. Despite these statistics, there
is still a desperate lack of awareness about the condition. For
instance, while estimates suggest CKD prevalence in the UK of
around 3 million, there are only 2 million who have been
registered with their GPxiv
.
As with many similar long term chronic diseases, those with CKD
can face years, if not decades, living with the effects of the illness.
For example it’s estimated that 60 year olds with stage 3a CKD
could live a further 14-16 years, whereas even those with
pre-renal failure (stage 4) can live 5-6 years after diagnosisxv
. It
is likely therefore, that in the face of such daunting numbers,
governments will struggle to support and fund the costs
Given the disparate causes and potential outcomes, the
underwriting assessment of CKD is understandably complex,
with decisions ranging from standard rates to declinature for life
Hannover Re UK Life Branch | 6
End stage renal disease, dialysis and
transplantation
So while the prevalence of CKD is fairly high it is important to
note that progression to ESRD is not universal, as the prevalence
of ESRD in the UK is about 0.06% versus 8-10% prevalence of
CKDxi
. However the risk of development of ESRD does increase
exponentially with each stage. Typically over a period of four
years <2% of stage 3, 10% of stage 4 and nearly 60% stage 5
CKD develop ESRDxii
. Once in established renal failure (ERF) or
ESRD, some form of renal replacement therapy (RRT) is required
for long term survival, although for elderly lives non-invasive
conservative therapeutic outcomes may be appropriate. RRT is
either via haemodialysis, peritoneal dialysis or transplant.
Survival rates for those on RRT have improved in recent decades,
for example one year survival has improved from 76.3% in 1997
to 85.5% by 2010. In the longer term, if we look at patients that
commenced RRT in 2002 <50% of 18-64 year olds survived 10
years, dropping to <7% for older lives. The relative risk of death
compared to non-RRT peers overall is 6.1(or 500% EM) and for
younger lives (30-39 year olds) 16.6 (or 1600%EM)xiii
.
products. Terms are not available for either critical illness or
income protection style products.. In our underwriting manual,
Ascent we stratify risk logically based on the key criteria above:
cause, stage progression, age and symptoms.

7. For further insight into product design and their pricing please
contact us uk.marketing@hannover-re.com. If you wish to discuss
the underwriting considerations and loadings for CKD please refer
to our Ascent underwriting manual or contact us at
uk.underwriting@hannover-re.com
Paul Edwards,
Manager, Medical Risk Research
7 | Hannover Re UK Life Branch
Contact: uk.marketing@hannover-re.com
We hope you enjoy infocus and we welcome your feedback, please
forward comments to Alessandra Pierandrei at
uk.marketing@hannover-re.com.
© Hannover Re UK Life Branch. All rights reserved.
The opinions expressed in this publication are those of the
authors. This publication is subject to copyright. All rights
reserved. Apart from any fair dealings for the purposes of research
or private study, no part of this publication may be reproduced,
stored in a retrieval system or transmitted in any form or by any
means without the prior permission in writing of Hannover Re.
Single copies may be made for the purposes of research or private
study. Multiple copying of the content of this publication without
permission is always illegal.
Graph 3: Growth of CKD (Stage 3-5) numbers 2011-36
associated with CKD. It appears likely that individuals will
increasingly need to self-fund their own care. The life and health
insurance industry has a clear role to play in continuing to
provide value for money traditional protection products, as well
as new hybrid care products, which cover individuals not only for
death and illness but also those that can support consumer needs
for long term care and medical intervention. At Hannover Re UK
Life Branch we have experience in assisting insurers to design a
new wave of products that intersect between providing both
traditional protection and longer term health needs.
Source: Aiken, Public Health England

8. Bibliography
Hannover Re UK Life Branch | 8
Aiken, G., ‘Chronic Kidney disease prevalence model’ Public
Health England
Jha and Garcia-Garcia.G. et al ‘Chronic Kidney Disease: global
dimension and perspectives’ The Lancet (2013) Vol 328, no 9888
p260-272
Kidney Research UK accessed 7th September 2015.
Landray, M.J., et al ‘Prediction of ESRD and Death among People
with CKD: The Chronic Renal Impairment in Birmingham (CRIB)
Prospective Cohort Study’ Am J Kidney Dis. Dec 2010; 56(6-2):
1082–1094
Lewis, D.W., ‘What was wrong with Tiny Tim?’ Am J Dis Child 1992
Dec;146(12):1403-7.
de Lusignan, S. et al ‘Chronic kidney disease frequently asked
questions, January 2010’ NHS Employers & BMA
Matsushita K, van der Velde M, Astor BC, et al. Association of
estimated glomerular filtration rate and albuminuria with all-cause
and cardiovascular mortality in general population cohorts: a
collaborative meta-analysis. Lancet 2010 Jun 12;
375(9731):2073-81
NICE Chronic Kidney Disease, Clinical Guideline 182. July 2014
Orantes, CM ‘Epidemiology of chronic kidney disease in adults of
Salvadorean agricultural communities’ MEDICC Rev 14
Apr;16(2):23-30.
Sharma, P, et al ‘Does stage-3 chronic kidney disease matter? A
systematic literature review British Journal of General Practice,
June 2010
Turin, T et al ‘Chronic Kidney disease and life expectancy’ Nephrol
Dial Transplant (2012) 27: 3182–3186
UK Renal Registry’s 16th Annual Report 2013
Sources:
Lewis, D 1992, believed that Tiny Tim may have suffered with Tubular
Interstitial Acidosis Type 1
Landray, 2010
CKD NICE clinical Guideline 182
De Lusignan. 2010
Jha and Garcia-Garcia.G. et al 2013
Matsushita, 2010
Jha and Garcia-Garcia.G. et al 2013 – more than half the cost was
spend on Renal Replacement Therapy which was provided to only 2%
of the CKD population
NHS Employers, 2010
De Luisgnan, 2010
Orantes. 2014
Dr Emile de Sousa, Hannover Re UK CMO
Landray, 2010
Pruthi et al Chapt 8, UK Renal Registry report 2013
Kidney Research UK – the Missing Million.
Turin 2013
i
ii
iii
iv
v
vi
vii
viii
ix
x
xi
xii
xiii
xiv
xv