Disability Doc

C. Persistent elevation of serum creatinine to 4 mg per deciliter (dL) (100 ml) or greater or reduction of creatinine clearance to 20 ml per minute or less, over at least 3 months, with one of the following:

1. Renal osteodystrophy (see 6.00E3) manifested by severe bone pain and appropriate medically acceptable imaging demonstrating abnormalities such as osteitis fibrosa, significant osteoporosis, osteomalacia, or pathologic fractures;

Blood and urine tests required for this listing must be documented in the medical records on more than one occasion over a period of at least three months.

Creatinine - normal product of muscle metabolism.
Serum creatinine - amount of creatinine in the blood, which measures renal function; determined by a blood sample
Creatinine clearance test - test for renal function based on the rate at which creatinine is excreted by the kidney; determined by a blood sample with a 24 hour urine sample

A specific assessment of an individual's overall residual function cannot be directly correlated with a set abnormality of serum creatinine or creatinine clearance alone. An individual with a serum creatinine less than 4 mg/dl may not have significant loss of function; however, as the creatinine begins to exceed 4 mg/dl, complications of chronic kidney disease and loss of the individual’s overall level of function increases.

Renal osteodystrophy - bone disorders usually caused by chronic kidney failure, and may result in bone pain and pathologic fractures (bone breaks due to weakening of bone structure).

Note that bone pain must be "severe," but the listing does not say that it must be intractable or consistent; therefore, intermittent "severe" bone pain would suffice.

Types of renal osteodystrophy include:

• Osteitis fibrosa - fibrous degeneration with weakening and deformity of bone 
• Osteomalacia - softening of bone
• Osteoporosis - thinning of bone with reduction in bone mass resulting from the depletion of calcium and bone protein

In this new listing, SSA has replaced the word “marked” with the word “significant” in the phrase describing osteoporosis. SSA notes they are not changing the degree of osteoporosis required to meet this listing, but in my opinion, changing one vague quantifier (“marked”) for another (“significant”) adds nothing but confusion to this listing.To help satisfy SSA criteria for this listing, I recommend you have the treating doctor quantify any existing osteoporosis as “significant.”

Medically acceptable imaging includes, but is not limited to x-ray imaging, computerized axial tomography (CAT scan), or magnetic resonance imaging (MRI), myelography, and radionuclear bone scans. These tests may be useful in documenting osteodystrophy (bone deterioration), osteoporosis (best test is a DEXA scan), and pathologic fractures due to bone thinning.

Complications of chronic kidney disease and associated loss of an individual’s overall level of function becomes more prevalent the longer chronic renal disease exists. In deciding residual function, SSA must assess the totality of the evidence including the chronicity and degree of renal failure, any complications and associated loss of function, other underlying conditions, and side effects of medications.