Julie Dorsman outlines the factors underwriters consider when applicants have a history of kidney failure
The kidneys are located in the upper part of the abdomen towards the back and each is roughly the size of a fist. Kidneys filter waste from the blood and regulate the volume and composition of body fluid.
If the kidneys fail, waste accumulates in the blood and in the body. Mild failure generally gives few or no symptoms, but if the failure continues then symptoms start to appear. Renal failure exists when approximately 60% of renal function has been lost.
Renal failure can happen abruptly over a period of days or weeks and is usually ' but not always ' reversible. This is known as acute renal failure. Alternatively, it can occur slowly and progressively over a period of years ' this is known as chronic renal failure.
Acute renal failure can cause sudden, life-threatening biochemical disturbances in the body and requires emergency medical treatment. There are several causes, including:
• Considerable blood loss or reduced blood pressure during or following a serious illness or operation.
• Severe dehydration.
• Kidney stones which block the drainage of urine from the kidney.
• Side-effects of some medications.
• Crush injuries. If large amounts of muscle are damaged, toxic proteins harmful to the kidneys may be released.
Acute renal failure is treated, in some instances, by a short period of dialysis. Normal function gradually returns within a matter of weeks.
Chronic renal failure can be classified as mild, moderate, severe, or end-stage. In end-stage disease, the kidneys are permanently working at less than 10% of their normal capacity. The disease is not reversible and most cases progress to end-stage disease. Without dialysis or a transplant it is fatal. Even with treatment, mortality and morbidity is greatly increased due to the greater risk of heart attack or stroke.
There are several causes of chronic renal failure, including:
• Glomerulonephritis, which is damage and inflammation of the glomeruli of both kidneys.
• Chronic blockage to the drainage of the kidney.
• Long-standing diabetes.
• Multisystem diseases such as systemic lupus erythematosus.
• Some inherited conditions, for example polycystic kidney disease.
There are not normally any symptoms until the condition is at an advanced stage, so damage to the kidneys is not usually noticed during the early stages.
Accidental diagnosis
Chronic renal failure is often discovered by accident while having a urine or blood test for something else, or when investigated for raised blood pressure. At an advanced stage, symptoms include:
• Tiredness.
• Itching.
• Loss of appetite.
• Nausea and vomiting.
• Breathlessness.
• Bone pain.
• Fluid retention (ankle swelling).
• Weakness.
• Impotence in men.
• Fits and confusion.
Initially blood pressure will have to be brought to a satisfactory level so that the progression of the failure can be slowed down. A change of diet may be required to reduce the level of salt, protein, phosphate and potassium intake. Vitamin D and calcium supplements may be required to prevent osteoporosis.
Any co-existing anaemia will need to be treated and certain medications will need to be eliminated as these can reduce kidney function, for example anti-inflammatory painkillers. If extensive, the kidneys may fail completely and urgent treatment in the form of dialysis or a kidney transplant will be required.
There are two main types of dialysis: peritoneal dialysis and haemodialysis. In peritoneal dialysis a tube is placed within the abdomen which leads out to the surface of the skin. The tube can be left there for some time. A fluid containing chemicals runs through the tube into the abdomen, left for several hours and then run out again. This washes out the toxic substances. The patient can carry out this form of dialysis at home.
With haemodialysis the patient's blood is run through a machine that acts as an artificial kidney. The machine cleans the blood and the blood is then run back into the patient's vein. This procedure takes approximately two to four hours to carry out and should be done every two or three days, usually within a hospital environment.
Awaiting a transplant
But most patients would prefer kidney transplantation, rather than have to undergo regular dialysis for life. However, due to the limited availability of donor organs, many patients have to wait years before they can receive a transplant.
The kidney can be from a live donor (the body can function perfectly well with just one kidney ' a near relative with a suitable tissue type and the same blood group would be an ideal donor. Otherwise the kidney could come from someone who has died (where they or their family have expressed a wish to be an organ donor).
Mortality is greatest in the first year following surgery, due to rejection and infections. Although the risk of rejection is ever present, it reduces as time progresses. Drugs need to be taken for life to stop rejection occurring.
Some of these may cause side effects such as: raised blood pressure; osteoporosis; increased appetite leading to weight gain; increasing facial hair growth; and very occasionally, diabetes. As these drugs are reduced over time the side effects are also reduced.
Sometimes there can be a recurrence of the original disease in the new kidney, particularly where glomerulonephritis was the initial diagnosis.
The original kidneys are often left in place with the new kidney transplanted into the groin where it is connected to the blood vessels that take blood to and from the leg. A kidney transplanted from a dead person can last from a few weeks to 20 or more years, but on average it lasts for eight years. Living donor kidneys usually last longer than cadaver kidneys.
Underwriting
The underwriter will obtain information from the applicant's GP in order to elicit accurate information regarding any underlying cause, previous and current renal function, the nature of treatment, details of any complications, current blood pressure readings and current urinalysis. If the GP does not have the results to these tests, new tests may be requested.
Neither life cover nor permanent and total disability (PTD) cover will be offered if the applicant has acute renal failure, or if there has been a history of it within the last six months.
If the applicant is seeking critical illness (CI) or income protection (IP), it will not be available if the patient has suffered from the condition during the last 12 months. Thereafter, any terms offered will be based on the underlying cause and any complications.
If the applicant has chronic renal failure (with or without transplant surgery) both critical illness and income protection will be declined. Similarly, severe or end-stage chronic renal failure will be declined for life protection and PTD. However, terms may be available for life protection and PTD if the condition is only at the mild or moderate stage. Any rating will be for the underlying cause.
If dialysis is being carried out the majority of applications will be declined. Terms may be available for life protection only for applicants under age 55 and for policy terms of 10 years or less. In these instances dialysis must have started more than six months previously, blood pressure must be well controlled and there should not be a history of diabetes, heart disease or stroke. These selected cases will usually be accepted with a large additional premium.
Where transplant surgery has taken place CI, IP and PTD will normally be declined. Terms will not be offered for life protection within 12 months of the surgery taking place.
If the donor was a living twin and there is no history of glomerular disease in the applicant, then it might be possible to offer standard terms. In all other circumstances, so long as there was no post-operative rejection, the applicant has remained under regular specialist follow-up, renal function is satisfactory, urinalysis and blood pressure are normal or near normal, daily prednisolone (oral steroid) is less than 15 milligrams, and the applicant is not an insulin dependent diabetic and has no history of heart disease or stroke, terms may be available with a heavy rating. In some instances it may also be necessary to limit the term of the policy.
Julie Dorsman is a life and disability underwriter at Scottish Equitable
