£1.45 billion on CKD in 2009–10, equivalent to £1 in every £77 of NHS expenditure. This spending estimate covers both treatment directly associated with CKD (renal care and prescribing to prevent disease progression), and also treatment for excess non-renal problems such as strokes, heart attacks and infections in people with CKD. In the case of non-renal problems, costs are estimated only for excess events, over and above the expected number for people of the same age and sex who do not have CKD. The distribution of NHS spending on CKD is shown in Figure 1. 6. There were an estimated 7,000 extra strokes and 12,000 extra myocardial infarctions (MIs) in people with CKD in 2009–2010, relative to the expected number in people of the same age and sex without CKD. The cost to the NHS of health care related to these strokes and MIs is estimated at £174–178 million. 7. People with CKD have longer hospital stays than people of the same age without the condition, even when they go into hospital for treatments unrelated to CKD. We estimate that the average length of stay is 35% longer for people with CKD, and that the cost to the NHS of excess hospital bed days for patients with CKD was £46 million in 2009–10. 06 8. Infections such as meticillin (methicillin)-resistant Staphylococcus aureus (MRSA) are more common in people with CKD, in particular in those receiving haemodialysis. The risk of MRSA is more than 100 times greater in people receiving haemodialysis than in the general population. The cost to the NHS of MRSA in haemodialysis patients is estimated at £1.4 million. 9. The costs in this paper cover only health care provision. In addition, there is likely to be considerable expenditure on social care services. It was not possible to produce robust estimates of most social care costs associated with CKD. In the case of excess strokes in CKD, social care costs have been estimated (see Appendix 2). The estimated cost of social care in stroke is more than 1.5 times the health care cost. 10. In addition to health and social care costs, CKD can place a financial burden on individuals with the disease and on their carers through lost working days and morbidity. These work and morbidity effects also entail costs to the public purse through reductions in tax revenue and increases in benefit payments. If all these impacts were taken into account the total cost of CKD, both to society and to the public sector, would be higher than the costs set out in this paper. 11. The estimate of total expenditure is more than twice the sum that would be produced by extrapolating from the figures in the 2002 Wanless report, Securing our Future Health: Taking a Long-term View. In that report, spending on kidney care in 2002–03 was estimated at £445 million (£580 million in 2009–10 prices). The number of people receiving RRT increased by 29% between 2002 and 2008. The total prevalence of CKD (diagnosed and undiagnosed) is also believed to be increasing. 12. Programme Budgeting analysis by the Department of Health estimated total NHS expenditure on renal problems at £1.64 billion in 2009–10. However, the Programme Budgeting renal category is broader than CKD. The Programme Budgeting estimates therefore include expenditure on other renal conditions such as acute kidney injury. Programme Budgeting data on renal problems do not include indirect costs (which contribute £211–£225 million to the total estimated in this paper). The total direct costs estimated here are £1.23 billion. 13. In the Programme Budgeting data, 5% of PCT expenditure on renal problems was attributed to primary care and 95% to secondary care. The proportion of direct costs attributed to primary care in this paper is considerably higher (12% without prescribing costs, 26% if prescribing costs are included). There are a number of reasons for this: as indicated above, the renal category considered in this paper is narrower than that used for Programme Budgeting; some of the prescribing costs included here (such as those for anti-hypertensive therapies in CKD) are likely to be attributed to non-renal categories in Programme Budgeting; and a more detailed examination of primary care resource use for CKD has been undertaken here than is generally possible in the context of Programme Budgeting. Executive Summary 07 Executive Summary EXECUTIVE SUMMARY Figure 1. Direct and indirect NHS expenditure on CKD, England 2009–10 Renal Replacement Therapy Renal Primary Care Dialysis £505m Transplantation £225m Anti-hypertensive prescribing £152m Primary care tests and consultations £143m Excess Non-Renal Care in CKD Renal Secondary Care BMD and anaemia £27m Dialysis Transport £50m Excess stroke £82m Renal admissions £75m Nephrology Consultations (Non-RRT) £53m Excess MRSA £1m BMD: bone mineral density Excess MI £95m Excess length of stay £46m 08 14. The purpose of this paper is to examine the impact of chronic kidney disease (CKD) and associated complications and comorbidities on quality of life, mortality and NHS costs in England. 15. The paper is divided into three sections: section I examines the prevalence of CKD and its impact on quality of life and mortality; section II examines expenditure on CKD; and section III discusses the implications of the study findings. 16. Costs are categorised here as direct and indirect. Direct costs are defined as those